Bile duct stones and laparoscopic cholecystectomy
Number (percentage) of deaths from various causes, England and Wales, 1989 Men
All ages All causesofdeath Cardiovascular disease (ICD 390-459) Ischaemic heart disease (ICD 410-414) Acute myocardial infarction (ICD 410) Heart failure (ICD428)
281 127 82 51 2
290(100) 435 (45-3) 847 (29-5) 344 (18-3) 252 (0-8)
statistics and could be made key areas only if specific monitoring was taking place. The epidemiology of chronic heart failure is relatively underdeveloped because of past problems with diagnostic criteria. There is a need for cross sectional and longitudinal population studies using recent techniques such as echocardiography, a need precipitated by the new treatments McMurray and Dargie list. My review was concerned more with primary prevention of coronary heart disease than treatment of advanced disease.3 There are many aspects of the treatment of advanced disease, such as fibrinolytic treatment, rehabilitation and secondary prevention, resuscitation, revascularisation, and heart failure, in which improved diagnosis or management, or both, should exploit proved therapeutic advances; the extent to which all of these are affordable will be determined in some degree by the success of prevention. HUGH TUNSTALL-PEDOE Cardiovascular Epidemiology Unit, University of Dundee, Ninewells Hospital and Medical School, Dundee DDI 9SY I Secretary of State for Health. The health of the nation. London: HMSO, 1991. (Cm 1523.) 2 Office of Population Censuses and Surveys. Mortality statistics 1989 by cause for England and Wales. London: HMSO, 1991. (DH2 No 16.) 3 Tunstall-Pedoe H. Coronary heart disease. BM3 1991;303: 701-4. (21 September.)
Health and the environment: population SIR,-In her article on population in the series on health and the environment Alison Walker commends China's programme to control the population.' Although she describes incentives to reward those adhering to the policy of one child families, she omits to mention the severe penalties imposed on those having more than one child. These range from crippling fines to intolerable peer group pressure-for example, if a woman refuses an abortion she is threatened that her work colleagues will suffer by losing their bonuses. There is also an enforced abortion policy, which has been pursued with varying vigour over the years. Women pregnant with a second or subsequent child can be arrested, held in cutody, and indoctrinated daily until they consent to an abortion. In some provinces the officials are not so scrupulous and arrest the woman and forcibly abort the fetus, even though she may not consent. Women have to obtain "conception certificates," which are valid for a year. If a woman is brought into hospital in labour and is unable to produce her certificate some doctors deem that she is delivering an "illegal child." These doctors, while the baby's head is still descending through the birth canal, then inject either alcohol or formalin through the fontanelle. In rural areas, where boys still have an important cultural value as it is the man who cares for his aged parents, it is not uncommon for a bucket of water to be available at the bedside during a delivery. The midwife is told that should the firstborn be a girl she should use the bucket before the child can take its first breath. I hardly believed such stories until I heard them BMJ
VOLUME 303
14 DECEMBER 1991
Women
Number (percentage) of deaths from various causes, England and Wales, 1989 Men
All ages All causesofdeath Cardiovascular disease (ICD 390-459) Ischaemic heart disease (ICD 410-414) Acute myocardial infarction (ICD 410) Heart failure (ICD428)
281 127 82 51 2
290(100) 435 (45-3) 847 (29-5) 344 (18-3) 252 (0-8)
statistics and could be made key areas only if specific monitoring was taking place. The epidemiology of chronic heart failure is relatively underdeveloped because of past problems with diagnostic criteria. There is a need for cross sectional and longitudinal population studies using recent techniques such as echocardiography, a need precipitated by the new treatments McMurray and Dargie list. My review was concerned more with primary prevention of coronary heart disease than treatment of advanced disease.3 There are many aspects of the treatment of advanced disease, such as fibrinolytic treatment, rehabilitation and secondary prevention, resuscitation, revascularisation, and heart failure, in which improved diagnosis or management, or both, should exploit proved therapeutic advances; the extent to which all of these are affordable will be determined in some degree by the success of prevention. HUGH TUNSTALL-PEDOE Cardiovascular Epidemiology Unit, University of Dundee, Ninewells Hospital and Medical School, Dundee DDI 9SY I Secretary of State for Health. The health of the nation. London: HMSO, 1991. (Cm 1523.) 2 Office of Population Censuses and Surveys. Mortality statistics 1989 by cause for England and Wales. London: HMSO, 1991. (DH2 No 16.) 3 Tunstall-Pedoe H. Coronary heart disease. BM3 1991;303: 701-4. (21 September.)
Health and the environment: population SIR,-In her article on population in the series on health and the environment Alison Walker commends China's programme to control the population.' Although she describes incentives to reward those adhering to the policy of one child families, she omits to mention the severe penalties imposed on those having more than one child. These range from crippling fines to intolerable peer group pressure-for example, if a woman refuses an abortion she is threatened that her work colleagues will suffer by losing their bonuses. There is also an enforced abortion policy, which has been pursued with varying vigour over the years. Women pregnant with a second or subsequent child can be arrested, held in cutody, and indoctrinated daily until they consent to an abortion. In some provinces the officials are not so scrupulous and arrest the woman and forcibly abort the fetus, even though she may not consent. Women have to obtain "conception certificates," which are valid for a year. If a woman is brought into hospital in labour and is unable to produce her certificate some doctors deem that she is delivering an "illegal child." These doctors, while the baby's head is still descending through the birth canal, then inject either alcohol or formalin through the fontanelle. In rural areas, where boys still have an important cultural value as it is the man who cares for his aged parents, it is not uncommon for a bucket of water to be available at the bedside during a delivery. The midwife is told that should the firstborn be a girl she should use the bucket before the child can take its first breath. I hardly believed such stories until I heard them BMJ
VOLUME 303
14 DECEMBER 1991
Women
