Rose’s strategy of preventive medicine
Rose’s strategy of preventive medicine
复制标题
罗斯的预防医学策略
DOI：
10.1007/s10654-009-9349-4
复制
发表时间：
2009
影响因子：
13.6
通讯作者：
P. Elliott
中科院分区：
文献类型：
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作者：
P. Elliott
杰弗里·罗斯的这本开创性著作的新版本非常受欢迎。伴随着凯-蒂-克恩和迈克尔-马莫特的评论，它正确地离开了罗斯的原始文本。15年来，他的文字翻译得有多好？答案确实很好。正如Kemper和Marmot在他们的评论中所说明的那样，大多数疾病和病因在人口中不断分布，大规模疾病需要大规模（全人口）解决方案的基本前提在今天和大约15年前一样正确。像Kestel和Marmot一样，我有幸成为杰弗里的流行病学学生之一，今天重读这本书（推荐）他明智的话语和清晰而敏锐的思维从页面上跳下来，就像参加他的一个著名讲座一样。在完成我的M后不久。当时，我是伦敦卫生与热带医学学院的流行病学硕士，杰弗里是该学院的教授和系主任。我对他说，流行病学真的很难（我记得当时我正在处理测量误差和重复测量的变幻莫测，为INTERSALT研究做准备）。他看着我，显然很惊讶，回答说，恰恰相反，流行病学真的很容易。杰弗里擅长使困难的概念容易理解，这是这本书的一大优点。正如杰弗里在书中所承认的那样，他关于人口预防方法的想法是在20世纪50年代皮克林和普拉特关于高血压性质的著名辩论中形成的。皮克林认为高血压本身不是一种疾病，而只是血压连续分布的一端，这在当时是革命性的。正如罗斯用他自己从白厅研究中获得的数据所说明的那样，在整个血压范围内，与血压升高相关的中风和冠心病的风险不断增加，并且不仅限于那些血压最高的人。因此，解决人口血压问题需要一个人口范围内，而不仅仅是一个“高风险”的方法（即治疗高血压患者）。他举了一个例子，减少人群中的盐摄入量是降低人群血压水平的一种低成本和有效的手段。15年后，这已经成为英国政府的政策，通过食品标准局的公共卫生运动和食品行业的自愿努力来减少制造食品中的钠含量（以及使用食品标签，这是杰弗里的另一个行动呼吁）。罗斯通过心血管疾病（血清胆固醇），心理健康和骨骼健康等其他例子将他的全民概念扩展到预防。在每一个案例中，他都展示了他的论文的核心概念：大量的人，每个人都有很小的额外疾病风险，在人口水平上产生的病例比少数高风险个体要多得多（即使他们从预防措施中获益最多）。同样，大规模疾病需要大规模解决方案。以酒精为例，他令人信服地认为，问题饮酒者的普遍性反映了社会中饮酒行为的规范-人口平均数预测了“越轨者”的数量-并且Kelvis和Marmot在他们的评论中显示出同样适用于问题赌博的证据。
This new edition of Geoffrey Rose’s seminal book is very welcome. Accompanied by a commentary by Kay-Tee Khaw and Michael Marmot, it rightly leaves Rose’s original text untouched. How well does his text translate more than 15 years on? The answer is very well indeed. As Khaw and Marmot illustrate in their commentary, the basic premise that most diseases and causes are continuously distributed in the population, and that mass diseases require mass (population-wide) solutions, is as true today as it was 15 or so years ago. Like Khaw and Marmot, I was privileged to be one of Geoffrey’s students in epidemiology, and re-reading the book today (at one sitting, recommended) his wise words and clear and razor-sharp thinking jump off the page, as if attending one of his renowned lectures. Not long after completing my M. Sc. in epidemiology at the London School of Hygiene and Tropical Medicine, where Geoffrey was professor and head of department, I remarked to him that epidemiology was really quite difficult (I recall I was dealing with the vagaries of measurement error and repeated measurements, at the time, in preparation for the INTERSALT study). He looked at me clearly surprised and replied that on the contrary epidemiology was really very easy. Geoffrey excelled at making difficult concepts readily accessible, and this is one of the great strengths of this book. As Geoffrey acknowledges in the book, his ideas on the population approach to prevention took shape during the famous debate between Pickering and Platt in the 1950s on the nature of hypertension. Pickering’s idea that hypertension was not in itself a disease, but merely one end of a continuous distribution of blood pressure, was revolutionary at the time. As Rose illustrates with his own data from the Whitehall study, the risk of stroke and coronary heart disease associated with raised blood pressure increases continually across the whole blood pressure range, and is not restricted to those with the highest pressures. Thus addressing the population blood pressure problem requires a population-wide and not just a ‘high-risk’approach (ie, treating people with hypertension). He gives the example of reducing salt intake in the population as a low-cost and effective means of reducing population blood pressure levels. Over 15 years later, this is now government policy in the UK, both through a public health campaign by the Food Standards Agency and voluntary efforts of the food industry to reduce the amount of sodium in manufactured foods (together with use of food labelling, another of Geoffrey’s calls to action). Rose extends his population-wide concept to prevention through other examples in cardiovascular disease (serum cholesterol), mental health and bone health among others. In each he demonstrates the core concept of his thesis: large numbers of people, each at small excess risk of disease, produce many more cases at the population level than a few individuals at high risk (even though individually they have most to gain from a preventive measure). Again, mass diseases require mass solutions. Using alcohol as an example, he argues cogently that the prevalence of problem drinkers reflects the norms of drinking behaviour in a society—the population mean predicts the number of ‘deviants’—and Khaw and Marmot in their commentary show evidence that the same is also true for problem gambling.