Public Health and the Risk Factor

Public Health and the Risk Factor: A History of an Uneven Medical Revolution

William G. Rothstein
Copyright Date: 2003
Edition: NED - New edition
Published by: Boydell and Brewer,
Pages: 480
https://www.jstor.org/stable/10.7722/j.ctt14brtq7
  • Cite this Item
  • Book Info
    Public Health and the Risk Factor
    Book Description:

    The greatest revolutions in twentieth century public health and preventive medicine have been the concepts of risk factors and healthy lifestyles as methods of preventing disease. A risk factor is anything that increases the risk of disease in an individual. Lifestyle refers to the individual's personal behaviors with regard to risk factors. Identifying risk factors and modifying them by changing lifestyles in order to prevent disease has become ubiquitous as a strategy in public health. The book examines the history and evolution of the concepts of risk factors and healthy lifestyles and their application to coronary heart disease, the major chronic disease of the twentieth century. The first part contains a history of the use of statistics in public health and medicine, and the ways in which various industries developed the concept of the risk factor. The second part describes the concept of healthy lifestyles, which was devised by municipal public health departments and life insurance companies in the early part of the century. The third and fourth parts examine how the concepts of risk factors and lifestyles were applied to the primary chronic disease of the twentieth century - coronary heart disease. The focus of the book overall is on coronary heart disease as a public health, rather than a medical, issue, and the various concepts that have been used in preventing it. William G. Rothstein is Professor of Sociology at the University of Maryland, Baltimore County.

    eISBN: 978-1-58046-614-1
    Subjects: Health Sciences, Sociology

Table of Contents

  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
  3. LIST OF TABLES
    (pp. ix-x)
  4. PREFACE
    (pp. xi-xiii)
  5. 1 INTRODUCTION
    (pp. 1-6)

    One of the fundamental transformations in twentieth century public health and medicine has been the widespread acceptance of a new concept of the causes of chronic and degenerative disease. This is the lifestyle theory, which holds that an individual’s state of health is affected by specific aspects of the manner of living of that individual. In the same way that an individual suffering from a disease must follow a prescribed regimen to recover from that disease, a healthy individual must engage in continuous activities that are an integral part of daily life in order to maintain health. According to the...

  6. Part 1 The Invention of the Risk Factor
    • 2 THE ORIGINS OF PROBABILITY AND STATISTICS
      (pp. 9-21)

      Unlike many discoveries in public health and medicine, the concept of the risk factor had its origins in two disciplines unrelated to the study of health and disease: probability and statistics. The two disciplines were combined when probability theory was applied to the analysis of the population and mortality data being gathered by statisticians. The new quantitative statistical methods were soon recognized by some as useful for resolving medical controversies, but others considered them worthless or contrary to the goals of scientific medicine.

      A probability, as applied to human behavior, is a ratio in which the numerator is the number...

    • 3 CENSUSES AND VITAL STATISTICS
      (pp. 22-35)

      One of the greatest advances in modern public health and medicine was the enumeration of mortality and disease rates and their longitudinal trends for the total population and for age, sex, locality, and other groups. This great innovation resulted from the discovery that statistics on births, deaths, and other social behaviors in geographic regions showed striking regularities from year to year. The enumerations were soon recognized as being of great practical value by governments. The United States government pioneered in developing the census while European governments assumed leadership in vital statistics.

      Public health and medicine were held back for centuries...

    • 4 STATISTICAL ANALYSES OF MEDICAL AND SOCIAL DATA
      (pp. 36-49)

      The discovery of regularities in social statistics led to efforts to use them to better understand the health and social conditions of the population. Physicians analyzed hospital and patient records and other investigators carried out social surveys of communities. Two investigators were especially effective in using statistics to understand health and disease. A physician, John Snow, used statistics to demonstrate the relationship between polluted water and the spread of cholera, and a statistician, Adolphe Quetelet, developed important new methods of categorizing and analyzing social and health data.

      The discovery of regularities in social statistics and the researches of Pierre Louis...

    • 5 LIFE INSURANCE AND THE RISK FACTOR
      (pp. 50-74)

      Life insurance companies devised a fundamentally new statistical approach to predicting chronic disease as they improved the process of selecting policyholders. They discovered that the risk of premature mortality was increased by specific personal characteristics that could be determined by analyses of policyholder mortality rates. Once the characteristics were identified, the companies required the physicians whom they employed as medical examiners to measure them in their medical examinations of applicants.

      Life insurance was the one field of commercial endeavor that was totally and irreversibly committed to mathematical statistics. Life tables based on statistical analyses of policyholder mortality rates were used...

  7. Part 2 Health Education for Healthy Lifestyles
    • 6 CULTURAL AND ENVIRONMENTAL INFLUENCES ON URBAN MORTALITY RATES
      (pp. 77-94)

      The invention of the actuarial risk factor was one of two major innovations required for the formulation of programs to promote healthier lifestyles. The other was the concept of educating the public that personal behaviors can affect health. The discovery that some lifestyles were healthier than others emerged from findings that nationality groups with similar incomes and living conditions varied widely in their total and infant mortality rates.

      One of the major uses of vital statistics in the early twentieth century was to compare the health status of different population groups. Nationality groups were the most important groups in the...

    • 7 THE GERM THEORY AND HEALTH EDUCATION IN DIPHTHERIA AND TUBERCULOSIS CONTROL
      (pp. 95-118)

      The contrast between public health programs based on the germ theory and those based on public education are exemplified by controversies over the effectiveness of diphtheria antitoxin and tuberculosis control. Evaluations of antitoxin treatment concentrated on the diphtheria bacillus and disregarded the patient, resulting in inaccurate and conflicting findings. Early tuberculosis control programs also emphasized the tubercle bacillus, but the lack of success led to greater concern with patient education and community involvement.

      Federal, state, and local governments undertook different types of public health activities in the first decades of the twentieth century. The federal government gathered statistical data, conducted...

    • 8 HEALTH EDUCATION AND INFANT MORTALITY IN NEW YORK CITY
      (pp. 119-145)

      Programs to reduce infant mortality provided the strongest evidence that public education was the keystone of all effective public health programs. Health departments learned that the education of the mother was essential to a healthy baby. In order to focus on mothers and families, the New York City health department provided integrated care in neighborhood health centers throughout the city.

      Few aspects of urban life in 1900 were more dispiriting than the seemingly ceaseless numbers of deaths of infants in the first year of life in the overcrowded, congested, and unsanitary tenement districts populated by new immigrants from Europe. In...

    • 9 THE METROPOLITAN LIFE INSURANCE COMPANY HEALTH EDUCATION PROGRAMS
      (pp. 146-176)

      After urban public health departments adopted health education to improve the health of their residents, the Metropolitan Life Insurance Company undertook a vast nationwide health education campaign as a distinctive advertising and public relations program. The multifaceted campaign included free nursing care for sick policyholders and materials to educate the general public about personal behaviors that contributed to infectious and chronic diseases. It reached more persons than any other public or private health campaign and made the Metropolitan the private counterpart of a national health department during the first half of the twentieth century.

      Health education for the general public...

  8. Part 3 The Coronary Heart Disease Epidemic
    • 10 EARLY TWENTIETH-CENTURY MORTALITY TRENDS AND RHEUMATIC HEART DISEASE
      (pp. 179-191)

      During the early twentieth century the declining mortality rates from infectious diseases brought chronic diseases to greater public attention. The history of rheumatic heart disease, then a major chronic disease, demonstrated the many difficulties involved in their management and control.

      Between 1900 and 1940 overall mortality rates declined more than in any comparable period in American history, but the amounts varied widely among age and sex groups. This is indicated by vital statistics from 1900 to 1940 for those states that were included in the death registration area since its inception in 1900 (see Table 10.1). These states, primarily in...

    • 11 THE EARLY YEARS OF THE CORONARY HEART DISEASE EPIDEMIC
      (pp. 192-218)

      The onset of the great coronary heart disease epidemic of the mid-twentieth century was marked by concern and confusion about this new and highly fatal disease. Clinical medicine and traditional public health measures provided few effective methods of treatment and prevention. The most useful knowledge came from vital statistics and the risk factors of the life insurance industry.

      Severe chronic diseases, including heart disease, became more important causes of death in the early twentieth century as more people survived to old age. This produced a demand for accurate statistics about their incidence, prevalence, and trends, which in turn created new...

  9. Part 4 Rick Factors and Coronary Heart Disease
    • 12 CAUSES, CORRELATIONS, AND THE ETIOLOGY OF DISEASE
      (pp. 221-237)

      The rise of coronary heart disease and other chronic diseases led to greater recognition of the inapplicability of cause-and-effect models based on laboratory experiments involving bacterial diseases. A more suitable conceptual framework was correlation, a new method of finding associations rather than causes. Correlation was one of the most important new scientific concepts in the twentieth century and greatly expanded the methods that could be used to study the causes, prevention, and treatment of disease.

      Prior to the nineteenth century, disease causation was a highly flexible concept that involved attributes of both the individual, such as age, gender, occupation, and...

    • 13 CIGARETTE SMOKING AND STATISTICAL CORRELATIONS
      (pp. 238-259)

      The use of statistical correlations to establish etiological relationships experienced its greatest challenge with cigarette smoking. Biomedical scientists and physicians who were committed to laboratory investigation refused to accept statistical correlations in epidemiological studies as compelling evidence that smoking caused disease. Their views were adopted by the cigarette industry and shared by many health-related government agencies and voluntary associations. The general public and government agencies not concerned with health were much more receptive to evidence provided by statistical correlations.

      Popular wisdom has long associated tobacco consumption with ill health and premature mortality. The popular American term for a cigarette, “coffin...

    • 14 BLOOD PRESSURE AND THE BENEFITS OF TREATMENT
      (pp. 260-278)

      High blood pressure rose to prominence as a health concern with the development of effective antihypertensive drugs. One issue for public health has been methods of preventing hypertension. Another has been the minimum blood pressure level that warrants medical treatment, which affects millions of persons and can have a significant impact on health care costs. As male coronary heart disease morbidity and mortality rates continued their relentless climb during the 1940s and 1950s, its prevention became the most compelling health problem of the twentieth century. In 1950 about 1.1% of men ages 45–54 and 2.4% of men ages 55...

    • 15 THE FRAMINGHAM HEART STUDY AND THE RISK FACTOR
      (pp. 279-285)

      The growing demand for preventive measures for coronary heart disease led to greater use of statistical correlations that related personal characteristics to future mortality rates. This model was applied most successfully in the renowned Framingham Heart Study, a unique long-term epidemiological community study. The Framingham study introduced the life insurance risk factor into research in medicine and public health, but restricted its scope by excluding the many social factors used by the life insurance industry.

      As coronary heart disease reached epidemic proportions in the late 1940s, epidemiological studies were undertaken to better understand the etiology of the disease. Most of...

    • 16 THEORIES OF THE CAUSES OF CORONARY HEART DISEASE
      (pp. 286-294)

      The analysis thus far has concerned risk factors that are associated with a number of diseases besides coronary heart disease. Risk factors specific to coronary heart disease are based on theories of the vascular changes that reduce blood flow to the heart muscle, with each theory being associated with different types of treatments.

      All theories of the etiology of coronary heart disease seek to explain its defining characteristic, the diminution of blood flow to the heart muscle. Early in the twentieth century, the primary cause was considered to be a thrombus (clot) in one of the coronary arteries. A thrombus...

    • 17 THE DIET-HEART HYPOTHESIS
      (pp. 295-313)

      The diet-heart or lipid hypothesis, based on the atherosclerosis theory of coronary heart disease, consists of a sequence of events involving dietary cholesterol and fats, blood cholesterol, atherosclerosis, and ultimately coronary heart disease. The most rigorous statistical studies have shown very weak or nonexistent relationships between diet or blood cholesterol and coronary heart disease.

      The underlying factor in the atherosclerosis theory of coronary heart disease is cholesterol in the human body. Cholesterol is found in all cell membranes and is especially prevalent in organs like the brain, liver, and kidneys; it plays a key role in the production of some...

    • 18 DIETARY RECOMMENDATIONS AND GUIDELINES
      (pp. 314-342)

      Despite the absence of statistical correlations relating diet and coronary heart disease rates in studies of individuals in natural environments, public and private health organizations and food producers have actively promoted dietary changes for the entire population, not just those at high risk. The result has been a massive risk factor health education campaign that has placed greater emphasis on dietary fats and cholesterol than smoking, physical exercise, and overweight.

      Throughout the twentieth century, Americans viewed food consumption as closely tied to other aspects of their lives. Early in the century, rising incomes and the greater availability of nutritious foods...

    • 19 THE SECULAR DECLINE IN THE CORONARY HEART DISEASE EPIDEMIC
      (pp. 343-358)

      The great twentieth-century coronary heart disease pandemic, which killed millions of persons in westernized countries, abated after 1960 and continued to wane for the remainder of the century. Its rise and fall has usually been explained by population-wide changes in personal risk factors, which include excessive animal fats and cholesterol in the diet, obesity, smoking, sedentary living, lack of physical exercise, and stress. According to this theory, a meaningful decline in coronary heart disease rates occurred after the risk factors were modified in large numbers of persons.

      From one perspective, it is inconceivable that an international pandemic of any disease...

    • 20 EPILOGUE
      (pp. 359-368)

      Risk factors have not been completely accepted in public health and clinical medicine, largely because of ambivalence about inferential statistics. Their prominent role in the health education movement has raised several fundamental issues, including individual versus social responsibility for disease and population-wide- versus high-risk strategies.

      Risk factors have brought public health and clinical medicine closer together than ever before. The role of public health is to identify risk factors, educate the public about prevention and treatment, and promote changes in individuals and public and private organizations. The role of clinical medicine is to diagnose risk factors in individual patients and...

  10. NOTES
    (pp. 369-426)
  11. BIBLIOGRAPHY
    (pp. 427-454)
  12. INDEX
    (pp. 455-466)