2 Public health: aims and advances

2.1 Central to our action programme for improving health, particularly for the most disadvantaged, is tackling these killers - cancer, coronary heart disease and stroke, accidents and mental ill-health. Not everyone who is touched by them dies. Many recover, and go on to resume normal lives. But the death rate from our four priority areas of ill-health is unacceptably high. And for those who do not die, the impact of long-term illness is dramatic - for them and for the people around them. We are determined to see the impact of these key killers reduced.

'we stand on the threshold of the 21st Century'

2.2 These four priority areas stand out increasingly starkly from the map showing the progress made in recent times in combating disease and illness. As we stand on the threshold of the 21st Century we can look back over more than a thousand years of struggle against the killer diseases of the past which brought early death, disease and misery to millions of people in cities and countries around the world:

• a third of the population of Europe and Asia lost to bubonic plague in the 14th Century
• the epidemic of cholera which descended on Victorian England leaving tens of thousands dead in its wake mainly in the towns and cities of the industrial revolution
• childbirth often not survived by mother or child.

2.3 We can take heart from the advances which have been made. Many of the infectious diseases which caused such devastation in the past - cholera, diphtheria, polio - have been brought under control. If we are vigilant they should not return.

Fig 2.1 A major decline in death from all infectious diseases in the 20th century

'dramatic improvements in health will continue'

2.4 The dramatic improvements in health seen during the present century will continue into the next. We now live longer and healthier lives. Survival into old age is commonplace. Life expectancy is currently 80 for women and 75 for men compared with 48 and 44 in 1900.

Fig 2.2 Major improvements in expectation of life after centuries of early death

2.5 Death in childbirth is now rare. Infant deaths in the first year of life have fallen from more than 100 in every 1,000 to only 6. Children's funerals, such a feature of even the recent past, are now an infrequent sight.

Fig 2.3 Major fall in infant deaths in the 20th century

Fig 2.4 Age at death at the start and end of the 20th century

Today's problems

2.6 But against this background of overall improvement and optimism, new health problems have emerged and others have increased in importance. Formidable challenges remain. We may have won many battles against deadly infectious diseases of the past, but some, like tuberculosis, are rising again. And new threats - like AIDS and variant Creutzfeldt-Jakob disease - have emerged, causing human tragedies.

'new health problems have emerged'

2.7 What is more, we are experiencing epidemics of health problems which were less prominent in the past. Cancer, coronary heart disease and stroke are our modern-day killer diseases. Together with accidental injury and mental illness they are prominent features of the health profile of the population of our country in the late 1990s.

Fig 2.5 Selected causes of death at the start , middle and end of this century

2.8 Cancer

Years of life lost

• at current rates about one in four (25 per cent) of us will die from cancer, which is responsible for 127,000 deaths every year
• a third of all cancer deaths, and between 80 and 90 per cent of deaths from lung cancer, are caused by smoking
• one fifth of cancer deaths in women are due to breast cancer

• approximately 200,000 cases of cancer are diagnosed in England each year
• more than one third of us will suffer from cancer during our lifetime
• about one fifth of cancer cases are cancer of the lung
• nearly one third of cancer cases in women are breast cancer

Health disadvantage

• 40 per cent of unskilled men smoke compared with 12 per cent of men in professional jobs
• Bangladeshi women are less than half as likely as other women in this country to come forward for cervical screening

Counting the cost

• cancer accounts for as much as £1 billion each year of NHS hospital expenditure
• by achieving our target there would be up to 100,000 fewer deaths from this cause over the period to 2010 - more than 60,000 through primary prevention and approximately 20,000 each through better screening and treatment

2.9 Coronary heart disease and stroke

Years of life lost

• coronary heart disease is one of the biggest single causes of death - causing almost 115,000 deaths each year in England
• about a quarter of people who suffer a heart attack die before they are admitted to hospital
• stroke is one of the main causes of death - it caused over 54,000 deaths in 1997, almost 12,500 in people under the age of 75 years.
• coronary heart disease, stroke and related diseases combined were responsible for 41 per cent of all deaths in 1997
• coronary heart disease is responsible for a total loss each year of over 1.25 million years of life before the age of 75 years in England

• coronary heart disease is an important cause of disability - one in every twenty people reporting serious disability identifies coronary heart disease as a cause
• stroke is also one of the leading causes of disability - one person in every 14 of those reporting serious disability identifies stroke as a cause
• coronary heart disease accounts for 2 million hospital bed-days per year
• stroke accounts for another 2 million hospital bed-days per year

Health disadvantage

• the death rate from coronary heart disease in people aged under 65 years is almost three times higher in Manchester than in Kingston and Richmond
• death rates for coronary heart disease for those born in the Indian sub-continent are 38 per cent higher for men and 43 per cent higher for women than rates for the country as a whole
• the death rate from coronary heart disease is now 3 times higher among unskilled men than among professionals and the gap has widened sharply in the last 20 years.
• stroke death rates in people born in the Caribbean and the Indian sub-continent are one and a half to two and a half times higher than for people born in this country - a differential that has persisted from the late 1970s

  'the death rate from coronary heart disease is now 3
  times higher among unskilled men'

Counting the cost

• coronary heart disease accounts for more than 2¹/_² per cent of NHS hospital expenditure and almost 2 per cent of NHS primary care expenditure
• stroke accounts for more than 4 per cent of NHS expenditure
• stroke is the second most important cause of expenditure on community health and social care for adults - accounting for over 7 per cent of such expenditure

2.10 Accidents

Years of life lost

• accidents claim over 10,000 lives per year
• nearly one third of deaths in 10-14 year olds are from accidental injury
• two thirds of accidental deaths among 15-24 year olds are due to road accidents
• every year more than 3,000 people aged 65 years and over die from falls

Years of health lost

• in one recent year there were 110,000 episodes of care in NHS hospitals solely because of unintentional injury in children aged under 15 years
• about 14 per cent of children consulted their general practitioner during the course of a single year about problems related to accidents and injury

Health disadvantage

• children up to the age of 15 years from unskilled families are 5 times more likely to die from unintentional injury than those from professional families
• children up to age 15 years from unskilled families are 15 times more likely to die in a fire in the home than those from professional families
• the rates of fatal accidents for 15-24 year-olds are higher in rural than in urban areas.

Counting the cost

• the NHS spends an estimated £1.6 billion every year to treat injury
• accidents in the home cost the country almost £30 billion a year
• the total value to the country of avoiding a single road accident death is estimated at almost £900,000

2.11 Mental health

Years of life lost

• suicide and undetermined injury cause 4,500 deaths every year
• suicide accounts for 400,000 years of life lost before age 75 years
• suicide is the leading cause of death among men aged 15-24 years and the second most common cause of death among people aged under 35 years
• over 95 per cent of those who commit suicide had been suffering from mental illness before their death
• 10-15 per cent of people with severe mental illness kill themselves
• people with mental illness are also at increased risk of dying early from respiratory illness, cancer and coronary heart disease

• 16 per cent of the adult population suffers from a common mental disorder such as depression or anxiety
• 12 per cent of children and adolescents suffer from a conduct or emotional disorder
• 30 per cent of people over 85 years suffer from dementia
• four people in every 1,000 suffer from a psychotic disorder such as schizophrenia

Health disadvantage

• women are more likely than men to seek help for a mental health problem
• suicide is three times more common in men than in women
• women living in England born in India and East Africa have 40 per cent higher suicide rates than those born here
• men in unskilled occupations are four times more likely to commit suicide than those in professional work

Counting the cost

• treating mental illness costs the NHS and social services an estimated £7.5 billion every year
• people with mental illness have increased sickness absence, change jobs more often and are more likely to be unemployed

More years of health

2.12 Combating cancer, coronary heart disease and stroke, accidents and mental ill-health will help reduce needless early deaths, reduce suffering and allow people to live longer lives.

Fig 2.6 Deaths before age 75 years in England annually: a major contribution from the four priority areas

2.13 But living longer lives is not enough. People want to enjoy their extra years as healthy active years. At present, men's average life expectancy of some 75 years will on average include 15 years of longstanding illness or disability. For women the picture is similar: they will spend 17 years out of 80 in some degree of ill-health. We want to see as many as possible of those years of illness turned into extra years of healthy active life.

Fig 2.7 Unhealthy years at the end of life

2.14 To do all that, we need to tackle the complex causes of ill-health - causes in individuals' own lives, and in wider community issues. The two go hand in hand in our new approach to better health.

We welcome your comments on this site. Prepared 5 July 1999