Epidemiological transition: a historical analysis of immigration patterns by country of origin (1861-1986) related to circulatory system diseases and all-cause mortality in twentieth-century Australia.

BACKGROUND AND OBJECTIVES: Circulatory system disease (CSD) patterns vary over time and between countries, related to lifestyle risk factors, associated in turn with socioeconomic circumstances. Current global CSD epidemics in developing economies are similar in scale to those observed previously in the USA and Australasia. Australia exhibits an important macroeconomic phenomenon as a rapidly transitioning economy with high immigration throughout the nineteenth and twentieth centuries. We wished to examine how that historical immigration related to CSD patterns subsequently. METHODS AND SETTING: We provide a novel empirical analysis employing census-derived place of birth by age bracket and sex from 1891 to 1986, in order to map patterns of immigration against CSD mortality rates from 1907 onwards. Age-specific generalised additive models for both CSD mortality in the general population, and all-cause mortality for the foreign-born (FB) only, from 1910 to 1980 were also devised for both males and females. RESULTS: The percentage of FB fell from 32% in 1891 to 9.8% in 1947. Rates of CSD rose consistently, particularly from the 1940s onwards, peaked in the 1960s, then declined sharply in the 1980s and showed a strong period effect across age groups and genders. The main effects of age and census year and their interaction were highly statistically significant for CSD mortality for males (p<0.001, each term) and for females (p<0.001, each term). The main effect of age and year were statistically significant for all-cause mortality minus net migration rates for the FB females (each p<0.001), and for FB males, age (p<0.001) was significant. CONCLUSIONS: We argue our empirical calculations, supported by historical and socioepidemiological evidence, employing immigration patterns as a proxy for epidemiological transition, affirm the life course hypothesis that both early life circumstances and later life lifestyle drive CSD patterns.

A mandatory intercalated degree programme: revitalising and enhancing academic and evidence-based medicine.

BACKGROUND: Recruitment of medical graduates to research careers is declining. Expansion of medical knowledge necessitates all graduates be equipped to critically evaluate new information. To address these challenges, a mandatory intercalated degree programme was introduced as part of curriculum reform. AIMS: To review the place on intercalated degrees, the methods available for learning about research and to analyse experience with a new university programme focusing on research. METHODS: A literature review followed by the analysis of experience with eight cohorts of students who had completed the new programme. RESULTS: A total of 1599 students completed the programme. Laboratory-based research was the most common choice followed by clinical research, population health, epidemiology, medical humanities and mental health. Also, 93% of students spent over 75% of their time undertaking research. Sixty-three students published their research, half as first authors. Students and coordinators support the programme. Learning about research during the postgraduate phase is variable and frequently left to individual choice. CONCLUSION: Intercalating an additional degree focusing on research can achieve a number of learning objectives but demands a level of maturity, autonomy and preparedness, not uniformly present in students undertaking a mandatory intercalated programme. A more realistic goal is the development of 'research-mindedness' amongst all students.

A health transition: birth weights, households and survival in an Australian working-class population sample born 1857-1900.

There is increasing interest in life course epidemiology. In this article we investigated the relationship between characteristics at birth and survival and year of birth and survival. We have detailed information about birth characteristics and cause of death for 8584 subjects from a cohort of 16,272 registered live births to European Australians in a charity hospital in Melbourne between 1857 and 1900. Women giving birth at the hospital were among the poorest in Melbourne, with almost half unmarried. The adult death certificates of the subjects were traced until 1985. We found that infant mortality was substantially higher in babies who were illegitimate, firstborn, had younger mothers, a birth weight <6lb or were a preterm birth. These factors had a weaker association with child mortality and were not associated with adult survival time. Infant mortality was substantially lower in the cohort born 1891-1900 (36%) than previously (58%), a major improvement not seen for child mortality or adult lifespan. Likely reasons for this improvement are the introduction of antisepsis in maternity wards, enforced registration and police supervision of persons other than their mother who cared for babies, strictly monitored feeding practices and a mandatory autopsy and coronial enquiry for such babies who died. We conclude that this is an early example of a successful public health intervention.

Birthweight and coronary heart disease in a cohort born 1857-1900 in Melbourne, Australia.

BACKGROUND: The widely observed association between birth size and risk of later coronary heart disease (CHD) has not been examined in an impoverished pre-20th century birth cohort. METHODS: Birth weights and maternal characteristics, for births between 1857 and 1900 in a charity hospital, were recorded from preserved ledgers. Names were linked to death certificates to determine age and cause of death. Death with CHD was coded using specific criteria, and survival analysis methods were used to relate risk of CHD to birth weight, allowing for competing causes of death and adjusting for potentially confounding maternal factors. RESULTS: Death certificates were traced for 8,584 (53%) of 16,272 registered live-births. Survival analyses were confined to 2,938 subjects (1,572 male, 1,366 female) who survived beyond age 40, since none of the 486 CHD cases was recorded earlier. CHD risk increased with time, but there was no evidence that it was related to birth weight, in men or women. CONCLUSIONS: We did not replicate findings in more recent cohorts. This may represent a true lack of association in a historical cohort who we believe remained impoverished through their early life. However, we acknowledge the strong possibility of misclassification of cause of death by the person filling in the death certificate and/or our coding criteria, and temporal change in diagnostic criteria for CHD. We cannot exclude the possibility that low birth weight babies 'programmed' in utero for later CHD were more likely to die in infancy, in this cohort with a high infant mortality rate.

Mothers' health and babies' weights: the biology of poverty at the Melbourne Lying-in Hospital, 1857-83.

Birth weight remains a major focus of medical research into the relationship between pre-natal growth and life course health, and historians have used mean birth weight to assess women's standard of living. However, there are intrinsic difficulties in inferring maternal health and nutritional status from birth weight, and some of the known data sets produce puzzling results. One rich data set comes from the Melbourne Lying-in Hospital, 1857-83, and the article discusses the complex institutional, social, and economic causes that may underlie its apparently counter-intuitive anthropometric results. This data set reveals the biological effects differential social conditions can inflict, even within an otherwise affluent society.

Trends in birthweight between 1857 and 1883, in Melbourne, Australia.

Epidemiological evidence suggesting that subjects with lower birthweight have an increased risk of adult cardiovascular disease has led to increased interest in factors influencing birthweight. We have documented large changes in mean birthweight over a relatively short historical period from 1857 to 1883. Mean birthweight declined progressively from 7.9 lb (3.6 kg) in the period 1857-63 to 6.9 lb (3.1 kg) in 1874-78, then rose to 7.5 lb (3.4 kg) for the period 1879-83. We found the expected relationships between infant birthweight and maternal age, parity and marital status, and identified an association between birthweight and maternal country of birth. However, neither temporal changes in recorded maternal characteristics nor external economic indicators for the colony explained the trends in birthweight. From historical information, we believe that the explanation for our findings lies primarily with the increasing poverty, disease, mental illness, alcohol abuse and criminal activity among women admitted to the hospital between 1860 and the mid-1870s, and improvements from around 1880, when old housing was replaced and prostitutes were moved out of the area. Our findings highlight the difficulty of capturing lifestyle factors using routinely collected data, and the need for historical expertise when examining historical data.