Bickenbach, Jerome

Chatterji, Somnath

Cieza, Alarcos

Jones, Richard N.

Kostanjsek, Nenad

Morris, John N.

Oberhauser, Cornelia

Üstün, Tevfik Bedirhan

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International Journal of Epidemiology, 2016, 586–587doi: 10.1093/ije/dyw063Health is not just the absenceof disease. . .From Alarcos Cieza,1,2,3 Cornelia Oberhauser,2 Jerome Bickenbach,3,4 Richard N Jones,5Tevfik Bedirhan Üstün,6 Nenad Kostanjsek,6 John N Morris7 and Somnath Chatterji81Faculty of Social and Human Sciences, University of Southampton, Southampton, UK, 2Department of Medical Informatics,Biometry and Epidemiology, LMU Munich, Munich, Germany, 3Swiss Paraplegic Research, Nottwil, Switzerland, 4Departmentof Health Sciences and Health Policy, University of Lucerne, Lucerne, Switzerland, 5Departments of Psychiatry and HumanBehavior and Neurology, Warren Alpert Medical School, Brown University, Providence, RI, USA, 6Classification, Terminologyand Standards, Department of Health Statistics and Informatics, World Health Organization, Geneva, Switzerland, 7HebrewSenior Life’s Institute for Aging Research, Social and Health Policy Research, Boston, MA, USA and 8Multi-Country Studies,Department of Measurement and Health Information Systems, World Health Organization, Geneva, Switzerland*Corresponding author. Professor Alarcos Cieza Faculty of Social and Human Sciences, Academic Unit Psychology, Room Number: 44/3061,University of Southampton, Highfield Campus, Southampton SO17 1BJ. E-mail: a.cieza@soton.ac.ukWe thank Stuckler and Reeves for their commentary1 onour re-evaluation3 of claims made by Banks et al.4 andothers that the English are healthier than the US Americans.Living in England, Stuckler and Reeves may be forgiven forconcluding their commentary by saying ‘So should you livein the US or England? Judging on the health data alone, wefind the weight of evidence still (slightly) favours—England’. The point of our article was not to suggest thatpeople move countries, but rather to propose a better meth-odology for tackling the difficult public health challenge ofcomparing health across populations.They1 begin by claiming that our aim was to operation-alize the well-known World Health Organization (WHO)1948 definition of health2. Our aim was actually the verydifferent one of arguing that it is a mistake to adopt theBanks et al.4 understanding of health merely as the absenceof disease. We rather claim that health needs to be meas-ured as a vector of functioning in a parsimonious set ofdomains that matches the intuitive notion of health suchthat one can compare the health of people with (for exam-ple) diabetes and those with depression, an approach pro-posed by Salomon et al.5We read with pleasure when Stuckler and Reeves1 pointout the convergence of inferences obtained by examiningrecent Global Burden Disease (GBD) 2010 efforts6 and ourown. We agree on this. The difference between us is thatwhereas the GBD says that the health differences betweenthe USA and the UK are trivial, we say they are really, reallytrivial! To see this, consider their Table 1,1 in which healthylife expectancy (HALE) at age 50 is reported to be about 25years for both the UK and the USA, with a 0.4-year advant-age for the UK. If healthy survival after age 50 has a Poissondistribution, this difference amounts to 8% of a standarddeviation. Life expectancy (LE), by contrast, at age 50 isabout 31–32 years for the UK and the USA, with a 0.8-yearadvantage for the UK. If survival after age 50 has a Poissondistribution, this difference amounts to 14% of a standarddeviation. But these differences are indeed very, very small.Imagine a sample of 1000 persons aged 50 years and olderfrom the UK and a matching number from the USA. Takingall possible pairs, selecting one person from the UK and onefrom the USA, if we predicted a longer life expectancy forthe person from the UK we would be right 52% of the time,instead of the 50% of the time that might be expected if thelife expectancy distributions were identical in the USA andUK or by chance. Our Rasch-based health metric,3 on theother hand, suggests a smaller difference (about 2% of astandard deviation) and implies a correct guess about healthin 51% of pairs of USA/UK elders instead of the 50%expected if the distributions were identical.A related feature of our approach,3 which Stuckler andReeves1 call ‘a major limitation’, is our reliance on self-report data, and the fact that culture is an important driverof how respondents answer questions about their health. Infact, our results argue for diminishing differences betweenthe USA and the UK after these cross-national differences inself-reporting of health are adjusted. In other words, ourresults are based on the Rasch model, in which the healthscore is estimated after correcting for differential item func-tioning (DIF) and therefore accounting for reporting biasesand hence population invariant. We think that culture and,more broadly, all social and environmental differencesbetween the USA and the UK, influence self-reported health.The Rasch and DIF scoring procedure—with differentthresholds for different sex, age and national groups—is anattempt to address this.586 International Journal of Epidemiology, 2016, Vol. 45, No. 2VC The Author 2016. Published by Oxford University Press on behalf of the International Epidemiological Association.This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permitsunrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.Although we do not report it, had we done our Raschscoring of health without correction for DIF by nationalgroup, we might have had larger USA/UK difference inhealth. This means that it is possible that all of the (negli-ble) health differences between the USA and the UK maybe due to measurement error caused by cultural differencesin the self-reporting of health.Regarding the ‘curious reporting conventions’, at leastone is the convention of this journal, namely that of report-ing 90% rather than 95% confidence intervals for the mainresult, following Sterne and Davey Smith.7 As for the sug-gestion that the goodness-of-fit tests we used would not per-mit our conclusion, this would be quite correct if we hadbased our conclusion on these tests. In fact, we only usedthese tests as further supporting evidence for our main con-clusions, which were derived from the regression coefficientsresulting from the linear additive model as reported inTable 4 of our paper.3 Another concern of theirs1 is thatalthough we object to Banks et al.4 looking only at a fewhealth conditions, we, it would seem, reduce all health con-ditions to a single unidimensional scale. But this is to mis-construe the fundamental difference between ‘countingdiseases’ as a measure of severity (like counting apples andoranges and then deciding which of these two groups aresweeter overall) and constructing a metric of health basedon the functioning domains that are constitutive of theessence of health. Finally, we are told that we have con-structed a ‘straw man’1 by citing examples of where theBanks et al.4 conclusions about UK health advantage havebeen relied on. It suffices to invite readers to peruse the Insti-tute of Medicine Report U.S. Health in International Per-spective: Shorter Lives, Poorer Health (2013)8 which citesBanks et al., and similar studies, extensively.Finally, although we are reluctant to recommend thatUS Americans immigrate to the UK to improve theirhealth, we definitely would recommend, when comparingthe health of populations, to supplement comparing preva-lence of diseases with a more nuanced and rich analysisbased on a fuller conception of health, since after all,health is more than the absence of disease…Conflict of interest: None.References1. Stuckler D, Reeves A. Commentary: Would your health be betterif you lived in England or in the USA? Int J Epidemiol2015;44:238–39.2. Preamble to the Constitution of the World Health Organizationas adopted by the International Health Conference, New York,19-22 June, 1946; signed on 22 July 1946 by the representativesof 61 States (Official Records of the World Health Organization,no. 2, p. 100) and entered into force on 7 April 1948..3. Cieza A, Oberhauser C, Bickenbach J et al. The English are health-ier than the Americans: really? Int J Epidemiol 2015;44:229–38.4. Banks J, Marmot M, Oldfield Z, Smith JP. Disease and disadvantagein the United States and in England. JAMA 2006;295:2037–45.5. Salomon JA, Mathers CD, Chatterji S, Sadana R, Üstün TB, MurrayCJL. Quantifying individual levels of health: definitions, conceptsand measurement issues. In: Murray CJL, Evans DB (eds). HealthSystems Performance Assessment: Debates, Methods and Empiri-cism. Geneva: World Health Organization, 2003.6. Global Burden of Disease Study. GBD 2010 Life Expectancy byCountry. Washington, DC: Institute of Health Metrics, 2010.7. Sterne J, Davey Smith G. Sifting the evidence – What’s wrong withsignificance tests? BMJ 2001;322:226–231.8. Woolf SH, Aron L (eds). National Research Council and Instituteof Medicine. U.S. Health in International Perspective: ShorterLives, Poorer Health. Washington, DC: National AcademiesPress, 2013.International Journal of Epidemiology, 2016, 587–589doi: 10.1093/ije/dyv335Advance Access Publication Date: 31 December 2015Continuing use of the termsprospective and retrospective andquality of reporting of observational studies: time to updatethe STROBE guideline?From Camila Caram-Deelder,1,2 Aukje L Kreuger,1,2 Frits R Rosendaal,2Johanna G van der Bom1,2 and Rutger A Middelburg1,2*1Center for Clinical Transfusion Research, Sanquin Research, Leiden, The Netherlands and 2Department of Clinical Epi-demiology, Leiden University Medical Center, Leiden, The Netherlands*Corresponding author. Center for Clinical Transfusion Research, Sanquin Research, Plesmanlaan 1a, 2333 BZ Leiden, The Netherlands.E-mail: R.A.Middelburg@lumc.nlInternational Journal of Epidemiology, 2016, Vol. 45, No. 2 587VC The Author 2015; all rights reserved. Published by Oxford University Press on behalf of the International Epidemiological Association

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Health is not just the absence of disease

Health is not just the absence of disease

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