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Inequalities in asthma mortality: a specific case of a general issue of health inequalities
  1. Michael Marmot
  1. Correspondence to Dr Michael Marmot, Department of Epidemiology and Public Health, UCL Institute of Health Equity, University College London, London WC1E 7HB, UK; m.marmot{at}ucl.ac.uk

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Respiratory disease was always the ‘British’ disease. Not the most common cause of death in Britain, but the cause that most marked Britain as being different from other countries. In the same way, liver disease was the French disease. In both cases, it is not difficult to think of reasons why. The French preoccupation with le foie had much to do with alcohol. French farmers were, in part, paid in wine: 1.5 L a day and for grape pickers 5 L a day, and for a time, France topped the league tables of per person annual alcohol consumption.

As for the British disease, it can be linked to foul air, polluted factories, crowded living conditions that promoted infection and exposure to moulds and other allergens, being early adopters of smoking. Dickens, in Hard Times, gave an account of Victorian living conditions:

In the hardest working part of Coketown,…where Nature was as strongly bricked out as killing airs and gases were bricked in… where the chimneys, for want of air to make a draft, were built in an immense variety of stunted and crooked shapes’.1

Not that ‘Nature’, bricked out, was salubrious. The foul air of Britain’s industrial cities was justly infamous. Think of Monet’s—he of the luminous Water Lilies—1903 painting of ‘Waterloo Bridge in Fog’. It was hard to see, let alone breathe. Fog was the backdrop and sometimes the centre of Sherlock Holmes’s career. Here he is, for example, gazing out from his Baker Street window in 1895 as a dense yellow fog descends on London:

we saw the greasy, heavy brown swirl still drifting past us and condensing in oily drops on the window panes’ (quoted, p   229).2

Victorians …

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