458
this compound is still used in commercial formulations. As with salicylates, discussion of the role of alkaline diuresis in treatment has focused on enhancement of elimination and has ignored the possible benefits of simple alkalinisation. Clearly alkaline diuresis enhances renal elimination of the chlorophenoxy compounds, and may protect against the toxicity of these compounds and also that of ioxynil by altering tissue distribution and/or plasma protein binding. Our results suggest that alkalinisation should be used in the presence of coma or other indicators of a poor prognosis, such as acidaemia, or if the plasma total chlorophenoxy concentration is 0-5 g/1 or more.
teratogenic effects,
We thank the doctors who supplied patient details and Dr C. Tang (Walton Hospital, Liverpool), Dr R. Haigh (Westminster Hospital, London), Dr P. Ascherson (Northwick Park Hospital, London), Dr P. Adams (Gloucester Royal Infirmary), Mr J. D. Ramsey (St George’s Hospital, London), Mr A. Bridge (University Hospital, Nottingham), Dr 1. R. Hainsworth (Singleton Hospital, Swansea), Mr P. Streete, Mr M. O’Connell, and Dr G. N. Volans (poisons unit, Guy’s Hospital) for assistance.
REFERENCES 1. Prescott LF, Park J, Darrien I. Treatment of severe 2,4-D and mecoprop intoxication with alkaline diuresis. Br J Clin Pharmacol 1979; 7: 111-16. 2. Wells WDE, Wright N, Yeoman WB. Clinical features and management of poisoning with 2,4-D and mecoprop. Clin Toxicol 1981; 18: 273-76. 3. O’Reilly JF. Prolonged coma and delayed peripheral neuropathy after ingestion of phenoxyacetic acid weedkillers. Postgrad Med J 1984; 60: 76-77. 4. Meulenbelt J, Zwaveling JH, van Zoonen P, Notermans NC. Acute MCPP intoxication: report of two cases. Hum Toxicol 1988; 7: 289-92. 5. Osterloh J, Lotti M, Pond SM. Toxicologic studies in a fatal overdose of 2,4-D, MCPP and chlorpyrifos. J Anal Toxicol 1983; 7: 125-29.
6. Fraser AD, Isner AF, Perry RA. Toxicologic studies in a fatal overdose of 2,4-D, mecoprop, and dicamba. J Forensic Sci 1984; 29: 1237-41. 7. Kancir CB, Andersen C, Olesen AS. Marked hypocalcemia in a fatal poisoning with chlorinated phenoxy acid derivatives. Clin Toxicol 1988; 26: 257-64. 8. Conso F, Neel P, Pouzoulet C, Efthymiou ML, Gervais P, Gaultier M. Acute toxicity in man of halogenated derivatives of hydroxybenzonitrile (ioxynil, bromoxynil). Arch Mal Prof 1977; 38: 674-77. 9. Abi Khalil F, Alvoet C, Ectors M, Molle L. Acute fatal ioxynil intoxication. International Association of Forensic Toxicologists, proceedings of 24th International Meeting, Banff, 1988: 512-15. 10. Dickey W, McAleer JJA, Callender ME. Delayed sudden death after ingestion of MCPP and ioxynil: an unusual presentation of hormonal weedkiller intoxication. Postgrad Med J 1988; 64: 681-82. 11. Arnold EK, Beasley VR. The pharmacokinetics of chlorinated phenoxy acid herbicides: a literature review. Vet Hum Toxicol 1989; 31: 121-25. 12. Moffat AC, ed. Clarke’s isolation and identification of drugs. London: Pharmaceutical Press, 1986: 965-66. 13. Done AK, Temple AR. Treatment of salicylate poisoning. Mod Treat 1971; 8: 528-51. 14. Hill JB. Salicylate intoxication. N Engl J Med 1973; 288: 1110-13. 15. Prescott LF, Balali-Mood M, Critchley JAJH, Johnstone AF, Proudfoot AT. Diuresis or urinary alkalinisation for salicylate poisoning? Br Med J 1982; 285: 1383-86. 16. Matthew H, Lawson AAH. The treatment of common acute poisonings. 4th ed. Edinburgh: Churchill Livingstone, 1979. 17. Flanagan RJ, Ruprah M. HPLC measurement of chlorophenoxy herbicides, bromoxynil and ioxynil in biological specimens to aid the diagnosis of acute poisoning. Clin Chem 1989; 35: 1342-47. 18. Vesey CJ, Kirk CJC. Two automated methods for measuring plasma thiocyanate compared. Clin Chem 1985; 31: 270-74. 19. Brodie TM. Effect of certain plant growth substances on oxidative phosphorylation in rat liver mitochondria. Proc Soc Exp Biol Med 1952; 80: 533-36. 20. Akerblom M, Lindgren B. Simultaneous determination of active ingredient and chlorophenol impurities in phenoxy acid herbicide
formulations by high-performance liquid chromatography with ultraviolet and electrochemical detection. J Chromatogr 1983; 258: 302-06. 21. Smysl B, Smyslova O, Kosatik A. Acute fatal ioxynil intoxication. Arch Toxicol 1977; 37: 241-45.
EPIDEMIOLOGY Health in Eastern
assess trends in health in Eastern Europe, age-standardised mortality rates since 1950 in four Eastern European countries (German Democratic Republic, Poland, Czechoslovakia, and Hungary) were compared with those in two Western European countries (Federal Republic of Germany and England and Wales). In the Eastern European countries mortality rates had increased or were virtually unchanged since the mid-1960s, especially in middle aged and elderly men. Death
To
rates in males in
Europe
Introduction At a time when democratic principles dominate debate in Eastern Europe, it is important not to neglect health issues. We here focus on mortality rates in four Eastern European countries (German Democratic Republic [GDR], Poland, Czechoslovakia, and Hungary) by comparison with those in the Federal Republic of Germany (FRG) and in England and Wales. In the inter-war years, economic development was similar in the UK, Germany, and Czechoslovakia.
Poland, Czechoslovakia, and
Hungary in the mid
to late 1980s were as high as those in the two Western European countries in the early 1950s. There was a shorter time lag for females. This poor health record in Eastern Europe will need to be addressed by the policy makers in the new democracies.
ADDRESSES Division of Community Medicine, Medical School, Newcastle upon Tyne, UK (D. P. Forster, FFCM); and Department of Population Statistics, Hungarian Central Statistical Office, Budapest, Hungary (P Józan, MD). Correspondence to Dr D P. Forster, Division of Community Medicine, Medical School, University of Newcastle upon Tyne, Newcastle upon Tyne NE2 4HH, UK
459
Before the 1939-45 war, medical care was paid for in each country on a fee-for-service basis and a large proportion of the population was not adequately covered by an insurance scheme. After the war, the FRG promoted the insurancebased approach while the Eastern European countries developed broadly similar Soviet-style health services which were provided by the state. The National Health Service in England and Wales, financed mainly by taxation, provides free health care, although there is a small but expanding private health sector.
TABLE II-AGE-STANDARDISED MALE DEATH RATE: DISEASES OF CIRCULATORY SYSTEM* ___
Method We examined the mortality rates, categorised according to the International Classification of Diseases (ICD-6 to ICD-9) and published by the World Health Organisation, of the six countries. The rates were standardised for age (direct method,l European Standard Population).
Rate per 100 000 European standard population. *ICD-9, basic tabulation list 25-30 or equivalents for earlier editions of the ICD. Source: World Health Statistics Annuals. Geneva: World Health Organisation,
Results
TABLE III-AGE-STANDARDISED MALE DEATH RATE: MALIGNANT TUMOURS*
Table I shows age-standardised death rates for all causes. Death rates for males in Poland, Czechoslovakia, and Hungary were as high in the mid to late 1980s as those in England and Wales and in the FRG in the early 1950s. Even the GDR had only achieved by 1987 the rates that the two Western European countries had reached in the 1970s. There is also a time lag for females, although the differences in the rates between the Western and Eastern European countries are not as pronounced. Age-specific mortality rates in the Western European countries decreased in every age group. However, in the four Eastern European countries, such reductions are found only up to age 34 and especially in males; according to life tables for the post-war period in these countries, life expectancy for males at birth has increased but at ages 30 or 45 it has been virtually stationary or has decreased. In females, life expectancy at birth, and at ages 30 and 45 has increased gradually in Eastern Europe but less than in the two Western European countries. Additionally, infant mortality has decreased steadily in all countries, except for Czechoslovakia in the 1960s. TABLE I-AGE-STANDARDISED DEATH RATE: ALL CAUSES
1986-1988.
Rate per 100 000
European standard population.
*ICD-9, basic tabulation list 08-14 or equivalents for earlier editions of the ICD Source. World health Statistics Annuals Geneva: World Health Organisation, 1986-1988
Diseases of the circulatory system account for about half of all male deaths and predominantly affect middle aged and elderly men (table II). Overall, mortality rates in the late 1980s in England and Wales and in the FRG are at least 30% lower than those in their Eastern European counterparts. England and Wales and the FRG achieved reductions of 44% and 46%, respectively, in death rates from cerebrovascular disease between 1950-54 and 1987. By contrast, there has been an increase in these rates in the Eastern European nations, although Hungary and the GDR have shown reductions since 1985. Some malignant tumours are thought to be due mainly to environmental factors or to certain lifestyles.3 We have found that the trend in death rates for malignant tumours differs from that for other disorders: rates have increased in all countries-most rapidly for Poland, Czechoslovakia, and Hungary and least of all for the GDR (table ill).
Discussion
Rate per 100 000 European standard population. Source World Health Statistics Annuals. Geneva: World Health 1986-1988.
Organisation,
The 30 year time delay in achieving equivalent mortality rate standards might worsen if the Eastern European countries do not establish policies for health that are as successful as those that have produced a decrease in mortality rates in England and Wales and in the FRG. We realise that our choice of countries has been selective. England and Wales and the FRG are not leaders among Western European nations with respect to reduced mortality rates. Moreover, rates for England and Wales are
460
representative of the UK as a whole: those of Scotland and Northern Ireland are higher than those of England and Wales. We also believe that changes in the ICD during the time studied are not important, in view of the broad diagnostic categories that we have used. Use of mortality rates to assess trends in health is a negative approach but such an approach is measurable. The positive definition of health is less tangible-ie, a sense of vitality and well-being, which is perhaps best described by the French word equilibre.4 This definition involves not only a sense of balance between the physical and mental components of the life of an individual but also a harmony with that person’s surroundings. We do not believe that the pattern of equilibre, if quantifiable, would be substantially different from that portrayed by mortality rates. The poor health record in Eastern Europe since the mid-1960s has been recognised in Hungary; thus, the prevention and treatment of the chronic degenerative diseases of adults are now a priority. From the 1939-45 war to 1964, the decrease in mortality rates in Hungary and many other Eastern European countries was similar to that in Western Europe.6 This period coincided with the post-war reconstruction stage, better nutrition, and the effective treatment of infectious diseases. There are several reasons why this improvement in mortality rates has not been maintained. In Eastern Europe, industrial production and other sectors have taken precedence over health. Indicators such as the percentage of the gross national product (GNP) spent on health only partly support this view7since the salaries of health care professionals in Eastern Europe are low. Neither the availability of doctors nor number of hospital beds per thousand population seems to be inferior in Eastern Europe,8 although we have found that hospitals in England and Wales are more efficient than are those in Czechoslovakia.9 In Eastern Europe, services for children have received priority, and compulsory schemes have always achieved high immunisation rates.7 By contrast, less attention has been given to the health of middle aged and elderly people and there has been a lack of investment in health care technology. Cigarette smoking is especially high in Poland and Hungary as is alcohol consumption in the FRG and Hungary." However, percentage dietary fat is higher in the FRG and in England and Wales than it is in Eastern Europe,12 where supplies of imported fresh fruit and vegetables are limited. Pollution levels from the heavy industry of Eastern Europe may also have contributed to poor health. In 1980, estimated wealth in the UK was$US 7920 per caput (GNP per caput); that of the FRG was much higher. In the same period, the GDR had 91 %, Czechoslovakia 73%, Hungary 53%, and Poland 49% of the wealth of the UK in terms of GNP per caput ($US).13 Thus, lack of wealth to buy appropriate drugs may have been a factor in the failure to reduce death rates from, for example, cerebrovascular disease in Eastern Europe. The emerging democracies in Eastern Europe must strive not only to improve their economic position but also to adopt policies for health promotion. In the early stages of political change, these improvements have not been forthcoming. Fukuyama14 believes that recent political events in Eastern Europe are a triumph of Western liberal democracy. With respect to health, there is a legacy that will challenge new governments and need attention far into the future. not
We thank Mrs Karen Cowley for secretarial assistance and the British Council for a travel grant.
REFERENCES 1. Hill AB. A short textbook of medical statistics. London: Hodder and Stoughton, 1984: 170. 2. Waterhouse J, Correa P, Muir C, Powell J, eds. Cancer incidence in five continents. Vol III. Lyon: IARC, 1976: 456. 3. Doll R, Peto R. The causes of cancer: quantitative estimates of avoidable
risks of cancer in the US today. J Nat Cancer Inst 1981; 66: 1193-1308. 4. Herzlich C. Santé et maladie: analyse d’une représentation sociale. Paris-Lettaye: Mouton, 1969. 5. d’Houtard A, Field MG. The image of health: variations in perception by social class in a French population. Sociology of Health and Illness 1984; 6: 30-60. 6. Józan P. Some features of mortality in Hungary in the post-war period: the third stage of epidemiologic transition in promoting health in Hungary. Report of a group established by the Council of Ministers of the Hungarian People’s Republic. Budapest: Central Statistical Office, 1987. 7. Global strategy for health for all: monitoring 1988-89. Detailed analysis of global indicators. Geneva: World Health Organisation, 1989. (Mimeo). 8. World Health Statistics Annual, 1983. Geneva, World Health Organisation, 1983. 9. Forster DP, Frost CEB. Hospital performance and regional equity. Social Policy and Administration 1984; 18: 247-59. 10. The work of WHO in the European region, 1987. Annual report of the regional director. Copenhagen: World Health Organisation Regional Office for Europe, 1988. 11. Walsh D. Alcohol-related medicosocial problems and their prevention. Public Health in Europe 17. Copenhagen: World Health Organisation Regional Office for Europe, 1982. 12. The work of WHO in the European region, 1986. Annual report of the regional director. Copenhagen: World Health Organisation Regional Office for Europe, 1988. 13. World Bank. World development report, 1982. New York: Oxford University Press, 1982. 14. Fukuyama F. The end of history. The National Interest 1989; Summer: 3-18.
From The Lancet Do heads grow with advancing
age?
Some amusing letters have appeared in a daily contemporary in regard to an alleged steady increase in the size of Mr Gladstone’s head, which, it is said, is rendered manifest by a progressive enlargement in the size of the hat required to cover it. The correspondence exhibits an extraordinary ignorance of wellascertained facts; for, if there is one thing which would be acknowledged by all anatomists and physiologists, it is that the nervous system, like other parts of the body, undergoes atrophy with advancing age-an atrophy that pervades every tissue, and is as apparent in the thinning of the vocal cords that alters the voice to "childish treble", as in the shrunk shanks for which the "youthful hose, well saved, are a world too wide". No reason can be assigned why the brain should escape the general change that affects the digestive and the circulatory systems alike. Its attributes and faculties attain their highest excellence at or before mid-age, and from that time forth exhibit only a steady decline. To compare Mr Gladstone with Napoleon, respecting whom a similar story is related, is absurd. The head of Napoleon may have grown between twenty and forty-five, because his brain was greatly exercised during the last ten years of the past century and the first ten of the present; but no calls have been made on Mr Gladstone of late years all comparable to the strain on the mental and bodily powers of the French Emperor during that eventful period. The ossification of the sutures of the cranium practically prevents increase in the volume of the brain in advanced life; and, even granting some slight increase, such increase would be compensated for by the attenuation of the cranial bones which is well known to occur in old age. A change in form there may be, but none in size. (29 March 1890) at
this compound is still used in commercial formulations. As with salicylates, discussion of the role of alkaline diuresis in treatment has focused on enhancement of elimination and has ignored the possible benefits of simple alkalinisation. Clearly alkaline diuresis enhances renal elimination of the chlorophenoxy compounds, and may protect against the toxicity of these compounds and also that of ioxynil by altering tissue distribution and/or plasma protein binding. Our results suggest that alkalinisation should be used in the presence of coma or other indicators of a poor prognosis, such as acidaemia, or if the plasma total chlorophenoxy concentration is 0-5 g/1 or more.
teratogenic effects,
We thank the doctors who supplied patient details and Dr C. Tang (Walton Hospital, Liverpool), Dr R. Haigh (Westminster Hospital, London), Dr P. Ascherson (Northwick Park Hospital, London), Dr P. Adams (Gloucester Royal Infirmary), Mr J. D. Ramsey (St George’s Hospital, London), Mr A. Bridge (University Hospital, Nottingham), Dr 1. R. Hainsworth (Singleton Hospital, Swansea), Mr P. Streete, Mr M. O’Connell, and Dr G. N. Volans (poisons unit, Guy’s Hospital) for assistance.
REFERENCES 1. Prescott LF, Park J, Darrien I. Treatment of severe 2,4-D and mecoprop intoxication with alkaline diuresis. Br J Clin Pharmacol 1979; 7: 111-16. 2. Wells WDE, Wright N, Yeoman WB. Clinical features and management of poisoning with 2,4-D and mecoprop. Clin Toxicol 1981; 18: 273-76. 3. O’Reilly JF. Prolonged coma and delayed peripheral neuropathy after ingestion of phenoxyacetic acid weedkillers. Postgrad Med J 1984; 60: 76-77. 4. Meulenbelt J, Zwaveling JH, van Zoonen P, Notermans NC. Acute MCPP intoxication: report of two cases. Hum Toxicol 1988; 7: 289-92. 5. Osterloh J, Lotti M, Pond SM. Toxicologic studies in a fatal overdose of 2,4-D, MCPP and chlorpyrifos. J Anal Toxicol 1983; 7: 125-29.
6. Fraser AD, Isner AF, Perry RA. Toxicologic studies in a fatal overdose of 2,4-D, mecoprop, and dicamba. J Forensic Sci 1984; 29: 1237-41. 7. Kancir CB, Andersen C, Olesen AS. Marked hypocalcemia in a fatal poisoning with chlorinated phenoxy acid derivatives. Clin Toxicol 1988; 26: 257-64. 8. Conso F, Neel P, Pouzoulet C, Efthymiou ML, Gervais P, Gaultier M. Acute toxicity in man of halogenated derivatives of hydroxybenzonitrile (ioxynil, bromoxynil). Arch Mal Prof 1977; 38: 674-77. 9. Abi Khalil F, Alvoet C, Ectors M, Molle L. Acute fatal ioxynil intoxication. International Association of Forensic Toxicologists, proceedings of 24th International Meeting, Banff, 1988: 512-15. 10. Dickey W, McAleer JJA, Callender ME. Delayed sudden death after ingestion of MCPP and ioxynil: an unusual presentation of hormonal weedkiller intoxication. Postgrad Med J 1988; 64: 681-82. 11. Arnold EK, Beasley VR. The pharmacokinetics of chlorinated phenoxy acid herbicides: a literature review. Vet Hum Toxicol 1989; 31: 121-25. 12. Moffat AC, ed. Clarke’s isolation and identification of drugs. London: Pharmaceutical Press, 1986: 965-66. 13. Done AK, Temple AR. Treatment of salicylate poisoning. Mod Treat 1971; 8: 528-51. 14. Hill JB. Salicylate intoxication. N Engl J Med 1973; 288: 1110-13. 15. Prescott LF, Balali-Mood M, Critchley JAJH, Johnstone AF, Proudfoot AT. Diuresis or urinary alkalinisation for salicylate poisoning? Br Med J 1982; 285: 1383-86. 16. Matthew H, Lawson AAH. The treatment of common acute poisonings. 4th ed. Edinburgh: Churchill Livingstone, 1979. 17. Flanagan RJ, Ruprah M. HPLC measurement of chlorophenoxy herbicides, bromoxynil and ioxynil in biological specimens to aid the diagnosis of acute poisoning. Clin Chem 1989; 35: 1342-47. 18. Vesey CJ, Kirk CJC. Two automated methods for measuring plasma thiocyanate compared. Clin Chem 1985; 31: 270-74. 19. Brodie TM. Effect of certain plant growth substances on oxidative phosphorylation in rat liver mitochondria. Proc Soc Exp Biol Med 1952; 80: 533-36. 20. Akerblom M, Lindgren B. Simultaneous determination of active ingredient and chlorophenol impurities in phenoxy acid herbicide
formulations by high-performance liquid chromatography with ultraviolet and electrochemical detection. J Chromatogr 1983; 258: 302-06. 21. Smysl B, Smyslova O, Kosatik A. Acute fatal ioxynil intoxication. Arch Toxicol 1977; 37: 241-45.
EPIDEMIOLOGY Health in Eastern
assess trends in health in Eastern Europe, age-standardised mortality rates since 1950 in four Eastern European countries (German Democratic Republic, Poland, Czechoslovakia, and Hungary) were compared with those in two Western European countries (Federal Republic of Germany and England and Wales). In the Eastern European countries mortality rates had increased or were virtually unchanged since the mid-1960s, especially in middle aged and elderly men. Death
To
rates in males in
Europe
Introduction At a time when democratic principles dominate debate in Eastern Europe, it is important not to neglect health issues. We here focus on mortality rates in four Eastern European countries (German Democratic Republic [GDR], Poland, Czechoslovakia, and Hungary) by comparison with those in the Federal Republic of Germany (FRG) and in England and Wales. In the inter-war years, economic development was similar in the UK, Germany, and Czechoslovakia.
Poland, Czechoslovakia, and
Hungary in the mid
to late 1980s were as high as those in the two Western European countries in the early 1950s. There was a shorter time lag for females. This poor health record in Eastern Europe will need to be addressed by the policy makers in the new democracies.
ADDRESSES Division of Community Medicine, Medical School, Newcastle upon Tyne, UK (D. P. Forster, FFCM); and Department of Population Statistics, Hungarian Central Statistical Office, Budapest, Hungary (P Józan, MD). Correspondence to Dr D P. Forster, Division of Community Medicine, Medical School, University of Newcastle upon Tyne, Newcastle upon Tyne NE2 4HH, UK
459
Before the 1939-45 war, medical care was paid for in each country on a fee-for-service basis and a large proportion of the population was not adequately covered by an insurance scheme. After the war, the FRG promoted the insurancebased approach while the Eastern European countries developed broadly similar Soviet-style health services which were provided by the state. The National Health Service in England and Wales, financed mainly by taxation, provides free health care, although there is a small but expanding private health sector.
TABLE II-AGE-STANDARDISED MALE DEATH RATE: DISEASES OF CIRCULATORY SYSTEM* ___
Method We examined the mortality rates, categorised according to the International Classification of Diseases (ICD-6 to ICD-9) and published by the World Health Organisation, of the six countries. The rates were standardised for age (direct method,l European Standard Population).
Rate per 100 000 European standard population. *ICD-9, basic tabulation list 25-30 or equivalents for earlier editions of the ICD. Source: World Health Statistics Annuals. Geneva: World Health Organisation,
Results
TABLE III-AGE-STANDARDISED MALE DEATH RATE: MALIGNANT TUMOURS*
Table I shows age-standardised death rates for all causes. Death rates for males in Poland, Czechoslovakia, and Hungary were as high in the mid to late 1980s as those in England and Wales and in the FRG in the early 1950s. Even the GDR had only achieved by 1987 the rates that the two Western European countries had reached in the 1970s. There is also a time lag for females, although the differences in the rates between the Western and Eastern European countries are not as pronounced. Age-specific mortality rates in the Western European countries decreased in every age group. However, in the four Eastern European countries, such reductions are found only up to age 34 and especially in males; according to life tables for the post-war period in these countries, life expectancy for males at birth has increased but at ages 30 or 45 it has been virtually stationary or has decreased. In females, life expectancy at birth, and at ages 30 and 45 has increased gradually in Eastern Europe but less than in the two Western European countries. Additionally, infant mortality has decreased steadily in all countries, except for Czechoslovakia in the 1960s. TABLE I-AGE-STANDARDISED DEATH RATE: ALL CAUSES
1986-1988.
Rate per 100 000
European standard population.
*ICD-9, basic tabulation list 08-14 or equivalents for earlier editions of the ICD Source. World health Statistics Annuals Geneva: World Health Organisation, 1986-1988
Diseases of the circulatory system account for about half of all male deaths and predominantly affect middle aged and elderly men (table II). Overall, mortality rates in the late 1980s in England and Wales and in the FRG are at least 30% lower than those in their Eastern European counterparts. England and Wales and the FRG achieved reductions of 44% and 46%, respectively, in death rates from cerebrovascular disease between 1950-54 and 1987. By contrast, there has been an increase in these rates in the Eastern European nations, although Hungary and the GDR have shown reductions since 1985. Some malignant tumours are thought to be due mainly to environmental factors or to certain lifestyles.3 We have found that the trend in death rates for malignant tumours differs from that for other disorders: rates have increased in all countries-most rapidly for Poland, Czechoslovakia, and Hungary and least of all for the GDR (table ill).
Discussion
Rate per 100 000 European standard population. Source World Health Statistics Annuals. Geneva: World Health 1986-1988.
Organisation,
The 30 year time delay in achieving equivalent mortality rate standards might worsen if the Eastern European countries do not establish policies for health that are as successful as those that have produced a decrease in mortality rates in England and Wales and in the FRG. We realise that our choice of countries has been selective. England and Wales and the FRG are not leaders among Western European nations with respect to reduced mortality rates. Moreover, rates for England and Wales are
460
representative of the UK as a whole: those of Scotland and Northern Ireland are higher than those of England and Wales. We also believe that changes in the ICD during the time studied are not important, in view of the broad diagnostic categories that we have used. Use of mortality rates to assess trends in health is a negative approach but such an approach is measurable. The positive definition of health is less tangible-ie, a sense of vitality and well-being, which is perhaps best described by the French word equilibre.4 This definition involves not only a sense of balance between the physical and mental components of the life of an individual but also a harmony with that person’s surroundings. We do not believe that the pattern of equilibre, if quantifiable, would be substantially different from that portrayed by mortality rates. The poor health record in Eastern Europe since the mid-1960s has been recognised in Hungary; thus, the prevention and treatment of the chronic degenerative diseases of adults are now a priority. From the 1939-45 war to 1964, the decrease in mortality rates in Hungary and many other Eastern European countries was similar to that in Western Europe.6 This period coincided with the post-war reconstruction stage, better nutrition, and the effective treatment of infectious diseases. There are several reasons why this improvement in mortality rates has not been maintained. In Eastern Europe, industrial production and other sectors have taken precedence over health. Indicators such as the percentage of the gross national product (GNP) spent on health only partly support this view7since the salaries of health care professionals in Eastern Europe are low. Neither the availability of doctors nor number of hospital beds per thousand population seems to be inferior in Eastern Europe,8 although we have found that hospitals in England and Wales are more efficient than are those in Czechoslovakia.9 In Eastern Europe, services for children have received priority, and compulsory schemes have always achieved high immunisation rates.7 By contrast, less attention has been given to the health of middle aged and elderly people and there has been a lack of investment in health care technology. Cigarette smoking is especially high in Poland and Hungary as is alcohol consumption in the FRG and Hungary." However, percentage dietary fat is higher in the FRG and in England and Wales than it is in Eastern Europe,12 where supplies of imported fresh fruit and vegetables are limited. Pollution levels from the heavy industry of Eastern Europe may also have contributed to poor health. In 1980, estimated wealth in the UK was$US 7920 per caput (GNP per caput); that of the FRG was much higher. In the same period, the GDR had 91 %, Czechoslovakia 73%, Hungary 53%, and Poland 49% of the wealth of the UK in terms of GNP per caput ($US).13 Thus, lack of wealth to buy appropriate drugs may have been a factor in the failure to reduce death rates from, for example, cerebrovascular disease in Eastern Europe. The emerging democracies in Eastern Europe must strive not only to improve their economic position but also to adopt policies for health promotion. In the early stages of political change, these improvements have not been forthcoming. Fukuyama14 believes that recent political events in Eastern Europe are a triumph of Western liberal democracy. With respect to health, there is a legacy that will challenge new governments and need attention far into the future. not
We thank Mrs Karen Cowley for secretarial assistance and the British Council for a travel grant.
REFERENCES 1. Hill AB. A short textbook of medical statistics. London: Hodder and Stoughton, 1984: 170. 2. Waterhouse J, Correa P, Muir C, Powell J, eds. Cancer incidence in five continents. Vol III. Lyon: IARC, 1976: 456. 3. Doll R, Peto R. The causes of cancer: quantitative estimates of avoidable
risks of cancer in the US today. J Nat Cancer Inst 1981; 66: 1193-1308. 4. Herzlich C. Santé et maladie: analyse d’une représentation sociale. Paris-Lettaye: Mouton, 1969. 5. d’Houtard A, Field MG. The image of health: variations in perception by social class in a French population. Sociology of Health and Illness 1984; 6: 30-60. 6. Józan P. Some features of mortality in Hungary in the post-war period: the third stage of epidemiologic transition in promoting health in Hungary. Report of a group established by the Council of Ministers of the Hungarian People’s Republic. Budapest: Central Statistical Office, 1987. 7. Global strategy for health for all: monitoring 1988-89. Detailed analysis of global indicators. Geneva: World Health Organisation, 1989. (Mimeo). 8. World Health Statistics Annual, 1983. Geneva, World Health Organisation, 1983. 9. Forster DP, Frost CEB. Hospital performance and regional equity. Social Policy and Administration 1984; 18: 247-59. 10. The work of WHO in the European region, 1987. Annual report of the regional director. Copenhagen: World Health Organisation Regional Office for Europe, 1988. 11. Walsh D. Alcohol-related medicosocial problems and their prevention. Public Health in Europe 17. Copenhagen: World Health Organisation Regional Office for Europe, 1982. 12. The work of WHO in the European region, 1986. Annual report of the regional director. Copenhagen: World Health Organisation Regional Office for Europe, 1988. 13. World Bank. World development report, 1982. New York: Oxford University Press, 1982. 14. Fukuyama F. The end of history. The National Interest 1989; Summer: 3-18.
From The Lancet Do heads grow with advancing
age?
Some amusing letters have appeared in a daily contemporary in regard to an alleged steady increase in the size of Mr Gladstone’s head, which, it is said, is rendered manifest by a progressive enlargement in the size of the hat required to cover it. The correspondence exhibits an extraordinary ignorance of wellascertained facts; for, if there is one thing which would be acknowledged by all anatomists and physiologists, it is that the nervous system, like other parts of the body, undergoes atrophy with advancing age-an atrophy that pervades every tissue, and is as apparent in the thinning of the vocal cords that alters the voice to "childish treble", as in the shrunk shanks for which the "youthful hose, well saved, are a world too wide". No reason can be assigned why the brain should escape the general change that affects the digestive and the circulatory systems alike. Its attributes and faculties attain their highest excellence at or before mid-age, and from that time forth exhibit only a steady decline. To compare Mr Gladstone with Napoleon, respecting whom a similar story is related, is absurd. The head of Napoleon may have grown between twenty and forty-five, because his brain was greatly exercised during the last ten years of the past century and the first ten of the present; but no calls have been made on Mr Gladstone of late years all comparable to the strain on the mental and bodily powers of the French Emperor during that eventful period. The ossification of the sutures of the cranium practically prevents increase in the volume of the brain in advanced life; and, even granting some slight increase, such increase would be compensated for by the attenuation of the cranial bones which is well known to occur in old age. A change in form there may be, but none in size. (29 March 1890) at
