Lecture 17 : The Epidemiological Transition (1)

Overview CHANGES IN CAUSE OF DEATH POSSIBLE EXPLANATIONS 1. Changes In Host-Agent Relationship 2. Immunisation And Therapy

Changes In Cause Of Death

Although Sweden and France have longer records on the numbers of deaths, Britain has the longest record of the cause of death (1838). McKeown estimated the contribution of different diseases to the improvement in life expectancy 1848-54 to 1971. of all improvements were directly due to a reduction in deaths from infectious diseases. However, many of the remaining were also probably due to reductions in infectious diseases.

Contributions To Improvements
AIRBORNE INFECTIOUS DISEASES
Tuberculosis Bronchitis, pneumonia, influenza Scarlet fever, diphtheria Measles Smallpox Cholera, diarrhoea, dysentry Typhoid (+typhus) Non-respiratory tuberculosis 17.5% 9.9% 6.2% 2.1% 1.6%

40.3%

WATERBORNE / FOODBORNE INFECTIONS

10.8% 6.0% 4.6%

21.4%

OTHER INFECTIONS
Convulsions and teething 8.0%

12.6% 25.6%
8.7% 6.2% 8.9%

OTHER CAUSES
Old age Prematurity, immaturity, infancy Other

Possible Reasons For Improvements

Overall about 5/6 of improvement was probably due to decline in infections. Why did they decline? McKeown suggested 4 possible explanations: 1. Changes In Host-Agent Relationship 2. Immunisation And Therapy 3. Reduced Exposure To Infections 4. Increased Resistance To Infections

1. Changes In The Host-Agent Relationship

Diseases can spontanously become more virulent or less virulent for no obvious reason. The decline in deaths from scarlet fever may be an example. May possibly have been a factor in the decline of diphtheria. Overall, such changes are probably only a minor factor.

2. Immunisation And Therapy

The late 19th and 20th century saw major advances in the ability of the medical profession to treat infectious diseases. McKeown suggests the impact of these advances was less important than is generally assumed. Diphtheria, polio and smallpox provide examples of where medical interventions did make an impact.

Airborne Diseases
The evidence for most airborne diseases suggest most of the improvement occurred before effective medical treatment: e.g. Tuberculosis Measles Whooping Cough Pneumonia Scarlet Fever

Water- And Food-Borne Diseases

Much the same conclusions apply to water- and foodborne diseases: e.g. Cholera Diarrhoeal diseases Non-repiratory tuberculosis Typhoid

Other Infections
Evidence suggests similar conclusions for: Typhus Tetanus However, medical science would appear justified in claiming credit for reduced deaths from: Puerperal fever

US Evidence
McKinley and McKinley reported similar findings for the USA. Medical science can claim credit for at most 20 per cent of the increase in life expectancy in the US in the 20th century. Medical science can claim virtually no credit for improvements in the 19th century.

Summary
Therapeutic medicine has played a useful role in the control of infectious diseases, but it did not really begin until the introduction of sulphonamides and antibiotics around 1935. By that time mortality from most infections had already fallen to a small fraction of their level in the midnineteenth century. McKeown claims that even after the introduction of chemotherapy, with the important exception of tuberculosis, it is probably safe to conclude that immunization and therapy were not the main influences on the further decline of the death rate.