Brexit: the decision of a divided countryBMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i3697 (Published 06 July 2016) Cite this as: BMJ 2016;354:i3697
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Gee Yen Shin explains why health professionals, including all four chief medical officers of the UK, have so far largely ignored the huge rise in mortality in the UK that occurred in 2015. They appear to have accepted his suggestion that “pathogens like influenza virus were the major contributor to the rise in numbers of deaths in the year to June 2015” . However, if this were the case, we need to know why the rise in deaths was spread out over so many months – unlike all previous influenza epidemics and why the old were hit the hardest.
The most recent severe influenza outbreaks in England and Wales began in late 1969, 1989, 1993 and 1999. Each resulted in a rise in mortality over the course of a few weeks and each mainly affected the people aged under 65 . The increases in mortality in 2012, 2013, and especially in 2015, lasted for many months, and resulted in many times more deaths than any of those previous influenza outbreaks. Furthermore the recent increases in deaths did not spread geographically as flu outbreaks do. There are many other reasons to doubt that influenza was the major contributor. For instance, since 2010, there has been a rapid and cumulative national decline in self-reported health, which had been improving before then. By 2014 only 57.8% of the UK population were somewhat, mostly or completely satisfied with their health .
In 2015 the UK suffered one of the largest rises in overall mortality measured since reliable annual records were first collected of the population in the late 1830s . The rise in mortality in 2015 was larger than any rise associated with influenza since at least 1951 . However, the rise in 2015 does not have the characteristics of previous influenza epidemics, nor has influenza been demonstrated to have been responsible for more than a tiny proportion of the increases in deaths in 2012, 2013 or 2015. In contrast, austerity has been linked to the rising old age mortality  and its timing coincides with the population reporting worse health and the rises in mortality over several years. Future analysis may well also show the connections to be complex. Rising austerity among the young, including care home workers, could be associated with rising mortality in the old. Future analysis should also consider how many people would have lived healthier longer lives had the mortality improvements enjoyed up until 2010 continued. Influenza is an easy scapegoat.
In answer to Gee Yen Shin’s other points, he may not know that voter registration in the UK has been made far more difficult due to legislative changes since 2010; resulting in fewer eligible younger adults being able to vote. He may not know that the UK spends less on health per person than any other Western European country other than Greece and Italy. If he actually studied the references I gave in my original article he can learn more on these issues. However, I would suggest it is more urgent that he considers the references in this reply, and decides whether he wishes to stand by his statement that “pathogens like influenza virus were the major contributor to the rise in numbers of deaths in the year to June 2015”. What is the evidence for this claim?
In 2014, Gee Yen Shin, as “a civil servant writing in support of this Government immigration policy” suggested that wealthy foreigners travelling to the UK to avail themselves of private healthcare were beneficial to the UK while providing free health care to immigrants no longer entitled to it was detrimental . This was in response to an article explaining the benefits of universal free state health care . Gee Yin Shin’s views on immigration and the supposed benefits of private health are in the public domain. However, what we need to know is the extent to which his views on influenza have influenced his employer’s early statements on why so many people have died. What evidence, if any, did he provide to his employer to back up his assertions that the major contribution to the mortality rise in the UK was “pathogens like influenza virus”? His views may be his own but they will have influenced the work he has carried out for his employer.
The last time there was a significant influenza outbreak in the UK geographers mapped it to show how it spread . The maps I have seen of the rise in mortality in 2015 bare no resemblance to how an infectious disease normally spreads. As the main causes of death were Alzheimer’s and dementia this is hardly surprising. Of course we need to know why so many people suffering from those conditions died earlier in 2015. If it had been undetected flu there would have been a spatial pattern. Flu also tends not to have the highest relative effect on the very old as even small numbers of additional younger people dying have a bigger relative effect and that is what has happened in every other recorded flu outbreak.
Competing Interests: Danny Dorling is a member of Public Health England’s Mortality Surveillance Advisory Group, which last met on July 6th 2016 and discussed the underlying excess mortality in 2015, how it may be related to issues of unsatisfactory secondary care, and that we do not understand why flu could have been related to so many deaths.
 Shin, G.Y. (2016) Rapid Response to Brexit: The decision of a divided country, BMJ, http://www.bmj.com/content/354/bmj.i3697/rapid-responses
 See Figure 2 of Fleming, D.M. and Elliot, A.J. (2008) Lessons from 40 years’ surveillance of influenza in England and Wales, Epidemiol. Infect., 136, 866–875. doi:10.1017/S0950268807009910
 Dorling, D. (2016) Austerity, Rapidly Worsening Public Health across the UK, and Brexit, Political Insight Blog, Political Studies Association, July 11th, https://www.psa.ac.uk/insight-plus/blog/austerity-rapidly-worsening-publ...
 ONS (2015) England and Wales Population Estimates 1838 to 2014: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigrati...
 ONS (2015) Vital Statistics: Population and Health Reference Tables: http://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigratio...
 Loopstra, R.,McKee, M., Katikireddi, S.V., Taylor-Robinson, D., Barr, B. and Stuckler, D. (2016) Austerity and old-age mortality in England: a longitudinal cross-local area analysis, 2007–2013, J R Soc Med.,109(3): 109–116, doi: 10.1177/0141076816632215
 Shin, G.Y. (2014) We must recognise the actual and opportunity costs of treating immigrants in the NHS, J R Soc Med., 107, 12, 466, http://jrs.sagepub.com/content/107/12/466.1.full
 Steele S, Stuckler D, McKee M, Pollock A. The Immigration Bill: extending charging regimes and scapegoating the vulnerable will pose risks to public health. J R Soc Med 2014; 107: 132–133, doi: 10.1177/0141076814526132
 Hunter J.M. and Young, J.C. (1971) Diffusion of Influenza in England and Wales, Annals of the Association of American Geographers, 61, 4, 637-653.
These two graphs show the change in mortality rate for people dying between July 2014 and June 2015, as compared to the rate for the previous 12 months. Data is for all of England and Wales from the ONS mid year estimates published on June 23rd 2016. Change is measured as the percent point change in the rate of death in the first graph and as the relative change in death rates in the second graph.
Competing interests: Competing Interests: Danny Dorling is a member of Public Health England’s Mortality Surveillance Advisory Group, which last met on July 6th 2016 and discussed the underlying excess mortality in 2015, how it may be related to issues of unsatisfactory secondary care, and that we do not understand why flu could have been related to so many deaths.
Dorling’s editorial on the EU referendum and austerity makes a number of assertions which require further critical examination.
He appears to question the validity of the EU referendum by pointing out the numbers of registered voters who did not vote as well as logistical difficulties faced by some voters e.g. those moving house around the EU referendum date. In our democracy, as Dorling surely knows, voters have the right to vote but also the right not to. This principle applies to other rights e.g. we have the right to practice religion & also the right to practice none.
As for those who moved house or travelled on June 23rd 2016, the option of a postal vote was open to them & few if any Britons can reasonably claim that they were unaware of the EU Referendum.
I hope Dorling and his supporters accept that voter turnout for the Referendum was actually relatively high & at 72.2%, it was the highest turnout for any national ballot since the 1992 General Election[2,3].
In relation to recent increases in mortality rates in England and Wales, Dorling is right to point out an increase in deaths between the year to June 2014 & the year up to June 2015. He apportions some of the blame for this to austerity-related cuts to health services. However, he did not report the linked Office of National Statistics (ONS) finding that numbers of deaths fell after June 2015 for the rest of the year back to long-term averages. If, as Dorling claims, the increased numbers of deaths to June 2015 was due to austerity, how can one explain the decline in numbers of deaths in the second half of 2015, since to the best of my knowledge, austerity continued beyond June?
As the same ONS report states, respiratory infectious diseases like pneumonia and influenza are probably under-reported on death certificates & therefore an underestimated cause of death.
Furthermore, one should not ignore the ONS finding that:
“The peak in influenza admissions to intensive care occurred in January (2015), at the same time as the peak increase in deaths. “
Given the above, it is reasonable to conclude that pathogens like influenza virus were the major contributor to the rise in numbers of deaths in the year to June 2015, rather than “austerity”.
The final point worth challenging is Dorling’s statement that “Almost all other European countries… spend more on health” (than the UK). According to the most recent available ONS data, as highlighted by the King’s Fund, eight European countries spend more on health as a percentage of GDP than the UK. However, at least fifteen European countries spend less than the UK on health. I am unclear as to how this data supports the Dorling’s claim that the UK underspends on health relative to “almost all other” European peers.
Despite disagreeing with most of what Dorling says in his editorial, I commend Dorling for inspiring this BMJ reader to study the references and statistics behind his debatable conclusions; it was an educational experience after all.
 Brexit: the decision of a divided country. Dorling D. BMJ 2016;354:i3697
 EU Referendum result visualisations. The Electoral Commission website (accessed 18/7/16): http://www.electoralcommission.org.uk/find-information-by-subject/electi...?
 General Election Turnout 1945-2015. UK Political Info website (accessed 18/7/16): http://www.ukpolitical.info/Turnout45.htm
 Dementia/Alzheimer’s and respiratory disease behind biggest annual increase in deaths since the 1960s. Office for National Statistics website (accessed 18/7/16): http://visual.ons.gov.uk/dementiaalzheimers-and-flu-behind-biggest-annua...
 Is the UK spending more than we thought on health care (and much less on social care)? Appleby J. The King’s Fund website (accessed 18/7/16): http://www.kingsfund.org.uk/blog/2016/06/uk-spending-health-care-and-soc...
Competing interests: For completeness and transparency, I work for Public Health England and am therefore a civil servant. However, I am writing in this response in a personal and not official capacity. The views expressed are my own and not those of my employer.
Your side lost. Get over it. Move on.
Competing interests: No competing interests
Having read the above article with interest, and agreeing with much of the content, I feel I must offer a point of information regarding the implied apathy among the younger electorate.
The most recent psephological analysis shows a turnout among younger voters approaching 70% compared to the national turnout of approximately 72%..
The young do care about their future, they were just outnumbered.
Competing interests: No competing interests
I’d like to thanks Christopher Hanretty and Rob Ford for their comment and, of course, they do have an interesting point to make, but I think it is one that has been over-made in recent days.
The term “size of the denominator population” is used to explain that some population groups are bigger than others, and that this really matters greatly. The attached map, which was kindly produced by Will Stahl-Timmins, shows the number of voters who were polled in each region adjusted to remove sampling bias. The proportion who voted Leave in each area is shown as an arc and these are then summed to illustrate how the absolute numbers of Leave voters was higher in the South. Geographers usually define the UK north/south divide by splitting the midlands in half.
Maps can often help clarify the importance of differing relative risks, especially when they use symbols or even projections that account for the differing size of the denominator populations. On November 28th I am giving the annual Political Studies Association Lecture on “Another World is inevitable: Mapping UK general elections - past, present and future”. I’ll try to explain more in that and also include some examples of mapping in medical journals. Future political analysis could well benefit from knowing that it is not just the highest relative risks that matter, but the overall spread of an affliction, or the causes of that affliction.
Furthermore there are often connections between politics and health that are not well known. I speculate on some here in regards to Brexit: https://www.psa.ac.uk/insight-plus/blog/austerity-rapidly-worsening-publ...
In the five years leading up to the Brexit vote the self-reported health of the population of the UK, across all of the UK, became much worse, year on year. This mostly effected older people. That rapid deterioration in people's health may well have had an impact on how many of those who got to vote on June 23rd felt about their lives.
Rudolf Ludwig Carl Virchow put it simply many years ago: "Medicine is a social science and politics is nothing but medicine". writ large
Competing interests: No competing interests
Professor Dorling is right to identify the culprit as austerity not immigration; that’s what the people of Scotland did, having a majority party which provided an alternative narrative of austerity as behind the worsening conditions of life. Scotland didn’t need to turn to immigration or foreigners as first to blame.
Competing interests: No competing interests
Prof. Dorling writes that
"the outcome of the EU referendum has been unfairly blamed on the working class in the north of England... [but] because of differential turnout and the size of the denominator population, most people who voted Leave lived in the south of England".
This statement is true but misleading. More people in the south of England voted Leave because there are more people in the South of England.
If we take regions in the North of England to include the North East, North West, and Yorkshire and the Humber, then 4,325,965 people in the North voted to Leave (according to figures from the Electoral Commission). If we take regions in the South of England to include the South West, South East, London and the East of England, then 5,750,908 people in the South voted to Leave. However, the electorate in the North was 11,053,689 people, compared to 16,028,306 people in the South. Thus, the proportion of registered voters in the North who voted to Leave was greater than the proportion in the South (39.1% compared to 35.9%). The proportion voting for Leave in the North is still greater than the proportion voting for Leave in the South if we instead express it in terms of the voting age population.
As political scientists, we are not familiar with the habits of medical journals. In most analyses of voting behaviour it is common to focus on the relative risk of voting for a party or an outcome; an analysis which focuses on absolute numbers is therefore liable to mislead. If medical journals also tend to focus on relative risks, then Prof. Dorling's analysis is also liable to mislead, notwithstanding the qualifications in relation to "differential turnout and the size of the denominator population".
Competing interests: No competing interests