ARTICLES ON STUDIES AND EXPERIENCES

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Title
ARTICLES ON STUDIES AND EXPERIENCES
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HEALTH EDUCATION THEORIES AND
RESEARCH FOR AIDS PREVENTION
Gerjo Kok

IDS is a new disease: it is a
behavioural disease and it is a
preventable disease. Health edu­
cation can make a valuable con­
tribution to AIDS prevention, while patient edu­
cation can have an important influence on the
care and support of AIDS patients and seropositives. In terms of research, we still lack sufficic't knowledge about people who are iniected, determinants of safe and unsafe behav­
iours, the best ways to implement educational
programmes, etc. We nevertheless have a
strong tradition in health education theories
and models, research methodologies and
techniques, that can be applied to this new
area. In the following text we will present theor­
ies of health education planning, of determi­
nants of behaviour, of health promotion, and of
the development and implementation of behav­
ioural change programmes, based on a long users. This example illustrates that the devel­
history of research and theory about the pre­ opment of health education programmes
vention of diseases like cancer (by nutrition consists of a series of decisions about content
education, smoking cessation and smoking of the message, timing, target groups, chan­
prevention), and about the care and support for nels. etc., that are not simply derived from some
patientsterminal diseases, e.g lung can.cer.

clear ’rules’. Instead, these are difficult deci­
sions, made on the basis of the knowledge
available at that moment. The only ’rule’ is: the
effectiveness of health education is dependent
on the quality of the planning procesd22'25.
This implies that to be effective, health educa­
tion should be a planned activity.
In Figure 1 a planning and evaluation model of
health education is presented1215. The planning
phase consists of five steps that can be for­
mulated as questions:
Fig. 1
Planning and Evaluation of Education

Planning
Probtem - Behavtor - Determinants - Intervention - Impiementafcn
Evaluation

Planned Health Education

1. How serious is the problem?
2. What behaviours and whose behaviours are
responsible for the problem?
3. What are the determinants of these behav­
iours?
4. What intervention is effective in changing
these behaviours?
5. How can such an intervention be imple­
mented on a larger scale?

In 1988 the first Dutch public campaign on AIDS
started with a short TV message and a pam­
phlet. The TV message showed a bee flying
from flower to flower, and dying some time later.
The spoken text indicated that there was a new
disease called AIDS that was deadly and
transmitted by sexual contact. The Dutch cam­
paign was different from campaigns in other
West- European countries in its being rather
funny instead of being very threatening. The
public campaign was also launched somewhat
later than in other countries; the educational
activities had primarily been directed at specific
risk groups: homosexual men and IV drug

The evaluation phase consists of five compa­
rable questions in the reverse order, the first
question being : has the implementation
been successful and the last two questions:
have the behaviours changed and has the
magnitude of the problem decreased. The latter
question is the most important one, but often
cannot be answered because of the delay that
exists between behavioural change and ob­
servable effects on the problem. In that case the
relation between the problem and the behav­
iours involved has to be very clear. Usually the
best possible indicator of effectiveness in the
evaluation phase, is the change of behaviodf.

32

Gerjo Kok, PhD, Dept, of Health
Education, University of Limburg,
Maastricht, the Netherlands.
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Applying the planning model to the AIDS prob­
lem, it is easily agreed upon that AIDS is a
serious problem. In most countries not be­
cause of the absolute number of AIDS deaths,
but because of AIDS being a terminal disease
with no cure or treatment at the moment.
Moreover, AIDS is an epidemic disease with an
increasing number of infected people, most of
whom will develop the disease years after they
have been infected. Even if some kind of treat­
ment were available, the need for primary
prevention would not decrease, since cure is
not related to infection"b. Primary prevention of
AIDS is the prevention of infection, which is.
primarily, prevention of unsafe sex and needle
sharing among infected persons. The first two
'eps of the planning model have been dis­
cussed: AIDS is a serious problem, and the
most important behaviours are unsafe sex and
needle sharing.

one's own previous attitudes. In condom use,
for instance, persons will be strongly influenced
by the expectations and behaviour of their
partners.
Self-efficacy stands for: "Do people think they
are able to perform the desired behaviour?"37.
Self-efficacy is an estimation of ability to cope
with possible barriers inside or outside the
person. Research shows that adolescents see
difficulties in buying and using condoms, and in
talking with a partner about condom use as a
means to prevent AIDS, especially when they
already use contraceptive pills. Self-efficacy is
shaped by experiences with barriers, exper­
iences with successes, attributions for succes­
ses and failures, vicarious learning, verbal
persuasion and physiological information2.
Attitude, social influence and self-efficacy de­
termine the intention to perform a certain behav­
iour. and the relation between intention and

Fig. 2
Model of Determinants of Behaviour

Determinants of behaviour
Research on determinants of health reiateo
behaviours usually distinguishes three deter­
minants of behaviour: attitude social influence
and self-efficacy ' see Figure 2
The attitude towards behaviour is the weighing
of all the advantages and disadvantages of
performing thgt behaviour Health or specific­
ally AIDS prevention, is only one of the possible
considerations and is often a relatively unimoormt one. Condom use for instance, might be
stigated for contraceptive reasons and not for
AIDS prevention which means that, when
people start using the pill, they stop using
condoms because of the inconvenience. When
health is considered to be a part of the attitude,
we suppose that the motivation to act in a
manner conducive to good health is a function
of the perceived severity of the health risk, the
perceived susceptibility to the health risk and
the effectiveness of the preventive behaviour. In
the case of AIDS, people know how serious
AIDS is (severity), they may know that condom
use is preventive (effectiveness), but they might
not consider themselves susceptible to infec­
tion with AIDS and therefore decide not to use
condoms.
Social influence refers to the influence of
thers: directly by what others expect, indirectly
by what others do (modeling). Social influence
is often underestimated as a determinant of
behaviour. Research shows that social influ­
ence can lead to behaviour that conflicts with

HYGIF — VOL. X 1991/2

adolescents'9. In the general publics level of
knowledge is very high with respect to the ways
of transmission of the virus. The knowledge
level is not as high with respect to the ways the
virus is not transmitted, e.g. normal social
contact with an AIDS patient. The increase in
knowledge about, for instance, the preventive
effect of condoms is not reflected in behaviour
change: in the general public the increase in
condom use for AIDS prevention is negligible.
One reason for this is 'unrealistic optimism', the
tendency to think that risks mainly apply to
other people and not to oneself44. Unrealistic
optimism has been shown to be a determinant
of unsafe behaviour, not only in the general
public but also in high risk groups40. Several
studies have followed cohorts of homosexual
men with different partners and were able to
identify incidence of transmission related to the
person's behaviour41. In this group there has

Attitude

■
Barriers

External
variables

Social
influence 1
Selfefficacy

behaviour can be influenced by barriers or lack
of skills Performing the actual behaviour, or at
least trying to. will lead to feedback, that might
change some of the determinants An adoles­
cent's self-efficacy in using a condom might
decrease after a bad experience, but will in­
crease after successful tries. Other possible
factors (external variables) are supposed to
influence behaviour through the three determi­
nants.
To be able to decide which are adequate inter­
ventions. we need insight into the target
group's determinants of safe and unsafe behav­
iours. AIDS education interventions have too
often been developed without sufficient ana­
lyses of the determinants of safe and unsafe
behaviours4'36. The picture that emerges from
determinant studies is still far from complete,
but suggests a number of determinants that we
may focus on. We will summarize the results of
Dutch studies on determinants of AIDS preven­
tive behaviours for four groups: the general
public, homosexual men, IV drug users and

135

-nl

Intention

- Behavior 1

------- 1 fr

Abilities

n

been a dramatic change in behaviour, but at the
same time most men still have unprotected anal
sex. However, the number of partners has
decreased and the partners are relatively more
familiar. One factor that is related to unsafe
behaviour is use of alcohol or drugs35. A sub­
stantial number of gay men indicate that they
have difficulties in translating their safe sex
intentions into safe behaviour. Many of them
experience lapses into unintended unsafe be­
haviour. Research in the U.S. supports these
conclusions36. Regretfully research data are
limited to openly gay men; younger gays and
men with anonymous homosexual contacts are
underrepresented in these studies.
AIDS prevention for IVdrug users'^ the Nether­
lands focuses on the use of clean needles, by
participating in needle exchange programmes
that are established in most larger cities. On the
whole, these exchange programmes are suc­
cessful: less needle sharing, and as an unin­
tended effect, less drug use29. IV drug users are..
convinced that the use of dean

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preventive for AIDS infection. Their social en­ Primary prevention of AIDS is the prevention of risky behaviour should act as if they were
seropositive. It is not unthinkable that some
vironment seems to be of less importance, and infection, which means primarily the prevention
the primary reason for unsafe drug use is low of unsafe sex and of needle sharing with in­ medication against AIDS will be found in the
self-efficacy: not being able to always use clean fected persons. Early detection is the diagnosis future. In that case HIV-testing can become an
needles26. Needle sharing is a result of positive of an illness at a stage where treatment is still adequate form of early detection.
social pressure (drugs being offered) and of effective (like breast cancer screening). As yet,
Behaviour change through
negative physical pressure (abstinence effects). early detection of AIDS is useless because no
effective
cure
is
available.
Patient
care
is
the
The availability of clean needles by needle
health education
exchange programmes should be improved care for, and support of, AIDS diagnosed per­
and training might be helpful for IV drug users sons and HIV-positive persons.
Health education starts with a clear behavioural
to reorganize their daily routine in order to have For primary prevention, health education activ­
goal: there is an undesired and a desired
clean needles available when needed. Re­ ities include AIDS prevention campaigns for the
(preventive) behaviour, and we want people to
search in the U.S. supports these conclusions, public or specific risk groups, training and
change from behaving in the undesired way to
although the resistance to needle exchange consultation. Facilities include needle exbehaving in the desired way; e.g. using con­
Fig. 3
programmes is much stronger, which limits the
Health Promotion Matrix
doms. Having a clear behavioural goal, we try to
implementation of effective preventive interven­ Health
Pattent
Primary
Early
change the determinants of that behaviour:
care
prevention
detection
tions.
promotion
attitude, social influence and self-efficacy.
Research shows that adolescents are positive Education
Changing through health education implies
about the AIDS preventive effects of condoms,
changing through communication. Therefore
but they view condoms as inconvenient and as Fadlities
the first goal is to get attention for the interven­
an interruption in the normal course of action33. Regulation
tion and comprehension of the message. The
Their estimation of their own susceptibility to
second goal is changing the determinants of
infection is low. The influence of the partner on change programmes, cheap or free condoms,
behaviour and the behaviour itself. The third
condom use is very strong and also they the availability of anal condoms and adequate
comply with the expectations of their parents. lubricants, telephone information services, but goal is maintenance of behavioural change. A
one-time-only change is not enough; we want
The self-efficacy of adolescents to use con­ also the financing of research for development
doms is not very high: unexperienced adoles­ and evaluation of effective interventions. Regu­ the desired behaviour to become a habit. These
cents see difficulties in buying and using con­ lations could imply obligatory AIDS education three health education goals are combined with
doms, experienced adolescents see difficulties at schools. In patient care, health education four communication variables and a measures
in discussing condom use to prevent AIDS with takes the form of patient education, like coun­ variable in the health education matrix (see
seling and helping AIDS patients, seropositives Figure 4), based on the determinants of behav­
their partner.
To develop interventions, we need to gain in­ and their friends and families to cope with fear. iour model (Figure 2), the work bn attitude
change and behaviour change by McGuire23
sight in ’the determinants of behaviour16. We It also includes public education on reactions to
and
the work on maintenance of behaviour
have different research techniques to analyse AIDS patients and seropositives. The most
change
by Rogers31.
those determinants: large scale surveys or important facilities are medical care and psy­
Decisions have to be made for each of the cells
small-scale group or individual interviews. It is chosocial support. In the Netherlands there
in this matrix; for example:
exists
a
buddy'-system:
a
volunteer
helping
a
essential that the determinants are measured,
‘ Which group of receivers should be prepared
and it is less important by which method (see single AIDS patient. Regulations for patient
for
negative experiences?
care include laws against discrimination of
Steckler et a!., in this issue).
*
Which
measures are needed to support
AIDS patients and seropositives.
At the moment, individual testing for HIV has a behaviour change?
very restricted usefulness, that is only in the * Which message can help people to continue
Health promotion
case of women who want to become pregnant after a lapse?
or a couple that has decided to be monoga­ In the literature a vast amount of empirical data
When the relevant determinants of safe and mous and want to engage in unsafe sex (both can be found with respect to each possible
unsafe behaviours are known, interventions forms of primary prevention). Knowing that one decision. In the next section we will describe
should be developed to change those determi­ is seropositive might be a stimulant for safe the three goals of health education mentioned
nants and behaviours. Health education is only behaviour, but everyone who has engaged in above.
one of many possible interventions to change
Fig. 4
behaviour. Other possible interventions are
Model of Behaviour change by Public Education
facilities and regulations. A combination of the
Mmmw
MessaQe
FUoaivec
Chmnd
Source
three is probably the most effective. Health
Attention and
Comprehension
promotion is the integrated combination of all
Change In
possible - non-medical - interventions to
Determinants
and Behavior
achieve health goals: primary prevention, early
detection and patient care8. Figure 3 presents
136 Maintenance of
Behavior Change
the health promotion matrix.

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and in governments. Health education
is based on Rogers’31 ideas about diffusion of large
I
Attention and comprehension: innovations in a population, recognizing that in (efforts have been less successful in this area,
some researchers have suggested that
different stages of the diffusion process, groups and
i
pretesting, two-sided
self-organization
of IV drug users should be
communication and the social of people adopt the innovation for different istimulated, in order
to develop social net­
reasons. Innovators and early adopters change
network approach
1'.
because of knowledge. However, the majority works
’
of people change because of social influence.
Successful communication s an essential con­ Social network approaches are characterized
dition for effective health education. Communi­ by six more or less essential elements:
Change in determinants and
cation is successful when the receiver comple­
behaviour: fear arousal, social
tely understands the message of the source. In 1. Social network approaches are directed at
the
existing
social
networks.
influence, and self-efficacy
general two barriers hinder successful commu­
2. Participation^ the target group is an impor­
nication: the receiver's lack of interest and the
improvement
difference between the source and the receiv­ tant aspect
3. Social network approaches are inter-sectoral
ers in knowledge, values, culture, etc. In gen­
The fact that people behave in a certain way,
eral people that we reach, mostly higher SES- (health promotion)
4.
Social
network
approaches
are
multi-media
implicates by definition that this behaviour is in
■'roups, are people that need the message
activities
some way rewarding for them. Health education
,ast. Health educators are aware of this phe­
5.
Health
is
seen
as
a
part
of
people's
lifestyle
should not take away people’s rewards, but
nomenon and a number of educational techni­
6.
Para-professionals
(trained
volunteers
from
should offer other or equivalent rewards by
ques has been developed to overcome these
the
group)
are
used
as
a
source.
other
behaviour3. Arguments to motivate people
barriers: pretesting, two-sided communication
Social
network
approaches
have
been
shown
to
change
their behaviours have to offer short
and social network approach. The goal of pre­
to
be
effective
in
reaching
more
people
from
the
term
rewards
to be effective, because the
testing is to check if the materials have the
target
group
than
other
types
of
interventions.
prevention
of
some
future disease is not suffi­
intended effect with respect to attention, com­
Applying
this
theory
to
AIDS
prevention,
we
cient motivation for most receivers. An example
prehension, credibility of the source, and fea­
may
conclude
that
in
the
Netherlands,
interven
­
is the argument that using clean needles makes
sibility of the implementation. It is not sufficient
tions
that
were
directed
at
men
with
homo
­
drug use easier. This has nothing to do with
that specialists in the health problem area
sexual
contacts,
show
all
the
characteristics
of
AIDS, but is a strong argument for IV drug users
agree that the information contained in the
a
social
network
approach
mentioned
above:
to use clean needles.
materials is correct. A next step is to have
1.
The
interventions
have
been
implemented
in
A frequently asked question in health education
communication specialists judge the materials.
the
gay
subculture,
involving
different
gay
orga
­
relates to the arousal of fear in the message.
The final step is to pretest the materials on a
Fig. 5
nizations
sample of the target group. Only then is it
Effects of Fear arousing Communication
possible to*enable successful communication 2. Decisions about interventions have been
Severity
----and to prevent unwanted side effects that have made with participation of gay men
Fear
not been recognized by health educators. 3. Aside from educational interventions, anal
Action
Susceptibility ------e. pretest'
essential in the planning condoms have been developed and are being
ft tiveneas —
|
pnase of any intervention and should therefore improved: bar owners are n . * vi YOU n i u iv
Self-efficaoy
be integrated in the materials development tribution
4. Mass media include different gay media, A feeling of threat or fear is the result of the
process (MacAskill & Hastings^, this issue).
awareness of one’s own susceptibility to a
Two-sided communication, compared to one­ interpersonal media include a video show with
severe disease (see Figure 5). Fear leads to
sided communication, has a much higher discussion, counseling, outreach activities.
action, but the kind of action people take
chance of achieving successful communica­ AIDS information hotline
depends on the effectiveness of potential pre­
tion. In two-sided communication the receiver 5. Safe sex is seen as part of a gay life-style
ventive responses and the perceived self-effi­
can ask questions, ask for elaboration and the 6. A number of gay volunteers has been trained
cacy to perform that response. An IV drug user
source can ask for confirmation of the message as educators or counselors. This approach has
might be aware of his own susceptibility to
and is able to correct misunderstandings. The been successful in terms of reaching the target
AIDS infection and be aware that clean needles
distinction between one-sided and two-sided group and getting the message across. Con­
are effective in preventing that threat, but he
communication is almost equivalent to the sequently gay men outside the social network,
may have low self-efficacy with regard to being
distinction between mass communication and e.g. younger gays or men with anonymous
able to always use clean needles. The combi­
homosexual
contacts,
have
been
reached
to
a
interpersonal communication. That implies that
nation of high fear and low self-efficacy will
mass media campaigns run a serious risk of: lesser extent. Applying the social network ap­
result in defensive reactions20 32. At the moment
being unsuccessful communications, if they are proach to IV drug users, we see that their social
this theoretical notion has not been studied
not supported by interpersonal communication. network is completely different, more diffuse,
specifically in the area of AIDS prevention.
In health education directed at lower SES-gro- more heterogeneous, more segmented. There
However the increase in aggression toward
ups, the social network approach (also calledI is antagonism between drug users and profes- homosexuals that has been reported after fear
community-based approach or local initiative29) sional health workers, and there are objections
has become popular. Social network approach against clean needle provision in the society at arousing mass media campaigns is completely

HYGIE — VOL. X, 1991/2

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in line with this theory. AIDS is a threatening
disease, which implies that in health education
messages we should focus on effective preven­
tive responses that are feasible.
Changing social influence is a rather difficult
target for health education. Depending on the
kind of influence (positive or negative), two
strategies have been used: mobilization of
positive social influence and resistance to
negative social influence. Mobilization of posi­
tive social influence is part of the social network
approach, mentioned above, assuming that
norms of the network are in favour of the
desired AIDS preventive behaviour changes.
Resistance to negative social pressure is used
in situations where people intend to change
their behaviours, but engage in social situations
where the norms are against that particular
change. Mostly people have different social
environments, some of which support the
change and some of which do not. Techniques
for building up resistance to social pressure
include explanation of the kind of pressure,
showing ways to cope with pressure, practicing
those coping responses, and commitment
procedures for resistance in future pressure
situations, including finding social support \
Actually this is a form of skills training and
self-efficacy improvement

suited in more communication between child­
ren and their parents. The conclusion is clear:
health education programmes designed to im­
prove self-efficacy should involve the actual
desired behaviour in the programme'. It is not
surprising that in the case of AIDS prevention
this principle sometimes leads to conflicts with
school boards, local governments, etc. More
research is needed on the issue of diffusion of
health education interventions, which are not
compatible with existing norms and values of
people responsible for implementing these in­
terventions3'.

Maintenance of behaviour
change: feedback, relapse
prevention

As has been shown in Figure 2, behaviour
leads to feedback, which in turn can influence
determinants. When actual experience with the
desired behaviour is different from people's
expectations, e.g. more unpleasant, more diffi­
cult, giving more social rejection, etc., they will
go back to their former behaviour. What we
have learned from, for instance, smoking ces­
sation programmes is, to never deceive people
about the negative consequences of the behav­
iour change. If the desired behaviour is difficult,
Both theoretical approaches so far. fear arousal people should know and they should be helped
and resistance to social pressure, suggest that to improve their skills to overcome these diffi­
self-efficacy improvement is essential in help­ culties. AIDS preventive programmes for ado­
ing people to realize their intentions for AIDS lescents used to stimulate condom use sug­
preventive behaviours. One method was de- gesting that condoms could be fun'. We now
scnoed above in building resistance to social know that experience with condom use will in
pressure. Another method will be described in general merely strengthen people's idea that
the section about maintenance of behavioural condoms are unpleasant. Knowing too. that
change through relapse prevention. Two gen­ experienced condom users nevertheless have
eral remarks; first, research on the potential a high self-efficacy about condom use, interven­
effects of mass communication and interperso­ tions should improve people’s self-efficacy,
nal communication shows that self-efficacy im­ thereby increasing their chance on positive
provement cannot be realized by mass com­ experiences and feedback.
munication, except for some very specific situa­ Prochaska & DiClemente28 describe phases of
tions. In practice, self-efficacy improvement change in addictive behaviours. In the last
interventions are based on group exchange phase, maintenance, there can either be lapse
and individual counseling. Second, it is impor­ or relapse. A lapse is a one-time failure to
tant to note that self-efficacy improvement al­ perform the desired behaviour (having unsafe
ways involves the actual desired behaviour as sex once), a relapse\s a complete return to the
part of the educational programme. Kirby'5 former (unsafe) behaviour. Marlatt & Gordon22
summarizes the results of studies about the have developed a theory of relapse prevention
effectiveness of sex education at schools. On that explains why people have lapses and why
the whole, the effect is only an increase in lapses lead to relapse. The moment a person
knowledge. Only two exceptions are men­ decides to change his behaviour, he applies a
tioned: a visit to a clinic for anti-conception rule to himself, for instance: having only safe
resulted in more contraceptive behaviour, and sex. At that moment he thinks he is in control
participation of parents in one programme re- over the situation. A problem might arise when

36

138

a high-risk situation is encountered. A high-risk
situation threatens the person's self-control
and the possibility of a lapse occurs. Research
identified three high-risk situations: negative
emotions, interpersonal conflict, and social
pressure. Whether a lapse occurs, depends on
the availability of a coping response. Having an
adequate coping response generally leads to
an increase in self-efficacy and a decrease in
the chance of a lapse. However, not having a
coping response will lead to a lapse and to a
decrease in self-efficacy. Also the ’forbidden’
behaviour is connected with positive expecta­
tions that make a lapse even more attractive.
When lapses occur, the attributions people
make for their lapse, predict their subsequent
cognitive and behavioural reactions. Attributing
a lapse to a stable cause (willpower), will lead
to a lower self-efficacy and to relapse; attribu­
ting a lapse to an unstable cause (effort, lack of
skills), will lead to increased self-efficacy and
no relapse42.
Marlatt & Gordon22 present a method for re­
lapse prevention that is comparable to the
strategies that are used in the building of resist­
ance to social pressure. Their relapse preven­
tion programme consists of four steps:
1. Convincing the person that maintenance of
behaviour change is not related to stable char­
acteristics like willpower, but is related to skills
that are needed to cope with difficult situations
(skillpower).
2. Identifying high risk situations and finding
adequate coping responses.
3. Practicing those coping responses until they
become automatic.
4. Learning how to handle lapses: not a com­
plete relapse but learning from the lapse in
order to improve self-efficacy.
Kelly eta/'" and Roffman30 applied the relapse
prevention model to AIDS prevention for gay
men who indicated having difficulties with the
maintainance of safe sex behaviour. The evalua­
tions of these programmes show promising
results.

Patient education:
stigmatization, social
comparison
Until now our description of health education
theories and research did focus on primary
prevention. In this last paragraph we will look at
patient care and patient education. First we will
describe ideas and research on the stigmatiza­
tion of AIDS patients and seropositivesLSect^

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ond, we will summarize the literature on social
comparison by patients, applying the results to
patient education for AIDS patients.

DOSSIER
uncontrolable disease would have counterpro­
ductive effects on preventive activities. There­
fore, public education against stigmatization
should focus on the right to help, and the safety
of normal social contacts with AIDS patients
and seropositives. The association with homo­
sexuality should be avoided, but at the same
time more positive information on homosexual­
ity should be given. Again, in some countries
the implementation of effective health education
programmes will be restricted by moral and
legal objections.

Weiner et ali3 apply attribution theory to reac­
tions on diseases. In short, the cause people
attribute 'to the disease influences the emo­
tional reactions on patients and subsequent
helping behaviour. Patients whose disease is
seen as caused by themselves, get unfavour­
able reactions; patients whose disease is seen
as caused by something outside their control,
get favourable reactions. AIDS is seen as under
the patient's own control, other diseases like Patients with AIDS and seropositives experi­
cancer and tuberculosis are seen as caused by ence situations with extreme stress and anfactors outside the patients control. As a result xiety. One way to cope with stress is by com-

patients. AIDS patients and seropositives have
the same need for upward comparison and
downward comparison. Groups of AIDS pa­
tients and of seropositives can supply the
conditions for comparison. It seems that in
AIDS patients the tendency for downward
comparison is stronger than the tendency for
upward comparison; patients do realise that
there is not so much they can learn to improve
their own situation. Next to support from other
patients, support from the social environment
is helpful in coping with AIDS. Kelly & St.
Lawrence13 suggest that AIDS patients receive
less support than patients with other diseases,
because of stigmatization, denial of severe
diseases and fear of contagion. It is very impor-

onbepip

VAN EEN BEETJE BEGRIP HEEFT NOG
NOOIT IEMAND AIDS GEKREGEN.

postkantoor oi bibliothcck.
Of bcl gratis de Al DS-mfoa rtt S
OVER

The Dutch public campaign against stigmatization of AIDS patients and seropositives: "Nobody got AIDS from a bit of compassion "

people react more favourably to patients with panson with others (social comparison). Re­
diseases like cancer and less favourably to search on cancer patients has shown that they
AIDS patients. Peters et aE confirm these have a need for affiliation with other patients24,
conclusions and also report that non-attribu- except in situations of extreme fear. Taylor et
tional variables influence the reactions to AIDS aE suggest that patients compare themselves
patients. A negative attitude towards homosex­ with patients that are in a better condition
uality is the most powerful predictor of negative (upward comparison) in order to improve their
emotional and behavioural reactions to AIDS own condition; while at the same time they
patients. Also a higher estimate of the chance of compare themselves with patients in a worse
contagion is hindering helping behaviour.
condition (downward comparison) in order to
cope with negative emotions: being able to
Public education tnat suggests that AIDS is an decide that one is better off than those other

- HYGIE - VOL. X, 1991/2

tant for AIDS patients to perceive the options for
support. People that live in contact with AIDS
patients should be willing to help instead of
offering inadequate help.

Conclusions
We have presented theories and research in
health education, relevant for AIDS prevention
and patient education. On the one hand more
research is needed, on the other hand more

139
—..................

DOSSIER

ROUND UP

■

health crisis. Clinical Psychology Review, 8,

skills training. We need more research 255-284, 1988.
knowledge is available than presently is used in offering
<
on
the
feasibility
of relapse prevention trainings 14. Kelly, J.A., St.Lawrence, J.S., Hood, H.V. A
health education campaigns. We will summa- ■
Brasfield, T.L. Behavior intervention to reduce
for
AIDS
prevention
in different risk groups.
AIDS risk activities. Journal of Consulting and
nze our conclusions:
Psychology, 57, 60-67, 1989.
1. To be effective, health education interven­ 7. AIDS patients and seropositives are being Clinical
15. Kirby, D. The effects of selected sexuality
tions should be based on a careful process of stigmatized, because of an unjustified attribu­ education programs: toward a more realistic
planning and evaluation. The epidemiological tion of own responsibility for the disease. view. Journal of Sex Education and Therapy, 11,
28-37, 1985.
basis for health education is strong enough to Health education campaigns that promote posi­ 16. Kok, G. A Bouter, L.M. On the importance of
start developing interventions, but we still need tive responses to AIDS patients should focus planned health education. American Journal of
Sports Medicine, 6, 600-605, 1990.
to know more about people that are infected on the right for help and the safety of helping 17. Kok, G., De Vries, H., Mudde, A.M. A Strebehaviour; moreover they should create a more cher, VJ. Planned health education and the role
and their behaviour.
of self-efficacy: Dutch research. Health Educa­
2. Behaviour is not only determined by know­ positive image of homosexuality.
tion Research, 4, in press, 1991.
ledge about health risks. People differ in their 8. The existing body of knowledge on the 18. Kok, G.J. A Green, L.W. Research in order to
health promotion in practice, a plea for
perception of susceptibility, their social support development and evaluation of interventions is support
more co-operation. Health Promotion Interna­
impressive,
but
we
lack
sufficient
understand
­
for change and their self-efficacy regarding safe
tional, 5, 303-308, 1990.
19. Kok, G.J. A Sandfort, Th. AIDS-preventie,
behaviours. Interventions should focus on de­ ing of the implementation process. Implementa­ voorlichting
en gedragsverandering (AIDS pre­
terminants of unsafe behaviours that are known. tion of effective AIDS preventive interventions vention, health education and behaviour
At the same time more research is needed on and adequate support for AIDS patients and change). Nederlands Tijdschrift voor de Psycholo­
seropositives is hindered because of incompat­ gic, 46, in print (Dutch Journal of Psychology),
determinants of different risk groups.
1991.
3. Health education should be part of a health ibility with values and norms of decision makers 20. Leventhal, H. A perceptual-motor theory of
emotion. In: L. Berkowitz (Ed.), Advances in
promotion policy. To be effective, health educa­ and the public. More research is needed on the experimental social psychology, volume 17
tion interventions should be combined with diffusion processes of AIDS educational inib-r- (pp. 117-182). New York: Academic Press, 1984.
21. Liedekerken, P.C., Jonkers, R., De Haes,
other interventions, like facilities and regula­ ventions.
W.F.M., Kok, G. A Saan, J.A.M. Effectiveness of
tions. We need more research about the opti­ References
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Gorcum, 1990.
mal combination of these three types of inter­
1. Ajzen, I. Attitudes, traits and actions: disposi­ 22. Marlatt, G.A. A Gordon, J.R. Relapse preven­
tion. maintenance strategies in the treatment of
ventions.
tional prediction of behaviour in personality and
4. Successful communication is a prerequisite social psychology. In: L. Berkowitz (Ed.) Ad­ addictive behaviours. New York: The Guilfort
Press, 1985.
for effective health education. Careful pretesting vances in experimental social psychology, volume 23.
McGuire, W.J. Attitudes and attitude change.
20(pp. 1-63). New York: Academic Press, 1987.
of materials will prevent expensive mistakes. 2. Bandura, A. Social foundations of thought and In: G. Lindzey A E. Aronson (Eds.), The hand­
Two-sided communication will promote a better action. Englewood Cliffs, N.J.: Prentice Hall, book ofsocial psychology, volume 2 (pp. 233- 346).
New York: Random House, 1985.
understanding and acceptance of the message. 3.1986.
Bandura, A. Perceived self-efficacy in the 24. Molleman, E., Pruyn, J. A Van Knippenberg,
More people from the target group will be exercise of control over AIDS infection. Evalua­ A. Social comparison processes among cancer
patients. British Journal of Social Psychology, 25,
and Program Planning. 13. 9-17, 1990.
reached if a social network approach is insti­ 4.tionBecker,
M.H. & Joseph, J.G. AIDS and behav­ 1-13, 1986.
gated, that involves the target group in the ioural change to reduce risk: a review. American 25. Mullen, P.D., Green, L.W. A Persinger, G.
Clinical trials of patient education for chronic
process of development and implementation of Journal of Public Health, 78. 394-410, 1988.
5. Brandt, A.M. No magic bullet. Oxford: Black­ conditions: a comparative meta-analysis of inter­
vention types. Preventive Medicine, 14, 753-781,
the intervention. We need more research on the wells, 1987.
1985.
effects of involving target groups in a social 6. Brandt, A.M. AIDS in historical perspective. 26.
Pa ulussen, Th.G.W.M., Kok, G.J., Knibbe,
American Journal of Public Health. 78. 67-371,
network approach, specifically whethe; such an
R.A. A Cramer, A. Determinanten van aan AIDS
1988.
approach is feasible in IV drug users networks. 7. Brooks-Gunn, J., Boyer, Ch.B. & Hein, K. gerelateerde risikogedragingen van intraveneuze
druggebruikers (Determinants of AIDS related
Preventing HIV infection and AIDS in children
5. People will only be motivated to change and
risk behaviours of IV-drug users). Tijdschrift
adolescents. American Psychologist. 43,
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when the desired behaviour is immediately 958-964, 1988.
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motion. Assen, the Netherlands: Van Gorcum,
tions of blame and reactions to AIDS patients; a
messages should be limited: instead the focus 1989.
comparison of AIDS and other diseases. Uni­
9.
De
Vries,
H.,
Dijkstra,
M.
&
Kuhlman,
P.
should be on effective and feasible preventive
versity of Limburg, Maastricht, the Netherlands,
Self-efficacy: the third factor besides attitude
behaviours. The social environment can be and subjective norm as a predictor of behav­ in preparation.
Prochaska, J.O. A DiClemente, C.C. The
helpful in supporting change, while on the other ioural intentions. Health Education Research, 3, 28.
trans-theoretical approach: crossing traditional
273-282, 1988.
hand people might need to build resistance for 10. Evans, R.I., Rozelle, R.M., Mittelmark, M.B., boundaries of therapy. Homewood, Ill.: Dowsocial pressures that stimulate unsafe behav­ Hansen, W.B., Bane, A.L. & Havis, J. Deterring Jones-Irwin, 1984.
29. Puska, P. et al. Evaluating community-based
iours. We need more (experimental) research the onset of smoking in children: knowledge of preventive cardiovascular programs: problems
immediate physiological effects, coping with
on interventions based on different theoretical peer pressure, media pressure and parent model­ and experiences from the North- Karelia project.
Journal of Community Health, 3, 100-114, 1983.
ing. Journal of Applied Social Psychology, 8,
ideas about effective educational methods.
30. Roffman, R.A., Gillmore, M.R., Gilchrist,
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11. Friedman, S.R., Des Jarlais, D.C. & Gold­
changes of behaviour, but we try to achieve smith, D.S. An overview of AIDS prevention tinuing unsafe sex: assessing the need for AIDS
prevention counseling. Public Health Reports,
aimed at intravenous drug users circa
maintenance of behaviour change. Therefore, efforts
105, 202-208, 1990.
1987. Journal of Drug Issues, 19, 93-112, 1989.
people should be prepared for negative con­ 12. Green, L.W. & Lewis, F.M. Measurement and! 31. Rogers, E.M. Diffusion of innovations. New
York: The Free Press, 1983.
sequences of new behaviour. We can help evaluation in health education and health promo­ 32. Rogers, R.W. Cognitive and physiological
tion. Palo Alto, Cal.: Mayfield, 1986.
people to overcome difficult situations by jointly 13. Kelly, J.A. A St-Lawrence, J.S. AIDS preven­ processes in fear appeals and attitude change: a
revised theory of protection motivation, la:
designing adequate coping responses and by tion and treatment: psychology’s role in the

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*

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J.T.Cacioppo & R E.Petty (Eds.), Social Psycho­
physiology, a source book. New York: Guilford,
1983.

33. Schaalma, H.P., Kok, G., Braecken, D &
Schopman, M. Sex education for adolescents in
the Netherlands. Special issue: Sexology in the
Netherlands and Belgium. Tijdschrift voor Seksuologie, 15, in print. (Dutch Journal of
Sexology), 1991.
34. Schumacher, G.M. & Waller, R. Testing de­
sign alternatives: a comparison of procedures.
In: T.M.Duffy & R.Waller (Eds.), Designing
usable texts. London: Longman, 1985.
35. Stall, R.D., Wiley, J.A., McKusick, L., Coates,
T.J. & Ostrow, D. Alcohol and drug use during
sexual activity and compliance with safe sex
guidelines for AIDS. Health Education Quarterly.
13. 359-371. 1986.

36. Stall, R D., Coates, T.J. & Hoff, C. Behavioral
risk reduction for HIV infection among gay and
bisexual men. American Psychologist. 43.878-885,
1988.
37. Strecher, V.J., DeVellis, B.M., Becker, M.H. &
Rosenstock, I.M. The role of self efficacy in
achieving health behaviour change. Health Edu­
cation Quarterly. 13, 73-91, 1986.
38. Taylor, S., Buunk, B. & Aspinwall, L. Social
comparison, stress and coping. Personality and
Social Psychology Bulletin, 16, 74-89, 1990.
39. Van den Hcek, J.A.R., Haastrecht, H.J.A. van
& Coutinho, R.A. Risk reduction among intrave­
nous drug users in Amsterdam under the influ­
ence of AIDS. American Journal of Public Health,
79, 1355-1357, 1989.

40. an der Velde, F.W., Van der Pligt, J. &
Hooijkaas, C. Risk perception and behaviour:

■ -w

pessimism, realism, and optimism about AIDS
related health behaviour. Psychology and Health,
in print, 1991.

41. Van Griensven, G.J.P., De Vroome, E.M.M.,
Tielman, R.A.P., Goudsmit, J., Van dcr Noorda,
J., De Wolf, F. & Coutinho, R.A. Impact of HIV
antibody testing on changes in sexual behaviour
in homosexual men in the Netherlands. American
Journal of Public Health, 78, 1575-1577, 1988.
42. Weiner, B. An attributional theory of motiva­
tion and emotion. New York: Springer, 1986.

43. Weiner, B., Perry, R.P. & Magnusson, J. An
attributional analysis of reactions to stigma’s.
Journal of Personality and Social Psychology, 55,
738-748, 1988.
44. Weinstein, N.D. Effects of personal experi­
ence on self-protective behaviour. Psychological
Bulletin, 105, 31-50, 1989.

RESUME
Theories et Recherche en Education pour la
Sante pour la Prevention du SIDA

e SIDA est une nouvelle maiadie : c'est
une maiadie liee dans certains cas au
comportement et c’est une maiadie que
i on peut souvent eviter. (-'education pour la
sante peut apporter une contribution precieuse
a la prevention du SIDA, de meme que l education du patient peut apporter une contribution
precieuse au soin et au soutien des sideens et
des seropositifs. En termes de recherche, on
manque encore de connaissances suffisantes
sur les personnes qui sont mfectees, les de­
terminants des comportements a risque ou
sans risque, les meilleurs moyens de mettre en
ceuvre des programmes educatifs, etc, Toutefois. il existe une solide tradition de theories et
modeles educatifs pour la sante, de methodo­
logies et techniques de recherche qui peuvent
s appliquer a ce nouveau domame.
Cans cet article, I'auteur presente des theories
sur la planification en education pour la sapte,

sur les determinants du comportement, sur la - etudier les combinaisons optimales de trois
promotion de la sante et sur le developpement types d’intervention : education, structures
et la mise en ceuvre de programmes visant a d'accueil et legislation;
changer des comportements, Ces theories
— etudier les effets de la participation des
sont fondees sur une longue experience de
groupes-cible a I'approche du reseau social
recherche sur la prevention de maladies
auquel appartiennent ces groupes-cible ; etu­
comme le cancer (par I'education nutritionnelle
dier en particulier si une telle approche est
et la prevention du tabagisme) et sur les soins
faisable dans les reseaux de toxicomanes ;
et soutien a apporter aux patients atteints de
maladies terminales.
— etudier de maniere experimentale les inter­
ventions fondees sur differentes idees theoriL’auteur en tire une serie de conclusions et fait ques de methodes educatives jugees efficale bilan des besoms en recherche sur la pre­ ces;
vention du SIDA:
— une fois obtenu le changement de compor­
tement souhaite, etudier la faisabilite de forma­
— en savoir plus sur les personnes mfectees et
tions pour prevenir les rechutes, auprbs de
leur comportement:
differents groupes a risque ;

- etudier les determinants des comportements de differents groupes a risque ;

HYGIE - VOL. X, 1991/2^^^ 141

^2

- etudier les processus de diffusion des inter­
ventions educatives sur le SIDA.

i^^’hboolc
Cyf^ 6

0 i»T t

2

TEXTBC)ok of international health

ence and technology both contributed to industrialization nnH ■

1

increased tenfold, from 0 56 to 5 4 TeTt/o^ °I £Op?latlon growth

-.nd „ „ i,.0„ „ „ forXulgp:L^“”i (c~le’ 1974>' ti»
The Industrial Revolution in England

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ning machines, and, above all intricate now
the production of vast amounts of cotton cl

flymg fhuttle’ sPin'
ma,klng PossibIe

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the person. Rosen (1958) has pointed out that

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and
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leac
pro<

HISTORICAL BACKGROUND

21

ious stages of modification. This transformation did not occur simply
because of the growth of humanitarian sentiment or of a social con­
science. Legislation on heaFtFind sanifatibn resulted from a variety of
forces within the social and economic order.

Legislation in England to control abuses of the industrial revolution
began with the Health and Morals of Apprentices Act of 1802 limiting
the work of childreiTmTextile factories to 12 hours per day, btrf setting
a new lower age limit for employment. The_Factory Act of 1833 finally
set a minimum age of nine years for work in textile^fectoriesTlimited the
workday of children from 9 to 13 years old to nine hours, and those from
13 to 16, to 12 hours. Certain other reforms, such as two hours of com­
pulsory schooling each day, were instituted. The Mines and Collieries
Act of 1842 set 10 years as the minimum age for boys to work under­
ground and forbade the employment of women and girls within the pits
but it was not until 1874 that employment of children under 10 in fac­
tories was prohibited in England. The writings of William Blake (Sones
oj Innocence) in the eighteenth century and of Dickens, Elizabeth Bar­
rett Browning, and other social reformers in the nineteenth were influ­
ential in inducing these changes, which were instituted over the vigorous
opposition of the leaders of the industries concerned.
The cities of England and of other industrializing nations grew rapidly
in the first half of the nineteenth century. Between 1800 and 1841 the
population of London doubled, and that of Leeds almost tripled. Bir­
mingham grew tenfold in fifty years. Birmingham, Manchester, and other
cities ad instituted cleanup campaigns in the 1760s, correcting centuries of decay by installation of paving, sewerage, and piped water but
these civic improvements were swamped by the rapid growth of popuation. As wage-workers came in from the countryside and Irish emigrant
laborers flocked to the factory towns, housing was constructed as quickly
and cheaply as possible. City planning was nonexistent and sanitation
neglected. Neighborhood standpipes provided water of poor quality to
numerous residences. The smoke from innumerable coal fires filled the
air and blackened buildings and lungs alike. The lack of recreational
facilities combined with general illiteracy and cheap alcohol from the
colonies to produce the conditions immortalized in Hogarth’s famous
Gln Lan'L etchings. Despite improvements in agricultural production,
nutrition was poor. Rickets became common in children rarely exposed
to sunshine, and contagious diseases such as tuberculosis, diphtheria and
louse-borne typhus took a great toll. The first cholera pandemic to strike
England and Western Europe took thousands of lives in the early 1830s
and quickly extended to North America via shipping. Occupational acci­
dents were common, as were diseases arising from unrestricted use of
lead, mercury, phosphorus, and other toxic substances in industrial
processes.

22

TEXTBOOK OF INTERNATIONAL HEALTH

Sanitary Reform in England

The period from about 1830 marked the beginning of widespread and
more or less coordinated efforts to alleviate many unhealthful conditions.
Brockington 1966) categorized these developments in England under
four principa! movements. First, the aftermath of the cholera epidemic
of 183! 1833 saw the formation of more than 1,200 locally elected
boards of health, which functioned mainly in the area of environmental
hygiene and proposed to prevent future epidemics by early detection of
cases, isolation quarantine, and similar measures. The true cause of cholera was still unknown, but the relationship of that and other diseases to
crowded and unsanitary conditions had become clear. Second, the
increase in wage dependency and altered socioeconomic conditions had
placed intolerable burdens on the parish-based relief mechanisms con­
tained in the Elizabethan Poor Laws of 1601. A Royal Commission,
appo>nted in 1832 to look into these matters, was eventually responsible
Poorhr P°cr LaWS °f 1 83l ' Thij le«is,ation provided for a centralized
Poor Law Commission with a medical officer and medical inspectors, and
for
CdT?
f°r S°me 8011 °f 8eneral'zed health services
for the poor. Third, the Factory Act of 1833 incorporated provision for
oVe7TennlnTCt0rSi? I116 field under the suPervision of the Home
Office. Finally the establishment of the Registrar General’s Office and
the division of the country into districts for registration of births mar­
riages, and deaths made possible the orderly accumulation of basic
demography data as a basis for further legislation and action.
The situation in American hospitals in that era was so dismal that
1 nomas Jefferson was prompted to write:
And I will ask how many families . . . would send their husbands, wives
or children to a hospital, in sickness? to be attended by nurses hard­
ened by habit against the feelings of pity, to lie in public rooms
harassed by the cries and sufferings of disease under every form,
alarmed by the groans of the dying, exposed as a corpse, to be lectured
over by a clinical professor, to be crowded and handled by his students,
to hear their case learnedly explained to them, its threatening symp­
toms developed, and its probable termination foreboded? (Jefferson,
1824 in a letter to James Cabell, quoted by Savitt, 1978)

Edwin Chadwick. Gradual recognition of the importance of sanitation
in the maintenance of public health was crystallized in Edwin Chad­
wick’s 1842 Report ... on an Inquiry into the Sanitary Condition of the
Labouring Population of Great Britain, a fundamental contribution to
the development of modern public health. Chadwick pointed out that
the majonty of children of the working classes died before their fifth
birthday and showed how mortality varied between social and economic
classes. He also made a key point about public health measures-

I

I

I

HISTORICAL BACKGROUND

23

The great preventives, drainage, street and house cleansing by means
ot supplies of water and improved sewerage, and especially the introduchon of cheaper and more efficient modes of removing all noxious
retuse from the towns, are operations for which aid must be sought
from the science of the Civil Engineer, not from the physician, who has
done his work when he has pointed out the disease that results from
the neglect of proper administrative measures, and has alleviated the
sufferings of the victims.

Chadwick’s report, which was based on an extensive survey and anal­
ysis of conditions in various parts of England, stimulated the appoint­
ment of a Royal Commision in 1843 charged with investigating sanitary
conditions in the larger towns. The findings of this commission, which
surveyed fifty towns, eventually formed the basis of the Public Health
Act of 1848 that established the General Board of Health and authorized
tv’edicaI1Officer of Health (MOH) to local boards. The first
MOH of London, John Simon, was imbued with the spirit of the environ­
mental reformer and fully recognized the economic implications of ill
health. He wrote, “Sanitary neglect is mistaken parsimony. Fever and
cholera are costly items to count against the cheapness of filthy resi­
dences and ditch-drawn drinking water: widowhood and orphanage
make it expensive to sanction unventilated work places and needlessly
fatal occupations. . . . The physical strength of a nation is among the
c 1j
national prosperity.” Simon knew very well the cost of
cholera; he had assumed his office the year before the great cholera epi­
demic of 1848, of which William Farr was to write:

If a foreign army had landed on the coast of England, seized all the
seaports, sent detachments over the surrounding districts, ravaged the
population through the summer, after having destroyed more than a
thousand lives a day, for several days in succession, and in the year it
held possession of the country, slain 53,293 men, women and children
the task of registering the dead would be inexpressibly painful; and the
pain is not greatly diminished by the circumstance, that in the calamity
to be described, the minister of destruction was a pestilence that
spread over the face of the island, and found on so many cities quick
poisonous matters ready at hand to destroy the inhabitants, (quoted by
Pollitzer, 1959)
The year 1849 also marked the publication of a slender pamphlet On
the Mode of Communication of Cholera, by John Snow, a work expanded
and augmented in 1854 and destined to become a classic of epidemio­
logical reasoning. Although ignorant of the still-undiscovered world of
microbiology, Snow correctly deduced the mode of transmission of chol­
era through contaminated drinking water. He showed how water drawn
trom the lower Thames, after passage through London, was far more
likely to transmit cholera than was cleaner water taken from localities

24
textbook of international health

Sanitary Reform in Other Countries
The appalling conditions in England at the turn of the nineteenth een

pSSSSSSSS
bv the f " Germ“y agltatlon for Similar legislation was led primarily
by the famous pathologist Rudolf Virchow and a small refn!^. r
Y
The yea, 184S w«, m„ked by
< 8™UP.
many. .„d « w„
„nti| 1S73
, „eich Hea||h
»£eeIn that year Max: eon Pe«.„We, delivered Ms well-known
The Value of Health
—ion .nd added ol^’io'Zn
°f

pared available mortality data from cities around the world with his own

ge good water supplies, good and clean streets, good institutions for
ood control, slaughter houses and other indispensable and vital neces

fr°m WhiCh 311 benefit b°th rich a"d p—
A decade later the paternalistic German state under Otto von Bismarck
as to undercut the growing power of the Social Democrats and to in^

■

event ii
f legislation in every other country of Europe and
eventually throughout the world.
Europe, and

t

HISTORICAL BACKGROUND

25

The cities of North America had the advantage of relative newness, but
by the middle of the nineteenth century the crush of immigation had
rendered the larger urban centers of the East Coast as noxious as their
European counterparts. New York City, for instance, increased in pop­
ulation from about 75,000 in 1800 to more than half a million in 1850.
Local boards of health had been established in some of the larger eastern
cities before 1800, but these were ineffective in stemming the tide of
disease. From early colonial times North America had been swept by
epidemics of smallpox, yellow fever, typhoid, and typhus; and tubercu­
losis, malaria, and other communicable diseases were firmly entrenched.
The cholera pandemics of 1831 and 1849 struck America with full force,
the latter coming to California along with the gold fever of the fortyniners.
Using Chadwick’s 1842 report as a model, John Griscom in 1848 pub­
lished The Sanitary Condition of the Laboring Population of New York,
and Lemuel Shattuck in Boston wrote his Report of the Sanitary Com­
mission of Massachusetts (1850). The gradual awakening of interest in
such matters resulted in the National Quarantine Conventions of the late
1850s, and a National Board of Health was established by Act of Con­
gress in 1879.
The Modernization of Medicine

The nineteenth century in the Western countries opened on a techno­
logical upbeat: ingenious mechanical devices were transforming the pat­
tern and quality of life in city and farm. Industrial processes, based on
advances in engineering and chemistry, were flourishing. Agriculture
was becoming more efficient and less labor-intensive. Unprecedented
volumes of raw materials and consumer goods crisscrossed the world. A
philosophical outlook of realism and pragmatism was becoming firmly
established. However, rational understanding of health and disease had
proceeded so slowly that as late as 1851 the most learned men of
Europe, debating for six months at the first International Sanitary Con­
ference, could not agree whether cholera was or was not contagious.
From such a shaky foundation, through a remarkably concerted
achievement of the human intellect, a flood of discoveries poured from
the world’s laboratories in the latter half of the nineteenth century, iden­
tifying the causal agent and means of transmission of almost every major
bacterial and parasitic disease of humans and domestic animals. Within
the span of one human lifetime, from about 1840 to 1900, vague theories
of miasma and divine displeasure gave way to experimentally based lab­
oratory data regarding the genesis of infectious disease and its effects on
the body. Repeated epidemics of cholera in Europe and continuing
havoc from other communicable diseases were intense stimuli for inves­
tigators. The intellectual ferment provoked by Darwin’s theories pro­
vided a further incentive to biological studies after about 1860. Knowl-

26

TEXTBOOK OF INTERNATIONAL HEALTH

edge of physiology, nutrition, and many other aspects of biomedical
science also advanced during this period, with the dawn of an under­
standing of endocrine and metabolic functions.
Although some important work on disease control had been done in
the eighteenth century (for instance, Lind’s demonstration of the pre­
vention of scurvy and Jenner’s work on cowpox vaccination), the rise of
microbiology depended on the chemical and technological underpinning
provided by the industrial revolution. Refinements in microscope design
produced the lenses of the 1880s, close forerunners of those in use
today. The chemistry of dye manufacture, developed for the textile
industry, was incorporated into histology and bacteriology. Little by lit­
tle the basis of modern medical practice was forged.
In this chapter we have touched lightly on a range of human condi­
tions, attitudes, interactions, and developments, which have left their
imprint on world health as we find it today. But more than this—the
hunter, farmer, city dweller, exploiter, humanitarian, and scientist are
all still here, and so are the basic problems of health that mankind has
encountered from the beginning. That is why the study of history has the
same relevance for students of international health as does the study of
embryology for students of medicine. As William Faulkner said, “His­
tory is not dead. It is not even past.”

References
Brockington CF. 1966. A Short History of Public Health, 2nd ed. London, Chur­
chill. 240 pp.
Coale AJ. 1974. The history of the human population. Scientific American
231:40-51.
Chadwick E. 1842. Report on the Sanitary Condition of the Labouring Popula­
tion of Great Britain. Reprinted 1965. Edinburgh, Edinburgh University
Press. 443 pp.
Crozier RC. 1972. Traditional medicine as a basis for Chinese medical practice.
In JR Quinn, Editor. Medicine and Public Health in the People’s Republic
of China. U.S. Department of Health Education and Welfare, Publication
No. (NIH) 72-67. pp. 3-21.
Curtin PD. 1968. Epidemiology and the slave trade. Political Science Quarterly
83:190-216.
Gelfand M. 1964. Rivers of Death in Africa. London, Oxford University Press.
100 pp.
Goerke LS, Stebbins EL. 1968. Mustard’s Introduction to Public Health, Sth ed.
New York, Macmillan. 472 pp.
Gourou P. 1980. The Tropical World, Sth ed. London, Longmans. 190 pp.
Hoeppli R. 1959. Parasites and Parasitic Diseases in Early Medicine and Science.
Singapore, University of Malaya Press. 526 pp.
Hoeppli RJC. 1969. Parasitic diseases in Africa in the Western Hemisphere:
Early documentation and transmission by the slave trade. Acta Tropica, Sup­
plement No. 10. 240 pp.

2
The origins and development of public health
in the UK
JANE LEWIS

The 1988 Government Committee of Inquiry into lthe future
development of the public health function’ defined public
health as ‘the science and art of prolonging life and promot­
ing health through the organized efforts of society’ (PP 1988,
para 1.3)*. Tn practice the committee saw the task of public
health as twofold: the prevention of disease and the pro­
motion of health on the one hand, and the planning and
evaluation of health services on the other. These twin pillars
of public health are also identified in the preface to this
volume. However, the history of British public health in the
nineteenth and twentieth centuries shows clearly, first, that
the balance between the two major emphases has shifted
over time, and second, the extent to which there has been
conflict, rather than compatibility, between them. These
points are crucial to an understanding of the changes in the
concept of public health reflected in the changes of
nomenclature, with the introduction of social medicine dur­
ing the Second World War and community medicine in the
mid 1970s; in 1988, the committee of inquiry advocated a
return to ‘public health medicine’.
In fact, the public health movement did not become firmly
medical until the last decade of the nineteenth century. The
first section of this chapter looks at the ‘heroic age’ of public
health and suggests the extent to which nineteenth century
public health smacked more of what today might be termed a
healthy public policy’ approach, the most crucial element
being the efforts made on the part of the central state (albeit
in an often ad hoc and piecemeal fashion) to regulate—
especially buildings, nuisances and foods—and of local
authorities (albeit with substantial regional variation) to
implement the sanitary idea. The encouragement given by
Thomas McKeown’s (1976) analysis to a monocausal expla­
nation of the dramatic decline in death rates due to infectious
disease in terms of rising living standards, and in particular
standards of nutrition, has been subjected to severe scrutiny
in recent work. Undoubtedly more credit is due to the collec­
tive efforts of nineteenth century government and adminis­
tration to prevent disease and promote health.

The nineteenth century public health doctor was by no
means absent from these endeavours, but nor was he necess­
arily the critical variable. As public health was profession­
alized, so its focus narrowed and, in keeping with medical
practice, the focus in the early twentieth century became
increasingly the individual and what was termed ‘personal
prevention’. In practice, as the second part of the chapter
demonstrates, this became hard to distinguish from the work
of other medical doctors, especially general practitioners,
and by the inter-war period public health practitioners found
themselves engaged in battles that were more related to the
content and methods of delivering medical services than to
prevention and promotion. Indeed, public health doctors
were hopeful that the new National Health Service (NHS)
would be organized around the local authorities and the cli­
nic-based and municipal hospital services developed by pub­
lic health departments during the 1920s and 1930s. But this
was not to be and public health in the 1950s and 1960s found
itself searching for an identity within a framework of a rigid
and unreformed local government structure. The civic pride
of the nineteenth century had all too often given way to
municipal decline. Academic leaders in public health began
to seek a new role for the specialty, first in social medicine,
and then in medical administration. Finally, as the third part
of the chapter shows, they promoted the development of
community medicine as a specialty of population medicine
that was immediately recognizable and significantly different
from both general practice and hospital medicine.
When the new Faculty of Community Medicine (formed in
1972) referred to the specialty’s origins, it usually mentioned
the nineteenth century pioneers rather than the pre-1974
public health departments. There was a sense in which aca­
demics in the field believed that public health had ‘lost its
way’, having been diverted into the provision of personal pre­
ventive services in the early part of the twentieth century.
Yet, in the end, the new specialty was born more of adminis­
trative fiat than of professional strength. Its identity was inti­
mately bound up with the new structure of the NHS and was

O

24

The origins and development of public health in the UK

severely undermined by the subsequent reorganizations of
the NHS in 1982 and 1984.
The major sources of tension that community physicians
continue to experience reflect the long-standing problems of
public health in terms of its relationship to the state and to
the rest of the medical profession. In 1974, governmental
policy-makers were hopeful that the community physician
would be primarily a manager, working within the NHS bur­
eaucracy, looking at the need for medical services in a par­
ticular community and recommending a more rational
allocation of resources at one with the Government’s stated
aim of giving more support to the ‘Cinderella’ services. But
this took community medicine further than ever from the
idea that the concern of public health was the health and wel­
fare of the people, and threatened to turn the community
physician into someone concerned above all with the efficient
management of services. Much of the debate in the com­
munity medicine literature since 1974 has been about how the
community physician may best advise on health problems
and health needs, and how he or she might become more
accountable to the local community. But community medi­
cine faces the problem that the adoption of a broader man­
date would inevitably entail political conflict. The kind of
collective effort required to promote health in the late twen­
tieth century is very different from that of a century ago, as
shown by the controversy over the recommendations of the
Black Repoit on inequalities in health (Townsend...and
Davidson 1982), which advocated greater public expenditure
on matters such as housing, education, and income mainten­
ance. Furthermore, to be successful, community medicine
would have to be treated ‘not so much as a specialty within
medicine as the way in which health services should be con­
sidered within a welfare state’ (Francis 1978), but this is
immediately to invoke the other major spectre of medico­
political conflict.

The heroic age? Victorian and Edwardian
public health
For many, the term public health still conjures up the names
of Chadwick, Farr, and Simon, charismatic figures doing
battle with Victorian vested interests for pure food and water
and for sewerage systems, and against infectious disease.
However, the reasons for the dramatic decline in mortality
have been the subject of fierce debate. Most influential has
been Thomas McKeown (1976), who analysed the changes in
cause-specific mortality and then inferred from the aetiology
of the diseases concerned the most likely factors causing their
decline. Working with the returns of deaths classified by age
and certified causes of death, which are available for England
and Wales from 1837 onwards, McKeown calculated that the
overall mortality rate fell by some 22 per cent between
1848-54 and 1901. Dividing cause-specific mortality into four
categories, McKeown argued that airborne diseases
accounted for 44 per cent of the decline in late nineteenth

0.50

________ L
Environmental changes
- improvements in
standard of living
especially diet

Tuberculosis
(respiratory and
non-respiratory)

____________ [

0.25

Specific measures of
sanitary reformers
- public and personal
hygiene

Cholera,
Typhus - Typhoid

Change in character
of disease

**^0.38

[

Scarlet Fever

_____ MORTALITY
"“6.25““*
* DECLINE

r

X 0.12

0.25

Fig. 2.1. A generalized model of Thomas McKeown's interpretation of the
reasons for the decline of mortality in late nineteenth-century England and
Wales. (Source: Woods and Woodward 1984, with permission.)

century mortality; water- and foodborne diseases for 33 per
cent; other conditions attributable to micro-organisms for 15
per cent; with only 8 per cent due to conditions not attribu­
table to micro-organisms. In regard to the airborne category,
McKeown’s case hinged on the dramatic decline in deaths
due to tuberculosis, and within the water- and foodborne
category, on the decline of cholera, typhus, and typhoid
mortality.
In searching for an explanation of this pattern of mortality
decline, McKeown proceeded deductively. First and most
simply, he showed that mortality from all the important dis­
eases other than smallpox pre-dated significant scientific
advance in terms of immunization, chemotherapy, and hospi­
tal treatments. Second, he considered the possibility of a
spontaneous change in the virulence of some of the infective
micro-organisms and concluded that this was significant in
the nineteenth century only for scarlet fever and influenza.
Third, he considered the influence of sanitary and hygienic
measures of reform, concluding that these were crucial to the
diminution of water- and foodborne disease mortality. But,
according to McKeown’s data, these diseases accounted for
proportionately less of the decline in mortality than airborne
disease. Pride of place in McKeown’s explanation was there­
fore reserved for improvements in the standard of living,
especially in nutrition, which raised the potential victim’s
resistance to airborne diseases. Woods and Woodward
(1984) have constructed a useful model summarizing the
essence of McKeown’s argument (Fig. 2.1).
Thus, in McKeown’s view, the part played by public health
measures in reducing mortality from infectious disease comes
a rather poor second, but the criticisms of his argument sug­
gest that he may have fallen victim to the epidemiologist’s
desire to isolate a single cause, whereas in this instance the
historian’s instinctive rejection of monocausal explanations
may be a sounder guide. As Woods and Woodward (1984)
have pointed out, the central problems in any assessment of
McKeown’s analysis are, first, the need to establish that there
was a rise in standards of living and nutritional status during
the late nineteenth century, and, second, the need to prove

The heroic age? Victorian and Edwardian public health

I

I

i

the extent
the quantitajive contribution of the various
possible factors contributing to the decline in mortafity. On
the first, historical debate has been prolonged (Taylor (1975)
provides a useful summary), but the burden of argument now
suggests that while the fall in real wages was reversed at some
point during the second decade of the nineteenth century,
differentials between the skilled and unskilled workersoevertheless remained virtually unchanged up to the 1880s
(Lindert and Williamson 1983). Wrigley and Schofield’s
(1981) data show virtually no improvement in life expectancy
between the 1820s and the 1870s. In Liverpool, a city whose
population had trebled in size between 1801 and 1841, life
expectancy was a mere 25.7 years in mid-century, compared
with 36.7 years for London and 45.1 years in Surrey (Szreter
1986). Although new technologies allowed Britain to escape
from the Malthusian trap, industrial workers paid thejadce-Of
overcrowded and insanitary living conditions in the fast­
growing towns and saw a relatively high proportion of their
rising wages disappear on rent. McKeown’s emphasis on the
part pFayeH^by rising hufritidnal standards in causing the
decline of tuberculosis in particular is additionally problem­
atic because the aetiology of tuberculosis is very complex. In
her study of mortality from tuberculosis among women in
urban areas, Cronje (1984) has attributed improvements to a
combination of factors, including better diet, housing, and
changes in work patterns. Bryder’s (1988) exhaustive study of
the late nineteenth and early twentieth century anti­
tuberculosis movement favours the idea of rising living stan­
dards as the chief explanation of the decline in mortality, but
includes in the term living standards improvements in hous­
ing as well as nutrition. Certainly, from 1870 onwards the ‘ris­
ing living standards’ argument is on stronger ground,
especially if it is defined to include more than just nutritional
status. In his study of the decline of infant mortality during
the First World War, Winter (1982, p. 729) concludes that
‘the prime agency at work . . . was a rise in family incomes,
especially among the poorest sections of the population’.
In the early and mid-nineteenth century, not only is it more
difficult to demonstrate the validity of this sort of conclusion,
but also there is considerable doubt about the relative quanti­
tative contribution of the factors involved. In this regard
Simon Szreter’s (1986) contribution appears to be one of the
most powerfuL He has suggested that fhe evidence“addUced'
by McKeown to demonstrate the early decline of tuberculosis
is far from convincing. In particular he stresses the import­
ance of the strong counter-trend in deaths due to the acute
bronchitis group of diseases which registered an increase in
mortality rate of over 20 per cent to 1901, due largely to the
conspicuous failure of the Victorians to tackle the problem of
air pollution. This trend is important because either the trend
in bronchitis deaths has to be accepted as genuine, thereby
constituting a contradiction of McKeown’s argument that a
general fall in airborne diseases was the major element dur­
ing the nineteenth century, or if, as is likely, some change in
the practice of certification of death took place in mid­
century from tuberculosis to bronchitis, then the fall in mor­

25

tality due to tuberculosis becomes less spectacular (see Hardy
(1988) on the problems of disease classification more gener­
ally). Szreter (1986, p. 19) concludes that it may be that
water- and foodborne disease mortality account for ‘at least
half as much again, and perhaps almost twice the absolute
quantity of mortality reduction during the nineteenth cen­
tury’, which argument reiterates the importance of according
more attention to factors other than improvements in nutri­
tional status when seeking to explain the decline in nine­
teenth century mortality. In particular, Szreter (1986z p, 5)
argues for the importance of ‘human agency in the form of
politically negotiated expansion of preventive public health
provisions and services, rather than the impersonaLinvisible
h^ndj)£risjng.JLLving.5tandards’. His argument is convincing,
but it is important, first, that in prioritizing public health
measures the argument is not permitted to swing towards
another form of monocausal explanation, and second, that
the limitations of Victorian public health efforts at both the
national and the local level be acknowledged.
The response of Victorian central government to health
problems may be interpreted as largely ad hoc and permis,sive. Epidemic disease, particular^of cholera in 183_l-2_jand
1865-6, acted as the catalyst to reform. It was the report of
three doctors in the aftermath of the 1832 cholera epidemic
that led the ubiquitous Victorian civil servant, Edwin
Chadwick, to investigate ‘the sanitary _condition of the
labouring poor’. His famous report of 1842 emphasized the
crucial link between dirt due to insanitary conditions and
overcrowding, and disease, and stressed the need for a cen­
tral administrative structure to oversee health issues. A cenwas aba.ridQnecLin1854. Indeed, the 1848 Public Health Act was nothing if not
tentative; no national system of sanitation, sewerage, drain­
age, and street cleansing or public health departments was set
up. Rather, the legislation made action at the local level
permissive. Communities without local councils were com­
pelled to set up local boards of health only when the death
rate reached 23 per 1000, which encouraged a crisis interven­
tion approach.
While nineteenth century central governmental interven­
tion on health issues cannot be described as either strong or
consistent in terms of administration, it was nevertheless
informed by a clear body of economic and social ideas, which
helps to explain the wide-ranging nature of the issues sub­
jected to central governmental scrutiny. Chadwick’s 1842
report stressed both the economic cost of ill-health and the
social cost in terms of its effects on morals and habits (Finer
1952; Flinn 1965). As Smith (1979) has remarked, Chadwick
was the first man since William Petty to use the economic
value of man to justify improved health-related services.
Classical economic theorists saw labour as the source of value
and abhorred unproductive people and expenditure.
Chadwick himself came to the study of health problems from
his involvement with reforming the poor law, and the main
question that interested him was that of the relationship
between poverty and ill-health. In common with most

26

The origins and development of public health in the UK

Victorian and Edwardian reformers, he was convinced that
the causal relationship between these two variables operated
in only one direction: ill-health was the major cause of pau­
perism, which necessitated large amounts of unproductive
expenditure on poor relief, which in turn served only further
to demoralize the poor. Measures to improve the health of
the people, whether through better sanitation, the tightening
of building regulations, or broadening the scope of poor law
medicine may be seen within the context of this human capi­
tal approach. William Farr's work at the General Registry
office was also intimately linked to the contemporary^preoccupation with the productivity of the popujation and the
fear of physical degeneration among town-dwellers (Eyler
1979).
As Sutcliffe (1983) has perceptively argued, the urban vari­
able acted as a spur to Victorian state intervention and
government growth because a large number of social ques­
tions concerned with poverty and housing as well as health
were packed into the fear of urban degeneration and physical
deterioration. Public health reform increasingly served as a
filter for more general social reform. This was clearly visible
in the provisions of the 1872 and 1875 public health legis­
lation, which established a sanitary authority for every dis­
trict and gave local authorities powers to deal with water,
sewerage, nuisances, the quality of food, and regulations
concerning lodging houses, bakehouses, and artisans’ dwell­
ings (Brand 1965). While the last three decades of the nine­
teenth century have been generally interpreted by historians
(Flinn 1965; Lambert 1963; MacLeod 1968) as ones in which
Treasury control and the poor law mentality of the Local
Government Board (the central governmental department
which controlled public health and poor law matters from
1871 to 1919) stifled new initiatives in the public health field,
it is nevertheless possible to see the housing legislation of the
1870s and the increasing local effort to introduce elements of
the sanitary idea as proof of the way in which concern about
the conditions of the urban population continued to act as a
spur to health reform. Wohl (1983) and Szreter (1986) have
stressed the extent to which local government spending on
sanitary provisions increased. Between 1858 and 1870 only
£11 million in public works loans were requested by local
authorities, whereas between 1871 and 1897, £84 million was
borrowed. Of course some local authorities were consider­
ably more active than others in this respect. It is no coinci­
dence that the investigations of infant mortality during the
1910s by doctors employed by the Local Government Board
revealed the incidence of mortality to be highest in those
areas where least had been accomplished in providing mains
drainage, sewerage, cleansing, and scavenging. Luckin’s
(1984) study of typhus and typhoid in London has shown that
in neither case can the diminution of mortality be correlated
successfully with the provision of pure water or of sewerage.
Typhoid showed a substantial and continuous decline
between 1871 and 1885, but it was only in the 1890s that more
than 50 per cent of London’s population had access to a con­
stant water supply, while in the case of typhus, extra-urban

sewerage was not introduced until the 1860s, and overcrowd­
ing persisted through the 1880s. Such findings serve to rein­
force the importance of seeking multicausal explanations;
indeed Luckin suggests it is necessary to take into account the
decrease in migration from urban Ireland after the 1870s.
Nevertheless, in reaching some assessment of public health
provisions in the nineteenth century, it is important to
acknowledge the breadth of the public health remit. ‘Slum’
and ‘fever den’ were terms used interchangeably in the nine­
teenth century (Wohl 1983). Both they and their inhabitants
were feared as agents of infection before it was even under­
stood exactly how this occurred. As Starr (1982) has pointed
out, all dirt was considered dangerous. By the end of the cen-.
tury, social investigators were convinced that physical wellbemg was a necessary prerequisite for further social progress.
The urban environment was feared to be producing a race of
de^efatesTpEysicany^^
slippage between social and moral categories, so characteris­
tic of Victorian social science, served only to intensify the
fear of contamination. Fear, together with religious zeal and
civic pride (albeit often moderated by ratepayer parsimony),
combined to effect the sanitary reform associated with the
early public health movement. Collective action, most impor­
tantly at the local level, was the means of accomplishing
reform, and those best served by modern local government
after 1835 got the best protection against disease (Flinn
1965).
The role of doctors was muted in the Victorian public
health effort. Flinn (1965) has argued though that their real
contribution consisted in the promotion of an awareness of
the association between dirt and disease and has suggested
that there was little in Chadwick’s 1842 report that had not
already been discovered by doctors. Chadwick’s own propen­
sity to see the medical profession as merely ‘the first among
equals’ rather than the sole source of professional expertise
on issues of public health is well known. The 1848 Public
Health Act permitted local boards of health to appoint a
medical officer of health (MOH), but it was not until the 1872
Act that the new local sanitary authorities were required to
do so, and not until 1909 that the county councils were also
compelled to appoint county MOsH. As Watkins’ (1984)
revealing analysis of the professionalization of the MOH has
shown, the definition of the role of the medical officer caused
considerable heart-searching during the last quarter of the
nineteenth century. The problem was how to make the MOH
an independent medical practitioner, as opposed to a poor
Faw doctor or an engineer' The main duties^ftheMOH were
twofold (Wilkinson 1980), involving first the duties of sani­
tary inspection and improvement (which were to earn the
MOH the derogatory title of ‘drains doctor’), and second,
disease control, emphasizing primarily isolation and removal
to hospital and the tracing of the foci of infection in epide­
mics. The lonely battles of some late nineteenth century
medical officers to raise the awareness of a backward council
or to take on negligent landlords were real enough, and
before legislation was passed to give MOsH security of ten-

A

©

The heroic age? Victorian and Edwardian public health

I

ure (in 1909 to county medical officers and in 1921 to district
MOsH) they ran the risk of being dismissed for their pains.
However, it was not until the 1890s that the publicjiealth.
doctors emerged as a clear professional group, and as late as
1893 some were arguing against security of tenure and fulltime employment because they felt this would stop them
from practising curative medicine as general practitioners.
The emergence of a definable group of public health doctors
was grounded firmly in the development of medical qualifi­
cations and an effort to distinguish preventive from curative
medicine. The 1888 Local Government Act, which created
the exclusive appointment of only suitably qualified officers
to county posts, together with the Medical Act of 1886, which
required candidates for the Diploma of Public Health to have
a medical licence, combined to produce the basis for a new
professionalism. Above all, training in public health stressed
the importance of understanding the aetiology of disease,
and by the 1900s advances in bacteriology had come to domi­
nate the public health curriculum. Fee (1990T shows that the
story is similar in the US. Indeed Starr (1982) has character­
ized the shift in the changing nature of public health work in
the twentieth century as a move towards a ‘new concept of
dirt’. As a result of germ theory, the twentieth century con­
cept of dirt ‘narrowed’ so that it proved considerably cheaper
to clean up. This analysis is valuable for the way in which it
acknowledges the importance of the political imperative to a
more limited, less costly, mandate for public health, in
addition to that of developments in medical science.
C. E.-A. Winslow, the early twentieth century American
authority on public health, identified three phases in the
development of public health: thefirst, from 1840 to 1890 was
characterized by environmental sanitation; the second, from
1890 to 1910, Ty~ developments in bacteriology, resulting in
empfiasiT on “isolation and disinfection; and the third,
beginning around 1910, by an emphasis on education and
personal hygiene, often referred to as personal prevention
(STaff TVS'ZjT'This chronology is broadly congruent with
developments in Britain. For despite a dramatic growth in
the statutory powers of public health departments, twentieth
century developments resulted in a narrowing of public
health’s mandate. Scientific advances in bacteriology re­
defined the kind of intervention appropriate for public health.
Once it was realized that dirt per se did not cause infectious
disease, the broad mandate of public health to deal with all
aspects of environmental sanitation and housing as the means
of promoting cleanliness disappeared. Germ theory deflected
attention from the primary cause of disease in the environ­
ment andTromThe incfividuaFs relationship to that environmenf7_and~nTacfe“a“direcf appeal from mortality figures to
social reform much more difficult (Hart 1985). Increasingly
public health authorities and the growing numbers of MOsH
in them focused on what the individual should do to ensure
personal hygiene. During the Edwardian period, there was
much more legislative activity in the field of social policy—
Harris (1983) has argued that during these years social policy
issues, for example in the form of national insurance and old-

27

age pensions, entered the realm of ‘high politics’—but public
health reform no longer served as the filter for more general
social reform. Health and welfare were firmly separated in
Edwardian Britain and a tighter mandate was imposed on
both. Thus, in narrowing its focus, public health was arguably
responding to the changing framework of state intervention
as well as to changes in medical science.
No clearer example of the effects of these developments
can be found than in the campaign to reduce the infant mor­
tality rate (Lewis 1980). Epidemiological studies of the prob­
lem conducted by public health doctors in the 1910s revealed
the death rate to be highest in poor inner-city slums, where
insanitary and overcrowded conditions prevailed. Yet
government officials and public health doctors tended to view
maternal and child welfare in terms of a series of discrete per­
sonal health problems, to be solved by the provision of health
visitors, infant welfare centres, and better maternity services.
The bulk of their attention as well as that of the large volun­
tary maternal and child welfare movement was focused on
health education, encouraging mothers to breast-feed and to
strive for higher standards of domestic hygiene. Dwork
(1987) has argued that this emphasis was justified by the bac­
teriological work on infant diarrhoea. Furthermore, public
health doctors could only do what was politically feasible.
Unable to abolish poverty and secure better environmental
conditions, they concentrated on mothers. This_js___fair
enough; pubiicTeaith was no 16nger~the~vehicle through
which a variety of collective provisions could be justified. But
opinions differ over the effectiveness of the new twentieth
century focus on the individual, justified by public health
doctors as ‘applied physiology’ and a new kind of preventive
medicine. Dwork (1987) and Szreter (1986) are probably
overly optimistic in the praise they reserve for the edu­
cational efforts of public health workers; the number of
mothers reached must have been relatively few, and in this
instance Winter’s (1982) emphasis on the importance of ris­
ing living standards during The First World War, and
especially on rising real wages, appears more crucial.
The vision of nineteenth century public health was broad,
not least because in the period before other social policy
issues such as housing and income maintenance entered the
realm of ‘high politics’, public health legislation provided the
only legitimate means of attacking them. Leaders such as
Chadwick and Simon were able to exploit this situation,
albeit that Simon experienced considerable civil service
opposition to his expansionist ideas in the last part of the cen­
tury. But the existence of such a broad vision does not
necessarily mean that proponents of health were bent on pur­
suing an optimal strategy to secure the health and welfare of
the people. It would be more accurate to describe nineteenth
century aims as minimalist, designed to secure a functioning
working population. Chadwick, after all, was inspired to
action on health reform by the idea that disease brought large
numbers on to the poor law. Nineteenth century public
health measures isolated infectious people and began clear­
ing the slums that were the product of poverty, but they made

28

9

The origins and development of public health in the UK

no attempt to tackle the issue of poverty directly. Public
health was defined in such a way that a wide range of social
issues fell within its compass, and its effectiveness was due in
large part to the degree of state intervention ancT collective
provision that was achieved. ButThis didTiot mean that its
proponents saw it necessary to take positive action to tackle
social issues or to put accountability to the people before
accountability to the state. The nineteenth century sanitar­
ians were not afraid to tackle water companies, landlords,
and other vested interests, but it was not part of their plan to
change radically the social and political fabric. By the early
twentieth century, the concerns of public health were chiefly
those of personal hygiene. Indeed, the Fabian model for
reform of state medical services developed by the Webbs
sought to use the public health departments because they felt
that public health doctors created ‘in the recipient an
increased feeling of personal obligation and even a new sense
of social responsibility . . . the very aim of the sanitarians is
to train the people to better habits of life’ (Webb and Webb
1910). While in 1911 a national insurance rather than a public
health model of reform was adopted in the restructuring of
publicly provided medical services, the Webbs were correct
in their perception of the direction of public health practice in
the early twentieth century, with its increasing emphasis on
the delivery of personal preventive medical services. This was
to render public health’s impact on the structural variablescrucial to the prevention of disease and the promotion of
health more limited.

Community watchdog or ‘Third Grade
Doctors’? Public health 1919-681
By 1918, the chief medical officer to the Local Government
Board, Sir George Newman, was arguing that preventive
medicine must be given a greater place in the education of
every medical student. He insisted that public health was no
longer concerned with sewerage, disinfection, the suppres­
sion of nuisances, the notification and registration of disease,
and the implementation of by-law regulations, but rather was
about ‘the domestic, social and personal life of the people’
(Newman 1928). In his riwmbran<3um~dn the practice of pre­
ventive medicine, first issued in 1919, Newman argued for a
new ‘synthesis and integration’ in medicine and, in particular,
a closer integration of preventive and curative medicine. But
emphasis on the idea_ that the preventjpi^^^
become less a matter of removing external environmental
‘nuisances' and more a personal concern brought the practice
of public health very close to that of the general practitioner.
Public health doctors welcomed a wider recognition of the
importance of the ideas they promoted. However, if it could
be argued that a ‘preventive consciousness’ was something
that all doctors should have, it became additionally difficult
1. The issues raised in the next two sections are dealt with more fully
in Lewis (1986a).

to distinguish the core of public philosophy and practice from
the work of other medical practitioners. Throughout the
inter-war years, there was considerable antagonism between
public health doctors and general practitioners over the role
of the public health clinics, with general practitioners
accusing medical officers of health of ‘encroachment’ on their
private practices. However, in terms of medical politics, pub­
lic health departments felt themselves to be in a position of
strength during this period. Governments of the inter-war
years failed to extend health service provision under the
National Health Insurance Act, and instead added piecemeal
to services provided by the local authorities via the public
health departments. By 1939, local authorities were permit­
ted to provide maternal and child welfare services, including
obstetric and gynaecological specialist treatment; a school
medical service, including clinics treating minor ailments;
dentistry; school meals and milk; tuberculosis schemes,
involving sanatorium treatment, clinics, and aftercare ser­
vices; health centres, the most elaborate being that built by
the Finsbury Borough Council in 1938; and local regional
cancer schemes. The most important addition to the medical
officer of health’s responsibility came in 1929 when local
authorities were permitted to take over administration of the
poor law hospitals and many MOsH found themselves taking
on the role of medical superintendent. From a position of
growing strength, in terms of the tasks they were being called
upon to perform, MOsH spoke with increasing confidence of
the importance of the public health service in leading the way
in preventive medicine, primarily through the work of edu­
cating the public in personal hygiene, and of the importance
of educating general practitioners to play their part. But at
the end of the day, it may be argued that public health failed
adequately to distinguish the content and direction of its
work from that of other practitioners, especially general
practitioners, which made its position extremely vulnerable
when, in the post-war reorganization of health services,
government decided not to take the public health service as
the model for the new NHS. In addition, public health’s pre­
occupation with, first, the hygiene of the individual and,
second, the administration of a growing number of services,
resulted in a neglect of the MOH’s traditional task of ‘com­
munity watchdog’ in respect to sources of danger to the
people’s health.
There was considerable discussion as to the meaning of
preventive medicine in the public health journals during the
inter-war years, but new thinking about health as opposed to
sickness and about the determinants of both came not so
much from the public health practitioners as from privately
funded experiments such as the Peckham Health Centre
(which aimed to promote health rather than to prevent dis­
ease); pressure groups, such as the Women’s Health Inquiry
and the Children’s Minimum Council (a forerunner of the
Child Poverty Action Group); and most importantly, from
academics in medical and social science, who began talking in
the 1940s about the importance of a concept they called social
medicine rather than public health. It is significant that public

Community watchdog or ‘Third Grade Doctors’? Public health 1919-68
health practitioners were at first puzzled by the discussion of
social medicine and by the late 1940s had rejected it.
Throughout the 1920s, public health departments were
able to sustain their claim that ‘public health work is mainly
clinical medicine but clinical medicine of a special kind’ by
following the principles of Newman. The division of labour
between MOsH and general practitioners rested on the sep­
aration of health education and advice from treatment.
Despite the charges of general practitioners, the evidence
suggests that public health departments were, in fact, careful
not to offer any treatment other than for the mildest ail­
ments, but the boundary between the two types of provision
was obviously hard to draw and was indeed sustained largely
by a system of health services in which treatment was not free
at the point of access. Nevertheless, increasingly MOsH
looked forward confidently to the time when, in the words of
the MOH for Willesden, ‘the very large provisions and con­
centrations in respect of public health and medical work
made by the Local Government Act of 1929 are likely to lead
to a state medical service’ (Buchan 1931, p. 9).
By the 1930s, many MOsH were greatly involved in their
new administrative responsibilities for the former poor law
medical institutions. Fears were expressed that the work of
hospital administration was diverting MOsH from their main
task of prevention. The editor of the Medical Officer (Editor­
ial 1930, p. 21; 1931, p. 1) wondered whether MOsH would
be able to return ‘from the pursuit of pathology to their
proper allegiance to physiology’, commenting that ‘much
recent public health work seems to aim at converting it into a
gigantic hospital’. But, by defining preventive medicine as
including all measures devised to prevent premature death
and to maintain optimum health, at least one MOH produced
a spirited defence of the MOH’s involvement in hospitals
(Ferguson 1938). Most MOsH were content to define public
health in terms of the tasks it was prepared to assume.
The history of diphtheria immunization gives point to the
criticism that MOsH had become too involved in day-to-day
administrative duties, particularly in respect of hospitals.
Responsibility for immunization rested very much with indi­
vidual local authorities and the local MOH, whose task it was
to persuade the local public health committee to pursue an
active immunization campaign. This often required special
persistence in the financially straitened circumstances of the
1930s. Effective immunization agents were available by the
early 1920s and reports of successful large-scale trials in
Canada and the US were published at the end of the decade.
Yet between 1927 and 1930 the medical journals show that
large numbers of MOsH were preoccupied with more tra­
ditional approaches to the control of the disease and were
deeply distrustful of immunization. A significant number
seem to have concentrated their efforts on swabbing throats
and noses in an effort to identify carriers, and on confining
victims in isolation hospitals. Bryder’s (1988) research has
also shown that public health doctors employed as tuberculo­
sis officers tended to identify with the institutional treatment
of the disease. In the case of diphtheria, the result was that

29

while the death rate in Canada fell steadily in the 1920s and
the 1930s, in Britain the rate showed no decline until 1941,
when a national immunization scheme was eventually imple­
mented (Lewis 19866). Certainly, R.M.F. Picken, the pro­
fessor of preventive medicine at the Welsh School of
Medicine, felt that the case of diphtheria proved that the
MOH had taken on too much administrative work to be an
effective proponent of preventive medicine (Picken 1959).
Recent research provides considerable evidence that
MOsH neglected many aspects of their duties as community
watch-dogs during the 1930s, both in regard to more tra­
ditional areas such as immunization and to the new-found
concerns over the effects of long-term unemployment on
nutritional standards and levels of morbidity and mortality.
For the most part, MOsH filed optimistic annual reports on
the health of their communities. Government opposition to
increased public expenditure during the Depression made the
Ministry of Health wary of supporting any findings that might
have been interpreted as necessitating more spending on wel­
fare benefits, and it consistently refuted evidence provided by
pressure groups and social scientists as to the existence of a
relationship between high unemployment and deteriorating
health standards, reserving particular condemnation for the
handful of MOsH who expressed similar opinions. Some fifty
authorities, mainly in the depressed areas, sent in returns to
the Ministry of Health suggesting that they were experiencing
less than half the average incidence of subnormal nutrition.
Some MOsH were philosophically opposed to giving nutri­
tional supplements despite the apparently good results in this
regard achieved by the National Birthday Trust among preg­
nant women in South Wales (Lewis 1980). It is hard to avoid
Charles Webster’s conclusion that in adopting an optimistic w
view, MOsH were telling the Ministry of Health what it
wanted to hear (Webster 1982, 1985).
‘
■
The lead in raising questions about the health status of tne
population during the 1930s was taken by political lobby
groups such as the Children’s Minimum Council, the Com­
mittee against Malnutrition, and the National Unemployed
Workers Movement, all of which called for a higher level of
unemployment benefit to enable families to secure the mini­
mum nutritional requirements set out by the British Medical
Association. Groups such as the Women’s Health Inquiry
surveyed the health status of some 1250 working-class wives
and found that only 31.3 per cent could be considered to be in
‘good health’ (Spring Rice 1981), while a professional social
scientist like Richard Titmuss (rather than a public health
doctor as was the case in the 1910s) undertook a survey of
infant mortality and concluded that the decline in the overall
infant mortality rate was not matched by a narrowing of the
gap between social classes (Titmuss 1943). Finally, a small
number of consultants, particularly obstetricians and gynae­
cologists, attempted to draw attention to the high rate of
maternal mortality and morbidity. Sir James Young esti­
mated about 69 per cent of hospital gynaecology to be a leg­
acy from vitiated childbearing and despaired of ‘the apathy of
organized medicine towards the positive value of health

V

0

30

The origins and development of public health in the UK

ideals’ and ‘the profession’s devotion to disease [which] has
blinded us to the duties of health’ (Young 1933, pp. 119-20).
G.C.M. McGonigle was one of the very few MOsH who
attempted to link public health more to ideas of positive
health, rejecting the idea of ‘personal preventive clinical
medicine’. For example, he was virtually alone among public
health doctors in insisting that the general decline in infant
mortality had begun long before the advent of generalized
child welfare work. In his own district of Stockton-on-Tees
he undertook an influential study of a group of families who
were moved from slum houses to a new housing estate and
showed that their health status deteriorated relative to those
who stayed behind, largely because of the greater proportion
of their income that was absorbed by the higher rents that
they had to pay (McGonigle and Kirby 1936). Essentially
McGonigle was defining public health^ task as a co.nce.in
with the determinants of health and their promotion at a time
when the majority of MOsH were content to expand the
range of the services provided by their public health depart­
ments, expecting that the balance of medical care provision
would soon swing in favour of a state service, thereby
increasing the influence of the MOH as the only salaried doc­
tor. However, in view of both the British Medical Associ­
ation’s resolute opposition to such a vision (British Medical
Association 1938) and the Ministry’s disinclination to opt for
a full state-salaried service, such hopes were unrealistic.
In the meantime, public health practitioners_faile_d to sup­
port the first major initiative to provide a new direction for
public health in the twentieth'century: social medicine. The
rodtTof social medicine were to be found in the work of
social investigators and pressure groups concerned about
health status during the 1930s. John Ryle paid tribute to their
work when he became the first professor of social medicine at
Oxford in 1942. Lecturing to his medical students in
Cambridge in 1940, he stressed the importance of developing
a social conscience and of considering the larger social prob­
lems (Ryle 1940, p. 657). Richard Titmuss played a major
part in developing the concept of social medicine and in 1942
drafted a paper explaining the idea as ‘yet another stage in
the growing recognition of the social relations of Health. Our
vision is broadening; men are being pictured against a man­
made environment; the multiple factor in disease and dis­
order is replacing the single causation concept; the study of
life is replacing a morbid concentration of death’ (Titmuss
1942). Titmuss was consciously seeking to make public health
departments take the lead in promoting renewed collective
action against the structural impediments to health.
However, after the establishment of the Oxford chair in
1942, the development of social medicine was conditioned by
the fact that its voice was confined to a few university depart­
ments , and in thcscarchjor academic credibilityaLniQ-ved
further away from a congern with health policy and social
scienceTfKus social medicine failed in two crucial respects to
fulfil its early promise. In part because of this and in part
because of their own narrowness of vision, public health
practitioners did not take up the idea of social medicine. This

in turn resulted in a damaging rift between the leading
teachers of social medicine and practitioners of public_healih.
T^ylFs own later work emphasized not only the links \
between social medicine and clinical medicine and epidemio­
logy at the expense of social science and health policy, but 1
also the importance of the study of ‘social pathology’—the
quantity and cause of disease—at the expense of the more
radical and difficult aim of promoting health. As an Ameri­
can observer remarked in 1951, the Oxford Institute con­
cerned itself more and more with factors affecting mortality
and morbidity, shying away from ‘the allegedly sentimental
aspects of social medicine . . . often stigmatized as the
“unmarried mother” category of social problems’ (Weiner­
man 1951). For example, Ryle criticized J.N. Morris and R.
Titmuss’s study of the epidemiology of rheumatic heart dis­
ease for paying too much attention to ‘the poverty factor’.
Leff (1953) noted that the practice of social medicine had
increasingly come to mean the collection of medical statistics
and that one of its main weaknesses lay in the arbitrary selec­
tion of problems for study which were often unrelated to the
practice of medicine or to the life of the community.
Medical officers of health were offended by the criticisms
levied at public health departments by academic leaders of
social medicine and registered their impatience with its high
academic tone. At the same time social medicine failed to
have the kind of impact on the medical schools that Ryle had
hoped for. The 1944 Report of the Inter-Departmental Com­
mittee on Medical Schools recommended the development of
departments of social medicine, seeing them as a means of
reorienting the whole medical curriculum (Ministry of Health
and Department of Health for Scotland 1944). However,
most medical schools responded by slightly modifying their
departments of public health but without fundamentally
changing their approach to medical education. Indeed./
Ryle’s chair was not filled when he died in 1950.
In the way that it developed, social medicine was arguably
deeply flawed. However, in^the_early 1940s it offered an
opportunity for challenging the whole nature of medical edu­
cation and for creating an exciting synthesis between social
science and medicine. As it was, the influence of social medi­
cine departments remained limited and the schism between
academics and practitioners persisted, attracting the atten­
tion of the 1968 Commission on Medical Education (PP
1968a), which, recommended., that a new specialty j>f„Qonimunity medicine be estaJbhsh£±.tQ..bndRg. the gap between
the two groups.
In the new NHS of the post-war period, public health doc­
tors found themselves searching for a new direction, having
lost control over the municipal hospitals and facing the inevi­
table decline in their clinic work because of the universal
access to general practitioner services provided under the
NHS Act. The immediate inclination of MOsH was to look
for new services to administer. Responsibility for running
ambulance services, home helps, and old people’s homes
became particularly time-consuming tasks. As a result, local

I

Community watchdog or ‘Third Grade Doctors’? Public health 1919-68
authorities expressed the view that MOsH were but ‘adminis­
trators with medical knowledge’, and public health doctors
spent much of the 1950s and 1960s fighting the insistence of
local authorities that they should be paid on a scale comparable to other administrative officers rather^ than to other,
doctors.
Increasingly MOsH found themselves squeezed between
pressures from within—in the form of the local government
hierarchy and the desire on the part of sanitary inspectors,
health visitors, and social workers for greater professional
freedom—and pressures from without. The latter included
general practitioners, with whom they had to share the extra­
hospital territory, and from academics and social scientists
who expressed increasing impatience in respect of the per­
ceived failure of the public health departments to deliver
effective community care. As Walker (1982) has observed,
community care meant different things at different times and
in relation to different groups in need. In respect of the
elderly, where it was originally intended to mean domiciliary
care, it was reinterpreted to include local authority residen­
tial care. Thus both the Hospital Plan of 1962 and the local
authorities’ Health and Welfare Plans of 1963 envisaged the
expansion of residential provision. In the meantime, the
shortage of beds in both sectors resulted in increasing confu­
sion as to the boundaries between the two types of care. With
the failure either firmly to distinguish community care from
institutional provision or to increase the flow of resources to
domiciliary care, the Ministry resorted to exhorting the three
parts of the NHS—general practitioners, hospitals, and pub­
lic health—to co-operate and co-ordinate their work. MOsH
were seen as the principal co-ordinators and increasingly
found themselves condemned as unimaginative and narrow
in their approach. In the view of Titmu§s and Morris, for
example, the description of ‘administrators with medical
knowledge’ was broadly accepted and MOsH were seen pri­
marily as managers of services, doing little to investigate
properly the health status of their populations and to plan
services accordingly. The public image of the MOH was
unhappily personified in the dreary and obstrucTi^^Fcharacter of Dr Snoddy in the popular television series, ‘Dr Finlay’s
Casebook’.
Academics in departments of social medicine and of public
health and social scientists began as early as the 1950s to urge
substantial reform in the training of public health recruits and
in public health practice in order to reinvigorate the spe­
cialty. In particular a case was made for ‘medical administra­
tion’ as specialized work, not in the sense of institutional
administration, as was the case in the 1930s, but rather in the
hope that MOsH would become broadly based ‘health strate­
gists’ (e.g. Irvine 1954; Wofinden 1959). The Department of
Social Medicine at Edinburgh University was the first to offer
a diploma in medical services administration in 1959. How­
ever, in the debates over the possibilities of medical adminis­
tration, the relationship between the executive (or
management) and advisory roles inhefenfih the work of Jtbe
medical administrator was never made clear. These issues

7

31

were to continue to bedevil the conceptualization of com­
munity medicine and the role of the community physician.

Specialist advisers or managers?
Community medicine 1968-88
In the context of the strong arguments for reform and revital­
ization being provided by the academics, the recommen­
dations of the Seebohm Report on social services and of the
Government’s Green Paper on NHS reorganization, both
published in 1968 (Ministry of Health 1968; pp. 1968/?), pro­
vided the final push. J.N. Morris was the only medical mem­
ber of the Seebohm inquiry, and both he and Titmuss were
convinced of the weakness of local authorities in general and
of public health departments in particular in achieving pro­
gress in the field of community care and in developing new
approaches to social work. In recommending the setting up
of new social service departments, the Seebohm Report
threatened to remove the fastest growing services that came
under the MOH’s control. It was no coincidence that the
Green Paper sought to reassure public health doctors that
they would find a new expanded (albeit unspecified) role as
community physicians within the reorganized NHS.
It was J.N. Morris who first defined the role of the com­
munity physician. He believed strongly that public health
practice should be grounded moreL fiimly in the principles pf
modern epidemiology. His textbook on epidemiology identi­
fied the major uses of the subject as historical study, com­
munity diagnosis, analysis of the workings of health services,
analysis of individual risks and chances, the identification of
syndromes, and the completion of the clinical picture (Morris
1969a). From this he evolved the concept of a community
physician responsibleToFcommunity diagnosis and thus pro­
viding the ‘intelligence’ necessary for the efficient and effec­
tive administration of the health services (Morris 1969/?).
Morris did hot agree with the attempt of some American
epidemiologists to ‘rescue’ epidemiology from public health
and bring it back to the ‘laps of practising physicians’ (Paul
1958), but he nevertheless approached prevention through
the needs of the individual, believing that a multicausal, epidemiological approach would ensure consideration of socioeconomic and environmental variables and eliminate the
danger of ‘blamlng the victmi’ for illness. Using the example
of coronary heart disease, he argued that the barriers
between prevention and cure were crumbling and that ‘public
health needs clinical medicine—clinical medicine needs a
community’ (Morris 1969/?). Like Ryle, Morris emphasized
the importance of co-operation with clinicians.
His ideas were fed directly into two crucial policy docu­
ments of the late 1960s, the Seebohm Committee and (via
Richard Titmuss) the Todd Commission on Medical Edu­
cation, which also reported in 1968. The latter clearly articu­
lated the two main strands of Morris’s formulation of
community medicine when it defined it as ‘the specialty prac­
tised by epidemiologists and administrators of medical

I

' (Au,< 'i 'v
32

The origins and development of public health in the UK

services’ (PP 1968a). It also recommended closer links with
clinical medicine and between academics and practitioners in
the field and, like the Seebohm Committee, envisaged envir­
onmental health services and social work services leaving the
public health department, and the community physician mov­
ing away from clinic work.
MOsH showed considerable awareness of the problems of
coming under the control of central government and of for­
ging working relationships with other doctors in the NHS,
particularly in the hospital sector, but were nevertheless
attracted to the idea of community medicine chiefly because
they understood that it meant a substantial rise in status for
the specialty. They also interpreted the job description for
the community physician as recognition of their past work in
administering services; at no time were they able to concep­
tualize the nature of their management role in the
reorganized NHS.
This was particularly crucial because it would seem that
olicy-makers’ understanding of the role of the community
physician differed in emphasis from that of academics. The
key documents published prior to NHS reorganization in
1974 saw the new community physician as the key to effective
integration of the health services, linking lay administrators
to clinicians and co-ordinating the work of the NHS with that
of the local authorities. The community physician was recog­
nized as a specialist adviser, with particular skills in epidem­
iology, but a substantial number of community physicians
were to be given management responsibilities in the new con­
sensus management teams in order properly to utilize their
expertise (Department of Health and Social Security 1972a,
b). It seems clear that while the Faculty of Community Medi­
cine stressed the community physician’s specialist/advisory
role and stressed the complementarity between community
and clinical medicine, policy-makers stressed the importance
of the community physician recommending changes in the
deployment of resources and of management.
MOsH moved into the role of community physician believ­
ing that they were to be the linchpins of the new NHS, coirdinating and administering services, but with little idea as
to the meaning of their formal role in the new management
structure or the place of ‘management’ in their total package
of tasks and concerns. From the beginning, community phys­
icians found the ‘community hat’ a difficult one to wear.
While the Todd Commission on Medical Education had pro­
posed that the term community should embrace the whole
population, including those in institutions, increasingly ‘com­
munity’ came to described the non-hospital services. Thus
while it was intended that the community physician should
provide the necessary ‘intelligence’ for adjudicating the
resource needs of various types of health services including
the hospital, in practice the title of community physician
often meant that other members of the management teams
expected them to speak for the community services outside
the hospital. On the other hand, the battle to come to terms
with the problems of the hospital services meant that many
community physicians who continued to feel considerable

C-Ar

Vj t,

commitment to the extra-hospital health services and to the
work of prevention and promotion, felt that their work was
determined more by the needs of the NHS than by those of
the communities they served (Scott Samuel 1979). Thus the
position of community physicians was subject to serious con­
flicts in terms of both their relationship with other members
of the medical profession and the nature of their primary
responsibility, whether for the management of health ser­
vices or for the analysis of health problems and health needs.
The image of the community physician as primarily a part
of the NHS management structure was reinforced when in
1976 community medicine posts were included in a review of
management costs. The idea that community physicians
should look at the health needs of the district and the alloca­
tion of resources across the whole spectrum of the NHS
would have led to difficulties in relations with other members
of the medical profession at the best of times, for as Gill
(1976) pointed out, their role could easily be ‘interpreted as
an additional mechanism for increasing the accountability of
the profession through internal review and evaluation’. But
during the mid-1970s, when severe financial restraints were
imposed on the NHS, the position of the community phys­
ician became considerably more difficult.
Furthermore, the crucial policy documents of the 1980s
have shown little awareness or appreciation of the com­
munity physician’s role. Increasingly integration of the health
service has ceased to be the focus of attention and the con­
cept of management has shifted away from the achievement
of consensus towards a more straightforward preoccupation
with careful administration and clear lines of accountability.
The 1979 Government document which signalled the 1982
reorganization of the NHS made no mention of community
medicine and the emphasis was clearly on better manage­
ment of the hospitals (Department of Health and Social
Security and Welsh Office 1979). The Griffiths Report of
1983 (Department of Health and Social Security 1983) also
focused firmly on the hospitals and recommended the
appointment of a single general manager, readily identifiable
at all levels of administration.
Because the role of community physicians was determined
in large part by the place they occupied in the 1974 NHS/
structure, this shift has clear implications for community
medicine. While the tensions between the community phys­
ician’s role as specialist adviser or manager has largely disap­
peared since 1984—very few community physicians became
general managers—so also have the tasks of community
medicine become fragmented and the numbers of community
physicians been reduced in many districts. Nor is there any
shared view among the new general managers as to com­
munity medicine’s purpose. In many districts it seems that
the mandate of the community physician has been further
narrowed, to evaluation and audit, or to medical staffing, for
example.
These changes in the fortunes of community medicine jiLust
be located more widely. The reorganization of the NHS in
1974 was motivated in large part by the Treasury’s desire to

1

i
'i

1I
I'
.

■

Specialist advisers or managers? Community medicine 1968-88
gain more control over public spending by the Department of
Health and Social Security. In this attempt, the community
physician was perceived by policy-makers as the linchpin.
When costs in the hospital sector continued to rise, further
reorganizations followed, and in 1984 professional managers
rather than community physicians were seen as the answer to
containing costs and achieving a more rational allocation of
resources. In all this, it would appear that Government has
effectively overlooked the other side of community medi­
cine’s task—that of preventing disease and promoting health
through the provision of specialist advice. But Government
in the 1980s has not been oblivious to the idea of prevention
and promotion, although it has not been inclined to link it
either to the need for a body of specialist medical practitioners or to the need for collective provision, as the poor
response to the BIack'~Report on iriequalrfies in health
(Townsend and Davidson 1982) has shown.
One of the reasons that Governments have gained confi­
dence in their dealings with the medical profession is the pub­
licity accorded to studies that suggest that medical services
have played very little part in raising the health status of
populations (e.g. McKeown 1976). In the light of such evi­
dence, Governments have tried first to switch resources away
from the expensive acute sector to preventive medicine, com­
munity care, and the ‘Cinderella’ specialties, and in so doing
have harnessed the rhetoric of prevention to the cause of
cost-control. When proponents of social medicine talked
about prevention in the 1940s, they meant the identification
of social and environmental factors inimical to health. How­
ever, the concept of prevention in the last decade has concen­
trated on the individual’s responsibility to maintain a healthy
lifestyle. Second, Governments have sought to invoke the
right to consumers to increased choice and have sought to
achieve this negatively, by decreasing the power of providers
rather than by empowering consumers (Davies 1987).
//
Because community medicine was embedded in the struct
ture of the_NHS, it can be argued that it requires political will
to revitalize the specialty. But current Government thinking
is along very different lines from that of 1974 and the role of
community medicine does not figure largely on the political
agenda, notwithstanding the 1988 Government inquiry into
'r, public healthi or the renewed interest in communicable dis­
ease, the traditional preoccupation of the MOH, because of
AIDS. Any attempt to broaden the mandate of community
. J
medicine to a full-blown consideration of health problems
< ; ' < and healtTTstatus must have both political and medico-politi■' 5 c
implications. First, the task of taking a holistic view of
(. health services and of assessing the best balance to be
t e - achieved between services means that public health doctors
v '
run the risk of conflict with other members of the medical
1
profession. The second task of analysing patterns of health
and health needs is likely to involve consideration of factors
outside the scope of the NHS, such as work, environment,
income, and housing. In the last quarter of the twentieth cen­
tury, unlike in the mid-nineteenth century, these factors are
not usually thought of as health problems per se and for doc-

I &

JI

r,

33

tors to talk about them may require the abandonment of
scientific neutrality. A return to ‘public health medicine’ in
accordance with the recommendations of the 1988 committee
of inquiry (PP 1988) may help to clarify the task of public
health doctors, but in and of itself is unlikely to resolve these
fundamental problems.

References
Brand, J.L. (1965). Doctors and the state. Johns Hopkins University
Press, Baltimore, Maryland.
British Medical Association (1938). A general medical service for the
nation. BMA, London.
Bryder, L. (1988). Below the magic mountain. Oxford University
Press, Oxford.
Buchan, G. (1931). British public health and its present trend. Pub­
lic Health 45, 9.
Cronje, G. (1984). Tuberculosis and mortality decline in England
and Wales, 1851-1910. In Urban disease and mortality (ed. R.
Woods and J. Woodward). Batsford Academic, London, p. 79.
Davies, C. (1987). Things to come: the NHS in the next decade.
Sociology of Health and Illness 9, 302.
Department of Health and Social Security (1972^). Management
arrangements for the reorganized NHS. HMSO, London.
Department of Health and Social Security (1972Z>). Report of the
working party on medical administrators. HMSO, London.
Department of Health and Social Security (1983). Report of the
management inquiry. HMSO, London.
Department of Health and Social Security and Welsh Office (1979).
Patients first: consultative paper on the structure of the NHS in
England and Wales. HMSO, London.
Dwork, D. (1987). War is good for babies and other young children.
Tavistock, London.
Editorial (1930). Medicine and the state. Medical Officer 44, 21.
Editorial (1931). Preventive medicine in 1930. Medical Officer 45,1.
Eyler, J. (1979). Victorian social medicine. Johns Hopkins Univer­
sity Press, Baltimore, Maryland.
Fee, E. (1990). The values and impace of the Fox and Welch
reports: alternative conceptions of public health education in
the United States, 1910-1939. In Public health education in
nineteenth and twentieth century America and Britain (ed. R.
Acheson and E. Fee). Oxford University Press, Oxford.
Finer, S.E. (1952). The life and times of Sir Edwin Chadwick. Meth­
uen, London.
Flinn, M.W. (1965). Introduction to Edwin Chadwick’s The sanitary
condition of the labouring population of Great Britain. Edin­
burgh University Press, Edinburgh, pp. 1-73.
Francis, H. (1978). Towards community medicine: the British
experience. In Recent advances in community medicine (ed. A.
E. Bennett). Livingstone, Edinburgh, p. 1.
Gill, D. (1976). The reorganization of the NHS: some sociological
aspects with special reference to the role of the community
physician. In The sociology of the NHS (ed. M. Stacey). Univer­
sity of Keele, Keele, p. 9.
Hardy, A. (1988). Diagnosis, death and diet: the case of London,
1750-1909. Journal of Interdisciplinary History XVIII, 387.
Harris, J. (1983). The transition to high politics in English social
policy, 1880—1914. In High and low politics in modern Britain
(ed. M. Bentley and J Stevenson). Clarendon Press, Oxford,
p. 58.
Hart, N. (1985). The sociology of health and medicine. Causeway
Books, Ormskirk, Lancs.
Irvine, E.D. (1954). Medical administration. Public Health 67, 172.

THE LANCET

European schools of public health in state of flux
Evelyne de Leeuw

Summary
In 1992 there were in Europe 54 schools of public health
and six out of eight possible structures were represented.
To meet future needs two types (the US style school of
public health as a stand-alone academic entity and the
cross-school programme in public health with formal ties to
national public health authorities) seem to be the most
promising alternatives. New schools should strive to take
on one of these shapes, and the rejuvenation of existing
schools might, via accreditation procedures, evolve in

those directions too.
Lancet 1995; 345: 1158-60

Introduction
In Europe public health training seems to be less
developed than it is in the US. The organisational
structures, teaching programmes, disciplinary emphases,
professional profiles of graduates, and quality of teaching
and research vary hugely, as do the populations served by
European schools of public health.1"’ The changing
European scene presents health and higher education
authorities with several opportunities and options: the
Maastricht Treaty establishes new priorities in public
health for the fifteen-member European Union and the
new states and structures in countries of central and
eastern Europe (CCEE) provide unique opportunities for
• innovative teaching models.
One issue in efforts aimed at the professionalisation of
public health in Europe is the integration of the academic
and field activities of public health workers, and that
begins in the educational environment. This article
analyses that environment in structural terms and then
looks at the options both for new sschools of public health
in Europe and for existing ones that wish to define their
role.
Institutionalised public health training in Europe is
highly diverse, with eight different types of structure
(figure 1). Types 1 and 5 are common in the CCEE and
types 2, 6, and 8 are more typical of western Europe;
types 3, 4, and 7 are unusual.
Type 1 has been predominant in the former
communist countries in which the traditional multischool
universities were abolished and replaced by single-school
“universities”. A university of medicine would offer
various programmes in medical and paramedical
education. These programmes are compact, and
restricted in resources both human and financial. This
model is not unique to countries under communist rule,

Secretary-General of ASPHER (Association of Schools of Public
Health In the European Region) (E de Leeuw pud)
Correspondence to: Dr Evelyne de Leeuw, University of Limburg,
PO Box 616, 6200 MD Maastricht, Netherlands

1158

28

even industrialised nations such as Japan have used it, the
Tokyo Medical and Dental University being an example.
Public health research and training within these
universities of medicine tends to be allocated to a
department of hygiene or of social medicine, and the
public health identity of professionals educated in this
environment
is
closely
linked
to
medical
professionalisation patterns.
A type 2 school is similar to type 1. Departments of
public health (community medicine or public health
medicine) offer courses, programmes, and curricula,
mostly at postgraduate level but also for undergraduate
medical students. As in type 1 the staffing and financial
budgets restrict the education that can be offered.
Although the school of medicine is now embedded in a
wider university structure, which would in principle
permit multidisciplinary research and teaching, type 2
schools tend to the medical professional model.
A few European public health training programmes are
based in non-medical schools, such as social sciences or
engineering, but these type 3 institutions are restricted to
specific themes—for example, health education and
health promotion in a school of social sciences or
environmental health in an engineering school. They do
not offer master of public health (MPH) courses and
focus on specialist postgraduate education for social
scientists and engineers. Their graduates lack a public
health identity and for their peer group support and
professional associations they will look to their own
disciplines. For instance, health educators trained in such
a setting are inclined to associate with social psychologists
and/or health sociologists.
To counter the discipline restraints of types 2 and 3 a
few universities have established multischool programmes.
The problems these type 4 programmes face are inherent
in the managerial complexity caused by such horizontal
structuring. Most of them offer public-health
specialisations for a variety of professionals and
disciplines. The major advantage is that both staff and
students are more sensitive to features of other disciplines.
A public health engineer in a type 4 school might more
easily appreciate and integrate health promotion thinking
in his or her work. Even so professional identity as a
public health specialist may still be undeveloped unless
the programme as a whole can, despite its horizontal
organisation, present itself as a unique entity within the
university setting.
Elsewhere public health training is claimed as the
responsibility of national ministries of health. About ten
European schools are the training arms of their countries’
ministries. There are two models here. In type 5 the
institution is entirely under the authority and
management of the national (or regional in some
countries) health authorities. These schools almost always
offer only postgraduate programmes suiting needs defined
Vol545-M«y6,lWtj^

*

THE LANCET

University of medicine

University

University

University
nc

o «

|.i

p

<81

Type 1

£8

Type

Ministry of health

Type 3

£5

Type 4

Ministry of health

University

Research institute

■

Type 6

Type 7

Type 5
no

o £

p is Si

° Q

■c Q

(J o

jz no
o c
m cd

Type 8
Figure: Eight types of school of public health

by government. There are links with the university-based
academic community’ but these are not formalised. On
the other hand, the public health identity of those
educated in this environment may be strong; they form an
elite. A more formal link between the national health
authority’ and the higher education sector is present in
type 6, in which the ministry of health designates multi­
school programmes in a university (sometimes even a
consortium of universities) as the national school of
public health. These programmes serve the needs of the
health ministries yet retain their academic integrity. The
difect link with central government eases access to
research funding. Programmes focus on postgraduate
training, often for a multiprofessional student body. The

Type of echool

Number*

1992

1 (in medical university)
2 (m medical school)
3 (m other school)
4 i university programme)
5 (ministry branch)
6 (ministry programme)
7 (research institute)
8 (school of public health)
Total______________

1995

Stable

In transition New

5

2

18
3
0
10
0
5
13
54

15
3
0
8
0
5
13
46

3+
3t
0
0
2§
0
0
0
8

0

3
1
2
4
2
2
2
16

•Source: 1993 ASPHER directory and reports by ASPHER members during Krakbw
General Assembly (October. 1994) and communications with prospective members.
This account may be Incomplete. There Is no European definition of a ‘school of public
health". The US model la often used But the typology shows that many training other

I

initiatives seif-deflne as schools. The ASPHER progrsmme Collaboration In European
Public Health Training and the European Commisslonn Initiative on the establishment
of sn inventory ell public health training In the European Community will provide better
information In time.
♦Moving toward reintegration as type 8 in universities.
^Developing into type 8 In universities.
§1 moving towards type 7 (indepenoent research insitute), the other towards type 8
(or. possibly type 6).
Table: Number and types of self-defined schools of public health
In European region, 1992 and 199S

Vol 345 • M«y 6, 1995

managerial problems resemble those of type 4 and
although an elite may emerge from these settings, they do
not necessarily identify themselves as public health
professionals.
Two types of school of public health remain. Type 7 is a
stand-alone research institute with a public health
capacity’, offering occasional, and often market-oriented
specialist public health courses. The advantage is
education in the form of innovative applied research but
the absence of professional identification is a serious
disadvantage. Type 8, the equivalent of the accredited
school of public health in the US, an independent
research-and-training institution within the university
system. These schools offer research and training in all
areas relevant to public health; they are multidisciplinary
and interdisciplinary and can draw on a variety of staff
resources; they offer postgraduate training and research
programmes, and most offer undergraduate courses to
students with a variety of backgrounds. Graduates from
type 8 schools strongly identify themselves with “the
profession of public health”.

State of flux In Europe
Public health training in Europe is changing. Schools are
being transformed into new organisational lay-outs and
new schools are being set up. Thble 1 shows that the
number of new initiatives is impressive. Sixteen such
initiatives are known to the Secretariat of the Association
of Schools of Public Health in the European Region, and
there are plans for several others.’ The new schools are
evenly distributed among the eight types. The four type 5
initiatives are in the CCEE, where there may be historical
reasons to set up such training institutions under the
umbrella of a ministry of health. In all 4 countries there is
no other public health training institution.
Of the 54 schools known to ASPHER in 1992 only 8
are in transition and the direction of change is towards

♦

THE LANCET

type 8. Two of the new schools are type 8 too and it looks
as if the stand alone model will take over the lead
previously held in Europe by the medical school-based
institutes (type 2). Is this development desirable?.

Development strategies
“Development of a knowledge base adequate to sustain
research and action in public health well into the next
century will require a breadth of vision hitherto lacking in
those parts of universities and health services where work
on health of populations is funded, researched, taught,
and acted upon.” This call for innovation, in a 1994
Lancet editorial,0 can be answered in part through the
establishment (or re-establishment) of schools of public
health that are not isolated within a purely medical
environment. Schools of types 1, 2, 3, and 5 do not
provide the learning and research settings that fit this
vision. Schools based outside medicine (types 3 and 7)
can contribute to the idea. Types 6 and 8 have the
potential too, as do type 4 schools although the
managerial problems of horizontal academic public health
programmes make this a less attractive alternative.
Although there are examples in Europe where
innovations are likely to match the vision, it is too early
for a rigorous analysis. Schools set up with such a vision
in mind (the Nordic School and the Maastricht and
Bielefeld schools of health sciences) meet the
requirements but there are few such examples and most
new schools of public health in Europe have evolved from
earlier arrangements. The most fundamental innovations
will be seen in CCEE, with schools being designed from
scratch or reintegrated within multifaculty universities. In

1160

some countries, such as Hungary, rigorous accreditation
procedures are being implemented by national science
and education authorities. This accreditation must be
driven by a wish to establish a knowledge base that will
sustain both research and action in public health—and
not by the continuation of a power base that maintains the
status quo. This is a challenge for national authorities and
public health communities both in the CCEE and in the
EU and other parts of western Europe. ASPHER in
conjunction with TEMPUS and PHARE initiatives of the
European Union and World Bank programmes, is
prepared to participate in bilateral and multilateral
support strategies for new and renewed schools of public
health.

References
1 Association of Schools of Public Health in the European Region.
ASPHER collaboration in European public health training. Maastricht:
ASPHER, 1994.
2 WHO/EURO. Training and research in public health: policy
perspectives for a “new public health” (Traimng Res Publ Health Dialog
Ser 1994, no 1). WHO Regional Office for Europe,
Copenhagen/Centre for Public Health Research, Karlstad, 1994.
3 WHO/EURO. Training in public health: strategies to achieve
competences (Training Res Publ Health Dialog Ser 1994, no 2). WHO
Regional Office for Europe, Copenhagen/Centre for Public Health
Research, Karlstad, 1994.
4 Laaser U, de Leeuw E, Stock C. Scientific foundations for European
public health policy. Munich: Juventa, 1995.
5 de Leeuw E. The best school of public health. Int Med Rev (in press).
6 Editorial. Population health looking upstream. Lancet 1994; 343:
429-30.
7 Association of Schools of Public Health in the European Region.
ASPHER directory. Paris: ASPHER, 1993.

30

Vol 345 • May b, 1995

>

it-.’

Section I:

HEALTHY PEOPLE

Chapter 1—Toward a Healthier America

I

The case for preventing disease and injury has been established in part
by a number of accomplishments. Some of the most successful prevention
programs described in the readings that follow are fluoridation otdrinking
water to prevent dental caries, changes in the formulation and packaging
of poisonous agents to reduce childhood poisonings, and immunization
to prevent infectious diseases.
Although the increased survival of Americans into middle age that has
occurred since the beginning of this century is widely recognized—and
resulted from the decrease in infectious diseases—even in the past few
years the U.S. pattern of morbidity and mortality has altered rather
markedly. Much of this recent change has occurred in two serious chronic
diseases—the cardiovascular disorders and cancer. The two brief papers
on these diseases find these recent changes a tantalizing indication of the
potential for prevention, notwithstanding our present inability to link
conclusively the decline in heart attacks, strokes, and some types of cancers notably stomach cancer—to specific causes or preventive measures.
The paper on economic evidence cites studies of screening procedures,
public health measures, and lifestyle determinants of health that find
prevention attractive on economic grounds alone.
Many papers in this volume make strong cases for greater preventive
efforts, using means presently available but not now fully exploited, as
in preventing injuries, mental disorders, and occupation-related condi­
tions. The paper on adolescents points to the unmet physical and mental
health needs in this often-neglected, but critical, age group. Adolescents
take good health for granted, because they seldom have serious health
problems, but persistence of this attitude discourages behavior change to
a more prudent” course—a type of challenge to prevention noted in
the paper on cardiovascular disease.

5

infam'deatVrX-higt'

Xrcromerated ShVir

death rX
d WItho‘her Sloped countries—are the relatively higher
prenatal carejlefs ofte^used b'^SThiXisk^oZ6

Chapter 2—Risks to Good Health
Risks to good health come in various guises. Some are biological, and
many of these are inherited. Others result from individual behavior. Still
others arise from the environment in which individuals find themselves.
Environmental influences on health include the physical environment and
socioeconomic conditions, with the family an important part of the socio­
economic environment. Because risks often work in concert to produce
a particular disease, and synergistic action can multiply risk enormously
controlling risk is rarely a simple matter.
Inherited disorders can cause early death or impairment of physical
or mental function that ranges from slight to disabling—the extent often
depending, in part, on environment. Research is only beginning to
identify the effects of heredity on the likelihood of chronic disorders
occurring in adulthood. The importance of inherited conditions and
congenital disorders in producing morbidity and mortality in infants and
young children is much clearer. This problem is discussed most fully in
the paper on child health. The paper on mental disorders discusses some
or the issues raised by prenatal diagnosis of inherited conditions that
produce mental retardation and the risks and benefits of several screening
procedures. The major difficulties of trying to prevent such mental dis­
orders as schizophrenia through genetic counseling of affected parents is
explained.
The importance of behavioral factors in the etiology of diverse diseases
is becoming increasingly recognized by health professionals and is
described in virtually all of the papers that focus on preventing specific
disorders—including cancer, cardiovascular diseases, oral diseases, and
injuries. Yet, developing strategies to change individual behavior, even
for demonstrably unhealthful activities, is still problematic. The com­
plexities faced by preventive efforts in this area are well described in the
paper on preventing the onset of tobacco, alcohol, and drug abuse.
One of the key environmental correlates of ill health that recurs
throughout this manuscript is poverty. Poverty is related to poor health
in all three age groups that receive special attention—infants and chil­
dren, adolescents, and the elderly—as well as being linked to specific
diseases and events, such as injuries. Poverty can affect health in various
ways. It influences individual behavior that, in turn, can negatively affect
health, and also largely determines the physical surroundings and condi­
tions to which people are exposed.
In his paper on preventing mental disorders, Leon Eisenberg states his
view that universally available, high-quality medical and social services
could diminish “the immorality of social class health differentials” in

oiS “eSk ta",Vr’ I''”"'

1

““

'"’ironmn, «,e dis-

soraers, although they receive mention elsewhere, as well Neverthe
report ST Me T m°St Controversial dewpoints presented in this
haP° ’ J°h". Cairns believes that artificial additions to our environment
have madelittle contribution to the current levels of any of the common

reason K Zm’beT'*16
chapter 6J

°f MediCine adviS0ry c°"™i«ee’s
m°re

Y ” the section 'dn ^eers,

risk JinZidmTf enttrSOC1OCCOnOm,C and Pbysical-is the source of “highmen relX to S
°f StreSS' Rapid cha^es in
environ-

6
7

Section II:

HEALTH GOALS

Chapter 3—Healthy Infants
T ,hea h °f
lnfant during ‘he first year of life is greatly deterFiIner
" H’0"1’’8 befOre birth' Julius Richmond and Barbara
in this serf6 paper °n lnfants and children, from which most'statements
n th s secfon are drawn, point out that two-thirds of all those who die
m infancy are of low birth weight (less than 2,500 grams) Reducine the
inXenUCnitOed s7atesrth
"3
“ Pr°mOting infant hea,th
ba£XdntiOd Of l0'T birth weight is not merely a matter of assuring welltion aftcte the oS c16 "“'"f10"
311 pregnant women- Although nutriXi • . H oatcome of pregnancy, less obviously or less directly
or cigaretteT "and
SOC'O,ecOnomic status’ eternal age, use of alcohol
cigarettes, and prenatal care services also are important Black
omen, poor women, and teenagers, who are at greatest risk of delivering
atow birth weight infant, are least likely to obtain any or early prenatal

Because high quality prenatal care services have a beneficial effect a
major strategy to reduce the incidence of low birth weight entails incre’as
is not ,2a
of prenatal care services. Availability of care however
grams
Ac®e,SsibiIity of care is as important, and outreach pro8 Tn hi? Y b needed t0 encourage w°men to use available services
n his paper on appropriate preventive services for the well nopula

SX? 5ldinB

k- gr",p'!

in thp fi
■ unng PreSnancy should include initiation of prenatal care
alcSo.SdoZd^OOd nUtriti°n’ 3nd tHe 3V°idanCe
Ciga-S

Another way to reduce the incidence of low birth weight is to provide
waeT?abJutn30S00e0V1CeS t0,SeXUal,y active adolescents. In 1976 there
were about 30,000 conceptions among those under age 15 and about
ofnthe n?
.teenagers- In both these age groups, about 40 percent of the pregnancies were terminated by abortion The oaner nn
beF^V1!165
>need f°r SfUdy Of the Psychological-behavioral factors
hmd adolescents motivation to use or not to use contraception
nri^df1Clng 'r6 Incidence of congenital abnormalities is a second appro­
priate focus of a national policy aimed at improving infant health Cong mtal defects are the second leading cause of death for infants and
9

5 to 14. Congenital abnormalities include all those present num uiiin.
Their origin may be genetic, a severe environmental insult ’ <tero, or a
birth injury.
Genetic services—including genetic counseling, testing of parents for
carrier status, and prenatal diagnosis—could reduce the incidence of
genetic disorders; however, diagnostic testing is available only for a
limited, although increasing, number of inherited conditions. Most pro­
grams are now feasible only for identifiable high-risk groups. The feasi­
bility of more wide-scale testing will depend on increased and improved
laboratory and trained manpower resources, which are not expanding as
rapidly as technological innovations are increasing the number of diagnos­
able diseases.
A shortage of resources for prevention notwithstanding, Fielding
reports that genetic screening of would-be parents and early detection of
genetic diseases—both in conjunction with the requisite counseling serv­
ices—have been recommended for high-risk couples as part of a package
of preventive services for the well population. Early detection of meta­
bolic disorders and congenital diseases has been recommended for infancy
and early childhood. Because of the seriousness of these diseases and the
costs of necessary care, screening for some congenital disorders—phenyl­
ketonuria, hypothyroidism, and spina bifida cystica—was cited in the paper
on economic evidence as having passed the test of cost-effectiveness.
Many types of congenital disorders result in mental retardation. In the
paper on preventing mental disorders, the prospects for preventing some
of the more common types are discussed, and some of the risks and bene­
fits of prevention for each are outlined. For example, preventing the birth
of a significant number of Down Syndrome infants is possible by means
of amniocentesis and selective abortion for women over 35, among whom
the incidence is higher. But, declining birth rates in this age group are
reducing the effectiveness of this preventive strategy. Because the risk of
amniocentesis exceeds that of Down Syndrome, screening all pregnant
women, rather than only the high-risk group, would not be medically
justified, even if resources were available. Eisenberg affirms that screening
for mental disorders should not be instituted without the array of fol­
lowup services, diagnostic facilities, and treatment programs necessary to
make effective use of information obtained through screening. He points
out that prenatal diagnosis can serve a salutory purpose when it reveals
that a particular pregnancy is normal, thus reassuring parents at risk who
otherwise would have been afraid to have children.
There have been strong arguments for a genetic predisposition as a
necessary, although insufficient, condition for the appearance of schizo­
phrenia. As a public health measure, genetic counseling of schizophrenics
(primary prevention1) is an inefficient preventive technique, however
1 As to secondary prevention, appropriate treatment at the onset of acute phychosis can
markedly influence outcome, shortening the duration of the acute episode, and increasing the
likelihood that a productive life can be resumed. Some people are benefited more than others,
and recrudescence rates are high. With the methods of care available today, there still remains
a small proportion of patients with chronic schizophrenia who continue to require long-term e
in-patient care—perhaps 50 long-stay beds per 100,000 population.

10

afcted offing in famU^’wh^Tne^t

£

most case:
schizophrenia, neither parent has the disorder. (Schizo­
phrenias remain a major national mental health problem, partly because
they begin at a relatively early age—most frequently in late adolescence
u y aduIthood—they are chronic, and their etiology is unknown.)
More research is needed that would lead to detection of the carrier
state prenatal or neonatal screening, and treatment strategies. An even
roader research strategy would determine the overall incidence of
,c°ndltl0ns and assess the psychological and social impact of
Carrier status.
Environmental hazards that can cause congenital defects include radiation, drugs—including many common medications—alcohol, and viruses.
Even though i the
period of
j
~ 8reatest danger may be during the early
weeks of fetal development—even before a woman
woman realizes
realizes she
she is
is preg
preg-­
nant—these hazards should be avoided throughout pregnancy. Preven­
tion, through avoidance of unnecessary exposures to 'dysgehic or
teratogenic substances (and eliminating head trauma during birth or in
ncc'dents) would reduce the incidence of severe mental subnormality in
children by perhaps between one-third to one-half, Eisenberg estimates,
n general, education programs may help women who are considering
pregnancy or who are pregnant to avoid environmental risks. The paper
on health education states that more effective community health educa­
tion depends at least somewhat on “where and how health care services
are provided. Stud.es indicate that pregnant women are much more
likely to seek early prenatal care (and parents more likely to take their
children for regular pediatric checkups) if these services are offered in
nearby, neighborhood health clinics—with services presumablv planned
around community needs-rather than more distant, and more impersonal, sources of care.
H
Greater education efforts are also needed to alert women to the risk
of fetal alcohol syndrome, a characteristic set of mental and physical
abnormalities
abnorm
ahttes brought on by heavy use of alcohol in pregnancy. “The
risk of and the degree of abnormality increase with increased consumption
oi alcohol, Richmond states.
K
As specific preventive measures, avoiding exposure to radiation and
drugs any time during pregnancy, but especially during the first trimester
om theiOr™^ended’ UnleSS tHe mOther s health wouId be jeopardized with-

Because birth injury is a leading cause of infant morbidity and mor­
ality, there is great interest in medical and technological developments
that will lead to its prevention. Electronic fetal monitoring is one such
development and is used to monitor fetal distress, signaling the need for
quicker delivery. But, electronic fetal monitoring has been accompanied
by a controversial increase in the frequency of cesarean deliveries. While
many obstetricians and hospitals are strong supporters and frequent users
f electronic monitoring, some evidence shows that neonatal mortality
has not been improved due to the practice. The paper on infants and
children concludes that the evidence, both pro and con, is equivocal.
11

red^n^in bZdXu?e7ne.XPenTntal S‘UdieS that have achievcd

laxation therapy (2).

°me hypertensive pat

asj* *«>•* •'r w »•.

s through re-

loin's™1 rtis di“X”th/is°b’ i“,k'd ”,h W'°s”«i <«c-

”■ p.X"bis

?xiss,n '“i y

•n »«ta“LSc.l

"«>■ i"»««ed b,

In their
of health services, Beatrix^ambirrran/M^’^'KIlbS,'11'1^’ and

mg strategies, and the social and^n '
cha,ractenstlcs> personal cop(For more information «e Chanter
COnteXt °f the Iife ~
Further research o^he effects o^’
T PrO”°tio^ ^ess control.)
diseases, particularly cardiovascular disea^^TJ. 511658 m Producing
effects is clearly needed. However n f ’ and how to mediate these
environmental, cultural and hch •’ ^yestl0ns relating to the genetic,
diseases also remain unresolved Bask™ COntJ'lbutions t0 cardiovascular

ad,™ ta e.rdiov.scd,,

One of the primary reasons for the continued belief that at least snmA
cancers are preventable is epidemiologic evidence showing that the 200

?„5“.Cli™1

P'o„™

2 n"db0™“|U're

Reducing Cancer Deaths and Disability

The second leading cause of death in adults is cancer The
for cancer prevention, as presented in the paner bv John r .pr0Spects
seem an overly conservative
.
paper by John Cairns, may
focuses much of his ^XTsm oLh^h"1: J63^5' H°WeVer’ Cai™
improved treatment of cancer which he ma- ^™ pro.spects for new or
prevention. Cairns’ approach is not tn
!\tains boIsters the case for
and other data as one mieht normall n ,provide as muc11 epidemiologic
but rather to present h F hiX
& reVieW article of this ki"d.
in greater detail elsewhere (5-9)P 150113 Vlewpomt on a toPic covered
three Jpes^ctcer-iun!™051
°f CanC6r deaths come from
intestine cancer (50,000)/a^d"breas^ca^ceflSO^OoS.

!arge

advanced very far ” and points
d or ‘we cannot really claim to have
therapy that 7re now avahX ““V
SUCCeSsful forms of Demo­
Annual death rates from cancer^ °r 5kme .atypical” tyP65 °f cancer,
great increase in Jung cancei death^deat:6" r’"6,635^ beC3USe °f 016
cers have declined slightly for women anVh65
nonre®Plratory canfor men since the 1940’s
^3Ve remained quite stable

proved difficulTfor
StOp peoPle from smoking cigarettes. This has
poo0? ^not1101 tJhanged
habffs-perSps'bLause beTng oM and
responded thaUheno1 prOSpeCt-ra? afoul °f commi«ee members who
and that this opinionTmpo^outsid^Xes on Aem^5 m°re S1°Wly
Institute committee members differed with some nf Cnirnc’

22

*r

^iZ^ionEg^i^^68 WiI1 remail ai‘ed- Cai™

fat and mentions evidence suLeshn
high in animal
certain bacteria produces mml
ga
dc8radat'on of bile acids by
members, these diet-cancer linkfTre baseZ1"8 t0 Institute committee
associations, but considerably more
Z °n su88estlve epidemiologic
b'to ■

enhance their likelihood of avoiding prevalent canrrre Thk mic

he™ n..,

dil„,. pnblic „pp<)„

nMdrf b„,c\

,n'Z""' h^“’e’” ,h" h”

committee members-the attempted a ~ r COns£ldered “"Proved by
lack of dietary fiber. Fiber is found in m at'on of colon cancer with
fndts, vegetables, and cereal grains W^Zhigh fiZ" 7°^

Tie“e”tt“ V"“ b"' *Cid‘
(linked with cancers of the esonhZ

deslres~for cigarettes, alcohol

«eus,™ed dle.sJLtme .“tfinS"'- “'d ““

»“
_____ Fioxzo ,-l-l

h.v°”r%Kse°'“h"” 'h“.

b' P"™»W« •*». individual bn-

XL" Z XL“m,"

,j

xi'

r

access to certain kinds of infor-

it ifc^/rhA^T-"8 discussions of cardiovascular disease and cancer
d y du brisks ForenV,r°Tental
behaVi°raI actions should ™rk-’
eoiy reouce risks. For some types of cancers, prevention seems to be a
mort^litv^^rom01^^^ matV’ Documenting reductions in morbidity and
rhJn ty f ? cardiovascular diseases stemming from recent lifestvle
have sX”™
"™TO“
Few .Mea

S™y.""

paper is the powmi.i torXueX'LZXhTdeuLXT" '"d "’!

to the increased use of menopausal eXne vT® t0 be reIated
the risk of breast cancer (76 17\ n f ’ WhlCh may aIso lncrease
responsible for an increas nZhho OJa' “ntraceptives appear to be
and malignant tumors of the liver an^h S ' , Sma11’ number of benign
endometrial cancer m young women
re'ated t0
for some diagnostic and theranpnt’
i ^onizing radiation used
an increased cancer risk (20). For exampZthere8 Z” aSSOciated with
between excessive radiation pynnc
’ t!iere IS a known association

and a study in North Karelia Finland
tf
°gram (27, 22)
flVserum^ch^6?
(particularly cigTene^mohng d^a"

through nnWie H ° ’ a U hypertensi°n) can be reduced substantially
establishment AfdUC
‘hat bnngS ab°ut behavior change and through
nary results of
con’munity services and activities. Prelimi­
nary results of the Finnish study reportedly show declines in eardin
vascular mortality and morbidity, but these need further corroboration

.hyn.^ S™X3“ 53 XX"”',he

exposed to thymic or other head «nrt ,,..,.1, • y, ia cancer in persons
would b. possible .hrough
„p™d.X

op.Xb™“^
come. However, he emphasizes that

S f°r cfncers W111 eventually

■ =''h“"b
>»o.»o I.

24

poop. (r„

•

.hre.<x,“=r s

rates, and among black men. from 46 to 78 nement tower

Chapter 6—Healthy Adults
the major^auses of death and^erhTtOn0miCaany deveIoPed countries,
eases, in particular the ca and disability in adults are the chronic disgoals’ concernedI with imptotS
and cancers. National
these two types of diseases.
8
th StatUS °f adults center on

hLS5it ES^‘1’'he '“ic effre,s the ’l“h<>1 ’“'“f

ST™pk*^

Cardiovascular Disease Risk Factors and Their Control

pX„“. pr'v',“"’7,h’

thisIndiscUSPstoneriS°based
°i Cardiovascular disease, on which
approaches currently I’yailahWr311
C‘early that there are
proved efficacy but Led tn hbJ preve,ntlon- Some °f these are of
if there are no risks could be ad
°therS are unProved but,
may make then, ofi’ntiS appl ca£
haVe rfsks that
on the etiology nathocenesk o h Y' Jhe growing body of knowledge
disease is the foundation for nre^ Pathophysiology of cardiovascular
cussed extensIvX efseXr fFo e 10nt
and has been dis'
raphy covering these tonics h h xample, see (7).) A selected bibliog-

is a healthy one

reveafed" sE

ffective in preventing some

‘“a

SegmentS °f the P°pulation for rcgular exerci^

X-“E’““ta

may be preventable in the futureP New cases of th h ma]0?ty of cases
have been reduced substantially duct
,
f rheumatic heart disease
coccal infections. Surgical
^atment °f Strept°by rheumatic fever (tttiari plevendon) has htl hi
" been damaged
mortality among patients^aEd s
u
ped leSSen morbidity and
sudden heart attack deaffis )

recommende
r the public at large by the American Heart Association
and other £groups, but Paul believes further investigations are needed
Not everyone
me can achieve desirable blood cholesterol levels through diet
alone.
cular toeas^risk facm?°nent,.that
been of concern as a cardiovas­
that thflro
K fact°r IS sodlum. The consensus among authorities is
ha there may be value in limiting sodium intake “moderated’’ and
there are no deleterious side effects of doing so.
aeratety, and
ofXnhn8! heart mTle d*Sease can result from excessive habitual use

^“db“d=E’ £

< b°^ °f epidemioI°gi«l and affimal research thathas

disease, and mortal^ f™m ^artdS’aS^offi^Z^

“ to^eS X"
or protracffid^LoneTa tVIty' InHS°me PeoPle> this response is exaggerated

associated with another risk factor

P.„»d by prem.lnre ,,h“X0J “

te-y er
20

olh„ rilk

t Orverweight

W“ “

s“ “

also

'
more often associated with hypertension. Con-

.......... °

UIUHL

VVUU1U

HcMv

U1L

rates among both whites and blacks

fcicaicbL iiHpdci un Ltiu cieatii

m

mment „( whW1 risk t;ctor isPnos™

’h?h ■

™
■"

”»*'• b« ■’■Il­
ins priorities ta Zsl „ ' " , 8
i”™
O' establishauthor notes, p^fc .To”” 'h'
reduce stroke deaths and efforts o 77
b d preSSUre should also
reduce deaths from lung cancer and X'dXseT smoking would also

Chapter 7—Healthy Older Adults
canPpOonulSoanndrhP1rr
“ ^sing proportion of the Ameri­
can population. Their social, economic, and health status is diverse but
eiceTVn
that aggr®gate those °ver 65 often mask these differ­
ences. In their paper on reducing functional dependency in the elderly
^FraZntZm
f011°Winflg Stat£men'S’ Barbara ^ner and’
1. Franklin Williams use aggregate figures when necessary ’buFemohahron c'di eT
°f
65” ™SeS
^robabfihy of
chronic disease, dependency, and institutionalization. In fact “chronic
disease is a fact of life for most older Americans,” with 80 percent having
one or more chronic conditions. Enduring chronic disease" may prodTcf
tiona7Xng TS
PhJSiCa’ °r mental facilitF Atting the stage for funcional dependency and institutionalization.
r^bfUti5t-PerCent °f ‘he US' P°PuIation 65 and over is in long-term
3d
T’ pnmanly nursing homes. Although most peopfe are
20™ 40 nercemterfm
beCaUSe °f mediCal Care needs’ PerhaPs
20 to 40 percent of nursing home residents do not need intensive or
xtensive care. For these people, the “overcare” provided tends to
are'primariK iJd''hdOd1 thati.they eventually wil1 need such care. These
to aS toynP
I13 7th SOme functional dependency-the inability
to attend to personal needs, such as ambulation, eating hygiene shoorecreatoT’"^
mea' preparation> P^g bills, social Activities, or
recreation—that need not result in institutionalization.
of fu'ncdo^!0^ ,nt"twined with physical health as prime determinants
of functional dependency are poor mental health, low economic status
and social isolation. Yet, dependency is not inevitabie, and mTny condi­
tions predisposing to it are amenable to prevention, reversal, or reduction.
Poor Mental Health
nh]?6
Y T ln/ “hl8h-nsk situation,” predisposing to mental (and
p ysical) disorders for a number of reasons suggested by Lennart Levibasic environmental changes relevant to the care of the elderly have
occurred rapidly; there is a stigma attached to being old; the elderly are
ronme tOt
‘b 't1 d'Sp,acement”; and depersonalization occurs in envistoe a “hi hhlCv th6y a-- ‘ransP'anted- Elderly individuals also con, ‘r“ ® L h’gh-r,sk group, because old age is often accompanied by
tucreased vulnerability (and exposure) to noxious environmental stimuli

26

grief overUtL^U Pf%PSy^ O1°giCa' S‘reSS ar‘SeS from social isolation,
grief over the loss of loved ones, and fears of illness and death Many

elderly carry a heavy burden of stress quite well, but fox jme, an addi­
tional stress—even a minor one—may increase the total burden beyond
manageable limits.
Social isolation and social disruption are cited as major etiologic fac­
tors in depression and consequent physical illnesses. Depression, drug
toxicity, and endocrine-metabolic disorders are the most common rever­
sible causes of mental deterioration. (Although effective treatment for
many causes of senility is unknown, an estimated 10 to 20 percent of
cases of senility result from unrecognized, treatable causes.) Antidepres­
sant drugs provide “powerful methods of secondary prevention,” accord­
ing to Leon Eisenberg.
Low Economic Status

Almost one-quarter of the elderly are poor or “near poor.” 1 Poverty
often underlies malnutrition, an important problem among the elderly,
and another common cause of reversible senility. A frequently overlooked
factor in malnutrition of the elderly is poor dental health. (The available
means for controlling gingivitis and destructive periodontitis in order to
limit tooth loss are detailed in the paper on preventing oral diseases.)
Low economic status contributes to poor dental health.
It is as significant that poor health causes poverty as that poverty
causes poor health,” say Filner and Williams. The intensification of prob­
lems in such cases is clear. Income can determine access to good housing
and to transportation, which have an impact on health status, as well as
increase the likelihood of adverse psychosocial conditions such as stress,
social isolation, and alienation.

Social Isolation and the Need for Social Support

Maximum functional independence requires various types of social
and community support. In their paper, Beatrix Hamburg and Marie
Killilea say that the absence of such support can result in increased use of
the health care system when the problem is not disease. Absence of such
support can also lead to increased use of health services when the major
problem is disease. For example, families could more frequently sub­
stitute for nursing homes during illness recovery, were appropriate sup­
port services more readily available.
Social support networks can reduce isolation, and anticipation of and
planning for expected stressful situations—such as retirement—can obvi­
ate the impact of the change. Natural networks for coping and mutual
aid sometimes exist and have been found, for instance, among minority
elderly groups. In one such group, certain members provided extensive,
assistance to their fellow elderly, serving as a source of information on,1
and a bridge to, helpful resources.
j
1 Based on the Department of Commerce definitions of poverty as annual income below $2,895
for one person and of “near poverty” as annual income above $2,895 but below $3 619 (125
percent of poverty).
’

More formal support networks could be provided by the health care
system. Thus, in the listing of preventive services for the well population
described by Jonathan Fielding, health counseling for the elderly focuses
on adjustment to the problems of aging as an important route to pro­
longing the period of physical, mental, and social functioning, and fos­
tering the continued ability to live independently.
Despite the many adverse psychosocial factors affecting the elderly,
Levi says there are “almost no outreach efforts or in-home services in
existing mental health programs to bring [elderly people] into contact
with the assistance they need.” The paper on the elderly agrees that many
elderly people have needs that are not now being met, but also says that
many support service programs are working well. Such successful pro­
grams are usually characterized by flexibility and integrated, coordinated
services. One measure of the need for achieving such integration is that
people with depressive symptoms tend to seek general medical—not psy­
chiatric—help, according to Eisenberg.
The importance of finding effective ways to integrate health and mental
health services with effective social and community support systems is
crucial, Hamburg and Killilea contend, particularly given the prospect
of national health insurance. Similarly, Filner and Williams conclude
that “the most compelling health promotion need for the elderly is for
integrated, comprehensive services, without the usual health and social
services dichotomy imposed by medicare and other health insurance
coverage.”

Chapter 9—Health Protection
The five health protection targets identified by the Surgeon General’s
Office as part of its strategy to prevent disease and promote health are:
• accident control
• occupational safety and health
• fluoridation of community water supplies
• environmental protection
• infectious agent control

The first three are discussed at length in various papers of this report.
Accident Control
This summary chapter emphasizes strategies for the prevention of
motor vehicle injuries. Prevention of other injuries in childhood and
adolescence was discussed in chapters 4 and 5.
The general approach taken in the paper on injury control by Susan
P. Baker and Park Elliott Dietz is an environmental one. Past strategies
emphasizing changing human behavior have proved largely ineffective,
they believe. However, each of the factors that affects the risks of suffering
injury or death as an occupant of a motor vehicle—amount of highway
travel, road characteristics, speed, vehicle crashworthiness, and use of
restraints—is amenable to prevention through an environmental action.
The effect of better highway design on fatalities is indicated by the
markedly lower death rate per vehicle mile on interstate highways as
compared to other roads. Among the highway design features that reduce
crashes are separation of opposing lanes, improved lighting, and remov­
ing hazardous roadside structures or “using only structures that attenuate
crash forces.”
Speed not only increases the risk of a crash, but increases the likeli­
hood and severity of injury when a crash occurs. An estimated 5,000 lives
have been saved each year since enactment of the 55 mph speed limit,
even though it is not universally obeyed or enforced.
Larger vehicles decrease the risk of death or serious injuries in a crash
(larger cars can be lighter than present vehicles if new, stronger, and
lighter materials are used in their construction, eliminating the conflict
between improved gas mileage, a function of car weight, and automotive
safety). Designing energy-absorbing structures in cars (steering wheels, for
example), eliminating sharp edges, and padding protruding surfaces wou[d
make cars more crashworthy. Industry decisions on whether to incor­
porate such features—an emphasis on safety versus styling—are not
always the most health-protective ones.

Restraint systems—seatbelts and airbags—allow vehicle occupants to
decelerate with their vehicles and spread the decelerative forces over a
wider area. “Use of the combined lap and shoulder belt reduces the likeli­
hood of death or serious injury by about 60 percent,” say the authors.
Yet, only about one-fifth of front-seat occupants wear them. Only about
7 percent of children ride wearing seatbelts or adequate car seats. “The
best protection for a child is to ride in the back, properly restrained.”
“Passive” designs automatically protect occupants in a crash, and the
Federal Government requires that by 1983, new cars must provide devices
to protect front seat passengers with devices like the airbag or passive
seatbelt, which is automatically positioned when the car’s door is closed.
The paper about economic evidence favorable to prevention includes
results of an analysis of the costs and benefits of regular use of auto seat­
belts, which suggests that with full compbance, the annual net benefit
would be about $22.2 billion.
One-sixth of highway fatalities are pedestrian deaths. Better separation
of pedestrians from moving vehicles would benefit all pedestrians, not
just those most likely to be injured—the aged, the very young, or those
impaired by alcohol—who are also those least likely to benefit from
pedestrian education programs.
The basic strategies for protecting riders of all two-wheeled vehicles
are the same. Collisions could be reduced by reducing speed capabilities,
improving visibility, separating two-wheeled vehicles from cars and
trucks, improving operator competence, and making handlebars and other
likely contact points less dangerous. “The most effective strategy for
reducing motorcyclist deaths has been the required use of helmets”; repeal
of these laws in some States resulted in a 24-percent increase in motor­
cycle fatalities between 1976 and 1977. Helmets would also protect riders
of mopeds and bicycles, and wider use of helmets is an “urgent need.”
Various needs for research on preventing unintentional injuries, in
addition to areas stressed by Baker and Dietz, would address risk-taking
and self-destructive behavior, especially in young people, the extent of
drug involvement in accidents, and ways to improve the safety component
in school health education curricula.

Occupational Safety and Health

The paper on improving the quality of the workplace notes that “per­
haps the most important characteristic of occupation-related diseases is
that they are almost wholly preventable.” Potentially, at least, population
groups and hazards can be relatively easily defined and monitored. This
is much less true of hazards that appear in the general environment, to
which an entire population may be exposed. In that sense, occupational
health serves as a paradigm for environmental health. Occupational haz­
ards do not respect workplace boundaries. Toxic substances spread
beyond factories to affect the health of those less directly exposed.
The paper concentrates on health hazards, rather than safety hazards,
which are more readily controlled. Although their death and illness toll
is significant, occupational diseases have long been undercounted, because
of difficulties in linking disease with specific job exposures, lack of aware-

<»

some of these workplace hazards Jr.

'

.....

V'nyl chloril,e- Although

’X" “ ’"J*-

h,ve b“

o«up."V„™

---

to
logical damage, behavioral effects derm/tT Oth^ 1Ung dlsorders’ rneuro
---- ­
Such as Sterility, ahonlan, or teratogen™
”"d re',rod“‘:,i,e Problems.
lor^Tple""X;‘X'es".?T
Hosplta! workers,
suffer kidney ailments, menstrual nr , , 6386 and lnJury; flight attendants
air traffic controllers can suffer mernal
,stress’reIated disorders;
job stress.
mental strain and unpaired health from

However, both the nrr„nof-

trough prowlAct’have existed since 1970

,

only 10 major health standards at least f n
haS ISSUed
down by an appeals court. In a enntrnv • i °twhich has been struck
by the U.S. Supreme Court the an
ersial ruIlng scheduled for review
failed to estabfish thaFcompliance with thTa deCi’6d that °SHA had
standard would yield benefits
consideration of benefit cost nueef

ag?I?c^ s ProPosed benzene
nS^r^e !WIth lts costs- Painstaking

several years ago. Economic incentives could increase industry com­
pliance, as might local pressure from public health professionals, government agencies, and information media.
Workers can take some actions to protect their own health The most
important is to stop smoking cigarettes, because constituents of cigarette
smoke apparently act as powerful cocarcinogens. Workers can also help
identify dangers, file complaints with OSHA, or request a health hazard
eva uation from NIOSH. To be more effective in protecting their own
health, workers need to know what substances they work with their
dangers, and conditions at their work sites—basic information that’in the
past has not been readily available. Some unions actively inform their
members about health hazards and their rights under the law.
There is a great need for health professionals skilled in preventing
detecting, and treating job-related illnesses. Not only are such proFe^
sionals in short supply, but the occupational disease component Pjn the
education of other health professionals also has been remarkably low
The overview paper on manpower issues cites data from several sources
hat conclude there will be future shortages in the fields of occupational
h^flth8’ occupatlonal medicine, and general occupational safety and
neann.
J
nf
?•a b?SjC IaCk °f knowledge about the causes and manifestations
tialN
atlona* dlsease- Needed are increased laboratory testing of potennrior-i- T SUfS'anCeS1 before they are widc|y used in industry, better
Hfn^aT On-Of hazards’ and epidemiologic studies. The inaccessibility of
information is a significant barrier to occupational health research
™f,,?yer C°nCynS over trade secrecy restrict the availability of data
Whhrdlng manufacturing processes and materials. An ostensible concern
with worker privacy has been raised to limit access to employee medical
A CVLza US.

deS^someT"'1 ’S efStabIished’ workplace screening programs can help
detect some types of abnormalities at an early stage, when effective
treatment may still be possible.
b
enective

™

»d the

difficulties, OSHA and NIOSH have " orc^men.t Pro.cess- De$pite these
situations.
eacted swiftly in some emergency
relXX CpdorffytnmuchhOWfinAg
hazards could be coXfled at

“emP‘Oyee heaIth remains a
lndustry-” In ’"any cases,

tions. Prevention efforts ataed a ehengineering modifi^ing exposure bj rolador> toTafer L nt T® emplOyee behavi°r’ or limittive to eliminating hazards Offer? k ifaS aFe an unsabs^actory alterna^orces workels^to IthTose betweer^lotfg'-ternTliealtl^bene'fff1186^118^°b*

term financial ones ”

-IQ

S

neanh benefits and shortj

Fluoridation of Community Water Supplies
FiuGridaticn of community water supplies to prevent dental caries
has been highly cost-effective. But, as the paper on preventing oral
iseases states, nearly half of Americans are not now reached by this prepramT meiSKre' Fluond® mouth rinses or tablets, given in school pro® ™ °r at home> can also provide caries protection. Fluoride supple­
mentation is most important when teeth are forming and in the subse­
quent, preeruptive phase. The optimal time for beginning supplementaarTeff Si’011 Y
blrth’ APProPriately formulated fluoride dentifrices
are effective preventive agents, even where community water is fluori­
dated, and are considered a very cost-effective preventive measure.
nrP^mf°Vmg P aq“e from teeth by brushing and flossing is effective in
preventing caries, but most children and adults are unable to achieve the
necessary degree of oral cleanliness. Reducing sweets, particularly those
consumed between meals and in a farm tnnrKr.~
.1. .
y .

should help reduce caries. Although study results c<

•

rt

periodontal diseaseTwhich iTubiquito^s^n't^^XTsmt801^ 'en8th

Chapter 10—Health Promotion
he m°St StrOngly related factor

in all age groups Various m.rrn

The third set of health strategies for prevention, developed by the
Surgeon General’s Office relates to health promotion:

gingivitis and destructive periodontitis Whh tlV6 ‘n ^ontr°IlinS both

“,h’

»p—

«Mu.hST„”taM“do“ JX'"8”

™' d»““

With statements in its text Tnstitnt H PaP6r °n denta dlsorders is at odds
foreseeable future, bot^i are neclsslry01"11111166
be'ieVe that ” the

• smoking cessation
• reducing abuse of alcohol and drugs
• stress control
• improved nutrition
• exercise and fitness
The first three of these are discussed in detail in these selected readings.
Smoking Cessation

Alcohol and Drug Abuse Reduction
Environmental Protection and Infectious Agent Control

PUbIiC health eff°rtS are nOt di™<*

needed within dteTe^tT8 that m°re environmental toxicologists will be
est mated 50^
yea?-perhaPs 2'000
than the present
the Toxic S^ubsU^esa^ntrol^ct61116111
SUCh aS

Heavy tobacco, alcohol and drug use have been linked to much morbid­
ity and mortality described in previous chapters of this summary: low
birth weight and congenital abnormalities in children of users; accidents,
homicides, and suicides; chronic disorders, such as cardiovascular diseases
and cancers; and as a possible factor in treatable “senility.” The destruc­
tive effects on the heavy user of alcohol or drugs include rapid mental
deterioration and violent death, or irreversible damage to various body
systems and organs, including the brain.
How costly these behaviors are to society is indicated by studies cited
m the paper on economics. The direct and indirect economic costs to the
United States of smoking and alcohol abuse were estimated to be $59.6
billion in 1976, not including fire losses due to smoking or motor vehicle
accidents and crime due to alcohol abuse. The net economic benefit of a
program that would result in only one-quarter of the Nation’s heavy
smokers’ quitting has been estimated to be $2.35 billion annually.
The review paper on adolescents cites 1977 survey figures showing the
proportion of tobacco, alcohol, and drug use among youth. In that year,
22 percent of young people ages 12 to 17 smoked cigarettes—almost
double the proportion of smokers in 1968. Adolescent girls were as likely
as boys to be smokers. Thirty-one percent of all adolescents had drunk an
alcoholic beverage within the month prior to the survey; for those 16 and
17, 52 percent had; and, more than 90 percent of the high school graduat­
ing class of 1977 reported having tried alcohol. Surveys beginning in
1941 showed a steady increase in the proportion of teenage drinkers until
1965, when rates leveled off. However, about twice as many adolescents
reported having been intoxicated, or havinp been intoxicated at least

monthly, in 1975 as compared to 1966. In the more recei
;ar, 19 per­
cent of high school students reported being drunk at least once a month.
In a 1977 survey, 16 percent of adolescents reported having used mari­
juana within the previous month, and 28 percent had tried it at least once.
Recent years have found no increase in the proportion of adolescents
reporting the use of other illicit drugs, and more than 90 percent have
never used drugs other than marijuana. The common practice of using
drugs and alcohol in combination increases the health and safety hazard.
There has been increased interest in preventing the onset of these
behaviors, particularly in adolescents,1 the focus of the paper by Alfred
McAlister, on which many of the following statements are based. How­
ever, the underlying etiologic factors are complex, and research to date
has been limited and inconclusive. Risk factors for substance abuse
relate to basic processes of socialization and development, and suggest
some preventive strategies.

Risk Factors for Substance Abuse
The onset of puberty, with its concomitant cognitive and hormonal
changes, coincides approximately with the onset of using tobacco, beer,
and wine. Strong evidence exists that early use of these substances pre­
dicts later use of other—possibly more harmful—ones. A trait central to
early adolescence is experimentation with various interpersonal styles
and behaviors, including substance use, according to the paper on adoles­
cent health needs.
The age at which young people can become involved in smoking or
drinking has decreased rapidly in recent years, partly because young teen­
agers were provided with contacts for obtaining alcohol when State laws
reduced drinking ages to 18 or 19. The action of many States to reinsti­
tute legal drinking at age 21, taken in order to reduce automobile
injuries, may again decrease opportunity in the younger age group.
In the past, adolescent boys tended to experiment with dangerous sub­
stances at younger ages and more extensively than girls, but that has
begun to change. Sex differences in the frequency that individual sub­
stances are used may reflect various combinations of social processes.
The higher rates of cigarette smoking and alcohol abuse found among
the poor and uneducated result from a number of factors. Although
some theories ascribe a primary causal role to economic deprivation,
many social processes may exert influence. Anxiety, low self-esteem, and
hostile urban environments, all of which are often associated with’eco­
nomic deprivation, apparently increase the likelihood of substance abuse.
The model provided by parents tends to influence the prevalence of
substance use among their children. For example, drug use habits of
parents, offspring, and siblings are said to be consistently and strongly
correlated. On the other hand, some young people, alienated from their
parents, may adopt contrary habits.
/Health consequences behavioral aspects, and education and prevention of smoking have been
discussed at length ir Smoking and Health: A Report of the Surgeon General, issued JLua^

42

The models j
ided by peers are a particularly important influence on
adolescents. For those who are anxious, low in self-esteem, or lacking in
assertiveness, selection of a peer group may be a critical factor in deter­
mining substance abuse habits. That is demonstrated by the diversity of
drug use patterns that occurs among different adolescent social groupings.
For example, heavy alcohol and marijuana users tend to be concentrated
among those “least engaged in adult-sanctioned activities”—such as sports
or academics. In these groups, deviance that elicits peer esteem can
become a way of life.
Heavy use of mood-altering substances also has a symbolic value.
Often it is associated with daring and glamorous personal lifestyles por­
trayed in the entertainment media and exploited by advertisers. Such
lifestyles provide alternate, if unrealistic, role models for youth.
Various psychological states—unhappiness, dissatisfaction, isolation,
and alienation—may also lead to use of mood altering substances,
because of their effects on self-esteem and anxiety. The attractiveness of
abused substances for their direct effects, their properties as mood eleva­
tors, sedatives, and aids in coping with stress, cannot be ignored. The
interaction of these direct effects with individual psychological factors
may underlie the establishment and persistence of patterns of abuse.
These ingredients combine to outweigh adolescents’ concern for health.
A Department of Health, Education, and Welfare survey (25) has found
that over 90 percent of adolescents agree that cigarette smoking can
harm the health of teenagers (about the same percentage of adults agree
with similar statements). Yet, another survey has found that less than half
of current teenage smokers are “fairly” or “very” concerned about the
possible health hazards (26).
Because of the complexity of the above factors, “narrow strategies of
prevention can yield only weak and sometimes paradoxical results,”
McAlister says. For example, simply providing information about drugs
and their effects has been found not only ineffective in reducing onset of
use, but may also result in increased experimentation.
Mobilizing the power of the peer structure to help young people under­
stand and overcome the factors that lead to substance abuse is a promis­
ing strategy. The paper on adolescents cites several instances in which
peer groups have been used for this and similar purposes. Teaching
parents to be better models and promoting more positive models in the
entertainment media would capitalize on other natural socialization
forces.
Adolescents need multiple behavior skills to resist persuasion and
overcome their own susceptibilities. Psychological inoculation—teaching
ways to refute anticipated arguments—can be effective. Assertiveness
training has shown promising short-term results, McAlister says. Ado­
lescents will also be helped by improvements in their general abilities to
manage stress and anxiety (such as through various physical and psycho­
logical practices—sports, yoga, meditation) and gain self-esteem, by de­
veloping competence in activities that bring a positive response from those
around them. Social support systems must be sufficient to help achieve
these goals. McAlister concludes that “increased economic opportunity
43

and political and religious community organization may be as important
as any more psychological or educational approach to prevention.”
•
better research is needed to substantiate present hypotheses
crted by McAlister, but the governmental initiatives that have recently
joined in this effort are considered an encouraging trend. The paper on
research mentions numerous studies needed on tobacco use, alcohol
abuse, and drug abuse that would contribute to development of more
effective prevention strategies. Studies are needed to assess the social
psychological, and pharmacological determinants of smoking; cultural’
socioeconomic, genetic, and metabolic determinants of alcohol abuse; and
the contribution of biological, psychological, and sociological factors that
differentiate between occasional drug users and abusers, as well as pos­
sible environmental triggers for drug abuse.
Stress Control
The two papers most directly related to stress control complement each
other in their scope and approach. Lennart Levi, in his paper describing
psychosocial factors in preventive medicine, establishes a theoretical
framework for viewing stress as part of a complex organism-environment
interaction, citing much of the basic research from which this framework
has evolved. He examines the range and seriousness of problems related
to psychosocial factors (a term Levi prefers over “stress”) in making a
case for broad-scale prevention efforts. In their paper on the relation of
social support, stress, illness, and use of health services, Beatrix Hamburg
and Mane Kilhlea take the analysis a step farther. Their cumulative find­
ings show that stress and social support are interactive factors affecting
und 1 ness behavior- Based on these findings, health professionals
should be more aware of available sources of social support and should
use them to the benefit of their patients. Public policies should encourage
the development of natural support systems, like the family, even though
such systems are separate from the health care system.
Levi says that high-risk situations—those likely to elicit pathogenic
mechanisms under certain circumstances—abound in modern life, brought
on m part by population growth, urbanization, industrialization, and other
environmental problems. In addition, many people are in high-risk groups
due to adverse changes in social situations. As a result, certain people
suffer a ‘high-risk reaction”—anxiety, depression, or a physiological re­
sponse-determined by the interaction of environmental stimuli on the
one hand and constitutional predisposition (psychobiological program)
on the other.” In some cases, these reactions can lead to disease or for
that matter, injury from violence or so-called accidents.
Physiological reactions are described that have been established by
animal and human studies. Reactions of the sympatho-adrenomedullary
system that lead to dysfunction in various organs and organ systems “may
result in permanent structural changes of pathogenic significance, at least
m predisposed individuals.” Increased reactions of this type have been
demonstrated in a wide range of situations, including such common ones

I
I

p

1

I

as driving a car, taking examinations, or interacting with the health care
system. Increased adrenal cortical activity, a second type of reaction, has
been demonstrated in many of the same situations. There is some evidence
that psychosocial stimuli also affect thyroid function.
These three types of neuroendocrine reactions to environmental stimuli,
including psychosocial stimuli, can directly or indirectly influence many
existing physiological variables. They are a relic of man’s earlier evolu­
tion—part of bodily preparation for “fight or flight.” In today’s world,
however, these internal body processes are incongruous with the social be­
havior expected in many stressful situations, creating an additional source
of stress. “Good evidence” exists, Levi says, that “processes of this kind
constitute a major factor in the causation of several psychosomatic
diseases.”
When major life changes occur—such as marriage, pregnancy, divorce,
death of a family member, or altered work situation—human beings react
with the same constellation of physiological reactions developed in pre­
historic times. The greater the number and intensity of life changes in a
given period, the greater the risk of ill health. Further, animal studies
have shown that acute or chronic adverse psychosocial stimulation can
lead to death; an important factor contributing to this outcome is the
animal’s sense of being powerless to control or ameliorate the stressful
situation. This factor is also characteristic of situations in which stressful
stimuli have been linked epidemiologically with changes in human mor­
bidity and mortality. Sudden death from cardiac disorders 2 “may often
result from undamped autonomic discharges.” The body’s ability to regu­
late autonomic function is apparently diminished “in situations that are
interpreted as overwhelming and without hope.” Examples of stimuli for
which such links have been shown are an adverse national economy and
high unemployment rates. One can presume that divorce or death of a
spouse may also be perceived as beyond the control of the bereft partner.
In the face of such situations, emotional support from other people or
environmental circumstances may help reduce the lability of autonomic
responses.
Helping people develop the capacity to change situations, to cope with
stress, and to modify the deleterious health effects of stress is a goal of
social support systems. The most important of the naturally occurring
social support systems is the family.
Research findings on stress and social support have important implica­
tions for the health care system. First, health care workers must be alert
to the kinds of life changes that may produce psychosocial stress in their
patients. Greater interaction with, and mobilization of, the natural sup­
port system of the family may be effective in mediating stress; where
necessary, other, informal support systems (self-help groups, or commu­
nity organizations, for instance) may have to be involved, or the social
support capacity of the medical care system itself called into play. Social
support can be a major influence on the use of health services and in
gaining compliance with medical regimens. This last has direct bearing
2 Levi’s analysis of the evidence relating psychosocial factors to hypertension and other cardio­
vascular diseases is summarized in chapter 6.

reEtar "••n,r°l

“thbs*iterch"s“m”'“"4

institutions, including many of those not usually thought of as influencing
health-related behavior. These are the kinds of groups potentially useful
in preventing the onset of adolescent drugs, alcohol, and tobacco abuse,
McAlister believes.
Among the pertinent research questions are: what is the direction of
the relationship between the effects of stress on health and social support,
which factor is cause and which, effect; what do models for intervention
show that variously examine the effects of removing or moderating stress,
strengthening social supports, and teaching coping skills; can attachment
behavior be promoted; can professionals stimulate the development of
social support networks and systems for their clients where they are
absent, and mobilize social support systems for those with inadequate or
deficient support systems; and how does the effectiveness of such systems
compare with that of naturally occurring networks?
The effect of psychosocial factors on health is often given inadequate
consideration. These two papers make a compelling case for forging better
links between the health and mental health care systems, with a much
more integral role for social support systems in each.

the public health significance of
ui
Pr°bIems» as cited by Levi:
ness regarding the problem and th Pr°blem, the level of public awareity of the problem by available
assigned to it, the modifiabilaction, the possibility of identifying taXt & S°CIietal Costs of action or inof an appropriate agent of
a A PoPuIatlons, and the availability
limited capacity to effect change^n ad1 °Ugh he^,th Professionals have a
selves, there are certain important a verse P5^110800131 factors of themdial and apply to the heah TsvX T they Can .take- Some are re™both public health and prevention’ w^h’
’ncreasing.the orientation to
responsiveness to people’s nsvchoco i 10
Profession’ or increasing
quire cooperative effoS wTp0S
aCtions would -

toXin exn;ng rmunities and red“g “ ~“ers

Levi’s view. Man^nd his^nvko^ient shffeCldVh prevention Pr°gram, in
an “equal and integral consideraZ fo physical meTt^S31'^
nomic aspects.” Consideration nf
>slca1’ mental, social and ecoand the entire environment and the in
between<tIle “whole” person
should yield the necessary ecological ^es^ant cJlan^s in system dynamics,
greatest possible influence over fheir o^
Indlv,duaIs should have the

being, Levi believes This availahU

i„.=8raM.„d,

Improved Nutrition

^orders, and enhance well
=™pw.

i””"* "“«• >»

i"
» area where sig.
that social support can help modifvThed
t00’. CIte research showing
Social supporthas been concTpSi^
^alth/ffects
^resS8
that he/she is loved valued and is nart f f mation that tel,s a person

and mutual obligatori ” but’
P
'
port»..*&,;■ n‘eK °P'r“""’'
“e“h^”'s

°f com™nication
»'
“P■"<' >-

the requirements of a new situation, and prepare foAhe SUre°UP’

I

The Institute of Medicine committee that selected topics and papers
for this report considered nutrition an important, if controversial, area.
Several authoritative, forthcoming reports about the effects of nutrition
on health may help dispel some of this controversy. Preparation of a
paper on nutrition for this volume therefore appeared untimely.
One of the studies underway is that of an expert committee formed by
the American Society for Clinical Nutrition. Their report is expected to
give as detailed a view as possible of the evidence from both animal and
human experimental research that should be used to make rational deci­
sions on dietary recommendations for the public. To that end, subcom­
mittees are working on the issues related to salt intake, alcohol, calories,
carbohydrate, fat, and cholesterol.
Another effort in this field is the work of the Nutrition Coordinating
Committee, National Institutes of Health. Their conference of June 1978
on the biomedical and behavioral basis of clinical nutrition covered such
topics as genetic and acquired disorders of metabolism, nutrition in
pregnancy and early life, basic biochemical research, the relation of
nutritional and environmental practices, nutrition and human function,
and nutrition and behavior. One panel at the conference explored some
of the nutrition issues that Congress sees as important, including the need
for greater emphasis on nutrition in biomedical research, recent initiatives
to obtain better coordination between the Departments of Agriculture
and Health, Education, and Welfare to improve current nutritional status
monitoring programs, the need for immediate transfer of existing nutrition
knowledge to the public, and the degree to which nutrition concerns are
currently being weighed in appropriating funds for food programs.
Current studies notwithstanding, the importance of nutrition to many
aspects of health and disease occasioned its mention in numerous papers
in this volume. They discuss:

1

g
• low Wrth weT^t'011 bef°re and during Pregnancy

relation to

• the link between malnourishment in early infancy and develop­
mental disabilities in childhood
• the link between diet and dental diseases
• the possible role of high-fat diets in the etiology of breast and
colon cancers
• the relationship of high saturated fat/high cholesterol diets to the
atherosclerotic process
• the role of salt intake in hypertension
• the association between overweight and diabetes
• the association between overweight and hypertension
• recommendations for diets low in saturated fats, low in cholesterol,
athighrisk117 <<Optimal” calories t0 prevent heart attacks in people

• the potential effect on coronary heart disease mortality of risk
factor reduction, including reduction in serum cholesterol
• the importance of adolescence as a time when health behavior
patterns are set, including dietary ones
• malnutrition as a significant problem among the elderly
• nutrition counseling as an important part of preventive services
tor all age groups.
At least some of the major changes that occurred in the American diet
uring the past century have begun to reverse themselves. Declining

tCiontTfPth?T?«egn8S 3nd bUtterfat haS been rePOrted in routine

ons of the U.S. Department of Agriculture. Further reductions in con­
sumption of saturated fat and cholesterol and reductions in consumption
of refined carbohydrates (particularly sugar), salt, and protein derived
®°urces’ w,th a concomitant increase in consumption of
crude dietary fiber appear at this time to be dietary trends that would be
prudent for most Americans (27-33). More precise statements of an
optimum diet, objective and critical analysis of the impact of dietarv
components on specific diseases and on health, ways to accommodate
individual variations m requirements, and analysis of the health impact
of greater use of processed foods await the findings of expert groups

CONCLUSION

That the time is here for greater attention to the prevention of disease
sne
hlS bef°me a unifying theme among the many voices that
£eak °at on health matters in this country-physicians, consumers, pubhc heal h professionals, employees, workers, legislators, and policymakers
e at the Institute of Medicine hope that this report will attract more
attention to the possibilities for disease prevention and health promotion
that lies within our control, in our roles as leaders, as teachers, as em-

ployers, as parents, and as stewards of our own health. To be sure, not
all the answers are in on prevention, but prudent actions can be taken
based on knowledge available now. We hope also that this report prompts
debate on some of the issues and strategies raised, that there is a call for
greater efforts to resolve some of the unanswered questions posed, and
that a wise public policy emerges from a combination of sound scientific
knowledge and a healthy respect for diversity of individual action.
References

(J) Levy, R. I. and M. Feinleib. “Coronary Artery Disease: Risk Factors and
Their Management.” Chapter 33. In Heart Disease, E. Braunwald, ed.
Philadelphia: W. B. Saunders (in press).
(2) Taylor, C. B., J. W. Farquhar, E. Nelson, and S. Agras. “Relaxation Therapy
and High Blood Pressure.” Archives of General Psychiatry 34: 339-342, 1977.
(3) Cairns, J. Cancer, Science, and Society. San Francisco: W. H. Freeman and
Company, 1978.
(4) Cowdry, E. V. Etiology and Prevention of Cancer in Man. New York:
Appleton-Century-Crofts, 1968.
(5) Fraumeni, J. F., Jr., editor. Persons at High Risk of Cancer: an Approach
to Cancer Etiology and Control. New York: Academic Press, Inc., 1975.
(6) Hiatt, H. H., J. D. Watson, and J. A. Winsten, editors. Origins of Human
Cancer. New York: Cold Spring Harbor Laboratory, 1977.
(7) Mason, T. J., F. W. McKay, R. Hoover, W. J. Blot, and J. F. Fraumeni, Jr.
Atlas of Cancer Mortalities for U.S. Counties: 1950-1969. DHEW Publ.
No. (NIH) 75-780. Bethesda, Md.: National Institutes of Health, 1975.
(5) Saffiotti, U. and J. K. Wagoner, editors. Occupational Carcinogenesis. New
York: New York Academy of Sciences, 1976.
(9) Schottenfeld, D., editor. Cancer Epidemiology and Prevention; Current*
Concepts. Springfield, Ill.: Thomas, 1975.
(10) Burkitt, D. P„ A. R. P. Walker, and N. S. Painter. “Dietary Fiber and
Disease.” Journal of the American Medical Association 229: 1068-1074, 1974.
(11) Kritchevsky, D. “Dietary Fiber: What It Is and What It Does.” In Food
and Nutrition in Health and Disease, pp. 283-289. N. H. Moss and J. Mayer,
eds. New York: New York Academy of Sciences, 1977.
(72) Burkitt, D. and N. Painter. “Gastrointestinal Transit Times; Stool Weights
and Consistency; Intraluminal Pressures.” In Refined Carbohydrate Foods
and Disease, pp. 69-86. D. P. Burkitt and H. C. Trowell, eds. London:
Academic Press, 1975.
(13) Eastwood, M. A. and D. Hamilton. “Studies on the Adsorption of Bile
Salts to Non-Absorbed Components of Diet.” Biochimica et Biophysica Acta
152: 165-173, 1968.
(14) Kritchevsky, D. and J. A. Story. “Binding of Bile Salts In Vitro by
Nonutritive Fiber.” Journal of Nutrition 104:458-462, 1974.
(75) Story, J. A. and D. Kritchevsky. “Comparison of the Binding of Various
Bile Acids and Bile Salts In Vitro by Several Types of Fiber.” Journal of
Nutrition 106: 1292-1294, 1976.
(16) Mack, T. M., M. C. Pike, B. E. Henderson, et al. “Estrogens and
Endometrial Cancer in a Retirement Community.” New England Journal of
Medicine 294: 1262-1267, 1976.
(77) Hoover, R., L. Gray, P. Cole, and B. MacMahon. “Menopausal Estrogens
and Breast Cancer.” New England Journal of Medicine 295: 401-405, 1976.
(18) Edmondson, H. A., B. Henderson, and B. Benton. “Liver-Cell Adenomas
Associated with Use of Oral Contraceptives.” New England Journal of
Medicine 294: 470-472, 1976.
(79) Silverberg, S. G. and E. L. Makowski. “Endometrial Carcinoma in Young
Women Taking Oral Contraceptive Agents.” Obstetrics and Gynecology
46: 503-506, 1975.

The European Community will certainly have a continuing interest in a very
wide range of activities affecting health and grea
efforts will be made to
coordinate these activities, in close cooperation with the Member States.
Cooperation with third countries and in particular the new democracies of
Central and Eastern Europe will also be central to the concern of the
Commission. For the same reasons the Commission, intends to take advantage
of the work carried out by major international organisations such as the
World Health Organization and the Council of Europe, and to cooperate
with them. This cooperation will be clarified and reinforced to avoid
duplication of effort and increase the effectiveness of the actions of each
organization.

Finally, we can now look forward to the development of Community actions
in the field of health baseson the concept of health protection and promotion,
as well as disease prevention. In so doing we will be bringing the European
Community close to each and every person, since good health is precious to
us all.
By providing substantial support lor this 15th Assembly ot ASPHER the
Commission recognizes the importance of the role which ASPHER is
playing in trainingand research in public health in Europe. The Commission
looks forward not only to the results of this assembly, but also to a closer
collaboration with health professionals, working together towards our
common goal, improving and preserving the health of the people of Europe.
Alexandre Berlin, PhD, Adviser, Commission of the European Communities, Health
and Safety Directorate, Bat. J. Monnct - Plateau du Kirchberg, L-2920 Luxemburg

Ulrich Laaser
*

The Contribution of the Schools of Public Health
to Public Health in Europe1
Der Beitrag der Ausbildungseinrichtungen fur Public Health zur
dffentlichen Gesundheit in Europa

With regard to public health the final ratification of the Treaty of Maastricht
late in 1993 is an event of great importance. As many different views however
as there might be around this document, for public health it is going to change
the rules of the game. For the first time there is an agreed mandate for the
development of Public Health Policy in Europe, even if admittedly in the
first instance it regards only the present Member States of the European
Union.
The Association of Schools of Public Health in the European Region
(ASPHER) is the only all-European institutionally based organisation for
public health training and research; most of its member institutions are
linked to the national health administration, many are likewise linked to
academia. Thus ASPHER bridges-policy and science;a historical gift which
now in a new Europe is in high demand. Our organisation therefore has to
contribute to the scientific, professional and administrative foundations of
Public Health Policy in Europe.

7

European status

In spite of the generally high life expectancy in Europe, the health status of
many of its subpopulations is unsatisfactory, and such a statement certainly
is not restricted to the East. People still suffer from avoidable diseases,
impaired somatic and mental functions of daily living and insufficient
participation in medical decision making. Social gradients - sometimes with
steepening trends - can be demonstrated - almost everywhere - e.g. for the
quality of and the access to medical care. On the other hand more resources
are necessary to still improve the population’s health. As the marginal
benefits decrease for additional resource-allocations in the classical medical
sector of clinical care it becomes more apparent that the dominating diseases
of today are mainly determined by lifestyle, environment and occupational
settiTTgTHereTVSPHER’s new slogan that “public health investment harvests
ricErewards”, delineated from AndrijaStampar’s writings [ 1 ], is immediately

1 Presidential address to the 15th General Assembly of the Association of Schools of
Public Health in the European Region, Bielefeld, November 29, 1993. Slightly
shortened version.
109

f G<’<un(1h<‘i!s\viss' ? Ip. 1994. H. 2

Z. f. Gesundheitswiss.. 2. Jg. 1994, H. 2

109

1

applicable. Although by no means a new insm it still constitutes a great
challenge to the health systems in the industrial) , countries. The limitations
based on a biomedical
of conventionally organized health care - primarily
[
scientific concept - are obvious.
In the following 1 shall deal with (A) a common potentially European
understanding of public health, (B) the ideal qualities of a European School
of Public Health and (C) the specific contributions of the European Schools
of Public Health to a Public Health Policy in Europe.
A. Common understanding

In order to define the potential contribution of the “European Schools of
Public Health to Public Health in Europe" it is necessary to describe what
public health in Europe ought to be. Certainly at the present time there is no
consensus on that issue. However, a few cornerstones of what constitutes
public health in Europe can be identified. For that purpose I take two core
definitions or perhaps better still task descriptions of public health in current
use throughout Europe. The first I obtained from discussions under the aegis
of the regional office of WI IO. It is widely adopted now to my believe by
WHO and around the world. To the best of my knowledge it was published
originally in the Report on Public Health in England in 1988 |2|.

1) „Public Health is the science and art of preventing disease, prolonging life
and promoting health througPTthe organized eitorts of society?*
The second description of public health stems from a political compromise
of the Member States of the European Community and is a citation from
article 129.1 on Public Health in the Treaty of Maastricht (1993) [3].
2) “The Community shall contribute towards ensuring a high level of human
health protection by encouraging cooperation betweenJVlember States arid,
if necessary, lending support to their action.

Community action shall be directed towards the prevention of diseases, in
particular the major health scourges, including drug dependance, by
promoting research into their causes and their transmission, as well as health
information and education.

Health protection requirements shall form a constituent part of the
Community's other policies."

There is a certain common ground to both concepts of public health -, the one
used widely although not exclusively by WHO and the other by the European
Union. These two organisations constitute the most important “amalga­
mations" in health care at the European level
with a technical and a
political public health mandate respectively.
a) First and most important, both definitions refer to society and jts
organisation as a state, not to the individual per se. Although health is a
personal good, it is not only an individual but also a collective responsibility
[4]. Whereas the monitoring and restoration of individual health mainly is a
I DO I

task of the curative eoctor in medicine, the health of the entire population is
subject to the soci
and to the - democratic - state.

Il goes far beyond the present reality but opens a wide and important field
when - in the last part of the article 129- one can read: “Health protection
requirements shall form a constituent part of the Community's other policies."
This is a very revolutionary wording potentially meaning:... part of allot the
Community’s other policies.

b) Second both citations refer to science and research respectively. It should
be underlined that the improvement of the population's health requires a
scientific base. Public health cannot be built on either an uncritical (first)
administratively executed top-down approach or an uncritical (second)
action-oriented bottom-up movement. Rather it needs careful evaluative
analysis and monitoring. However, to delay action or put-off intervention
until perfect proof from perfect studies is available, would be wrong. What
is much more important is to work with the results of imperfect studies
keeping critically in mind, that they are imperfect and that newly acquired
results might change the action. Unscientific appraisal or overinterpretation
arc the dangers not the detractions from scientific perfection in public health
research.

c) Third the wording of both definitions stress prevention. The first one
accentuates health promotion, the second health protection. There is a
narrow interpretation of prevention as preventive medicine, obviously that
is not meant here. Rather the explicit references that health is to be
promoted or protected, point to a broader interdisciplinary understanding.
But again we should not be misled by the reference made to health in this
context. Health is not an ideal or perfect state but a relative condition in
terms of adequacy and appropriateness. This relates to the three categories
of prevention: maintaining good health, avoiding impaired health to worsen,
and enable people to live with reduced health. In this sense e.g. to set a
motivational and organizational framework for nursing of the elderly is an
important issue of public health.
d) Forth there is a striking omission common to both definitions: medicine
or at least public~health rnedicirfe'is noUmentionedTWhat then is' the
relationship between public health and medicine and the medically
determined health care system ?
To describe this relationship between medicine and public health from the
public health point of view I best modify a quote of Thomasio di Aquino on
the role of theology: ‘Like the architect thinks out a plan and directs the
construction according to it, so the public health professional designs a
system for the delivery of medical care.’

The fact that the system of delivery of curative care consumes about 90 % of all
financial resources invested in the health sector-i.e. between 5 and 10 % of the
GNP - makes it a legitimate subject to consider with regard to its impact on the
public health . for example in the context of benefit to cost analyses. Although
the problem would be misunderstood if an economic calculus were applied to
1001 II ->

Ill

the palicni-pnysician iciauonbiiip mhcuuj,
............. .
hesitate to set explicit priorities lor resource-allocation whereever possible.
This is appropriate as long as limited means arc
?e distributed in a regulated
market, and that is the situation we find universely, and certainly everywhere
in the European region. Thus although the delivery of medical care consciously
has not been made part of the Community s mandate for a European Health
Policy, its organization and quality will necessarily come into focus through
comparative health systems research. Here e.g. the WHO is very explicit,
namely in the wording of target 34 on management, where the effectiveness of
the health system is judged according to its impact on the health status and the
quality of life of the population. The criteria enumerated are the citizens
satisfaction with services, their efficiency or cost-effectiveness and measurable
contribution to the HFA-targets [5].
Those are the four cornerstones of public health which I can extract from
these two definitions: the societal dimension, the scientific foundation, the
preventive orientation and the independance of clinical care. Is there
anything specifically “European” about the architecture of the house which
we can build upon these cornerstones? In order to illustrate that aspect, I
would like to look back to the year 1883 when Bismarck presented his
legislation on sickness funds - the “Krankenversicherungsgesetz ” - to the
Reichstag [6]. He based it on four principles: obligatory membership for
everybody, variety of competing funds, partition of cost between employers
and workers, and salary compensation during temporary disablement. What
I consider to be the European quality is the attempt of Bismarck - who by
no means can be called a socialist to balance solidarity and free choice in
such a way that the highest possible degree of equity and social security is
achieved.

Table 1:
Qualities of public health in Europe

Resulting institutional features of
Schools of Public Health

The societal dimension

Linkage to the political and
administrative system
Linkage to academia in
teaching and research
Linkage to practice and intervention
Autonomous institutional basis

The scientific foundation

The preventive orientation
The independance (of care)

B. The European School
Before I come to deal with the essential contributions of the Schools of
Public Health in Europe to a Public Health Policy in Europe, I would like to
examine from the aforementioned fundamentals what kind oi training
institutions are needed:
112

Z. f. Gesundheitswiss., 2. Jg. 1994, H. 2

defined links with the political and the administrative system. I know that
this statement is :
popular everywhere in spite of the fact that many of
ASPHER s members are state-based institutions. Nevertheless it remains
true that exerting influence in an open society is a two-way activity. Our
schools need a direct and stable connection to the decision-making process
if they want to channel their services adequately.

2) Second in order to fulfill their duties properly and according to scientific
standards, the ideal European school requires some links - direct or indirect
- with the universities. Most likely this could be in terms of a postgraduate
organisation of training schemes leading to academic degrees, and in terms
of common projects of applied research. Funding policies should support
this kind of cooperation. Also there should be legal provision for exchange
of staff between schools and related faculties, and perhaps through national
and international scholarship schemes. The difficulty very often is the
notorious antagonism between the Ministry of Health and the Ministry of
Science to both of which a School of Public Health has to be related.

f

-

3) Third as much as public health is an applied science of preventive
orientation and not Tart pour Part, the schools must relate to the practice of
public health and to practical intervention. They have to be institutional
change agents not only executives. I believe that here in Bielefeld we have
a good example in the way the faculty of health sciences has contracted a
network of institutions in the field like the Johanneswerk or Bethel caring for
the physically and mentally handicapped - the latter wellknown through the
recent visit of the Japanese Emperor Akihito - or like my own institute, the
Slate Institute for Social Medicine and Public Health (IDIS). Staff of the
institutes lecture at the university, students of public health work on their
theses in the institutional settings and common research projects are pursued
like e.g. the development of a health audit for public construction works or
similar activities.
4) Forth because of multiple and potentially conflicting relationships the
European School of Public Health must have an independant institutional
basis. It should neither be an institute of the Ministry of Health exclusively, nor
part of another faculty. A School of Public Health should cooperate closely with
but needs to be separate from the school or faculty of medicine. Again this is not
always popular and even not the prevailing model in Europe but at least a
department of public health should be an autonomous unit even within a
medical faculty. Why do I say this ? Because I foresee that the public health
group will remain in a structural minority versus the clinical disciplines which
means a persistant disadvantage when scarce resources are to be distributed.
In summarizing the European School of Public Health should be an inde­
pendant institution with equally strong links to the administration, to the
universities and to the practicing institutions. How this triangle can be organized
and what the locally appropriate balance should be is up to those who want to
invest in public health to quote Andrija Stampar’s words. Those who tackle the
work should also be responsible for these decisions and no binding rule can be
Z. f. Gesundheitswiss., 2. Jg. 1994, H. 2

113

1

1

“■

CAUCpi 1O1 II IU I Ckjllll U 111<- 111 HUH pui'liv iivcinn liiu.ti I'V 141

K.

corners of the triangle of administration, academia and practice.

The basic public he

) sciences

C. The schools' contributions
What contributions to the public health of Europe can we expect from such
institutes and what is most necessary?

The above defined cornerstones and the delineated qualities of a European
School of Public Health can also be read as a broad task description but I
want to be a little more specific and relate to the immediate priorities in the
region:
Table 2:

High ranking contributions of the European Schools of Public Health to
public health in Europe
Teaching

Research

Practice

Development and review of European standards
and internationally exchangeable training modules
Development of essential public health objectives-,
at the operational level and of a European public health
information network, based on standardized health'Hulic'ators
Agreement on professional guidelines for the practice of public
health in Europe and promotion of mutual inncr-European ~
site-visits to enhance personal contact and first hand knowledge

1) Teaching: The primary task of ASPHER is to foster qualified public
health training in Europe. This is not restricted to an organizational model
c.g. graduate or postgraduate. But as to the application in research and
practice, it is necessarily an interdisciplinary one and teaching therefore has
to be /rzz/ZrZdisciplinary. The question is whether this can be done without
m/erdisciplinary communication. We in Bielefeld have learned during the
early years that this is not a good will action alone - sometimes difficult
enough - but one of structure. Not only lecturers have different concepts,
languages and terminologies. Also students at least the postgraduate ones
depend on their original training and profession. You can not simply add,
you have to modify. That can only be done in an interdisciplinary group
situation, which brings together students and lecturers of different background
in a common setting, even in a common room and over longer periods. They
need to accept each other as equal personalities and differently formed
intellectual minds. As I believe this is the strongest argument for a liberal
admisson policy and to some degree for a postgraduate model.
cum
4 .•
.
Modifying a little bit MoysesSzklo |7|, one of the most distinguished members
of our scientific advisory committee, I would define three groups of basic
disciplines of public health: (1) epidemiology and biostatistics, (2) health
protection and health promotion and (3) health policy and management. These
are essential for efficient health planning and policy making.
114

Scientific foundation:
(Academia)
Preventive orientation:
(Practice)
Societal dimension:
(Administration)

epidemiology and biostatistics
health protection and health promotion
health policy and management

7 he board of ASPHER has presented a European Public Health Training
Programme [8] and suggests the establishment of a European Review Board
in order to set and to help implement standards of public health training in
the region. This will be achieved by proposing a system of certification of
Europe-wide acknowledged training modules.
2) Research: 1 believe we should stick to Humboldt’s ideal of “Lehre und
Forschung”, teaching and research interlinked. Therefore if ASPHER is
charged with the promotion of public health teaching in Europe, it is also
charged with research or more precisely training for research.
I suggest that in this area we cooperate as closely as possible with the
European Public Health Association which was founded as recently as
December 1992 and is still in its early stages of development. To illustrate
tentatively the extreme importance of the public health research agenda I
want to give you a simple account of the hypotheses developed to explain the
wideningdifferencesin life expectancy since 1970between the twoGermanics
[9|, accounting for more than 2 years in favour of the West by the year of
change 1989:
Table 4:

Hypotheses raised to explain differences in life expectancy between Germany
East and West:
* he organisation of health care (centralization, institutionalization)
Resources allocated
The provision of high-tech medicine
Degree of public information and participation (e.g. self-help-groups)
Quality of nutrition
~ onsumption of tobacco and alcohol
““ Environmental pollution
_
- East-West
East-West miprat'
migration
_
------------------------------- —
In order to develop a systematic approach to these issues a reliable routine
Public Health Information System is needed in Europe. For example the one

Z. f. Gesundheitswiss., 2. Jg. 1994, H. 2 Z. f. Gesundheitswiss., 2. Jg. 1994, H. 2

115

having been iniiiaicd Dy Uiu LUU and WHO together: the European
Nervous System Project which has been presented yesterd' r 10J. It might
be considered a first pilote for the international exchange < .ospital data.

I know that there has been a very well developed international data bank in
this field produced by the former socialist countries together and hosted in
Sofia, Bulgaria. Only a few days ago I got the information that it seems to
have survived the political changes, so why not taking up this idea again?
Links could be established to other existing data banks like SOMED, which
is produced at the WHO Documentation Centre at the IDIS here in
Bielefeld and covers the literature on social medicine and public health [ 111.

Also ASPHER could provide a forum for the necessary international
agreement on conventions and standards. Whcreever we have the means to
exchange students, lecturers and researchers we can make a substantial
contribution to the merger of Europe through merging information systems.
In certain sectors however, e.g. with regard to lifestyle change, routine data
from health services and sentinels do not suffice, we also need valid data
from representative samples, i.e. from a European Health Survey, which of
course in the beginning might start between a few partners only.
I see a new chance for this concept especially in the context of the Europe of
Regions: it might be much easier to agree among a number of regions and
their representative bodies than among national governments with all their
problems of prestige and neutral balance. The recently established WHO
Regions for Health Network [12] is a promising example.
3) Practice: We have little common understanding of the European Public
Health Professional, not even of the public health officer in the community
or state health offices. One of the first steps could be to compare the various
public health legislations, in Germany being even different between the
„Lander“. Do the main public health issues really constitute the main
professional tasks or is the public health official typically overwhelmed by
administrative red tape, not sufficiently free to deal with epidemiological
monitoring, with health reporting and planning and with the realization of
effective health promotion and health protection programmes? What about
continuing education, what about international contacts and cooperation,
not only one of the most important stimuli for progress in public health but
also adequate to the border-crossing health problems e.g. in the area of
environmental pollution? What about support of colleagues in the sometimes
bitter conflicts of interest-situations and lobby-groups? I suggest the formation
of a working group on professional guidelines for the practice of public
health in Europe. Let us call it a consensus group. I consider such a group also
to be the only gateway to allow for effective quality assurance. Again I am
sure that we can find ways to work closely together with organisations like
EHMA and EPHA, to relate to viewpoints of providers and consumers.

of professions, goods, services and finances, for good reasons should name
professions first: knov
geable people clear the way for all other substantive
matters.
Resume

ASPHER is in a transitional phase of reorientation, and of upward
acceleration. I hope this is true for Europe too! I know that what I have
outlined needs much more discussion and further refinement but not of I
hope the theoretical reshuffling of conceptual pieces alone. I suggest the
formation of three task forces on the teaching, research and practice of
public health in Europe together with the Commission of the European
Union and WHO and in close cooperation with and perhaps divided
responsibilitiesbetween the European Healthcare Management Association
(EHMA), the European Public Health Alliance (EPHA) and the European
Public Health Association (EUPHA). The terms of reference should be as
pragmatic and down to earth as possible. The end result hopefully will be an
agreed upon core training scheme, an integrated and sufficiently financed
research and development progamme on a European public health knowledge
base and a well managed and easy exchange and scholarship organization.
This is a preliminary though demanding programme. To avoid a common
misunderstanding in connection with the issue of convergence in Europe, I
should underline that this programme does not strive for uniformity but for
uniqueness and excellence. All of us work hard for a stepwise realisation and
so ASPHER shall do vividly throughout the next 25 years of its existence.

References

It is not only a pleasure to intensify the contacts with colleagues, as this
conference is proof of, it is also a must in the field of public health. The four
freedoms of the Common European Market concerning the free movement

[ 1 ] Grmek MD, ed. Serving the Cause of Public Health. Selected papers of Andrija
Stampar. Zagreb: University of Zagreb. 1966.
[2] Public Health in England. The report of the Committee of Inquiry into the future
development of the Public Health Function. London: Her Majesty’s Stationery
Office. 1988.
[3] Treaty on European Union. Luxemburg: Amt fur amtliche Verdffentlichungen
derEG. 1992.
[4] Laaser U, Wolters P. Das gesundheitswissenschaftliche Graduiertenstudium an
der Universitat Bielefeld im Rahmen vergleichbarer Bestrebungen. Sozial- und
Praventivmedizin 1989; 34: 223 f.
[5] Targets for health for all. The health policy for Europe. Copenhagen: WHO.
Regional Office for Europe. 1991.
[6] Engelberg E. Bismarck: Das Reich in der Mitte Europas. Berlin: Siedler-Verlag.
1990: p. 392/3.
[7] Szklo M. Personal communication.
[8] ASPHER Ad Hoc Group. The Future of ASPHER Collaboration in European
Public Health Training. Zeitschrift fur Gesundheitswissenschaften 1994; 2. Jg,
H. 2.
[9] Laaser U. Trends and Developments in East and West German Health and
Health Care. In: The Economics of Health Care: Challenges for the Nineties.
London: Mediq Ltd. 1990: p. 109-116.

116

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Z. f. Gesundheitswiss., 2. Jg. 1994, H. 2

117

[10] Nanda A, Bardehle D. Computer Networks in Europe for Data Exchange in
Public Health. Conference Programme on Scientific Prere*' ’ ites for Effective
Health Policies at the 15th General Assembly of the Asso< .on of Schools of
Public Health in the European Region. Bielefeld. November 28, 1993.
1111 Institute for Social Medicine and Public Health (IDES), WHO-Documentation
Centre: Data-Base SOM ED on scientific public health literature. P.O. Box 20 10
12, D-33548 Bielefeld.
[12] Regional Health Policy Development: Regions For Health Network. Copenhagen:
WHO. Regional Office for Europe. 1993.

Prof. Dr. med. Ulrich Laaser, DTM&H, MPH, University of Bielefeld, Faculty of
Health Sciences, School of Public Health, UniversitatsstraBe, D-33615 Bielefeld

J acques Bury, L 'nart Kohler, Evelyne de Leeuw, Patrick V aughan

The Future of ASPHER Collaboration in
European Public Health Training1
Zur zukunftigen Zusammenarbeit von ASPHER in der europaischen Public-health-Ausbildung

1. Background2
/./ The challenge of public health

By the early 1980s the face of public health in Europe was seen to have been
changing radically. “Social and political inequalities, the demographic
revolution, the health effects of a vandalized environment and the burgeoning
technological advances in medicine are generating unprecedented problems
for public health practitioners.”3 The current economic developments in
western Europe and the continuing drastic changes in countries of central
and eastern Europe (CCEE)4 are generating yet more problems for the
1990s.
In the European Region of WHO, a response to these challenges has been
articulated in a regional HFA policy and strategy to advance public health.
The HFA strategy principles have been systematically elaborated into 38
operational targets specifically applicable to the European situation? The
integration of these targets into public health practice has been termed „the
new public health11 (Asvall, 1989)? However, existing programmes of public
health education also need to provide training for practitioners which
enables them to tackle new problems and exercise leadership in facilitating
appropriate changes.

1 Position Paper from the 15th General Assembly of the Association of Schools of
Public Health in the European Region in Bielefeld, as of November 29, 1993.
slightly shortened version edited for this publication. The final publication will
follow soon and lay the legitimate foundation for a European public health review.
2 This section of the paper draws extensively on F. Eskin and A.M. Davies. Steps
towards the Development of European Standards for Public Health Training.
EJPH 1991;1:110-112.
3 Eskin and Davies op cit citing P. O’Neill, Health Crisis 2000, Heinemann Medical
Books, London 1983.
...
riou
4 M. McKee et al. The new programme for public health training in Hungary. EJ1 H
1993;3:60-65.
4
5 Targets for health for all: the health policy for Europe, approved by WHO
Regional Committee, September 1991 (updatedfrom 1984), published Copenhagen
1992.
6 J.E. Asvall. Address to ASPHER General Assembly, Budapest, 1989.

118

Z. f. Gesundheitswiss., 2. Jg. 1994. H. 2

Z. f. Gesundheitswiss., 2. Jg. 1994, H. 2

119

ZX 1I1.M Milin VI

1.2 AS Pl 1 ER's response
ASPHER links over 80 institutions and individual members i
2 promotion
of education and research in public health. Since 1981. there nas been close
cooperation with WHO European Regional Office (EURO). In the first
stage the focus was on development of research programmes7 x and learning
materials? 10

The next step in this cooperation was the creation of a joint WHO-ASPHER
Task Force. Its original brief (1986-1987) was to test the hypothesis that the
leaching of public health, incorporating relevant components of the basic
sciences and technologies within case study material, could be reoriented
and reorganized around the European HFA targets. Preliminary work was
carried out in relation to targets 9 (cardiovascular disease control), 13
(healthy public policy) and 23 (hazardous wastes). Some of the work resulted
in self-learning modules, while other efforts were designs tor learning which
teachers could adapt and develop to meet local needs.
1.3 The EM PH concept - ASPH ER's role
In early 1988 the Task Force was asked by the W1 IO Regional Director tor
Europe to expand its original brief to prepare proposals for the development
of a European Master's Degree in Public Health (EMPH) based on HFA
principles, which would set a European standard and which could be
accredited jointly by ASPHER and WHO. A workinggroup was subsequently
set up by the Task Force to prepare draft proposals.

It was envisaged that the establishment of such a degree programme would
serve a number of purposes. It would develop learning materials and
methods to equip public health managers to develop and apply the new
public health approach. It would raise standards of education and training,
particularly in emergingschools and institutions. Finally, a European degree,
with the imprimatur of WHO and the professional association, would
provide a „gold standard1' to which all could aspire and which would further
the development of a European practice of public health to enable them to
confront and effectively manage the complex health problems challenging
European society in the last decade of the 20th century and beyond."

LandheerT. (1984) European collaborative health services studies: a proposal for
the development of the studies, ECHSS Report.
8 Doeleman F. (1991) A comparative study of eight area health services, ECHSS
Programme, ASPHER, Utrecht.
9 Leliefeld H, Hollander H. (1985) Health management training workbook,
ASPHER, Utrecht.
10 Eskin F. de Neergaard L. (1987) Training in motivation for health care managers:
a manual for course organisers, CDP/ASPHER Learning Manual No.l,
Manchester.
11 AsvallJ.(1989) Openingaddress to ASPHER 11th General Assembly, Budapest.
7

120

Z. f. Gesundheitswiss., 2. Jg. 1994, H. 2

HIV LU11.VU.U..,

......

-------------

-

j

-

reviewed at a WHO consultation meeting in Dusseldorf in November of the
same year, attenc.
by members of the Task Force together with teachers
from 25 European Schools of Public Health. The work of the sub-group was
endorsed in principle and its members charged with refining and expanding
the original proposal. A revised draft was endorsed by the ASPHER
General Assembly in Budapest in August 1989.12 In November 1989 a
substantial financial allocation was made by WHO/EURO to enable the
development of the first phase of the envisaged EMPH programme - the
production of four core HFA-based learning modules.

1.4 EMPH curriculum development - the experience

The approach adopted in agreement with ASPHER. was that WHO funded
4 of its member schools (Department of Community Health, University of
Nottingham; Ecolc Nationalc de la Sante Publique (ENSP), Rennes; Nordic
School of Public Health, Gdteborg; and Academy of Public Health. Dussel­
dorf) to each organize a workshop to design curricula and develop learning
materials based on various targets or clusters of targets.
As in the earlier round of preliminary work, the schools concerned adopted
different approaches, this time influenced by the content of their targets,
their own experiences, and what they believed was a realistic goal in the
circumstances. At the extremes one workshop resulted eventually in the
production of guidelines and suggestions for curriculum development and
the preparation of learning materials. These were illustrated by outline
course programmes and exercises related to various targets, developed by
academic peers brainstorming during the workshop. In contrast another
school developed a full case study with extensive supporting material and
used the workshop to test the use of the case study, refining it later in light
of that experience.
1 n the first case the school made assumptions about the pedagogic competence
of any instructor using the guidelines and the way the related basic sciences
and technologies would be dealt with. In the second case, the school created
a ready-made package related to one target. This included material which
could be cross-referenced to other targets and which fitted with more
general HFA-related learning, but did not develop guidance on how to
expand beyond the case study other than by producing other case studies for
other topics.
The project raised questions, doubts and objections from various schools
and university departments of public health across Europe. A follow-up
workshop convened by the Task Force and hosted by Frada Eskin on behalt
of Yorkshire RHA, was held at Harrogate, November 1991. This was an

12 Wojtczak A, Kroger E, Eskin F (1989) A European HFA-based Master s degree
in public health: a proposal for an EMPH Curriculum. ASPHER/WHO Task
Force, Copenhagen.
Z. f. Gesundheitswiss., 2. Jg. 1994, H. 2

121

/. Kecpiests the Executive board, m consultation wun w//mz/suai/ ana
others as they s ht, to establish an Ad Hoc Group with terms of reference:
i) to seek view yf all member institutions concerning the desirability of
pursuing further the implementation of a European MPH;
the feasibility of establishing courses (of whatever kinds) which would enjoy
mutual recognition with academic and professional institutions in other
European countries;
alternative recommendations for the consideration of the Executive Board
and of the Assembly based on the views of member institutions and analysis
of possibilities and feasible options;
ii) to present to the Executive Board a report for consideration at the 1993
assembly.

attempt to put the experience of the four workshops together and chart a
future course. The report of the Harrogate workshop e xcluded that it
would not be useful to continue the existing approach of us
workshops of
ASPHER members to cover the full spectrum of HFA Targets.13 It was felt
that at that stage with such diverging views and experience among ASPHER
members, it would be more fruitful to develop HFA-based training through
peer review and validation approaches, and by encouraging collaboration
among members through the establishment of consortia of schools with
complementary strengths.

The subsequent ASPHER Executive Board Meeting requested a draft
paper on the next steps in proposals for EMPH, including the guidelines on
content and'accreditation. A first draft of this paper was circulated to all
ASPHER members in the Spring 1992 and comments were received from 23
centres. A revised paper, which had been approved by the ASPHER
Executive Board, proposing a modular approach to establishing EMPH
course, was circulated at the ASPHER Annual Meeting in Athens in
October 1993.14

2. Remits to the Executive Board responsibility for determining the membership
of the Ad Hoc Group, its methods of working and all related administrative
matters.
3. Invites all member institutions to submit their views in writing to the
secretary-general of ASPHER.

1.5 The EMPH debate crystallized
At the Athens General Assembly, October 1992, a draft resolution was
drawn up, which summarized well the character of the debate and the
emerging recommendations;
This Assembly,
Noting the outcomes and conclusions of the ASPHER-WHO Task Force on
HFA-based training and the proposals of 6th of October submitted to this
assembly and the discussions which followed,
Noting further the initiatives taken by WHO/EURO relevant to public health
training, including the Rome Dialogue, June 1992,15 and work in hand
including the preparation of a schedule of HFA-related public health
competences.
Aware that many member institutions have taken their own initiatives in
collaboration with others to promote and develop HFA-related training; and
concerned that such initiatives should continue to gain momentum.
Mindful also of the differing judgements among member institutions of the
desirability and feasibility of implementing a European MPH scheme; and of
the continuing uncertainty as to the most advantageous way forward for
member institutions.

2. Euro-ASPHER Ad Hoc Group on Public Health Training
2.1 Terms of reference
Accepting the principles put forward in the draft resolution, the General
Assembly in Athens, October 1992, requested the Executive Board to create
an Ad Hoc Group to propose a mechanism for reviewing courses and
modules in terms of academic level, curriculum, scope and learning objectives,
as well as scale, contents and methodologies, and to define principles to be
satisfied for such courses or modules.

I

The group was given the following terms of reference:
To prepare a draft document on mechanisms for reviewing educational'
activities (courses and/or modules and/or programmes) offered by training
institutions in public health in the European region. This includes preliminary
sets of aims, principles, process stages, time frames, expected outcomes,
costs and partners related to this enterprise.
2.2 Current context

on a consultation workshop held 20-23 November 1993, Harrogate, England.
14 Vaughan P. Proposals for the Future Development of the European Masters in
Public Health (EMPH). October 1992. 18 pages.
15 The European Dialogue on Public Health Training, Rome 1992: Alderslade,
Richard: Education Policies for Training in Public Health; Barnard, Keith and
Kohler, Lennart: Learning Environments in Public Health Training; de Leeuw,
Evelyne: Competences required in Public Health Training in a Health for All
Perspective: A Framework. (Under publication) WHO/EURO.

2.2.1 ASPHER’s role and the needs of its members
From the discussions and experiences within ASPHER and with other
relevant organizations, it has become obvious that a new approach is needed
to strengthen ASPHER’s internal coherence and common collegiate culture
as well as its relevance, credibility and sustainability towards the European
public health community. As the most appropriate way of doing this it is
proposed to concentrate on renewed efforts to create a coherent education
and training policy and to present it to the public health community as a
European public health training strategy.

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13 The European Mastersin Public Health Programme: The Way Forward. Report

Z. f. Gesundheitswiss., 2. Jg. 1994, H. 2

123

in order to meet me challenges implicit in rir /\ ano me new pnonc iicaiui n
must be recognized that publichealth professionals require a «et of competences
(knowledge, skills, behaviour and attitudes) additional to
;e that they may
already possess. The intention is not in any way to support the creation of an
additional public health profession. These proposals reflect the changing
demands on all existing public health professionals which will have to be faced
in the coming decades. Their purpose is to ensure that practitioners are properly
equipped with the necessary professional competence to enable them to meet
the challenges of their role in an HFA context.
2.2.2 WHO
In June 1992, WHO/EURO organized a workshop in Rome for defining a
renewed educational policy for training in public health as well as the
required competences and learning environment.
In early 1993, Jacques A. Bury was internally reassigned to a post devoted
to training and research in public health. The policy for this new programme16
is in development and will be presented and copies made available at the
ASPHER 93 Annual Meeting. A first informal consultation of European
experts will be held at the end of September 1993 to review a draft of the
policy paper for the development of the programme.

The main orientation of the programme will be:
To promote, within the framework of WHO's Health for All policy and in
a political context of change and transition in Europe, an integrated
development of training and research in public health to support the
development of health policies and health care reforms, with special
concern for equity in health within and between countries.
2.2.3 European Health Management Association (EHMA)
European Health Management Association has during the last decade
developed and refined a programme review system, which is an advisory
service to help members enhance their management education and
development activities.
EHMA brings together four-person expert teams, designed to meet the
special needs of the client, drawn from the 120 institutions that are members
of the Association. The expert teams have an international character which
gives the programme review process a unique strength.

The process is based on a voluntary and confidential peer review, and its aim
is mutual learning and growth, not sanctions.

So far, EHMA has reviewed or evaluated more than 20 educational or
training programmes in seven countries, including PhD courses in health
care management. Master’s programmes in schools of public health,
undergraduate and continuing educational programmes.

The Executive >ard nominated Patrick Vaughan and Lennart Kohler and
Evelyne de Le>—vv, Secretary-General, as members of the Ad Hoc Group.
WHO/EURO was represented by Jacques A. Bury, Regional Adviser for
Training and Research in Public Health.

The group met in Copenhagen, on a cost-share basis between ASPHER and
EURO, on 23-24 February, 18-19 March, and 21-22 June 1993.
The group studied the three components of the mission. They agreed that as
the focus was on peer review and accreditation issues, it was important to
consult Philip Berman, Director of EHMA, and EURO covered the cost
incurred for two consultations.

3. A European Training Programme in Public Health

The Ad Hoc Group’s deliberations resulted in the following proposals,
subsequently discussed and endorsed by the Executive Board.
The strategic aim is to enable public health professionals in Europe to obtain
an academic training with a European perspective, widely recognized as
valid and equivalent across Europe. The group clearly recognized that this
ambitious aim could only be achieved over a number of years.
In terms of European collaboration, the approach required depends on a
more flexible and pragmatic use of schools' varying resources, competences,
culture and languages.

3.1 Structuring modules, and Masters Degree schemes in public health
The approach would be to develop a number of recognized postgraduate
Masters level schemes of study, either as combinations of modules or a single .
full course, in public health which are equivalent in content and status and
which train a variety of different health professionals. These would fit with
a two-tier approach with a) a focus on free-standing courses/modules and/or
combinations thereof, and b) full programmes made up of a set of courses/
modules with a consistent programmatic nature.
In the short and medium term, different European training centres could
either:

a) offer a full Master’s programme by modifying an existing course or begin
the planning of a new course;
b) offer only certain modules or components which are recognized by other
centres, which can be stand-alone courses or ones which can be incorporated
within a future EMPH scheme. The European Masters in Public Health
could be obtained at either one or several centres and over one year, or
spread over several years; or

16 Policy and Plan of Work of WHO/EURO’s Programme on Training and Research
in Public Health. June 1993.

c) offer self-standing courses of a developmental nature.

124

Z. f. Gesundheitswiss., 2. Jg. 1994, H. 2

Z. f. Gesundheitswiss., 2. Jg. 1994, H. 2

125

J.2 CollaDoration mrougn peer /< i/< h unu i/uttum >c

There is a need for a system whereby ASPHER, in collabor ' m with WHO,
EHMA and other organizations, would create a proces jf recognizing
various courses or modules, that would fulfil certain criteria of quality,
content, educational framework and philosophy.
This would allow schools run their courses/programmes according to the
national context and requirements; at the same time it will enable students to
see the European dimension in national courses. It is expected that this system
of European recognition of courses/modules or programmes will be seen as
supportive to schools in all parts of Europe. It should be attractive to both the
old schools that want to take a lead in new developments and the new schools
that want to quickly feel accepted members of the European league.

The underlying intention behind such an approach is to encourage schools
or institutions to enter into voluntary association with others, collaborating
and helping each other to provide postgraduate training according to
specified European multiprofcssional and public health principles.

Schools should be encouraged, therefore, to create formal or informal
consortia, as ad hoc partnerships for one or more courses/modules. There
are already some good examples of such consortia nourishing in Europe.
The expectation is that in time these consortia would evolve into fully
structured and validated multinational training programmes, fulfilling the
requirements of a European Master’s Degree.
3.3 Underlying principles and the prerequisites
In determining the orientation of a training programme, the sine qua non
must be the values inherent in HFA and its effective implementation. The
second founding principle is to have a distinct European perspective.
Therefore, the following constitute the fundamental prerequisites for the
success of the new European training programme in public health and for
any EMPH scheme developed by schools:

1. The essence of the programme is its focus on leadership and HF A.
2. An awareness of the health situation and systems throughout Europe and
some in depth foreign studies are important components of the programme.
3. The participants are drawn from all disciplines and professions relevant to
the public health.
4. The participants have been exposed to substantial field experience prior
to being accepted for the programme.17
5. The educational approach is that of “learning by doing ’ and reflects the
working environment. Students are expected to involve themselves fully
in the learning process by utilizing their work experience and otherwise
contributing to enrich any “classroom” activities.
17 Further criteria for student selection can be developed on a national basis
according to a country’s particular needs and approaches.

126

Z. f. Gesundheitswiss., 2. Jg. 1994, H. 2

activities with in-service training, and essentially comprises two
components: f
ling modules and a service-based project.
4. Implementing Reviews
4.1 The value of reviews

In this section, the schools’ perspective is taken into consideration. The
following are questions that are commonly asked about a review process:
What are legal and factual status of a recognition procedure, and which
consequences may be expected?
What are (he reasons why an institute might submit itself for scrutiny under
such a scheme?
What value might be attached to such a review?
What infrastructure has to be in place and available?

4.2 Reasons for entering into a review

The European Healthcare Management Association (EHMA) over time
has found that in essence there are four reasons for institutions to submit
themselves or their programmes to external scrutiny:
The wish to improve the standard of teaching;
The desire to be seen as an outstanding and prestigious institute;
To have a "quality mark " attached to their courses in order to increase their
commercial value;
The needfor some sort offormal recognition, either by peers or by legitimating
authorities.
The latter form of recognition is generally awarded to most academic
institutes through national educational recognition mechanisms. From a
school’s perspective, the commercial value attached to a recognition „stamp“
is probably a most important motive. It is, therefore, important that a
legitimating body awards such recognition. ASPHER, in joint operation
with WHO/EURO, could prove to be such a body.
4.3 The review range

Between confidential peer review and public accreditation procedures there
exists an entire range of evaluation and assessment of educational offerings.
Both ends on this spectrum have their advantages and disadvantages.
Confidential peer review is suitable for those institutions which have a high
internal motivation to improve the quality of their teaching. The advantage
is that evaluators as well as those being evaluated can be frank in their
opinions and thus contribute to the quality of the assessment. Also, the
confidential nature allows for a high degree of flexibility. On the other hand,
as the procedure is confidential, it cannot be monitored as easily by external
agencies, unless the institution’s management allows for it. This could
obscure negative findings and conclusions.

Z. f. Gesundheitswiss., 2. Jg. 1994, H. 2

127

Public accreditation has as the main advantage that, through rigorous
application of explicit criteria, external peers can m;
a more objective
judgement, more suitable for making comparisons.

5. Rules ol Review0
The following \s are proposed:

It is of course possible that by their nature well-experienced and professional
peers can evaluate programmes fairly and honestly, without rigorous criteria.
Thus, the institution may be facilitated to improve standards where necessary,
either by comparison or independently. It also needs to be remembered that
once accreditation isawarded, the institution can retreat towards inertia and
standard can fall and hence it is necessary for all accredited centres to
undergo periodic review.

* A review may be concerned with a course or a module which is part ol a
wider programme, by a full programme or a whole training institution.
* The formal request must be made by the relevant authorities responsible
for the education in the institution and endorsed by their senior
management.
* A rationale for requesting the review process should be provided by the
institution and accepted by the Review Board.
* A formal contract will be set up between the institutions and the Review
Board, covering the contents, process and use of the outcomes as well as
the costs.

4.4 A possible recognition procedure

It is envisaged that the ASP1IER/WHO recognition procedure will be a
shade of grey in the range of options described above. In order to suit the
needs of the client, areview contract will have to be established. The contract
will lay out financial aspects of the review, agreements on the composition
of the review team, form and right of appeal to decisions taken, agreements
on the confidential nature of the evaluation, statements on publication rights
of the final report, and recognition options.

With the recognition there will always have to be a review report including
recommendations for further improvements of the evaluated entity (course,
modules, or entire institutes).
The review team should have the liberty to take into account the “contents
environment” (the degree to which the offering forms a programmatic whole
with other offerings, etc.) as well as the infrastructural environment of this
course, module, or programme.

4.5 Logistics and infrastructure required
Initially, the Executive Board of ASPHER will take up responsibility for
further development of this scheme. Adequate time and resource allocation
among its memberswill be a crucial prerequisite. Later on, it is proposed that
a governing body - the European Public Health Training Review Board may be established to develop and monitor the recognition procedure. This
Board will also act as a Court of Appeal, and may be composed of members
of ASPHER, WHO/EURO, EHMA. A secretariat will administer and
execute the actual process. The ASPHER Secretariat-General will be able
to take up this responsibility. It will have the right to negotiate contracts with
clients under the aegis of the Review Board, and will have a database of peer
consultants available for review missions. The Secretariat can be of assistance
in further implementation of recommendations of the review team by the
client.

5. / Preconditions

5.2 Central principles
* The course/modulc/programme/institution should be concerned with
postgraduate training in public health.
* The course/module/programme should be based on the philosophy of the
Health for All policy.
* The students should be exposed to a European perspective through
specified and clearly identified means,e.g. comparative issues, intercountry
cases, study tours, students or teachers from other countries contributing
to the content.

5.5 Framework for criteria
* For the courses or modules, there should be a significant course load
(minimum three weeks or 100 hours student workload).
* There must be an overall educational coherence, i.e. a proper fit between
objectives, content and student competence assessment.
* The course/module/programme should be population-based, community- '
oriented, student-centered and should incorporate problem-based
approaches.
* Organizers and all academic resource persons should be of sufficient
standing and recognized competence.
* The course/module/programme should be multidisciplinary in its approach,
using staff from relevant disciplines and attracting students from various
professions.
* There should be a proper quality of learning environment, the availability
of learning materials, etc.
* There should be an in-house mechanism for appropriate assessment ol the
course/module/ programme by staff, students and academic peers.

18 5.4 and 5.5 regarding certain operational principles are omitted in this publication

128

Z. f. Gesundheilswiss., 2. Jg. 1994, H. 2

Z. f. Gesundheilswiss., 2. Jg. 1994, H. 2

129

The Assembly appreciated that in preparing these pro
als, the Ad I loc
Group has been concerned:
not to lose the cumulative experience which ASPHER has built up during
the past decade;
to be aware of the new situation in Europe with new opportunities and
challenges to be faced if ASPHER is to respond effectively to the needs of
its members;
to identify opportunities for cooperation with both old partners (WHO and
EHMA) and new partners, notably CEC19 and their new Public Health
Mandate.
The Assembly concluded in light of the draft resolution drawn up in Athens
(page 4 of this report):
1 )That the Ad Hoc Group has identified the key issues and presented viable
proposals in terms of
a) the lessons learned from past efforts of ASPHER-led training activities,
b) the need lor (and interest in) an ASPHER-led initiative focusing on the
useof an HFA framework, broadened to encompass with equal authority the
CEC public health policy once promulgated, studcnt-centered/problcmbased learning approaches, collaboration between member schools with
complementary strengths and resources, mutual (intcrschool) recognition
of courses devised by member schools and observing the agreed basic
principles, peer review mechanisms as a means of establishing a European
standard in public health training and a common qualification,
2) that the specific practical steps that arc proposed are realistic as seen from
the perspective of member institutions.
3) That on the basis of the Ad Hoc Group's proposals, the EB should be
authorized to initiate some pilot projects based on its proposals.

Dr. Evelyne de Leeuw, University of Limburg, School of Public Health. Faculty of
Health Sciences, P.O. Box 616, NL-62(X) MD Maastricht

19 The Ad Hoc Group report should be read in conjunction with the report of the
meeting with CEC officials in Brussels 22 J une 1993. The main consequence of the
meeting is that ASPHER will play a substantial role in the further development
of European public health policies; the 1993/1994 Presidential Address during the
XV Assembly will reflect this involvement.

130

Z. f. Gesundheitswiss., 2. Jg. 1994, H. 2

Reiner Leidl

Gesundheitsokonomie als Fachgebiet
Health Economics as a Discipline

Die Knappheit der Ressourcen und wirtschaftliche Aspekte von Gesundheit und
Gesundheitsversor^ungformen dieAusgan^sbasisfilrdieGesundheitsokonomie. Das
Fachselbstistin derNachkriegszeitentstanden. Seine Wurzeln reichen zuriick bis in die
Zeiten des Entstehens von sozialpolitischem Denken, der Bewertung von menschlichem Leben undderinstitulionellen Krankenversorgung. Gesundheitsokonomie wird
als wissenschaftliche Beschaftigung mit den wirtschaftlichen Aspekten der Gesundheit
und Gesundheitsversorgung definiert. Trotz einiger eigener Entwicklungen liegt die
methodische Basis des Faches bei der Okonomie und ihren Teilgebieten, ergiinzt urn
Beitrdge angrenzender Disziplinen. Die Gesundheitsokonomie ist ein vielfiiltiges und
angewandtes Each, das eine eigenstiindige Rolle in den Gesundheitswissenschaften
spielt. Regelmdfig werden von diesem Each Beitrdge zur Politikberatung und
Entscheidungsunterstutzung erwartet. Daneben sollte der weiteren Entwicklung von
Theorien und Methoden zur Analyse der Produktion von Gesundheit und der Orga­
nisation von Gesundheitssystemen ausreichend Aufmerksamkeit gewidmet werden.
Schlusselwbrter: Geschichte, Definition, Methoden, disziplindre Einordnung der
Gesundheitsokonomie

Scarcity of resources and the economic aspects ofhealth and health care set the starting
pointfor health economics. The discipline has emerged in the post-war period. Its roots
reach back to the times when social policy was first formulated, when human life was
quantitatively valued, and when institutionalized health care was established. Health
economics is defined as the scientific analysis of the economic aspects of health and
health care. In spite ofa number of developments of its own, the methodological basis
of the discipline is founded in general economics and in its subfields. This is amended
by contributions from neighbouring disciplines. Health economics is a heterogeneous
and applied discipline, which plays an original role in health sciences. Regularly, this
discipline is expected to provide consultancyfor health policy and other decisions. Next
to this consultancy, sufficient attention should be devoted to thefurther development of
theories and methods for the analysis of health production and the analysis of the
organisation of health care systems.
Keywords: history, definition, methods, disciplinary relations of health economics
Am Beginn jeder okonomischen LJberlegung steht das Phanomen der
Knappheit: die vorhandenen Ressourcen reichen nicht aus, urn alle bestehenden Bedurfnisse zu befriedigen. Es bedarf heute keiner weiteren Erlauterung, daB auch im Gesundheitswesen Knappheit herrscht und daB es
verschiedene Moglichkeiten gibt, die knappen Ressourcen einzusetzen. Die
wissenschaftliche Beschaftigung mit der Knappheit und mit den Wahlmoglichkeiten zwischen alternativen Ressourcenverwendungen ist ein Kernstuck der okonomischen Analyse. Die Okonomie kann sich ohne Zweifel
auch mit Fragen des Gesundheitswesens befassen.
Z. f. Gesundheitswiss., 2. Jg. 1994, H. 2

131

3

fl

Medical Metaphors
of Women’s Bodies:
Menstruation
and Menopause

..
■

■>/

I

I

I
I

3

'J

Qrt
P
3
-

I

1

1

I

Lavoisier makes experiments with
substances in his laboratory and now he
concluded that this and that takes place
when there is burning. He does not say
that it might happen otherwise another

It :s difficult to see how our current
scientific ideas are infused by cul­
tural assumptions; it is easier to see
how scientific ideas from the past,
ideas that now seem wrong or too
time. He has got hold of a defnite world­
simple, might have been affected
picture—not of course one that he
by cultural ideas of an earlier time.
invented: he learned it as a child. I say
To lay the groundwork for a look
world-picture and not hypothesis, because
at contemporary scientific views of
it is the matter-of-course foundation for
menstruation and menopause, I
his research and as such also goes
begin with the past.
unmentioned.
It was an accepted notion in
—Ludwig Wittgenstein
medical literature from the ancient
On Certainty
Greeks until the late eighteenth
century that male and female bodies were structurally similar. As Nemesius, bishop of Emesa, Syria, in
the fourth century, put it, “women have the same genitals as men,
except that theirs are inside the body and not outside it.” Although
increasingly detailed anatomical understanding (such as the discovery
of the nature of the ovaries in the last half of the seventeenth century)
changed the details, medical scholars from Galen in second-century
reece to Harvey in seventeenth-century Britain all assumed that
women s internal organs were structurally analogous to men’s external
ones.1 (See Figures 1-4.)
Although the genders were structurally similar, they were not

58
27

Science as a Cultural System
Medical Metaphors: Menstruation and Menop.>ause

Fig. i Vidius' depiction of the uterus and
vagina as analogous to the penis and
scrotum. (Vidius 1611, Vol. 3. Photo taken
from Weindler 1908:140.)

Fig. 3 Georg Bartisch's illustration of
phallus-like female reproductive
organs. (Attributed by Weindler
1908:141 to Bartisch’s Kunstbuche, 1575
[MS Dresdens. C. 291]. Photo taken
from Weindler 1908, fig. 104b, p. 144.)
■

i
■X.’

* •*>•1

Fig. 2 Vidius’ illustration of how the
female organs are situated inside the body.
(Vidius 1611, Vol. 3. Photo taken from
Weindler 1908:139.)

l
I
II

y1

4 Bartisch s cross-section of the
female organs, showing a fetus inside
the uterus. (Attributed by Weindler to
Bartisch's Kunstbuche, 1575 [MS
Dresdens. C. 291]. Photo taken from
Weindler 1908, fig. 104b, p. 144.)

1
■

1
iI

28

59
F

29

Science as a Cultural System

equal. For one thing, what could be seen of men’s bodies was assumed
as the pattern for what could not be seen of women’s. For another,
just as humans as a species possessed more “heat” than other animals,
and hence were considered more perfect, so men possessed more
“heat” than women and hence were considered more perfect. The rel­
ative coolness of the female prevented her reproductive organs from
extruding outside the body but, happily for the species, kept them
inside where they provided a protected place for conception and ges­
tation.2
During the centuries when male and female bodies were seen as
composed of analogous structures, a connected set of metaphors was
used to convey how the parts of male and female bodies functioned.
These metaphors were dominant in classical medicine and continued
to operate through the nineteenth century:
The body was seen, metaphorically, as a system of dynamic interactions
with its environment. Health or disease resulted from a cumulative interac­
tion between constitutional endowment and environmental circumstance.
One could not well live without food and air and water; one had to live in a
particular climate, subject one’s body to a particular style of life and work.
Each of these factors implied a necessary and continuing physiological ad­
justment. The body was always in a state of becoming—and thus always in
jeopardy.3
Two subsidiary assumptions governed this interaction: first, that
“every part of the body was related inevitably and inextricably with
every other” and, second, that “the body was seen as a system of in­
take and outgo—a system which had, necessarily, to remain in balance
if the individual were to remain healthy.”4
Given these assumptions, changes in the relationship of body func­
tions occurred constantly throughout life, though more acutely at
some times than at others. In Edward Tilt’s influential mid­
nineteenth-century account, for example, after the menopause blood
that once flowed out of the body as menstruation was then turned into
fat:

Fat accumulates in women after the change of life, as it accumulates in
animals from whom the ovaries have been removed. The withdrawal of the
sexual stimulus from the ganglionic nervous system, enables it to turn into
fat and self-aggrandisement that blood which might otherwise have perpetu­
ated the race.5
During the transition to menopause, or the “dodging time,” the blood
could not be turned into fat, so it was either discharged as hemorrhage

30

ft

I
b

Ii i
h

Medical Metaphors: Menstruation and Menopause
or through other compensating mechanisms,
the most important of
which was “the flush”:
As for thirty-two years it had been habitual for
women to lose about
3 oz. of blood every month, so it would have been________ uia
indeed singular, if there
did not exist some well-continued compensating discharges acting
j as wastegates to protect the system, until health coud
L. P
r ermanently re-established
’UJd.bc
by striking new balances in the allotment of blood
-ri a ,
,
.
,
------------ —wd to the various parts .
The flushes determine the perspirations. Both evidence a strong effect of ’
conservative power, and1 as they constitute the most important and habitual
safety-valve of the system
1
at the change of life, it is worth while studying
them.6
In this account, compensating mechanisms like the “flush" are seen as
aving the positive function of keeping intake and outgo in balance
These balancing acts had exact analogues in men. In Hippocrates’
view of purification, one that was still current in the seventeenth cen-

women were of a colder and less active disposition than men, so that

way. Females menstruated to rid their bodies of impurities.’

■■i

U
H

u

3
$

g

I

3
60

■

Or tn another vie^ expounded by Galen tn the second century and
still accepted into the eighteenth century, menstruation was the sheding of an excess of blood, a plethora.8 But what women did through
menstruation men could do in other ways, such as by having blold
itself not’^l' hT
thC mechanism of menstruation, the process
Itself not only had analogues m men, it was seen as inherently healthZntaln,on^ M.enstrual blood- to be sure, was often seen as foul and
nclean but the process of excreting it was not intrinsically pathogical. In fact failure to excrete was taken as a sign of disease, and a

afm h a?e Y
int° the nlnctecnth century spe­
cifically to reestablish menstrual flow if it stopped."
estaBhLIh8<d,’faCIOrdingJ.t° Laqueur’s miportant recent study, this longestablished tradition that saw male and female bodies as similar both

m structure and in function began to come “under devastating attack
funderS °f a l4SmrtS Were determined to basc what they insisted were
fundamental differences between male and female sexuality, and thus
etween man and woman, on discoverable biological distinctions ”'2
Laqueur argues that this attempt to ground differences between the
genders in biology grew out of the crumbling of old ideas about the

31

sa

Science as a Cultural System
existing order of politics and society as laid down by the order of
nature. In the old ideas, men dominated the public world and the
world of morality and order by virtue of their greater perfection, a
result of their excess heat. Men and women were arranged in a hier­
archy in which they differed by degree of heat. They were not differ­
ent in kind.13
The new liberal claims of Hobbes and ) ocke in the seventeenth
century and the French Revolution were fa- ors that led to a loss of
certainty that the social order could be grou ded in the natural order.
If the social order were merely conventio
it could not provide a
secure enough basis to hold women and mei m their places. But after
1800 the social and biological sciences were wrought to the rescue of
male superiority. “Scientists in areas as dive ;e as zoology, embryology, physiology, heredity, anthropology, j I psychology had little
difficulty in proving that the pattern of n ic-female relations that
characterized the English middle classes w? natural, inevitable, and
progressive.”14
The assertion was that men’s and womei social roles themselves
were grounded in nature, by virtue of the d fates of their bodies. In
the words of one nineteenth-century theoris
the attempt to alter the
present relations of the sexes is not a rebelli . against some arbitrary
law instituted by a despot or a majority—n an attempt to break the
yoke of a mere convention; it is a strug^
against Nature; a war
undertaken to reverse the very conditions ur
r which not man alone,
but all mammalian species have reached the nesent development.”15
The doctrine of the two spheres discussed ii le last chapter—men as
workers in the public, wage-earning sphe outside the home and
women (except for the lower classes) as wi\ and mothers in the private, domestic sphere of kinship and mora y inside the home—replaced the old hierarchy based on body heat
During the latter part of the nineteenth entury, new metaphors
that posited fundamental differences between the sexes began to appear. One nineteenth-century biologist, Patrick Geddes, perceived
two opposite kinds of processes at the level of the cell: “upbuilding,
constructive, synthetic prosesses,” summed up as anabolism, and a
“disruptive, descending series of chemical changes,” summed up as
katabolism.16 The relationship between the two processes was de­
scribed in frankly economic terms:

Medical Metaphors: Menstruation and Menopause

I

SUM OF FUNCTIONS.

1 ■

a

I

Anabolism

Nutrition.

Reproduction.

Katabolism.

Female

A
Male.

Fig. 5 An illustration accompanying the late nineteenth-century biolo-

tabohe functions and the female by passive, conservative anabolic functions. (Geddes 1890:213.)

the ce capital of living matter will be lost,-a fate which is often not sucessfully avoided . . . Just as our expenditure and income should balance at
the year s end, but may vastly outstrip each other at particular times so it is
with the cell of the body. Income too may continuously preponderate and
we increase in wealth or similarly, in weight, or in anabolism. Conversely
expenditure may predominate, but business may be prosecuted at a loss- and
This los^r may fVrf°n f°7 Whi'e With ,OSS °f WCIght’ or in katabolism.
Ihis losing game of life is what we call a katabolic habit.17

ar thedldeS
these processes not cnly at the ievel of the cell, but also
at the level of entire organisms. In the human species, as well as in
almost all higher animals, females were predominantly anabolic
males katabohe. (See Figure 5.) Although in the terms of his saving­
spending metaphor it is not at all clear whether katabolism would be
an asset, when Geddes presents male-female differences, there is no
doubt which he thought preferable:

It is generally true that the males are more active, energetic eager nas
sionate, and variable; the females more passive, conservatL,
K

stable . . . The more active males, with a consequently wider range of exoe

. . . The processes of income and expenditure must balance, but only to
the usual extent, that expenditure must not altog- ther outrun income, else
32

61

33

uiichu uj u

w

^uimrai oysietn

In Geddes, the doctrine of separate spheres was laid on a foundation
of separate and fundamentally different biology in men and women,
at the level of the cell. One of the striking contradictions in his account
is that he did not carry over the implications of his economic meta­
phors to his discussion of male-female differences. If he had, females
might have come off as wisely conserving their energy and never
spending beyond their means, males as in the “losing game of life,”
letting expenditures outrun income.
Geddes may have failed to draw the logical conclusions from his
metaphor, but we have to acknowledge that metaphors were never
meant to be logical. Other nineteenth-century writers developed met­
aphors in exactly opposite directions: women spent and men saved.
The Rev. John Todd saw women as voracious spenders in the mar­
ketplace, and so consumers of all that a man could earn. If unchecked,
a woman would ruin a man, by her own extravagant spending, by her
demands on him to spend, or, in another realm, by her excessive de­
mands on him for sex. Losing too much sperm meant losing that
which sperm was believed to manufacture: a man’s lifeblood.19
Todd and Geddes were not alone in the nineteenth century in using
images of business loss and gain to describe physiological processes.
Susan Sontag has suggested that nineteenth-century fantasies about
disease, especially tuberculosis, “echo the attitudes of early capitalist
accumulation. One has a limited amount of energy, which must be
properly spent . . . Energy, like savings, can be depleted, can run out
or be used up, through reckless expenditure. The body will start ‘con­
suming’ itself, the patient will ‘waste away.’”20
Despite the variety of ways that spending-saving metaphors could
be related to gender, the radical difference between these metaphors
and the earlier intake-outgo metaphor is key. Whereas in the earlier
model, male and female ways of secreting were not only analogous
but desirable, now the way became open to denigrate, as Geddes
overtly did, functions that for the first time were seen as uniquely
female, without analogue in males. For our purposes, what happened
to accounts of menstruation is most interesting: by the nineteenth cen­
tury, the process itself was seen as soundly pathological. In Geddes’
terms,
it yet evidently lies on the borders of pathological change, as is evidenced
not only by the pain which so frequently accompanies it, and the local and
constitutional disorders which so frequently arise in this connection, but by
the general systemic disturbance and local histological changes of which the
discharge is merely the outward expression and result.21

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Whereas in earlier accounts the blood itself may have been considered
impure, now the process itself is seen as a disorder.
Nineteenth-century writers were extremely prone to stress the de­
bilitating nature of menstruation and its adverse impact on the lives
and activities of women.“ Medical images of menstruation as patho­
logical were remarkably vivid by the end of the century For Walter
Heape, the militant antisuffragist and Cambridge zoologist, in menstruation the entire epithelium was torn away,

leaving behind a ragged wreck of tissue, torn glands, ruptured vessels jag­
ged edges of stroma, and masses of blood corpuscles, which it would seem
hardly possible to heal satisfactorily without the aid of surgical treatment.23
A few years later, Havelock Ellis could see women as being “periodi­
cally wounded” in their most sensitive spot and “emphasize the fact
that even in the healthiest woman, a worm however harmless and unperceived, gnaws periodically at the roots of life.”24
If menstruation was consistently seen as pathological, menopause
another function which by this time was regarded as without analogue
m men, often was too: many nineteenth-century medical accounts of

menopause saw it as a crisis likely to bring on an increase of disease 25
Sometimes the metaphor of the body as a small business that is either
winning or losing was applied to menopause too. A late-nineteenthcentuiy account specifically argued against Tilt’s earlier adjustment
model: When the period of fruitfulness is ended the activity of the
tissues has reached its culmination, the secreting power of the glan­
dular organs begins to diminish, the epithelium becomes less sensitive
and less susceptible to infectious influences, and atrophy and degen­
eration take the place of the active up-building processes.”26 But there
were other sides to the picture. Most practitioners felt the “climacteric
disease, a more general disease of old age, was far worse for men
than for women.27 And some regarded the period after menopause far
more positively-than it is being seen medically in our century, as the
Indian summer’ of a woman’s life-a period of increased vigor optimism, and even of physical beauty.’”28
r
Perhaps the nineteenth century’s concern with conserving energy
and limiting expenditure can help account for the seeming anomaly
o at least some positive medical views of menopause and the climac­
teric. As an early-twentieth-century popular health account put it,

IMenopause] is merely a conservative process of nature to provide for a
igher and more stable phase of existence, an economic lopping off of a
function no longer needed, preparing the individual for different forms of

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acuvny, but is in no sense pathologic. It is not sexu.

B

. phyS1cal decreoi
• physical dccrcpi-

.. <—mTA-St
Geddes' d

Ki

Saw menopause as an “economic” phys.olog-

Srinen

mig

instead of their t,°n

SXXs

3Wn VCry POsitive conclusions from
aS?nabollc’ s^^mg their “thriftmess”

i
the,r 8r0W,ng bank aCCOUntS” —d of

f ?

s

sma^l b
hC b° Y 3S an intake-°utg° astern to the body as a
small business trying to spend, save, or balance its accounts is a radical
one, with deep .mportance for medical models of female bodies so
00 is another shift that began in the twentieth century with the de
velopment of scientific medicine. One of the early-twentieth-century
engineers of our system of scientific medicine Frederick T Cut Y

wh„ .dV„edJoh D. Roclefdler „ how to

d scientific medicine, developed a series of interrelated metaphors to
explain the scientific view of how the body works:

P

bodviandtLeSt’f8f tO
the Stnking COmPa-ons between the human
body and the safety and hygienic appliances of a great city Just as in the
streets of a great city we have “white angels” post everywh
c gather
of theZT maTa S fr°m the StreetS’ SO thc
greets and avenues
the body, namely the arteries and the blood vessels there are hri<« 4
r

X'Xt f

SEX'

g ther up into sacks, formed by their own bodies, and disinfect or eliminate
poisonous substances found in the blood. The body has a network of in
sulated nerves like telephone wires, which transmit instantaneous alarms at
system^wTthhlTd TfC bfdy “ fUrniShed W‘th the m°St claborate P°licc
y em with hundreds of police stations to which the criminal elements are
glaTds skil'f <11PO I" a.ndjailed' * refer to the great numbers of sanitary
ehh K k n Y P aCed a' P°lntS Where vicious Berms find entrance espe­
cially about the mouth and throat. The body has a most complete and elab

nomtsT" SynmK There are Wonderful laboratories placed at convenient
points for a subtle brewing of skillful medicines ... The fact is that the hu
man body is made up of an infinite number of microscopic cells Each one
rawmaterial is “ ^t"
labOratO^ lnto whlch
°wn appropriate
rado^and clmh
an Y
8 lntroduced’ the P™“sses of chemical separatmn and combination are constantly taking place automatically and its
thehT"
f'nlShed Pr°dUCt being nccessary for the life and health of
Stoma°chy' n
Y a ’ S°’ bU'
gre3t °rgans of the body
the liver
ters formed^T35’ kldne..yS’ga11 bladder are great local manufacturing cen­
ters, formed of groups of cells in infinite numbers, manufacturing the same

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sorts of products, just as industries of the same kind are often grouped in
specific districts.30
Although such a full-blown description of the body as a model of
an industrial society is not often found in contemporary accounts of
physiology, elements of the images that occurred to Gates are com­
monplace. In recent years, the “imagery of the biochemistry of the
cell [has] been that of the factory, where functions [are] specialized for
the conversion of energy into particular products and which [has] its
own part to play in the economy of the organism as a whole.” 31 There
is no doubt that the basic image of cells as factories is carried into
popular imagination, and not only through college textbooks: the il­
lustration from Time magazine shown in Figure 6 depicts cells explic­
itly as factories (and AIDS virus cells as manufacturing armored
tanks!).
Still more recently, economic functions of greater complexity have
been added: ATP is seen as the body’s “energy currency”: “Produced
in particular cellular regions, it [is] placed in an ‘energy bank’ in which
it [is] maintained in two forms, those of‘current account’ and ‘deposit
account. Ultimately, the cell s and the body’s energy books must bal­
ance by an appropriate mix of monetary and fiscal policies.”32 Here
we have not just the simpler nineteenth-century saving and spending,
but two distinct forms of money in the bank, presumably invested at
different levels of profit.
Development of the new molecular biology brought additional
metaphors based on information science, management, and control.
In this model, flow of information between DNA and RNA leads to
the production of protein.33 Molecular biologists conceive of the cell
as “an assembly line factory in which the DNA blueprints are inter­
preted and raw materials fabricated to produce the protein end prod­

ucts in response to a series of regulated requirements.”34 The cell is
still seen as a factory, but, compared to Gates’ description, there is
enormous elaboration of the flow of information from one “depart­
ment of the body to another and exaggeration of the amount of con­
trol^ exerted by the center. For example, from a college physiology

All the systems of the body, if they are to function effectively, must be
subjected to some form of control ... The precise control of body function
is brought about by means of the operation of the nervous system and of the
hormonal or endocrine system ... The most important thing to note about
any control system is that before it can control anything it must be supplied

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science as a ^unurat oysiem

Fig. 6 A cu. nporary image of cells
as factories. (Time magazine, 30 April
1984:67. Copyright 1984 by Time, Inc.
All rights reserved. Reprinted by
permission from TIME.)

The illustratic.. .a Figure 7 reiterates this account vividly: there is

I'

a “co-ordinating centre” which transmits messages to and receives
messages from peripheral parts, for the purpose of integration and
control. Although there is increasing attention to describing physio­

logical processes as positive and negative feedback loops so that like a
i

£

NERVOUS SYSTEM

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The N«rvous System is concerned with the INTEGRATION and CONTROL
of «H bodily functions
It has specialized in IRRITABILITY- Me abi//ty bs /•ece/ve e/x/zes^o/?^
/ncoapej Pwn
ixttrn*/ jmdmtirm/
and also in CONDUCTION - Me
to
to
*nd from CO ORDINATING Cbf/TAbS

Th< NERVOUS SYSTEM
consists of

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CENTRAL PART -

SP/WAL

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linked by an
outlying
or
/t

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\

.SENSORY Nerve fibres carry^messsge*

with information . . . Therefore the first essential in any control system is an
adequate system of collecting information about the state of the body . . .
Once the CNS [central nervous system] knows what is happening, it must
then have a means for rectifying the situation if something is going wrong.
There are two available methods for doing this, by using nerve fibres and by
using hormones. The motor nerve fibres . . . carry instructions from the
CNS to the muscles and glands throughout the body ... As far as hor­
mones are concerned the brain acts via the pituitary gland . . . the pituitary
secretes a large number of hormones . . . the rate of secretion of each one of
these is under the direct control of the brain.35

PERIPHERAL PART — Ngrve fit>rg«
■

I
of the body

from Tissues and Organs to the
Brain or Spinal Cord.

MOTOR Nerve fibres carry messac
to Tissues and Organsfrom tl
Brain or Spinal Cord.

Fig. 7 An image from a text for premedical students showing the brain as a coordinat­
ing center transmitting messages to and receiving them from outlying parts. (McNaught and Callander 1983:204. Reprinted by permission of Churchill Livingstone.)

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Mt'aicai Metaphors: Menstruation and Menopause

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rying positive or negative feedback, one element in the loop, the hy­
pothalamus, a part of the brain, is often seen as predominant. Just as
in the general model of the central nervous system shown in Figure 7,
the female brain-hormone-ovary system is usually described not as a
feedback loop like a thermostat system, but as a hierarchy, in which
the “directions” or “orders” of one element dominate (emphasis in the
following quotes from medical texts is added):

thermostat system no single element has preeminent control over any
other, most descriptions of specific processes give preeminent control
to the brain, as we will sec below.

Metaphors in Descriptions of Female Reproduction

In overall descriptions of female reproduction, the dominant image is
that of a signaling system. Lein, in a textbook designed for junior
colleges, spells it out in detail:

Hormones are chemical signals to which distant tissues or organs are able to
respond. Whereas the nervous system has characteristics in common with a
telephone network, the endocrine glands perform in a manner somewhat
analogous to radio transmission. A radio transmitter may blanket an entire
region with its signal, but a response occurs only if a radio receiver is turned
on and tuned to the proper frequency ... the radio receiver in biological
systems is a tissue whose cells possess active receptor sites for a particular
hormone or hormones.36
The signal-response metaphor is found almost universally in current
texts for premedical and medical students (emphasis in the following
quotes is added):
The hypothalamus receives signals from almost all possible sources in the ner­
vous system.37

The endometrium responds directly to stimulation or withdrawal of estrogen
and progesterone. In turn, regulation of the secretion of these steroids in­
volves a well-integrated, highly structured series of activities by the hypo­
thalamus and the anterior lobe of the pituitary. Although the ovaries do not
function autonomously, they influence, through feedback mechanisms, the
level of performance programmed by the hypothalamic-pituitary axis.38
As a result of strong stimulation of FSH, a number of follicles respond with
growth.39

And the same idea is found, more obviously, in popular health books:

Each month from menarch on, [the hypothalamus} acts as elegant inter­
preter of the body’s rhythms, transmitting messages to the pituitary gland that
set the menstrual cycle in motion.40

i

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Both positive and negative feedback control must be
be invoked,
invoked, together
together with
with
superimposition of control by the CNS through neurotransmitters released
into the hypophyseal portal circulation.42

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Each month, in response to a message from the pituitary gland, one of the un­
ripe egg cells develops inside a tiny microscopic ring of cells, which gradu­
ally increases to form a little balloon or cyst called the Graafian follicle.41

Although most accounts stress signals or stimuli traveling in a
loop from hypothalamus to pituitary to ovary and back again, car­

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Almost all secretion by the pituitary is controlled by either hormonal or ner­
vous signals from the hypothalamus.43

The hypothalamus is a collecting center for information concerned with the
internal well-being of the body, and in turn much of this information is used
to control secretions of the many globally important pituitary hormones.44
As Lein puts it into ordinary language, “The cerebrum, that part
of the brain that provides awareness and mood, can play a significant
role in the control of the menstrual cycle. As explained before, it
seems evident that these higher regions of the brain exert their influ­
ence by modifying the actions of the hypothalamus. So even though
the hypothalamus is a kind of master gland dominating the anterior
pituitary, and through it the ovaries also, it does not act with complete
independence or without influence from outside itself . . . there arc
also pathways of control from the higher centers of the brain.”45
So this is a communication system organized hierarchically, not a
committee reaching decisions by mutual influence.46 The hierarchical
nature of the organization is reflected in some popular literature meant
to explain the nature of menstruation simply: “From first menstrual
cycle to menopause, the hypothalamus acts as the conductor of a
ighly trained-orchestra. Once its baton signals the downbeat to the
pnuitary, the hypothalamus-pituitary-ovarian axis is united in purpose
and begins to play its symphonic message, preparing a woman’s body
or conception and child-bearing.” Carrying the metaphor further, the
o hcles vie with each other for the role of producing the egg like
violinists trying for the position of concertmaster; a burst of estrogen
is emitted from the follicle like a “clap of tympani.”47
The basic images chosen here—an information-transmitting sys­
tem with a hierarchical structure—have an obvious relation to the
dominant form of organization in our society.48 What I want to show

40

65

41

Science as a Cultural System

v
is how this set of metaphors, once chosen as the basis for the descrip­
tion of physiological events, has profound implications for the way in
which a change in the basic organization of the system will be per­
ceived. In terms of female reproduction, this basic change is of course
menopause. Many criticisms have been made of the medical propen­
sity to see menopause as a pathological state.491 would like to suggest
that the tenacity of this view comes not only from the negative stereo­
types associated with aging women in our society, but as a logical
outgrowth of seeing the body as a hierarchical information-processing
system in the first place. (Another part of the reason menopause is
seen so negatively is related to metaphors of production, which we
discuss later in this chapter.)
What is the language in which menopause is described? In meno­
pause, according to a college text, the ovaries become “unresponsive”
to stimulation from the gonadotropins, to which they used to re­
spond. As a result the ovaries “regress.” On the other end of the cycle,
the hypothalamus has gotten estrogen “addiction” from all those years
of menstruating. As a result of the “withdrawal” of estrogen at men­
opause, the hypothalamus begins to give “inappropriate orders.”50 In
a more popular account, “the pituitary gland during the change of life
becomes disturbed when the ovaries fail to respond to its secretions,
which tends to affect its control over other glands. This results in a
temporary imbalance existing among all the endocrine glands of the
body, which could very well lead to disturbances that may involve a
person’s nervous system.”51
In both medical texts and popular books, what is being described
is the breakdown of a system of authority. The cause of ovarian “de­
cline” is the “decreasing ability of the aging ovaries to respond to
pituitary gonadotropins.”52 At every point in this system, functions
“fail” and falter. Follicles “fail to muster the strength” to reach ovu­
lation.53 As functions fail, so do the members of the system decline:
“breasts and genital organs gradually atrophy,”54 “wither,”55 and be­
come “senile.”56 Diminished, atrophied relics of their former vigor­
ous, functioning selves, the “senile ovaries” are an example of the
vivid imagery brought to this process. A text whose detailed illustra­
tions make it a primary resource for medical students despite its early
date describes the ovaries this way:

Medical Metaphors: Menstruation and Menopause

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MENOPAUSE

t. ■?

Between the ages of 42 and BOyears OVARIAN tissue gradually
THOPMir
s“'Tuj|ation
ANTERIOR PITUITARY GONADOI Kwi niv

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IN L O.

OVARIAN CYCLE becomes irregular and finally ceases — Ovarv bemm.c
;
small and fibrosed and no longer produces Hoe
OESTROGEN and PROGESTERONE levels in Blood stream fall
TISSUES of
the body

^pSoDucnvE'uF'k9” which mark the znd of
fins/ r^/stnbut/on of
“* 'ess fyp/cs//y ftm/mnt
cf/str/bution
ffepress/on of Sscondsrv Ssx
a
Cfttnseictrist/cx
.......... ...
shrink.
^Atrophy //sir becomes spsrsg in sk/Z/sq
*c,n'‘
c
sne/ on pubis.
Organs atrophy
fa//opisn tubas shrink.
Utarina Cyc/c and Manstrustion

(Musc/a snd fining shrink)**5^

Uterus

I

tegms/ apifha/ium becomes thin.
£xternaf Gant tafia shrink.
^ycho/pgispi and ffersonaf/ty changes
Dec/ine in Sexuaf powers.
fmotionaf disturbances may
occur - often accompanied by
vasomotor phenomena such as
hbt r/ushes"(^uasod/fatat/on)
excessive sweating
and giddiness.

After the MENOPAUSE, a woman is usually unahfe to hear children

I

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Fig. 8 A summar^diagram from a text for premedical students that emphasizes
menopause as a process of breakdown, failure, and decline. (McNaught and Callander
1983:200. Reprinted by permission of Churchill Livingstone.)

The illustration in Figure 8 summarizes the whole picture: ovaries
cease to respond and fail to produce. Everywhere else there is regres­
sion, decline, atrophy, shrinkage, and disturbance.
The key to the problem connoted by these descriptions is functionlessness. Susan Sontag has written of our obsessive fear of cancer a
disease that we see as entading a nightmare of excessive growth and

the senile ovary is a shrunken and puckered organ, containing few if any fol­
licles, and made up for the most part of old corpora albincantia and corpora
atretica, the bleached and functionless remainders of corpora lutia and fol­
licles embedded in a dense connective tissue stroma.57
42

66

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otierae

a (^utiurai oysietn

rampant production. These images frighten
in part because in our
stage of advanced capitalism, they are close to a reality we find diffi­
cult to see clearly: broken-down hierarchy and organization members
who no longer play their designated parts represent nightmare images
for us. To anticipate a later chapter, one woman I talked to said her
doctor gave her two choices for treatment of her menopause: she
could take estrogen and get cancer or she could not take it and have
her bones dissolve. Like this woman, our imagery of the body as a
hierarchical organization gives us no good choice when the basis of
the organization seems to us to have changed drastically. We are left
with breakdown, decay, and atrophy. Bad as they are, these might be
preferable to continued activity, which because it is not properly hi­
erarchically controlled, leads to chaos, unmanaged growth, and dis­
aster.
But let us return to the metaphor of the factory producing sub­
stances, which dominates the imagery used to describe cells. At the
cellular level DNA communicates with RNA, all for the purpose of
the cell’s production of proteins. In a similar way, the system of com­
munication involving female reproduction is thought to be geared to­
ward production of various things. In the next chapter we look in
detail at images of production as they affect labor and birth. For the
present this discussion is confined to the normal process of the men­
strual cycle. It is clear that the system is thought to produce many
good things: the ovaries produce estrogen, the pituitary produces FSH
and LH, and so on. Follicles also produce eggs in a sense, although
this is usually described as “maturing” them since the entire set of
eggs a woman has for her lifetime is known to be present at birth.
Beyond all this the system is seen as organized for a single preeminent
purpose: “transport” of the egg along its journey from the ovary to
the uterus58 and preparation of an appropriate place for the egg to
grow if it is fertilized. In a chapter titled “Prepregnancy Reproductive
Functions of the Female, and the Female Hormones,” Guyton puts it
all together: “Female reproductive functions can be divided into two
major phases: first, preparation of the female body for conception and
gestation, and second, the period of gestation itself.”59 This view may
seem commonsensical and entirely justified by the evolutionary de­
velopment of the species, with its need for reproduction to ensure
survival.
Yet I suggest that assuming this view of the purpose for the process
slants our description and understanding of the female cycle unneces­
sarily. Let us look at how medical textbooks describe menstruation.

44

Medical Metaphors: Menstruation and Menopause

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They see the action of progesterone and estrogen on the lining of the
uterus as ideally suited to provide a hospitable environment for im­
plantation and survival of the embryo”60 or as intended to lead to “the
monthly renewal of the tissue that will cradle [the ovum].”61 As Guy­
ton summarizes, “The whole purpose of all these endometrial changes
is to produce a highly secretory endometrium containing large
amounts of stored nutrients that can provide appropriate conditions
for implantation of a fertilized ovum during the latter half of the
monthly cycle.”62 Given this teleological interpretation of the purpose
of the increased amount of endometrial tissue, it should be no surprise
that when a fertilized egg does not implant, these texts describe the
next event in very negative terms. The fall in blood progesterone and
estrogen deprives the highly developed endometrial lining of its
hormonal support,” “constriction” of blood vessels leads to a “dimin­
ished” supply of oxygen and nutrients, and finally “disintegration
starts, the entire lining begins to slough, and the menstrual flow be­
gins.” Blood vessels in the endometrium “hemorrhage” and the men­
strual flow consists of this blood mixed with endometrial debris.”63
The “loss” of hormonal stimulation causes “necrosis” (death of tis­
sue).64
The construction of these events in terms of a purpose that has
failed is beautifully captured in a standard text for medical students (a
text otherwise noteworthy for its extremely objective, factual descrip­
tions) in which a discussion of the events covered in the last paragraph
(sloughing, hemorrhaging) ends with the statement “When fertiliza­
tion fails to occur, the endometrium is shed, and a new cycle starts.
This is why it used to be taught that ‘menstruation is the uterus crying
for lack of a baby.’”65
I am arguing that just as seeing menopause as a kind of failure of
the authority structure in the body contributes to our negative view
of it, so does seeing menstruation as failed production contribute to
our negative view of it. We have seen how Sontag describes our horror
of production gone out of control. But another kind of horror for us
is lack of production: the disused factory, the failed business, the idle
machine. In his analysis of industrial civilization, Winner terms the
stopping and breakdown of technological systems in modern society
apraxia” and describes it as “the ultimate horror, a condition to be
avoided at all costs.”66 This horror of idle workers or machines seems
to have been present even at earlier stages of industrialization. A nine­
teenth-century inventor, Thomas Ewbank, elaborated his view that
the whole world “was designed for a Factory.”67 “It is only as a Fac-

45

tory, a General Factory, that the whole mater.. , and influences of the
earth are to be brought into play.”68 In this great workshop, humans’
role is to produce: “God employs no idlers—creates none.”69
Like artificial motors, we are created for the work we can do—for the
useful and productive ideas we can stamp upon matter. Engines running
daily without doing any work resemble men who live without labor; both
are spendthrifts dissipating means that would be productive if given to
others.70

Menstruation not only carries with it the connotation of a produc­
tive system that has failed to produce, it also carries the idea of pro­
duction gone awry, making products of no use, not to specification,
unsalable, wasted, scrap. However disgusting it may be, menstrual
blood will come out. Production gone awry is also an image that fills
us with dismay and horror. Amid the glorification of machinery com­
mon in the nineteenth century were also fears of what machines could
do if they went out of control. Capturing this fear, one satirist wrote
of a steam-operated shaving machine that “sliced the noses off too
many customers.”71 This image is close to the one Melville created in
“The Bell-Tower,” in which an inventor, who can be seen as an alle­
gory of America, is killed by his mechanical slave,72 as well as to
Mumford’s sorcerer’s apprentice applied to modern machinery:73

Our civilization has cleverly found a magic formula for setting both in­
dustrial and academic brooms and pails of water to work by themselves, in
ever-increasing quantities at an ever-increasing speed. But we have lost the
Master Magician’s spell for altering the tempo of this process, or halting it
when it ceases to serve human functions and purposes.74

Of course, how much one is gripped by the need to produce goods
efficiently and properly depends on one’s relationship to those goods.
While packing pickles on an assembly line, I remember the foreman
often holding up improperly packed bottles to us workers and trying
to elicit shame at the bad job we were doing. But his job depended on
efficient production, which meant many bottles filled right the first
time. This factory did not yet have any effective method of quality
control, and as soon as our supervisor was out of sight, our efforts
went toward filling as few bottles as we could while still concealing
who had filled which bottle. In other factories, workers seem to ex­
press a certain grim pleasure when they can register objections to
company policy by enacting imagery of machinery out of control.
Noble reports an incident in which workers resented a supervisor’s

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order to “shut c^n their machines, pick up brooms, and get to work
cleaning the area. But he forgot to tell them to stop. So, like the sor­
cerer’s apprentice, diligently and obediently working to rule, they
continued sweeping up all day long.”75
Perhaps one reason the negative image of failed production is at­
tached to menstruation is precisely that women are in some sinister
sense out of control when they menstruate. They are not reproducing,
not continuing the species, not preparing to stay at home with the
baby, not providing a safe, warm womb to nurture a man’s sperm. I
think it is plain that the negative power behind the image of failure to
produce can be considerable when applied metaphorically to women’s
bodies. Vern Bullough comments optimistically that “no reputable
scientist today would regard menstruation as pathological,”76 but this
paragraph from a recent college text belies his hope:
If fertilization and pregnancy do not occur, the corpus luteum degener­
ates and the levels of estrogens and progesterone decline. As the levels of
these hormones decrease and their stimulatory effects are withdrawn, blood
vessels of the endometrium undergo prolonged spasms (contractions) that
reduce the bloodflow to the area of the endometrium supplied by the ves­
sels. The resulting lack of blood causes the tissues of the affected region to
degenerate. After some time, the vessels relax, which allows blood to flow
through them again. However, capillaries in the area have become so weak­
ened that blood leaks through them. This blood and the deteriorating endo­
metrial tissue are discharged from the uterus as the menstrual flow. As a new
ovarian cycle begins and the level of estrogens rises, the functional layer of
the endometrium undergoes repair and once again begins to proliferate.77
In rapid succession the reader is confronted with “degenerate,” “de­
cline,” “withdrawn,” “spasms,” “lack,” “degenerate,” “weakened,”
“leak,” “deteriorate,” “discharge,” and, after all that, “repair.”
In another standard text, we read:

III
I

The sudden lack of these two hormones [estrogen and progesterone]
causes the blood vessels of the endometrium to become spastic so that blood
flow to the surface layers of the endometrium almost ceases. As a result,
much of the endometrial tissue dies and sloughs into the uterine cavity.
Then, small amounts of blood ooze from the denuded endometrial wall,
causing a blood loss of about 50 ml during the next few days. The sloughed
endometrial tissue plus the blood and much serous exudate from the de­
nuded uterine surface, all together called the menstrum, is gradually expelled
by intermittent contractions of the uterine muscle for about 3 to 5 days.
This process is called menstruation.79

68

47

Science as a Cultural System

Medical Metaphors: Menstruation and Menopause

r7!

.1,. „,P.,
J .

-

Prol iterative ph««
(11 days)

Secretory phase
(12 days)

Menstrual phase
(5 days)

Fig. g An illustration from a current physiology text showing changes in the
endometrium during the monthly cycle. The menstrual phase is represented visually
as disintegration of the uterine lining. (Guyton 1984:624. Copyright © 1984 by CBS
College Publishing. Reprinted by permission of CBS College Publishing.)

ft

3

°r

And ovulation fares no better. In fact part of the reason ovulation
all the
mentf7r e.nthusiasm that spermatogenesis does may be that
all the ovarian follicles containing ova are already present at forth Far
from being produced as sperm is, they seem to merely sit on the shelf
were, slowly degenerating and aging like overstocked inventory’
At birth, normal human ovaries contain an estimated one million follicles
and no new ones appear after birth. Thus, in marked contrast to the male’
the newborn female already has all the germ cells she will ever have Only a

The illustration that accompanies this text (see Figure 9) captures very
well the imagery of catastrophic disintegration: “ceasing,” “dying,
“losing,” “denuding,” and “expelling.”
These are not neutral terms; rather, they ^onvey failure and dissolution. Of course, not all texts contain su 1 a plethora of negative
terms in their descriptions of menstruation, ut unacknowledged cultural attitudes can seep into scientific wi ing through evaluative
words. Coming at this point from a slightl different angle, consider
this extract from a text that describes male .‘productive physiology.
“The mechanisms which guide the remarka
cellular transformation
from spermatid to mature sperm remain v certain . . . Perhaps the
most amazing characteristic of spermatogei ds is its sheer magnitude:
the normal human male may manufactur everal hundred million
sperm per day (emphasis added).”79 As we /ill see, this text has no
parallel appreciation of female processes sue1 as menstruation or ovuemarkable” process inlation, and it is surely no accident that thi
volves precisely what menstruation does nc . a the medical view: pro­
duction of something deemed valuable. Altnough this text sees such
massive sperm production as unabashedly positive, in fact, only about
one out of every 100 billion sperm ever makes it to fertilize an egg:
from the very same point of view that see menstruation as a waste
1 crying about!
product, surely here is something really w

48

4X*: "gw"/.m

hormonal support; the tmmediate result is profound constriction of the uterine
lbeOdsdtVrfS' S
Pr°dUCrtlOn of vasoc°™trictor prostaglandins, which
eads to dtmtmshed supply of oxygen and nutrients. Disintegration starts and
the entire lining (except for a thin, deep layer which will regenerate th 7dc.metnum in the next cycle) begins to slough ... The endometnal arter­
ioles dilate resulting in hemorrhage through the weakened capillary walls- the
menstrua flow consists of this blood mixed with endometrial debris
The
r'hH fl™’ flOW(-CeaSeS the endometnum repairs itself and then grows under
the influence of rising blood estrogen concentration. (Emphasis added.]*’

^S
sZh:ret estrto reach fun maturity durin*her act- p™
uctive life. All the others degenerate at some point in their development so
that few, if any, remain by the time she reaches menopause at approximately
foedUe
gC'
reSUk °f thiS " 'hat ‘he °Va Whlch are released (ovu­
lated) near menopause are 30 to 35 years older than those ovulated just after
puberty, it has been suggested that certain congenital defects, much com-

the ovu^’"8

“ °f °lder W°men’ arC the reSUlt Of ^"8 changes in

How different it would sound if texts like this one stressed the vast
excess of follicles produced in a female fetus, compared to the number

meTo/r

10 add'tlOn’ malCS

ais° bom with a comPle-

and rnn r 7mnCenS (sPermatOgOnla). that dlvide from time to time,
Irl S i° JW lck W1 eventually differentiate into sperm. This text
eny aft'al Y b™55
malC gCrm Cells and their P™gwe would sfll b'''tO a81n6’ muCh 3S female gCrm Cells are' Alth°“gh
e would still be operating within the terms of the production meta" W”,d
-enh.nded ’ y
both S,

some objective sense a process of breakdown and deterioration The

69

49

Science as a Cultural System

o

particular words are chosen to describe it because they best fit the
reality of what is happening. My counterargument is to look at other
processes in the body that are fundamentally analogous to menstrua­
tion in that they involve the shedding of a lining to see whether they
also are described in terms of breakdown and deterioration. The lining
of the stomach, for example, is shed and replaced regularly, and sem­
inal fluid picks up shedded cellular material as it goes through the
various male ducts.
The lining of the stomach must protect itself against being digested
by the hydrochloric acid produced in digestion. In the several texts
quoted above, emphasis is on the secretion of mucus,82 the barrier that
mucous cells present to stomach acid,83 and—in a phrase that gives
the story away—the periodic renewal of the lining of the stomach.84
There is no reference to degenerating, weakening, deteriorating, or re­
pair, or even the more neutral shedding, sloughing, or replacement.
The primary function of the gastric secretions is to begin the digestion
of proteins. Unfortunately, though, the wall of the stomach is itself con­
structed mainly of smooth muscle which itself is mainly protein. Therefore,
the surface of the stomach must be exceptionally well protected at all times
against its own digestion. This function is performed mainly by mucus that
is secreted in great abundance in all parts of the stomach. The entire surface
of the stomach is covered by a layer of very small mucous cells, which them­
selves are composed almost entirely of mucus; this mucus prevents gastric
secretions from ever touching the deeper layers of the stomach wall.85

In this account from an introductory physiology text, the emphasis is
on production of mucus and protection of the stomach wall. It is not
even mentioned, although it is analogous to menstruation, that the
mucous cell layers must be continually sloughed off (and digested).
Although all the general physiology texts I consulted describe men­
struation as a process of disintegration needing repair, only specialized
texts for medical students describe the stomach lining in the more
neutral terms of “sloughing” and “renewal.”86 One can choose to look
at what happens to the lining of stomachs and uteruses negatively as
breakdown and decay needing repair or positively as continual pro­
duction and replenishment. Of these two sides of the same coin,
stomachs, which women and men have, fall on the positive side; uter­
uses, which only women have, fall on the negative.
One other analogous process is not handled negatively in the gen­
eral physiology texts. Although it is well known to those researchers
who work with male ejaculates that a very large proportion of the
50

■"l

..

0
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I
I

J

a?

Medical Metaphors: Menstruation and Menopause
ejaculate is composed of shedded cellular material, the texts make no
mention of a shedding process let alone processes of deterioration and
repair in the male reproductive tract.87
What applies to menstruation once a month applies to menopause
once m every lifetime. As we have seen, part of the current imagery
attached to menopause is that of a breakdown of central control. Inex­
tricably connected to this imagery is another aspect of failed produc­
tion Recall the metaphors of balanced intake and outgo that were
apphed to menopause up to the mid-nineteenth century, later to be
replaced by metaphors of degeneration. In the early 1960s new re­
search on the role of estrogens in heart disease led to arguments that
failure of female reproductive organs to produce much estrogen after
menopause was debilitating to health.
This change is marked unmistakably in successive editions of a ma­
jor gynecology text In the 1940s and 1950s, menopause was described
as usually nm entailing “any very profound alteration in the woman’s

“In thT i f
Y thC ’k65 edltl°n dramatic changes had occurred:
In the past few years there has been a radical change in viewpoint
and some would regard the menopause as a possible pathological state
ra her than a physiological one and discuss therapeutic prevention
rather than the amelioration of symptoms.”89
In many current accounts, menopause is described as a state in
ich ovaries fail to produce estrogen.911 The 1981 World Health Or-

caTe - MureT
men°paUSe as an Orogen-deficiency distext' “Th
tO P*,
C “I™8'" is the ieitlnotif of another current
text. This period during which the cycles cease and the female sex

3
"J r;P,d'y tO a'mOSt n°ne « 311 15 Called meno.
I PXT The
The cause of the menopause is the ‘burning out’ of the ovaries
■ • ■ hstrogens arc produced in subcritical quantities for a short time
moerrdidefmi|n?PaUKSC' bUt °Ver 3 fCW yearS’ 35 the f,nal ^maining pri­
mordial follicles become atretic, the production of estrogens by the
nes falls almost to zero.” Loss of ability to produce estrogen is seen
as central to a woman’s life: “At the time of the menopause a woman
must readjust her life from one that has been physiologically stimuhoiSgen 3nd Pr°geSterOne Prod“«ion to one devoid of those

Of course, I am not implying that the ovaries do not indeed proi

thesluxtbo k5 T8™ thankbefore’ 1 am pointlng
the choice of
of »v
1
S tO emphasize above all else the negative aspects
2 text's ? "8 tO Pr°dUCe fem3ie h°rmOneS- By CMtrast’ onXr-

text shows us a positive view of the decline in estrogen produc-

70

51
i

aiiencf di u ^miuidi ay Him

tion: “It would seem that although menopaus.. women do have an
estrogen milieu which is lower than that necessary for reproductive
function, it is not negligible or absent but is perhaps satisfactory for
maintenance of support tissues. The menopause could then be regarded
as a physiologic phenomenon which is protective in nature—pro­
tective from undesirable reproduction and the associated growth
stimuli.”93

aiiaiidi Aieiapnars: Menstruation and Menopause

■. ■

?

1
I have presented the underlying metaphors contained in medical de­
scriptions of menopause and menstruation to show that these ways of
describing events are but one method of fitting an interpretation to
the facts. Yet seeing that female organs are imagined to function
within a hierarchical order whose members signal each other to pro­
duce various substances, all for the purpose of transporting eggs to a
place where they can be fertilized and then grown, may not provide
us with enough of a jolt to begin to see the contingent nature of these
descriptions. Even seeing that the metaphors we choose fit very well
with traditional roles assigned to women may still not be enough to
make us question whether there might be another way to represent
the same biological phenomena. In the following chapters I examine
women’s ordinary experience of menstruation and menopause looking
for alternative visions.94 And here I suggest some other ways that these
physiological events could be described.
First, consider the teleological nature of the system, its assumed
goal of implanting a fertilized egg. What if a woman has done every­
thing in her power to avoid having an egg implant in her uterus, such
as birth control or abstinence from heterosexual sex. Is it still appro­
priate to speak of the single purpose of her menstrual cycle as dedi­
cated to implantation? From the woman’s vantage point, it might cap­
ture the sense of events better to say the purpose of the cycle is the
production of menstrual flow. Think for a moment how that might
change the description in medical texts: “A drop in the formerly high
levels of progesterone and estrogen creates the appropriate environ­
ment for reducing the excess layers of endometrial tissue. Constriction
of capillary blood vessels causes a lower level of oxygen and nutrients
and paves the way for a vigorous production of menstrual fluids. As a
part of the renewal of the remaining endometrium, the capillaries be­
gin to reopen, contributing some blood and serous fluid to the volume
of endometrial material already beginning to flow.” I can see no reason
why the menstrual blood itself could not be seen as the desired “prod-

I
3
■4

I
7

uct” of the female cycle, except when the
woman intends to become
pregnant.
Would it be similarly possible to change the nature of the relationships assumed among the members of the organization—the hypo
thalamus, pituitary, ovaries, and so on? Why not, instead of an orga­
nization with a controller, a team playing a game? When a woman
wants to get pregnant, it would be appropriate to describe her pitui­
tary, ovaries, and so on as combining together, communicating with
each other, to get the ball, so to speak, into the basket. The image of
hierarchical control could give way to specialized function, the way a
basketball team needs a center as well as a defense. When she did
not
want to become pregnant, the purpose of this activity could be considered the production of menstrual flow.
Eliminating the hierarchical organization and the idea of a single
purpose to the menstrual cycle also greatly enlarges the ways we could
think of menopause. A team which in its youth played vigorous soccer
might, in advancing years, decide to enjoy a quieter “new game”
where players still interact with each other in
satisfying ways but
where gentle interaction itself is the point of the game,
, not getting the
ball into the basket—or the flow into the vagina.

i
■
s

52

53

71

«*

■

ir'W-

The Prue of Life

A ^fePrice of Life :
S" ' ■

■ '-'.■M;

as used by some authors partially depends on the cost of the
reatment. If it is permissible to forgo lifesaving treatment because >0

....;
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1--S^e^D:Bayles
'. .JAv'
i ta--

- y; ;x

■■ ■-■■'" •■

:si

g' Univtnnty of Kentucky

-

.

thatXu d SM

W°noInic limits °n the amount of money

I

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■feo .
M'

MSiv

-'■

■’

'■

‘

•

■‘“•a:

•

■
■■-

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-■

not acquirmg a burn center eVen though its acquisition would sa4 W
about a dozen lives a year.
'
ar. The c°ro,lary °f the equal value of human lives also frequently
arises in bioethics Questions about which research programs on
lifesaving technologies should be funded-those aimed at diseases
wh^h
016 ’P’ddle aged, or the elderly—raise the issue of
whether all lives are of equal value. It is also involved in determining
■W
criteria for selecting pauehts for scarce lifesaving treatments such a!
kidney transplants. Different criteria or method® of selection will be
used, depending on whether all lives are judged to be of equal value
plausible3^ nOt’ rand°m °r first-c°me selection methods are less

.

■•

°^ten ?a*<1 t^at human Hfeisspriceless. No amount of money or
IlgBP^goods equals the valuemf a human life. The only justification
not preventing the loss of a human life when one can do so is that
. ■fe^would result in the loss of even more lives. In short, only human
KsSfe lives' can be balanced against human lives.
^;oThe philosophical locus classicus for this view is Immanuel Kant’s
B<
a]m 1,131 human beings have a dignity but not a price. By ‘price’ he
^feA.flid not mean a merely monetary value but an equivalence. “Whatg^fer has a price can be replaced by something else as its equivalent.”1
1,16 c,aim that human lives are priceless is not merely that no
giwnetary value can ethically be placed upon them, but that no
Va ue of other goodmn be placed upon them'.
KfIFMC distinct but correlated claim is that all human lives are of
^^gqUal value. The pricelessness of human life does not imply that all
.ar? of equal value. Some lives might be more priceless than
ggUMhers just as some infinities are greater than others. However, it
fc’
SKInake PlaVslble.their having equal value. If no price or value
glByWft,he assigned to lives, there is no obvious basis for comparative
fe’;ffdpnents of their value, and they should be treated equally.
lf human llves do have a price, it is a priori unlikely that
. have the same value or price.
^|^..:.iTlie issues of whether human lives have a price, and if so, what
recur 111 bioethics and social policy generally. The
BWtihcUon between ordinary and extraordinary lifesaving treatment

s

This paper argues that (1) it is rational and morally permissible
‘It
to place a price on one’s own life, and (2) there is a moral v
policies rhe eth°d °f UfSlngLhin Pridng t0 determ*ne some social
policies. The argument for the first claim also provides reasons for
lives having different values or prices. The argument for the second
-■ /•.’■]
aim does not establish a method for assigning a price to the life of ’

a

need'S'lr b"™"

■B'

i^nt: F(n^^ns of fa Metaphysics of Morals with Critical Essays,
Wol« (Indianapolis: Bobbs-Merrill Co.,
THr T Tniv^itv of Cffeprf 66 T4-1 TfU/TO/ROOi -fWX)2«01 28

SUCh 3 method ls ^en not directiy

dh
£ Cjn ?nCe 1VeS SO that P°licies and rules may be
established, individual cases will often be decided bv the applicadon
rules and P° >«es. If a burn center is not worth having, then
the fate of individual burn patients is determined. There will still be
ome occasions when decisions must be made between
individuals—for example, which of two patients will receive an
Z’ J’r ^ranSP11antat’on’ T,lis. paper does^not attempt to provide
principles for making those decisions.
In the next section the issues are clarified, and some orelimi“hid’
'‘““bt uponTe Sm of
pricelessness The second section then argues that people can
rationally and morally place a price upon their own liveSP The third
section defends a version of the willingness-to-pay method for
technoVg™6 5003 P°hCy declsions about investment in lifesaving

1
I

See, e. g.^Edwin F. Healey, S.J., Medical Ethics (Chicago: Loyola University
Pr<“ss2. IQPJfi)

I

: -/I

II
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22

Ethics

23 ThePnceojUJe

PROPAEDEUTIC

highways knowingly and voluntarily assumed the risk. People do not
know the risks of accident on various highways and hence do not
choose their travel
best, they voluntarily
assume
'
7
assume aa range
range of .risk in using highWMilariy,, various
products, from
electric toasters to snowmbbfleJ, have associated
assc
risks of
------------------------------------------------------death in their use,^rii^Wch
usejrii^d which CQliia
CQpld W
; rfithiffifeed if not eliminated,
—t th>t
but at such a- cost
that those ^akirig and biiyihg them do not think it
is worth doing^Jg^^^^^gfej--;: :
It is someumes
someti^l^j^
om(^a^at?such ,examples are merely pricing
risks. Tliey do.nbt priccj'the life of a khoU n individual who
statistical risks:
will certainly die If/Orii^Sl
if oniefaliOiaQ^lS cho^en. However, this objection
is not satisfactofy^’^^B
real individuals.
living, breathing^gpnd/^hile
breathing hu
it may be psychologically ----morej. difficult
difficult tb condemn kndwh individuals, rather than
indeterminateto death becaUse if is too expensive to save
lhem,
.hat fen
them, that
fact does hpT^dw anything afeput the morality of doing

■Kfe-’. •

important distinctions should be mad with respect to
^| price-of-life issues. First, one should distinguish sues of amount
re-' and of distribution. This distinction is especially mportant at the
level of government health policy. One questio is/.How much
money should be invested in research on, ofr ptdviudn of, lifesaving
technologies? Should the U.S. government invest 3 billion dollars in
lifesaving health research, or only 200 million, or perhaps none? In
s^ort> h°w much is it worth to prevent deaths? The other question is,
How should funds be distributed? Should allocations emphasize
research to prevent deaths of infants, the elderl}, or members of
specific minorities? Some proposed principles pertain only to the
distribution issue, while others pertain to both th' distribution and
amount issues. A distribution principle need noi be based on the
price of human life, although if lives do have vary ig prices this will
affect judgments about distribution.
Second, one should distinguish between the j ice of life per se
Egfc'. ?nd the price of the lives of existing people. Som< people claim life
■' ■ itself, whether human or nonhuman, has valu and should be
respected. One version of this claim even su >orts producing
human lives. Yet one may deny that life itself is aluable and still
III hold that the lives of existing people are priceless. ) put, the issue is
not whether there is a price of a person’s entire ife, but whether
there is a price of a segment of it—at most, the r t of his potential

.

fc

Bi

M. .A

J
1

I

S C) •

One may reply that people do in fact think human lives are
priceless and that only the anonymity of statistics allows them to
price human lives. However, this claim may be reversed. Knowing
the particular individuals involved may provide a psychological bar
to doing what one thinks is morally permissible. For example, there
are those of us who believe it morally permissible to kill and eat
chickens but find it psychologically difficult to wring a chicken’s
neck, cut out its guts, and then cook and eat it. That does not show
we believe it wrong to eat chickens, only that we have weak wills or
stomachs — a luxury afforded only in modern industrialized
societies.
These cases of statistical pricing of human lives present a
challenge to those who claim that lives are priceless. It is incumbent
on them to suggest alternative practices. It will not do to say that
there are no alternatives, that these practices must be accepted as
part of the human tragedy, for there are alternatives. Products
could be required to be completely harmless before their use is
permitted; funds could be invested in highway construction to make
highways as safe as technically possible. The human tragedy, if there
is one, is that it is impossible to make all products and technologies
absolutely safe.

Third, one should distinguish between wl : may be called

is personal and social price. Personal price is that w ch an individual
places on his own life, its value to him. Social pric< is the value of an
individual’s life to others. One may also distinguisl between descrip­
tive and normative social price. The descriptive ocial price of an
individual’s life is that which others in fact place pon it, while the
normative social price is that which others should lace upon it. The
claim that human lives are priceless partially ste s from the fears
that if human lives are priced the descriptive rath r than normative
pigY social price will be used, and personal price
11 be completely
ignored.
tef
While it does not prove that morally human 1 ' e has a price, it is
||^4 worth noting that society does price human lives Descriptive social
Kg prices are used to make decisions. In buildii g skyscrapers, a
pfe' predictable number of construction workers will be killed. Yet the
building is thought to be worth the expected loss. However, one may
say J^at the workers knowingly and voluntarily < ssume the risk of
^fe^Hosing their lives. In highway construction, lives are also calculated
costs. There are known costs and accident rates for various
^^^^pes bf highway constructon. It is less plausible that those killed on

...

■I

2
I

3. I assume that no special relationship, such as doctor-pa tie nt or parent-child,
exists. Some arguments for distinguishing between the morality of risking statistical
lives and risking lives of known individuals only pertain to special relationships
(see, e.g., Charles Fried, Medical Experimentation: Personal Integrity and Social Policy,
Clinical Studies, vol 5 [New York: American Elsevier Publishing Co., 19741 no
67-78, 133, 156). ;;
■
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24
2.

Ethics

•* *

THE PRICE OF ONE’S OWN LIFE

If human lives are priceless, then it is irrational or immoral to
place a price on one’s own life. Kant consistently held that one
cannot rationally place a price on one’s own life. He held that suicide
to avoid misery and pain is irrational and immoral. However, he did
accept risking one s life in moral actions—for example, to save the
lives of others. Ultimately, Kant believed that only the rational self,
as opposed to the animal self, has absolute value. In suicide, he
t ought, one sacrificed the rational self for an end of inclination, for
the animal self. Without Kant’s metaphysical dualism which ulti­
mately places the source of all moral value outside the phenomenal
world, his argument for the pricelessness of human life collapses.
Although I cannot argue it here, I shall assume that Kant’s
metaphysical dualism is untenable.
Is there a way to argue for the pricelessness of human life
without adopting Kant’s metaphysical dualism? In a recent paper,
Kenneth Henley has suggested an alternative.4 He is concerned to
show that individuals are irreplaceable. If they are, then by Kant’s
definition there is nothing of equivalent value, and they are price­
less. He concedes that if they are irreplaceable, then they cannot be
valued for their qualities and characteristics. If they were valued for
characteristics, then there could, logically, be another individual
with these characteristics who would serve as a replacement. How­
ever, he asks whether it is irrational to value oneself, as an indi­
vidual, as irreplaceable. While no reasons can be given for so valuing
oneself, he concludes that although egotistic concern for self is
unreasoned it is not irrational.
However, showing that it is not irrational to value oneself as
irreplaceable does not show that one values oneself as priceless. The
Kantian definition of pricelessness as irreplaceability breaks down
because the concepts are not the same. I may consider myself
irreplaceable in the sense that if “I” die, there will never be another
me. No matter how like me, another being would not be “me.”
Nevertheless, my continued existence might have a price to me.
Even though “I” cannot be replaced, something of equivalent or
greater value might be exchanged for “me.”
it were possible to accurately predict how long a person
would live. One could always know, say, to the day, how much
longer one would live. Further suppose that for some reason
another person were willing to pay one to die a year earlier than
otherwise. For example, he might want to receive one’s heart in a
transplant and need it a year before one would die. Is there a price
4
’ ThC ValUC °f Individuals’” PWosophy and Phenomenological
Research 37 (1977): 345-52.

3

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--j

for which one might reasonably sell one’s last year of life? Wouic*
one sell it for a quarter of a million dollars now? Whether one would
be willing to sell, and the price one might demand, depends on a
number of factors. For example, a person’s present financial condi­
tion would obviously affect the price and even the willingness to sell
at all. Likewise, the predictable quality of life one would have the last
year may also make a difference. If one would be physically or
mentally incapacitated and in considerable pain, one might sell for
less. While there are many variables, the basic question is whether,
on the most favorable assumptions one :may make, it would ever be
rational to be willing to sell the last year.
Certainly it would not be irrational for some people to do so on
some terms in some circumstances. Their last year of life may
rationally have a price to them. Indeed, one can imagine cir­
cumstances in which one might rationally assign a negative price to
one’s last year of life. One would be so incapacitated and suffer so
much that it would be worth paying a certain amount of money now
to be sure that one died a year early. One might be willing to hire a
“euthanasist” to ensure that one did not live it. Generally, negative
prices will be much smaller than positive ones, because it is compara­
tively easy to bring about one’s early demise.
Some people may not be willing to sell a year of their life for any
amount of money. It does not follow that a year of life does not Pave
a price to them. They might exchange it for some nonmonetary
benefit—for evample, a year of private tutoring by Willard Quine
or writing the r.jst significant philosophical work of the century.
These prices are not significantly different from money. Except
perhaps by misers, money is not valued for its own sake but for the
things it buys. A monetary price merely indicates that there are
purchasable goods or services of an equivalent value. There is no
more reason to disparage a monetary price than there is anything
which money can buy. While there are things money cannot
buy—love, true friends, and happiness—that they are not in the
market is no indication of their value. Hatred and enemies are also
not in the market, but they are not thereby valuable. The difference
is merely one of production technique, and it may be possible to
develop techniques such as drugs or brain implants which produce
happiness or love.
It may be objected that this argument merely shows that people
may rationally put a price on their lives, not that it is morally
permissible for them to do so. In particular, one may object that it is
rational for them to do so only because unjust social conditions
might force them to sell. However, one must distinguish the
questions whether it is immoral to offer to buy a person’s life and
whether it is immoral for him to sell it. Even if buyers immorally
exploit sellers, it does not follow that the sellers are immoral.

8

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K cover, even if one assumes a morally jus
ciety, it does not
follow that there might not be things for which one would be willing
to sell the last year of one’s life. A morally just society does not
guarantee that all one’s desires will be satisfied. Consequently, there
may still be good reasons for being willing to sell the last year of
one’s life.
It may be further objected that, even if the argument shows that
part of one’s life may rationally have a price, that is different from
showing that the rest of one’s life may rationally have a price. The
structure of the argument is that one be willing to forgo the last year
of one’s life in exchange for benefits now. As one progressively sells
more and more of one’s remaining life, one has less and less time to
enjoy the benefits derived from selling it. At the point of selling the
rest of one’s life, one has run out of time in which to enjoy the
benefits for which one has sold it. That means, in effect, that there
can be no benefits from selling it, and so it has become priceless.
This counterargument takes too narrow a view of what might
count as benefits, what might be the price. One can distinguish
between the satisfaction and the fulfillment of a desire. The satisfac­
tion of a desire is the psychological state of a person who knows (or
believes) that a desired state of affairs obtains (or will certainly
obtain). The fulfillment of a desire is the obtaining of the desired
state of affairs.
The state of affairs one desires need not include oneself in any
way. My desire for the experience of sexual intercourse can be
fulfilled only if I exist, but my desire for peace in the world may be
fulfilled even if I do not exist. The preceding objection mistakenly
assumes that the price of life must always be, at least indirectly, the
fulfillment of a desire for a state of affairs including oneself. Since
desires are not so limited, one may “sell” the rest of one’s life
provided the price is some state of affairs not involving oneself.
Obviously, there are many such prices. Moreover, they need not
involve saving the lives of other persons. For example, the price
might be the happiness of one’s children while they live but not extra
life for them. Or it might be the continued existence of condors for
two centuries. Moreover, many of these prices have monetary
equivalents—for example, the rest of one’s life for a million-dollar
contribution to the Salvation Army. The price may even be rather
“selfish,” for example, a monument commemorating one’s selling of
one’s life. At best, the price of the rest of one’s life must not depend
on one’s personal existence.
Pricing part of one’s remaining life may be viewed as a willing­
ness to exchange the length of one’s life for its quality in the sense of
fulfillment of desires. At this point, it may be useful to classify
technologies with respect to their impact upon length and quality of
life. Some technologies shift the incidence of death but involve a net

4

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extension of li. . in society. For example, the introductic of
railroads shortened the lives of many people but may have increased
overall life expectancy in society by providing faster transportation
of food, medical supplies, etc. If those who lived longer gained more
life years than those who died earlier lost, railroads were a life­
extending technology. There are also some merely life-shortening
technologies—nuclear weapons, biochemical-warfare materials, etc.
Other technologies may be both life shortening and life enhanc­
ing. Electric toasters have probably not saved any lives and have
caused some to be lost, but they provide convenience. Motorcycles
and cigarettes may also be in this category. Technologies that
shorten but enhance life decrease expectable life yet provide bene­
fits which improve its quality (or at least are thought to do so by
those who use them). The use of such technologies involves placing a
price on part of one’s life. One exchanges part of one’s life for
something of equivalent or greater value. Nonsmokers have
difficulty understanding the attitude of smokers who are willing to
accept a lower life expectancy for what they consider to be the
benefits of smoking, but many nonsmokers use other shortening but
enhancing technologies or engage in activities which are such —
climbing mountains or eating high-cholesterol foods.
It may be objected that these cases differ from the earlier one
about selling part of one’s life. In these latter cases, there is no
certainty that one will die early, only a risk of doing so. This
objection is similar to the one about statistically predictable deaths
from highway construction. Some, maybe even many, people take
risks because they discount them psychologically. They may well
know the risk, say, of lung cancer from smoking cigarettes. How- .
ever, they may think that it will not happen to them, only to others,
or they may ignore it because it will occur many years hence.
Nonetheless, while some people delude themselves, not everyone
does. People have differing values and desires; some like cigarettes,
others fatty foods, others mountain climbing, and some all three.
The logical structure of the valuing is the same in risk taking as in
selling part of one’s life. One trades expectable quantity of life for
quality of life.
One can thus explain why individuals may rationally be unwil­
ling to invest in some lifesaving technologies. They have a price on
the extra life they might gain from the investment. The cost of the
investment is higher than that price. Thus, they prefer money to
obtain benefits now to life later. The benefits are of greater value to
them than the possibility of longer life.
A further question is whether the price of life may vary. First,
one might claim that life has a uniform price, that each year of life is
of equal value. However, this view does not allow for positive and
negative pricing. On it, one cannot claim that life with great

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ii pacities and suffering is not worth living—
all life is of equal
value. In short, this view does not allow differences in the quality of
life to affect its price.
Second, some views allow for a distinction between lives of
positive and negative prices but not among those with a positive
price. There is some standard or capacity or whatever which makes
life have positive as opposed to negative value, but all life of positive
value is of equal value. For example, some views claim that certain
capacities are necessary for being a person and having a right to life.
Such a standard is plausible for distinguishing between beings which
have a right to life and those which do not. However, it is not
plausible if taken to mean that all lives are of equal value to those
who live them.
If the price of life is a judgment of quality against length, equal
price of life must mean equal quality of life. If quality of life may
vary, different periods of one’s life may have different prices. If old
age involves a lower quality of life, the price per year of life then will
be lower than the price per year of life during youth or middle age
when quality is higher. Exactly how these prices vary depends on
what a person takes to be the qualities which give life value and his
expectations of these qualities at different times of life. Moreover, if
people,s personal prices of life may vary over time, then different
people’s lives may have different personal prices. Even at the same
age, people’s prices will vary depending on the quality of life they
have. Thus, there is no reason to expect the same price structure for
all people. Moreover, one cannot get around these variations by
ascribing them to social injustice. Differential pricing of lives is not
solely due to differences in income, etc., but also to differences in
desires and values. Only if all people had precisely the same desires
and values would their prices be the same.
3.

least cost. Howt.cr, this method ignores differences in personal
prices; that is, it mistakenly assumes that life is of equal quality and
price at all stages for all people.
One could, to some extent, account for quality of life by using a
more complex measurement of quality-adjusted life-years.5 How­
ever, even so adjusted, this method still does not do the job that
needs to be done. Maximizing life-years or quality-adjusted lifeyears saved is basically a method for distributing funds. While it does
permit cost-effective analyses to determine in which lifesaving
technologies to invest a given sum of money, it does not help
determine how much money, if any, ought to be invested. In short, it
determines only distribution, not amounts, of investment. It does
not permit one to judge that the cost of saving a life is simply too
great.
The human-capital or livelihood approach, which is the oldest
and most widely used method,6 does enable one to determine both
amount and distribution of investment. By this method, the price of
a life is the discounted value of the potential earnings of a person for
the rest of his expectable life. Others have presented detailed
criticisms of this approach which need not be repeated here.7 One
major flaw is that it allows for vast differences in the price of lives
depending upon people’s expectable incomes. High-income earners
receive preference for lifesaving technologies. Given the present
economic structure of the United States, lives of males are thus
usually preferable to those of females (except in old age), and those
of whites to those of blacks. It also supports a prime-of-life subprin­
ciple, with emphasis on saving lives of young adults, since peak
discounted earnings occur around the age of thirty.
The human-capital approach does not satisfactorily account for
the personal prices of lives. It primarily uses the social price of life,
monetary earnings. Personal pricing is accounted for only to the
limited extent that personal price is proportional to expectable
income. Moreover, discounted expectable income is not even a good
index of social price. The value of one spouse to another does not
depend solely on the first spouse’s expected earnings. Factors such
as love and companionship are also relevant to the value one spouse
has for another.
It is useful to back off and examine the sort of problem involved

LIFESAVING AS A COLLECTIVE GOOD

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Even if it is rational and morally permissible for an individual to
place a price on part of his life, it does not follow that there is a
rational and morally permissible method for pricing lives for social
policy decisions. There are “scientific” problems, such as construc­
tion and timing of surveys, in using all of the proposed methods.
The discussion here is confined to moral problems. Before develop­
ing the moral grounds for a modified willingness-to-pay method, it
is useful to look briefly at problems with the other commonly
suggested methods—the maximum life-years-saved and human­
capital methods.
The maximum life-years-saved method is to invest in those
lifesaving technologies which will save the most years of life for a
given investment. In short, one saves those lives which one can at

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5. Richard Zeckhauser and Donald Shepard, “Where Now for Saving Lives?”
Lmw and Contemporary Problems 40, no. 3 (Autumn 1976): 5-45.
6 Rashi Fein, “On Measuring Economic Benefits of Health Programs,” in Ethics
and Health Policy, ed. Robert M. Veatch and Roy Branson (Cambridge, Mass.:
Ballinger Publishing Co., 1976), pp. 262-63; generally, pp. 262-69.
7. Jan Paul Acton, “Measuring the Monetary Value of Lifesaving Programs ”
Law and Contemporary Problems 40, no. 3 (Autumn 1976): 46-72.
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ik ie provision of lifesaving technologies. Both i life-years-saved
and human-capital methods view the problem as one of production.
On the human-capital approach, it is one of rational economic
production. Lives are priced by their contribution to the gross
national product, with all the inadequacies oi the GNP as a social
measurement. Thus, one saves a life if its economic value is greater
than the cost of saving it. The life-years or quality-adjusted lifeyears-saved method also has a production perspective, although it
has a more humane notion of what is being produced. As a variant
of the total version of utilitarianism, it essentially adopts what has
been called the “milk production model.” The more milk of better
quality produced the better.
Instead of the perspective of a producer, one may adopt that of
a taxpayer-consumer or simply a citizen. From this perspective, the
development or distribution of many lifesaving technologies is a
collective-good problem. By a collective good is here meant some­
thing from which many people may benefit but which individuals
cannot feasibly provide for themselves. The cost of developing or
distributing many lifesaving technologies is too great for any one
person to bear for his own benefit. Yet many people perceive these
lifesaving technologies as a benefit or good for them. They are not
benefits to most people in that their lives will actually be saved by
better highways, a burn center, or a cure for cancer. Instead, they
are benefits in that the availability of the technologies, should they
need them, is valued by most people. Since most people desire the
technologies but cannot afford the total cost of providing them, the
problem is one of getting everyone (or nearly everyone) to contrib­
ute a portion of the cost of their provision. Often this contribution
is made by taxes for government funding of research or of distribu­
tion of the technologies. The subsequent discussion is limited to
those lifesaving technologies which are collective goods to be pro­
vided by governments. Extension of the method developed to other
technologies, or those not provided by the government, requires a
more complex analysis.
Viewing lifesaving technologies as collective goods to be pro­
vided by governments leads naturally to use of the willingness-topay method for social decisions about investment in them. The
simple model is that each person is asked how rriuch he would be
willing to pay for a technology which would have a probability P of
saving his life or x number of lives. One then totals the amounts
individuals are willing to pay. If the total amount people are willing
to pay exceeds the cost of the technology, then it is worthwhile. One
can then rank technologies by the differences between the total
amount people are willing to pay and their costs. The more the
amount people are willing to pay exceeds the cost, the higher the
priority of the technology. If the total amount people are willing to

6

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pay is less than th. jst of the technology, then it is not worthwL*.e.
One major virtue of this method is that it uses people’s own
pricing of their lives at different times. The human-capital approach
essentially operates on a social price system. However, what a person
is willing to pay largely depends on the chance of saving his life and
its value to him. The method thus avoids making decisions solely on
the basis of social price. To the extent people object to pricing lives
because personal prices are ignored, it avoids the objection. How­
ever, thefe are a number of moral objections to the willingness-topay method. Avoiding them requires modifying it.
The most serious objections to the willingness-to-pay method
are those of justice and equality. How much one would be willing to
pay is usually a function of how much one has. A person who earns
$50,000 a year would be willing to pay more for a given technology
than would a person who desires it as much but earns only $5,000 a
year. Thus, there would be a greater total willingness to pay for
cures of diseases affecting the rich than of those afflicting the poor.
Since the government is to provide the technologies, the method
supports a plutocracy rather than a democracy in which people’s
desires count equally.
1
However, one can modify the model to make it more democrat­
ic. Each person’s “vote” for investment in lifesaving technology may
be made as equal as possible. Instead of asking how many dollars a
person would be willing to pay, one might ask how large a percen­
tage tax increase he would be willing to pay. However, if there is a
diminishing marginal utility of income, then wealthier people may
be willing to pay a larger percentage of their income than the poor.
The goods they thereby forgo are of lesser value to them than those
purchased at lower incomes. Hence, there would still be a plutocratic
slant to the voting.
Progressive income taxes are widely thought to be designed to
avoid this problem. With a progressive income tax, the question may
be put in terms of a percentage surcharge on taxes paid. Thus, a 1
percent surcharge for a technology would be five dollars for a
person paying $500 in taxes, while it would be fifty dollars for
someone paying $5,000. If a majority of people would be willing to
pay a 1 percent surcharge and that would fund a technology, then it
would be worth doing.
By considering differences between the surcharge needed to
pay for a program and that which people would be willing to pay,
one can account for strength of desire. Suppose funding a technol­
ogy would require a 3 percent surcharge. Further, suppose 40
percent of the population would be willing to pay a 5 percent
surcharge, but 60 percent would be willing to pay only a 2 percent
surcharge. On a straight equal-“voting” method, the technology
would not be justified. However, the feelings of the 60 percent who

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the 40 percent in favor have a strength of desire of two (5 percent
minus 3 percent). If one weights “votes” by strength of desire and
aversion, then the technology is favored by a factor of four to three
(forty times two to sixty times one).
Another objection based on equality is that certain causes of
death are confined to relatively specific groups. For example,
Fay-Sachs disease primarily affects Ashkenazic Jews. Since those at
risk are a very small proportion of the population, most people
would know they were not at risk and would be unwilling to pay to
save lives from Tay-Sachs. In short, since many people know that
they are not at risk of certain causes of death, they are not willing to
pay to prevent them, Thus, lifesaving technologies to prevent deaths
confined to clearly defined subpopulations would rarely be supported, but this is unjust.
7
1
This objection is not as serious as it seems. First, the method to
take account of strength of desire partially alleviates this problem. If
a minority has a stronger desire for a technology than a majority has
aversion to paying for it, then it might be supported. Second, even
those not at risk might be willing to pay some money to save the lives
or others. The extent to which they would be willing to do so
depends upon their benevolence and the contributions they believe
people saved might make to society. Those not at risk may have
purely self-interested reasons for saving the lives of some peoplethat is, they can vote the social price of others to them. Moreover to
the extent that people are benevolent, they will pay for lifesaving
technologies even when they cannot expect to benefit personally
irom them in any way.
7
It may plausibly be argued that since social prices reflect
judgments about the worth of other people, they should not be
permitted in calculations for governmental decisions. Only personal
pre erences those for one’s own enjoyment of goods and
opportunities—not external preferences—those for the allocation
ot goods and opportunities to others—should count.8 However
external preferences are primarily objectionable when they are used
to override others’ personal preferences. In the present case, they
only support fulfillment of others’ personal preferences. People may
be willing to pay for a technology from which they will not directly
benefit and thus help fulfill others’ personal preferences. However
as the most negative vote possible is merely not to help, they cannot

7

express negative dgments on saving others’ lives. In short, the
method allows for benevolence but not malevolence. Moreover, in
the absence of sufficient benevolence to justify governmental provi­
sion of a technology benefiting a minority, it is still open to those
who desire it to combine together to obtain it.
• i SL111’, WIt.h. the.willingn.ess-to-pay method, the fewer people at
risk, the less likely it is that investment in a lifesaving technology will
be justified. But is this implication wrong? Would there not be
alternative investments which would be more worthwhile^ The
modified willingness-to-pay method places highest priority on those
technologies saving the lives most desired, with descending priority
as fewer people are involved (or strength of desire is less). Eventu­
ally there is a point, depending upon the prevalence and strength of
desires—including those of benevolence—at which a lifesaving
technology is not worth its cost. Any view which takes pricing lives
seriously will conclude that some lives are not worth saving at the
required price.
®
Finally, it may be objected that some people are used as means
only, because they are required to pay more for the benefit of others
than they are willing to do voluntarily. Theoretically, no one need be
compelled to pay involuntarily. With the willingness-to-pay method
it technologies are purchased only at prices everyone is willing to
pay, then no one is being used as a means to the benefit of others.
Everyone wou.d desire the technology at that price; it would be an
end each sought. However, this criterion would amount to
unanimous-consent democracy and is unrealistic.
Given that this theoretical ideal will not always be achieved, how
requently and how many people will have to pay amounts they are
unwilling to pay depends upon how much support is required
before a program is adopted. However, no matter what method is
used in any government program some people will be required to
PaYJor llfesaving technologies when they do not want to. With the
modified willingness-to-pay method, fewer people would be so used
01 they would be used to a lesser extent, than with any other
common method, since the other methods do not even consider
peoples willingness to pay. The more they support providing
llf«avmg technologies, which the modified willingness-to-pay
method does not, the more people will be forced to make unwilling
sacrifices for others.
8
In conclusion, the modified willingness-to-pay method is a
morally acceptable one for government decisions for investing in
ifesaving techno ogles which are collective goods. It takes account of
peop e s personal pricing of their lives more than the other methods
Social prices primarily enter as benevolent contributions to others
By using a surcharge on income taxes, it avoids plutocratic skewing
ot decisions due to possibly unjust distributions of wealth. By giving

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v ght to the strength of desire for lifesaving tec.^iologies, it is more
reflective of people’s desires than a simple voting procedure. Based
on people’s willingness to pay, it minimizes the frustration of
involuntary payments more than any other feasible method. Not all
possible lifesaving technologies will be justified by this method, but
that is simply the ultimate price of life.

Are Value Judgments Synthetic
A Posteriori?

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University of Manitoba

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INTRODUCTION

Concerning the epistemology of value judgments, I remain an
unrepentant empiricist. They are synthetic a posteriori. Judgments
of intrinsic value are about what is or would be liked or disliked for
its own sake. Judgments of extrinsic value are about what is or would
be liked or disliked for the sake of another, or, in other words, about
whether (and to what extent) things1 have a capacity to satisfy or
frustrate our wants. Some conscious experiences have both intrinsic
and extrinsic value, so the distinction between them is not mutually
exclusive and jointly exhaustive.
7
In what follows, I shall present some arguments which together
will show that whether or not something is good or bad or has value
is an empirical fact about it, as are whether or not it dissolves in
water or shatters when it is struck. My analysis of value is naturalistic
m the narrow sense that the value of something is one of its
empirical characteristics, and in the broad sense that value is not
something supernatural which must be revealed by a god or
semetis'keenOnnatUral
mUSt
*ntuited by those whose value

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© 1978 by The University of Chicago. 0014-1704/79/8901-0003$01.86
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George Rosen

and the

Social History of Medicine
CHARLES E. ROSENBERG
In some ways it is difficult to define George Rosen’s place in the
history of medicine; his work illuminated so many subjects, touched on
so many countries and every century from the Renaissance to the
present. One is continually amazed at his energy and fertility of imagi­
nation, at the nine books and more than 200 articles which he wrote
in four decades of scholarship.1 Yet, George Rosen’s contribution to
the history of medicine can be explained without difficulty, for a central
theme unifies his extraordinarily diverse writings.
George Rosen was not simply an historian of public health or of
social medicine—all medicine was social medicine to him. There was
no aspect of the healing art from the definition of disease categories
to the development of specialism that did not reflect social and eco­
nomic, demographic and attitudinal factors. The labelling of witches,
the nineteenth century’s broadening conceptions of insanity were as
much a product of intersecting social forces as the diseases which
afflicted sixteenth-century miners or the rickets which crippled chil­
dren in Europe’s new industrial cities.2 Not surprisingly, George
Rosen’s work has never seemed more relevant than it does in the 1970s
as a growing number of social historians and critical laymen turn
toward the history of medicine and health.
In some ways, indeed, this general shift of interest has made it
easy to forget how original George Rosen was, how much he an­
ticipated interests which seem timely and innovative in the 1970s.
But in the three decades between the mid-1980s and the mid1960s, his scholarly interests were still atypical among medical his­
torians, while general historians were little concerned with the his­
tory of medicine. Through the 1950s the ultimate reality of
medicine was to most of its chroniclers—for the most part, practic­
ing physicians themselves—a logically integrated structure of ideas
and techniques. It was a structure shaped by an inexorable and
laudable accretion of scientific insight; it was a structure inevitably
1

2

beneficial to man in its accumulation of skill and understanding.
Needless to say, this was a political as well as a sociological posi­
tion—though most of its advocates would hardly have understood it
as being either. In the past century, the claims of medicine to auton­
omy have increasingly rested on its claims to a scientific identity-and
to the interest free and inevitably beneficial implications of that view
of the profession. Certainly, no historian of medicine would deny that
practice was often less than ideal in the past, or that many practitioners
were unworthy of the status implied by their scientific identity . But the
moral compromises and intellectual inadequacies of individual priests
have never compromised the Church’s view of its ultimate spiritual
meaning; there was a similar awkward asymmetry between medicine as
a body of knowledge and ethical truths and the day-to-day transactions
of many of its practitioners. Had not modern medicine increased the
length of man’s life and made those surviving years increasingly tree
from pain and discomfort? The widespread scepticism of the 1970s
toward the reality and moral impact of such putative achievments
hardly existed when George Rosen began to study the history of medi­
cine. And in many ways, indeed, Rosen shared the optimism implicit
in this pervasive faith in medicine as inevitably progressive; but Rosen
also assumed that medicine’s humanitarian potential could only be
reached through careful and intelligent analysis of medicine s place m
society. Perhaps, indeed, that society itself would have to alter before
medicine could assume a different aspect. For George Rosen and
like-thinking critics realized how wide the gap was between knowledge
and its applications, how sensitively medicine mirrored social values
and the forms of economic power. He could not share the vision of a
medicineuhsuIliedTyThe realities of class interest, of social prejudice,

I

Charles E. Rosenberg

The Social History of Medicine

of economic constrajiit.
In removing medicine from a largely intellectuahstic and neces­
sarily benevolent framework, Rosen helped bring it not only into the
marketplace of social interactions, but into culture construed in its
broadest terms. He consistently emphasized how both medicine s in­
tellectual life and its institutional realities reflected extrinsic factors,
intellectual, economic, and social. He suggested, for example, that
mercantilist ideas shaped both medical theory and health policy in the
eighteenth century—in some ways, indeed, they were inextricable. He
emphasized, in parallel fashion, the role of certain Enlightenment
conceptions of epistemology in helping create the necessary precondi­
tions for the achievements of French medicine in the early nineteenth

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century.4 Rosen saw the line between social ideology and scientific
inquiry as a subtle and shifting one as he examined the classical texts
of medicine and social policy. Medicine was always a pervasive social
function to George Rosen, not a neatly ordered structure of ideas and
techniques; it was a reflection of society’s total being, not a cool and
distant intellectual activity.
But perhaps it should be no surprise that a poor Jewish boy who
came of age in New York City in the late 1920s and early 1930s and
was then denied admittance to an American medical school should
have failed to appreciate such medical claims to transcendent legiti­
macy. And in a climate of bitter social criticism—both in New York and
Berlin where Rosen studied medicine and began his work in medical
history—it is only natural that he might have seen the development of
medicine as a continuing interaction of the healing arts with the society
which nurtured them. Of course, Rosen was not alone in adopting this
broadly cultural—and necessarily relativist—view of medicine. In the
United States, for example, Richard Shryock, a scholar from a backround very different from that of Rosen, pioneered at almost the same
time in writing a history of medicine incorporating social and cultural
factors. In Germany, even more influentially, such historians as Henry
Sigerist, Owsei Temkin, Erwin Ackerknecht, and Walter Pagel all
sought in their diverse ways to relate medical ideas to the culture in
which they were elaborated. Even Pagel, of this group the most consis­
tently oriented toward the internal texture of ideas, saw medical and
biological ideas as parts of a more general world-view. In elucidating
the influence of philosophical and religious ideas in the works of van
Helmont, Paracelsus, and Harvey, Pagel emphasized the interpenetra­
tion of ideas between realms which previous generations of biomedical
historians had preferred to maintain as separate; the landmarks of
science were not to be confused with the crabbed theology and archaic
cosmologies which encrusted them.5 Let me cite another example:
Owsei Temkin’s first article, on the social context in which syphilis was
perceived and treated, provides another illustration of how young
scholars of Rosen’s generation brought problems conventionally med­
ical into the sphere of culture generally.6 Nurtured in the intellectual
atmosphere of Weimar Germany, Henry Sigerist’s explicit political
commitments are too well-known to demand comment. A sense of
social concern and a view of medicine as cultural artifact were funda­
mental to the work undertaken at Sigerist’s Leipzig Institute; it was
entirely consistent with the social attitudes and intellectual predisposi-

The Social history of Medicine

4

••;

1

7. The Specialization of Medicine with Special Reference to Opthamology (New York: Froben
Press, 1944, reprinted: New York: Amo Press, 1972). Erwin Ackerknecht’s influential
work in medicine and ethnology undertaken in the late 1930s and 1940s provides a
significant parallel to Rosen’s work in sociology; both, however, were atypical in their
formal commitment to the social sciences.

II

I

1. For a complete bibliography of Rosen’s books, articles, and translations, see below,

“Cameralism and the Concept of Medical Police,

Bull. Hist. Med., 27 (1952), pp.

21-42.
4. “The Philosophy of Ideology and the Emergence of Modern Medicine in France,”

5. In citing Pagel’s work, I have deliberately chosen a historian who might seem, at first
glance, to have little in common with Rosen’s approach in the hope of emphasizing this
area of overlap. See Walter Pagel, The Religious and Philosophical Aspects of van Helmont's
Science and Medicine. Supplements to the Bulletin of the History of Medicine No. 2
(Baltimore: The Johns Hopkins University, 1944); Paracelsus. An Introduction to Philosophi­
cal Medicine in the Era of the Renaissance (Basel and New York: S. Karger, 1958); William
Harvey's Biological Ideas (Basel and New York: S. Karger, 1967).

6. Temkin’s important essay "Zur Geschichte von Moral und Syphilis, ” which appeared
originally in Sudhoff's Archiv (19 (1927), pp. 331-348) has been translated by C. Lillian
Temkin, and appears in Owsei Temkin’s The Double Face ofJanus and other Essays in the
History of Medicine (Baltimore and London: The Johns Hopkins University, 1977), pp.
472-484. The title essay is autobiographical and pages 3-12 provide a number of
significant recollections of Sigerist and the Leipzig years.

Notes

3.

5

ibid, 20 (1946), pp. 328-339. Much, of course, has since been written on this subject.
See, Erwin Ackerknecht, Medicine at the Paris Hospital, 1794-1848 (Baltimore: The Johns
Hopkins University, 1967).

tions of the young George Rosen who returned from Berlin to practice
medicine during America’s worst depression.
George Rosen also soon undertook another line of inquiry, one
particularly significant in historiographical retrospect. This was his
deployment of social science literature and perspectives in shaping an
understanding of past medicine. As early as the 1940s, Rosen turned
to academic sociology and wrote what is in some ways his most influen­
tial study—on the origins of specialism—as a doctoral dissertation in
Columbia University’s department of sociology.7 Rosen had found a
prestigious, putatively scientific, and unavoidably relativist point-ofview from which to interpret the role of medicine in society and of
science in medicine.
Many of Rosen’s themes have, as we have suggested, become the
commonplaces of contemporary social criticism. When critics of psy­
chiatry see its diagnostic categories as socially determined labels for
deviance, not absolute and scientifically grounded truths, when the
women’s movement proclaims medical thought as one ideological
prop for male dominance; when sceptics cite the data and authority of
sociology and anthropology to demythologize medicine s claims to
interest free benevolence; when economically oriented critics of the
profession insist that medicine must be seen as at least in part a mar­
ketplace phenomenon they are all elaborating themes implicit or expli­
cit in the work of those context conscious students of medical history
who came of age in the 1920s and 1930s. As increasing numbers of
younger historians turn to the social history of medicine, they will
discover a long and sophisticated concern with medicine as a social
institution. In this tradition, no name looms more prominently than
that of George Rosen.

p. 252.
2. Most of Rosen’s conclusions on the place of mental illness in society are to be found
in his Madness in Society. Chapters in the Historical Sociology of Mental Illness (Chicago:
University of Chicago, 1968). The mention of miners’ ailments refers to Rosen’s The
History ofMiners ’ Diseases. A Medical and Social Interpretation (New York: Schuman’s, 1943).

Charles E. Rosenuerg

■

I

' 1

WHAT IS DISEASE?
LESTER S. KING

J

t

I

Biological science does not try to distinguish between health and disease.
Biology is concerned with the interaction between living organisms and their
environment. What we call health or disease is quite irrelevant.
These reactions between the individual and his environment are complex.
The individual and his surroundings form an integrated system which we can
arbitrarily divide into two parts. There is an “external” component, by which
we mean such factors as light, heat, percentage of oxygen in the air, quantity of
minerals or vitamins in food, micro-organisms in food or air, and so on. These
can induce changes in what we arbitrarily call the “internal” component. Here
we include such crude factors as anatomical structures, or finer details like com­
position of intercellular fluid, or secretions of glands, or changes of electrical
potential in nerve or muscle.
Medical science studies the. reactions of the internal component and its rela­
tions with the external component. A separation is artificial, but none the less
necessary for convenience and practicality. In any investigation science exerts
its prerogative to break down the total complex event into simple parts. The
scientist focuses his attentions on limited sequences, and partial aspects. If he
tries to preserve the unity entire, he would remain hopelessly bogged down.
For example, if we ask, what happens to the food that we eat?, we are asking a
question too complex for an intelligible answer. To make any reply meaningful,
we must analyze the problem into simpler parts. We must specify what happens
where. In the mouth? In the stomach? In the small intestines^ Or in the liver,
the pancreas, or the blood stream? We must specify u-hat food. Fats? Carbohy­
drates? Proteins? And in what quantity? Starvation diets, average amounts, or
surfeits? And then of course, when? At what points in the time-scale? At what
age, at what temporal relation to exercise, or stress? All of these questions re­
flect our fundamental interest, of trying to isolate the relevant conditions that
attend the phenomenon. But there are so many relevant aspects; what is rele­
vant for one person might not be significant for another. If everyone had the
same sort of liver or the same sort of pancreas, investigation would be a lot
simpler. But they don’t. Some individuals, for example, have stones in their
gall bladders. Others have very small amounts of thyroid gland secretion. Still
others harbor amoebae in their intestinal tract. In reply to our question, what
happens to the food that we eat?, our answer will depend, in part, on whether the
individual has stones in the gall bladder or amoebae in his colon.
Clearly, this “total environment” of which we speak is not identical for all
people. Science tries to isolate as many discrete factors as possible. Some will
apply to virtually all humans without exception, others may concern only a
minute fraction of the total population. Science, in studying reactions within
the total environment, cares not a whit about “health.
193

>:•

194

LESTER S. KING

Suppose, for example, that we are interested in the skin. As scientists we can
learn a great deal about the stricture and function of this part of the body.
There are many different types of cells and intercellular material. We distinguish
the epithelium from the sub-epithelial tissues. We note the various glands, blood­
vessels and nerves, the smooth muscle and the lymphatics, the collagen and the
elastic tissue. We observe these structures in their growth and in their decay.
We follow the circulation of blood, and the exchange of oxygen, carbon-dioxide,
and metabolic products. We learn that, with an intact epidermis, the reactions
tend to follow a certain pattern. If, now, we sever the skin with a sterile knife,
we find that the pattern of reactions undergoes a change. Certain cells, instead
of vegetating quietly, become veiy active. Blood vessels dilate, the flow of blood
increases, leucocytes immigrate, cells proliferate, the metabolism alters, and we
have a series of reactions which we designate as sterile or aseptic inflammation
and repair. If some staphylococci are introduced into the skin, along with the
knife edge, there is a different series of reactions; if some tubercle bacilli, then a
still different set of reactions, these latter we call infection, indicating a regular
pattern clearly distinguishable from other patterns.
We call these examples of disease. But as Sir Clifford Allbutt clearly stated
disease is a state of a living organism . . .the disease itself contains no elements
essentially different from those of health, but elemcrnlFpm^red-jn-^^
and less usgfulJMxiex.,,1 One combination, configuration, or pattern Is succeeHed"
by another. One is more “useful” than another. One we call health, another
“disease.” The word “useful” in Allbutt’s expression, is a judgment of value.
This is something more than TfieTsequerrces and laws vdu^h^cT?TTce~^ud'ies.“Health” or “Disease” are value judgments based on something more than the
study of reactions.
When we attend to the “elements” or sequences within the total environment,
the distinction between health and disease fades away to nothing. This is readily
seen in current research, which disregards boundaries between the “normal”
and “abnormal.” Physiology, supposedly, deals with the “normal” functioning
of the body, while pathology studies the “abnormal” function. This is sheer
nonsense, since physiology makes its great advance by studying highly “abnor­
mal conditions, like animals without a liver, or without a large portion of brain,
or lacking a thyroid; while pathology is intelligible only by reference to the
“normal.” We have books on that remarkable subject, “Pathological Physiol­
ogy.” All medical science studies facets of behavior under a wide variation in
conditions. Many of these variations we call disease. But the grounds for calling
them disease are not any essential part of the studies. Disease is an arbitrary
designation.
As illustrating the confusion surrounding the notion of disease, I recall a very
precise young physician who asked me what our laboratory considered the nor­
mal hemoglobin level of the blood (with the particular technique we used).
When I answered, “Twelve to sixteen grams, more or less,” he was very puzzled.
Most laboratories, he pointed out, called 15 grams normal, or perhaps 14.5.
’.4 System of Medicine, Ed. by Thomas Clifford Allbutt, New York, Macmillan and
Co., 1S96, Volume 1, Introduction, p. xx.xii.

r
WHAT IS DISEASE

195

He wanted to know how, if my norm was so broad and vague, he could possibly
tell whether a patient suffered from anemia, or how much anemia. I agreed that
he had quite a problem on his hands, and that it is a very difficult thing to e .
zr\ So difficult, in fact, that trying to be too precise is actually misleading, inac■\ t curate, stultifying to thought, and philosophically very unsound.
A
He wanted to know why I didn’t take one hundred or so normal individuals,
\ determine their hemoglobin by our method, and use the resulting figure as t re
normal value for our method. This, I agreed, was a splendid idea. But how were
)
we to pick out the normals? The obvious answer is, just take one or two hundred
healthy people, free of disease . . . But that is exactly the difficulty. We think
health as freedom from disease, and disease as an aberration from health. I his

■I ■

is travelling in circles, getting us nowhere.
Now when we speak of health or disease, we use certain implicit values.
Health’is something good and desirable, while disease, whatever else it means,
implies something bad. These values of ■■good1 and -bad” indicate attraction
towards or repulsion from something. There is a very definite sphere o rele­
vance, within which the values apply. The sphere of disease is the realm of pain,
disability and death, for its major groupings, while the minor stages we can ca
(subject to quibbling) -’unpleasant” or -disagreeable” or some suchi term.
Health deals with the opposite, with the conditions which give rise to the sub­
jective report, “I feel fine.” This state of awareness is subjectively recognizedg^
althoughindescBbable^-*
On^wavofdetermining health is hy this subjertlve report- The man .
' ’
“I feel jus't fine,” may consider himself entirely sound. Conversely, he who com­
plains of feeling “terrible” may think of himself as seriously ill. These subjective
impressions are essential, and highly significant, but they are not entirely re­
liable. Here we come up against the distinction between what "seems and what
“really is”, between “appearance” and “reality.” We are all familiar with the
man who had periodic routine examinations, who passed all tests, who felt sub­
jectively fine, and who suddenly dropped dead. Or the man with no complaints
at all but, cajoled into a routine chest x-ray, found he has a symptomless'«»"««••
In such cases the individual “seemed” healthy, subjectively he felt health} , but
“really” he wasn’t.
.
To understand health or disease_we must have some objective measurementsm—.
addiHbn^TEe^'fro^cWeTrcMnt. IfTecan weigh or measure something,
and we feel more firmly grounded m ob­
jective reality. And there is no end of different features that we can thus quan­
titate AVith the help of measurements and statistical analysis we can get a ten
reliable picture of what exists and in what distribution, and. moreover, what we
may reasonably expect in the future. But ordinarily statistics alone cannot label
aw part of the data as “diseased”. When we apply statistical methods we al­
ready have in mind the idea of health. We exert selection on the cases we study.
Thus to find the “normal” blood sugar level we eliminate known diabetics.
And the basal metabolic rate, in health, we determine after omittmg known

1

4

In spite of the circularity, the concepts of health and disease belong together.

!,

196

LESTER S. KING

There are certain factors which are important for defining and distinguishing
them. One is the subjective report, which is of only moderate reliability. The
sense of well-being frequently correlates with what we mean by health, but the
correlation is not high. Certainly a sense of well-being does not preclude the pres­
ence of disease, while the absence of such subjective feeling does not indicate

disease.
Another important factor is the statistical distribution, quite independent of
any subjective report. Let us imagine, for example, a statistical study of body
temperature, on completely random samples. We would find an overwhelming
majority of individuals within a narrow band, between 98° and 99° F. However,
a very small percentage will show much higher figures, such as 102°, 104°, or
105°, or more. These individuals who depart from the norm, are by definition
ab-normal. This deviation, by itself, does not make them diseased. Thus, per­
sons with an intelligence quotient of 180, or with the ability to run 100 jrards in
9?^ seconds, are also highly ab-normal. However, when a deviation is tied up
with malaise, pain, or death, or is intimately associated with conditions which
lead to disability or death, then the abnormality forms part of Disease.
Statistical norms, even when correlated with malaise, can furnish only a part
of the total picture. For example, statistics can establish the normal body tem­
perature and, by correlation with malaise, pain, or death, the desirable body
temperature. But in the matter of, say, dentition, the statistical norm does not
define the healthy or the desirable. Ver}' few native Americans possess thirty-two
intact, well-aligned teeth. Yet when we speak of sound or healthy dentition we
have in mind the ideal of thirty-two intact, well-aligned teeth. In this case it is
deviation from the ideal which constitutes disease, not deviation from a statis­
tical norm.
These ideals stem from two sources. One is concrete observation. Nothing can
serve as a model of health unless it has been an observed characteristic or feature.
And second, any such feature must be an object of general desire, possessing
value which appeals to the mass of the population. One person might desire to
be eight feet tall, yet the majority of people do not. The ideals of height, of
weight, of bust measurement, or head size, that is, the range which the majority
desires, vary from one nation or tribe to another, and from one generation to
another. Changes in diet, for example, can in a few generations change the
ideals in regard to stature. But at the present time a height of eight feet is not a
matter of general craving.
The ideal need not consciously be present in the minds of the majority, as
an object of desire, but it may be clearly and intimately connected with such
an object of desire. The more technical knowledge pertaining to ideals of health
we justify through such an intimate connection. We cannot expect the mass of
population to yearn for a particular pH level of the blood, however important it
may be, but a given pH level we can connect up with more obvious states that
do possess general or even universal appeal.
Disease lies in the realm of pain, discomfort, or death. There are, however,
many examples of pain and discomfort which we cannot so designate. A teething

HAT IS DISEASE

197

infant or a woman in childbirth, are suffering pain. V\ e may try to reliexe this
pain, but we do not think of teething or childbirth as diseases. We call them
normal functions. To be a healthy infant is to go through a period of teething.
WTe conclude that discomfort which constantly attends a normal desirable
function and is intimately or essentially bound up with that desirable function,
is not in the realm of Disease.
It follows that our concepts of disease are very closely related to our values.
Frequently our values may be severely determined by convention. China, for
example, did not regard as diseased those upper-class women whose feet were
bound, and who thereby suffered pain and diminution in function. Our contem­
porary’ culture takes a different view. Which means that our conventions and
values of health are different from the Chinese. In most of our western civil­
ization the seeing of visions we consider a sign of a diseased state. But in some
epochs of our civilization the seer of visions was a leader in the community,
receiving special honor because of his unusual endowment. Certainly the egre­
gious and unusual, the literally ab-normal, represent disease only if judged by
indigenous cultural values. Convention plays a very important part in shaping
our values. And the quantity of our knowledge plays a very important part in
shaping our conventions.
Disease is the aggregate of those conditions which, judged by the prevailing
culture, are deemed painful, or disabling, and which, at the same time, deviate
from either the statistical norm or from some idealized status. Health, the
opposite, is the state of well-being conforming to the ideals of the prevailing
culture, or to the statistical norm. The ideal itself is derived in part from the sta­
tistical norm, and in part from the ab-normal which seems particularly desirable.
Environmental states (both external and internal) which are intimately con­
nected with the ideals and norms, are part of health, even though the general
public is unaware of them, while environmental states intimately connected with
disease are similar parts of disease.
II

When most people talk of disease, they have in mind some particular condition
like diabetes or pneumonia, or peptic ulcer. In this more limited sense, the term
refers to a pattern of factors which somehow hang together and recur, more or
less the same, in successive individuals. Thus, pain in the right lower quadrant
of the abdomen, with nausea, vomiting, a fever, and a high white count, spell
out the features of acute appendicitis. With variations this combination tends
to recur. Or, severe headache, fever, stiffness of the neck, with abundant white
cells in the spinal fluid, spell out another condition that we label meningitis.
Or again, a condition of fever, cough, runny nose, sore eyes, and the later ap­
pearance of characteristic spots on the skin, we call measles. Each of these dis­
eases, so called, is a congeries of factors, and no single factor, by itself, identifies
the disease. It is only the recurrence of a pattern of events, a number of elements
combined in a definite relationship, which we can label a disease.
Since there is no strict specificity to individual factors, and one factor may

198

LESTER S. KIXG

recur in a variety of contexts, diseases that are quite distinct may nevertheless
have many features in common. So much so that, as Bartlett says, diseases may
“approach and touch each other in so many respects, and at so many points,
that it may not be possible, always, in the present state of our knowledge, to
fix upon positive means ... for distinguishing between them.”2 The various
properties occur in clusters. We try to distinguish one cluster from another, tryto be sure that it is a recurring pattern. This is a difficult thing to do, but if we
satisfy ourselves on that score, then we call that pattern a separate disease.
To discriminate and identify a disease entity, we cannot rely on abstract
speculation, but must study concrete particular sick people. In observing any
group of sick individuals whatsoever, there are always some points in common.
We can always find areas of resemblance. But when we become increasingly
critical, we realize that many resemblances are very superficial. It may be a
fever, or a rash, or a sore throat that different individuals exhibit. But eveiyone
who has a fever, or a rash, does not have the same disease. We distinguish still
more acutely, and we perceive not merely a rash, but a very special type of
rash, not merely a fever, but a fever with a definite course; not merely a sore
throat but one with a particular recognizable ulceration and membrane forma­
tion. Then with development of new techniques we are able to discriminate still
deeper, hidden similarities. We are able to say that certain sick individuals have
a uniform type of bacterial invader, or show a specific antibody content of the
blood.
Out of a number of sick persons the more points that we can compare and find
similar, the greater our assurance that a single common pattern affects the in­
dividual patients. If we can find enough similar features which recur as a cluster,
we can organize these features into a logical coherent order. The great men in
medicine are those who can perceive similarities, patterns, relationships, and a
“belonging together” of seemingly quite discrete factors.
Xow sometimes we confuse one disease with another. The histoiy- of medicine
is the history' of distinguishing one condition from another. What was thought
to be one disease is found, on careful analysis, to be two, and these in turn, may
prove to be multiple. The various exanthemata were long confused. Distinguish­
ing small-pox from measles, measles from German measles, scarlet fever from
measles, measles from the fourth disease”, these, over the centuries, were made
possible by acute obsen’ation. Or, the progressive differentiation of what the
Bible called “leprosy”, illustrates the confusion that has been steadily growing
less.
When there has been a failure of discrimination, and we confuse two diseases,
then, as Bartlett points out, we have paid attention only to “certain particular
and limited portions”3 of the diseases. We have not attended to the “most essen­
tial affinities.”
! Bartlett, Elisha: .-In Essay on (he Philosophy of Medical Science, Philadelphia Lea
and Blanchard, 1844, p. 129.
3 Ibid: p. 261.

WHAT IS DISEASE

199

The implications are clear and significant. Whenever we regard sick people,
we see a confusion of phenomena and relationships. Some of these are superficial,
inconsequential, others are “essential”. According to Bartlett, when we note
the “essential” features, we are observing the “real” disease. If we concern our­
selves only Anth the superficial, then we miss the “real” disease. Some one else,
more acute than we, may succeed in penetrating to the essential aspects which
we have missed.
,
It is an interesting commentary on human pride, that we are all too reaoy to
assume our own penetration into the real nature of things. Thus Bartlett, in
the year 1844, said, “It is only within a few years that we have been furmshed
w’ith a means of distinguishing, with clearness and certainty, between pleurisy
and pneumonia; but these two diseases have always been as distinct from each
other as they now are.”4
This point of view is important and influential—that diseases have an in­
dependent reality. They are not created by the act of thinking about them. They
are quite distinct, apart from the knowledge and recognition of the inquiring
physician. Thus, he states in unequivocal terms, “. . . classes, or groups, or fam­
ilies, cannot be created, arbitrarily, and at will, by our own skill and ingenuity.
We must take . . . individual diseases ... as they exist in nature. ’’
In view of this forceful assertion, we smile, in our sophistication, as we reflect
how Bartlett himself confused pleurisy and pneumonia. To call these separate
“diseases” and to maintain that they have been eternally separate even though
we did not know it, is rather silly. Nevertheless Bartlett points at a metaphysical
issue which very few physicians care to tackle. His blundering dogmatism is
only a mask for the important problem, What is Reality?
Let us illustrate this by a little conundrum. Let us ask,
hat was the small­
est continent before the discovery of Australia?” The majority of persons would
answer “Europe,” with a few perhaps, claiming North America or South Amer­
ica. But not Bartlett. If he were called on to give an answer he would say, -‘The
smallest continent before the discovery of Australia was . . . Australia.
Clearly we are beset by the interpretation of the verb “to be”, the problem
that has afforded 2500 years of philosophical dispute. The little conundrum
states, that a thing is, whether we know it or not. Now, most people would
readily agree that with material tangible things like rocks and trees and rivers
and continents, such an answer would seem correct. When we close our eyes,
the familiar objects in the room do not cease to exist. The first explorer who came
upon a waterfall did not create it by his act of discovery’. It was “there” all the
time, but neither he nor anyone else had known about it.
But it is a little different to ask, is this also the case with diseases? Diseases
are not things in the same sense as rocks, or trees, or rivers. Diseases represent
patterns or relationships, which are not material. The problem then becomes,
how real is a pattern, what is the ontological status of a relationship?
4 Ibid: p. 140, (Italics not in original text).
5 Ibid: p. 272.

200

LESTER S. KIXG

Within the realm of sounds, for example, there exists a certain pattern of mus­
ical tones which we call, say, Beethoven’s Ninth Symphony. Will we claim that
the Ninth Sypphony was there all the time waiting for someone to discover it?
Or will we declare, along with common sense, that the ‘‘skill and ingenuity'’
of Beethoven created it; that before Beethoven, it had no existence?
We are faced with the problem whether certain relational patterns, like dis­
eases, “exist in nature’’, while other patterns, like a melody or a poem, we can
create arbitrarily by our own skill and ingenity. The question becomes, does a
disease, whatever it is, have real existence, somehow, in its own right, in the same
way as the continent of Australia? Such real existence would be independent of its
discovery by explorer or investigator. A disease exists whether we know it or not.
The contrasting point of view would hold, that a disease is created by the in­
quiring intellect, carved out by the ven' process of classification, in the same way
that a statue is can'ed out of a block of marble by the chisel strokes of the sculp­
tor.
When we try to discuss the problem, What is a disease?, we are thus led into
metaphysical difficulties. Some persons, who may, perhaps, be the most sensible
among us, prefer to ignore the difficulty. But it never does any harm at least to
stare a difficulty boldly in the face. We can always hurry along and ignore it
later.
We will not even try to give a rigorous definition of the Real, for this has baffled
far keener minds, and, regardless of how subjectively adequate, no definition
could gain general approval. But in a relatively artless fashion we think of the
Real as the permanent, something that cannot be tampered with, that to which
we must conform. In the history of philosophy there have been two opposing
concepts. One equates the real with things, which may be coarse and gross or
immeasurably fine and subtle, but which nevertheless are things. The classical
atomism of Democritus is a good example. Indivisible ultimate particles which
do not alter—these were the Real. The particles re-arranged themselves end­
lessly, into constantly changing patterns and organizations which were evanes­
cent. Such patterns had at best only a derivative or incomplete reality, and were
not the Really Real. Atomism is thus one form of doctrine which distinguishes
between ultimately real (in this case, the atoms , and the derivatively real rela­
tions (i.e., the patterns) into which the atoms enter.
We are not at present concerned with atomism as such, which we offer only
as a crude example. We are more concerned with the general principle which
gives the primacy to individual things, be they separate atoms, or clusters of
atoms, packets of energy, or concrete individuals regardless of ultimate physical
components.
Attention to the individual as a concrete thing, makes up the doctrine of
Nominalism. According to this view, relations, patterns, and qualities are only
derivative. We call them abstractions. Thus, green grass and green leaves are
objects that we see. The grass and the leaves are real, green is only an abstrac­
tion. Or in the field of medicine. Mr. Smith may have diabetes and Mr. Jones
hypertension. Then Smith and Jones are real, while diabetes and hypertension

WHAT IS DISEASE

201

as abstractions, are not real m the same sense. This view is summed up in the
familiar expression, In ‘‘reality” there are no diseases, there are onl\ sick pa­
tients.’
There is a contrasting viewpoint in the Platonic tradition which the medieval
philosophers called Realism. In the Platonic doctrine the search for the Real
or the Permanent took a different tack. When we hunt for stability amidst the
ceasless change, we note certain equalities and relationships that persist. Grass
and leaves are green, while a ball is round, yet grass will wither and leaves will
fall and a ball wall disintegrate. Nevertheless, “green” will not fall or wither, and
“round” does not change. They remain, permanent, eternal, as Platonic Univer­
sals. Each is a Form or Idea. And similarly, according to some thinkers, with
properties like beauty or honesty or goodness. What we call particular things
mav be regarded as collections of universals. Ihe reality of a thing vould con­
sist, not in its concrete individuality but in the Forms or Universals which it
exhibits. Particulars come into being and pass away, but the Universal qualities
or Forms persist .
According to this doctrine, diabetes and pneumonia would be Real, while any
particular diabetic, like Mr. Smith, merely manifests the disease just as a leaf
manifests the color green. Of course, Mr. Smith presents other characteristics
besides diabetes, in the same way that a leaf has other qualities besides green.
But diabetes, according to this view, is a real entity. And whatever we compre­
hend by that term Real (and we must grant it some meaning), then a disease
possesses Reality in the fullest degree.
Bartlett is apparently a Platonist. He would very stoutly deny the bon mot,
that in nature there are only sick patients, but no diseases, let granting Bart­
lett’s point, that disease has reality in the fullest sense, we can wonder, how do
we make sure that we haA'e grasped that reality? His assertion that pleurisy
and pneumonia are separate diseases and have always been separate, is gro­
tesquely absurd. Today we regard pleurisy not as a disease but only as a symp­
tom. We must have some sort of distinguishing feature, according to which we
say, that pleurisy, or fever, or jaundice, or headache, are not diseases, but only
symptoms. In times past, in our ignorance, we may have accorded them full
status as disease entities, as did Bartlett, but this we do no longer.
We resolve the difficulty only by admitting that we carve out whatever
disease patterns we wish, in whatever way we desire. In accordance with our pre­
vious discussion of Classification, a disease pattern is a class, or niche in a frame­
work. This framework is a means of approaching and organizing crude experi­
ence, that is, for dealing with every-day events in the most satisfactory way.
These classes will vary in their utility in the handling of experience. What we
call a fever is a very broad and inclusive class. There is only one reason why we
should not regard fever as a disease entity and that is, such an entity is so broad
and inclusive, so general and nondiscriminating, that it lacks utility. T sefnlness” means not only the practical taking-care of patients, but also the intellec­
tual facility with which we can assimilate new discoveries and observation.
We can continue to call fever a disease, if at the same time we blithely ignore all

202

LESTER S. KING

the various discriminations that keen observers have made over the centuries.
If, however, we wish to use these observations either theoretically or practically,
then we find it more useful to discard the concept of fever as a disease, and con­
sider it merely a part found in a number of more complex patterns. The term
fever then ceases to be a major category for analyzing experience.
A “symptom” is a class or term, which does not serve as a useful major organ­
izing principle, but instead is only an element of the pattern characterizing some
other more useful category or class. A disease, on the other hand, is a complex
pattern (or class) which does usefully organize experience. That pattern which
we call a disease is subject to modification, recombination and subdivision of its
elements, as our knowledge increases. What one epoch calls a disease is, to a
later period, only a symptom. A pattern has reasonable stability only when its
criteria are sharp, its elements cohere, and its utility in clarifying experience
remains high. Let these factors become blurred, and the erstwhile disease, as a
well-defined and useful class, will melt away.
Medical science concerns itself with tracing out patterns, carving them out
according to the insight of the investigator. But we do not carve out or create
patterns capriciously. Science does not act in an arbitrary or despotic fashion.
There is an ultimate arbiter which we call Experience.
Experience is not a matter of wishful thinking. As William James said, “sensa­
tions are forced upon us, coming we know not whence. Over their nature, order,
and quantity we have as good as no control. They are neither true nor false;
they simply are.”6 There is Something which forces itself upon our consciousness
and determines our experiences, even as the ocean forced itself upon King Canute
over his express objections.
This Something which underlies experience and determines its order, can
never appear directly in sense experience. It is the Really Real which we can
never know in sensation but whose nature we infer. It is, so to speak, a sub­
strate. We have a fundamental assumption that the substrate, directly unknow­
able, exhibits pattern, order, arrangement, and organization. Moreover, it is
remarkably patient of multiple interpretations, each of which may grasp a small
fragment of its arrangement. When we create a schema of classification and hold
it up to nature, we believe that our schema reproduces the conditions of the sub­
strate. It is faintly analogous to a blind man drawing a picture of an object
which he cannot see but whose nature he infers from the other sense modalities.
With any pattern, hypothesis, or classification that we create, we say, in effect,
we believe the substrate giving rise to our experience has a type of organization,
and this particular pattern that we offer is, we believe, an approximation of
that organization which obtains in the Unknowable.
Whatever Reality may be. organization and arrangement are part of its
essence. It is quite absurd to make any separation between Things and their
Arrangement. Things are real, but are unthinkable except in some pattern.
6 James, William: Pragmalis'ii. New York mid l.ondon. I.onunian. (Irren and Co., 1925,
p. 244.

1

i
t

WHAT IS DISEASE

203

Patterns and relations are real, but are unthinkable apart from something whic
is related. As we, in our own experience, create one pattern after anot ,
wonder whether these match the patterns of Reality. Sometimes we feel that we
have constructed a reasonable approximation. Then we can only wa>t and see
how our proffered blueprint of organization enables us to deal with future ex­
perience. Our difficulties arise only when we are arrogant in our assurance.

lUinms Masonic Hospital

/

Consciousness
and Ideology

“You are talking
like a madwoman,”
he said.

“My hands are rocks,
my teeth are bullets,”
she said.
“You are
my wife,”
he said.

“My throat is an eagle,
my breasts
are two white hurricanes,” she said.
“Stop!” he said.
“Stop or I shall call
a doctor.”
“My hair
is a hornet’s nest,
my lips
are thin snakes
waiting for their victim.”
He cooked his own dinners,
after that.

The doctors diagnosed it
common change-of-life.

She, too, diagnosed
it change of life.
And on leaving the hospital
she said to her woman-friend
“My cheeks
are the wings
of a young
virgin dove.
Kiss them.”35

178

78

MARGARET LOCK
i

AMBIQUITIES OF AGING: JAPANESE
EXPERIENCE AND PERCEPTIONS OF MENOPAUSE

Despite a paucity of data, an assumption is generally made that, at the biological
level, the changes which take place at menopause are universal although subject,
of course, to individual variation in the timing of the event. This assumption
appears to be generally valid, in that, as far as we know, women everywhere
experience a drop in estrogen production leading to the eventual cessation of
menses in mid-life. However, the complex interrelationship of genetic, environ­
mental. and dietary variables with hormone production, and also the relationship
of hormone decline and the postulated accompanying symptoms of hot flashes,
are topics which have been only rarely investigated to date, and which are not
usually raised as issues for discussion (for a notable exception see Coope et al.
1978).
Unlike studies of biological variation, investigations into the relationship
of psychosocial variables with the experience of menopause have been given
considerable attention of late (see Davis 1982; Green and Cooke 1980; Mikkelsen
and Holte 1982; Moaz et al. 1977, for examples). The best executed of these
studies reveal that simple associations between such variables as “empty nests”
and a high incidence of menopausal symptoms, or release from female role
restrictions and low incidence of menopausal symptoms, are not generalizable
either within or between populations. It is necessary first to establish if the
psychosocial events under consideration do indeed coincide with the physical
process of menopause, secondly, where appropriate, to distinguish between
natural and surgical entry into menopause, and thirdly, to investigate the meaning
of the social transitions under study for the individual informant, in the context
of her personal life history, social roles, and particular culture.
It was with the intent of carrying out research in which biological, psycho­
logical. and social variables could be examined to generate data for controlled
comparative purposes that I undertook a study of menopause in Japan from
1983-84. Some preliminary results are presented below, including a description
of the cultural construction, lay and professional, of menopause; in addition, a
portion of the data from a cross-sectional survey and results of indepth inter­
views are used to discuss experiences and symptom reporting at menopause. In
conclusion, the complexities of undertaking comparative studies in menopause
will be considered in light of the foregoing data presentation.
The rapidity and success with which Japan has adapted to a life-style
dominated by technology is no longer a surprise to anyone. During the course
of this transformation, however, the observations of both Japanese and foreigh
Culture, Medicine and Psychiatry 10 (1986) 23-46.
© 1986 by D. Reidel Publishing Company.

24

MARGARET LOCK
AMT

scholars on the form that change has taken have been considerably modified.
In the fifties and sixties economic theories of convergence1 were dominant,
and the assumption was that, given time, Japan, in becoming modernized,'

25

Japan probably has the most highly educated and well-read general public
in the world today (Cummings 1980), a public which is very conversant with
scientific language and thought and at the same time pays a great of attention
to health and illness. These features, combined with a Confucian legacy and
a philosophical tradition which has never split psyche from soma, make con­
temporary Japan a fertile ground for the study of events such as menopause
which have both biological and psychosocial dimensions.

would also become Westernized. During the last fifteen years this viewpoint has
been called into question with increasing vehemence, and it is now fashionable
to view Japan’s modernization as a product of the interaction of contemporary
scientific thinking with innovative technology and built up-m the distinctly
Japanese social and cultural legacy of the past 1400 years or more. “Confucian
capitalism,’’ as this system is sometimes called, poses an interesting challenge
to analysts since, not only in the keenly observed business world, but also
in industry, schools, the scientific community, and the family, a great many
features are apparent which seem anomalous and even antithetical to a rational
and efficient society. One such feature is the status and role of women in modern
Japan. Things have certainly changed since the famous Meiji2 politician and
educator Fukuzawa Yukichi wrote his “radical” essay entitled “Women arc
also Human Beings,” but there is considerable disagreement as to how profound
these changes are. Contemporary Japanese women are depicted by many as
“strictly bound by the rule of segregation and division of labor, confined to
domestic drudgery and pitiably deprived in status, power and opportunities”
(Lebra 1984: ix). It is said that women in the labor force are shamelessly
exploited, and stated by some that Japan’s modern economy could not continue
to exist without such exploitation (Cook and Hayashi 1980).
On the other hand Japanese women are also described as powerful and
enjoying a great deal of autonomy; Japan is a matrifocal society in which the
mother image is idealized (Doi 1973:150), and it is claimed that women are not
denied access to the public sphere, rather they choose to stay out of it. Indeed
many Japanese women consider the roles of mother and homemaker to be more
important than employment outside the home. At first glance these images
appear contradictory, but recent studies indicate that this is not necessarily so
(Lebra 1984; Pharr 1976). that both images are in part products of a Confucian
heritage, an ethical system which is not based upon distinct dichotomies, but
one in which language, stated beliefs, and behavior are modified contextually;
an ethos of relativism in which a person’s behavior cannot be understood in
isolation from the web of social obligations which continually shape it.
Moreover, as Kondo (1985) points out, although the middle-class ideal is
dominant and lauded in modern Japan, nevertheless, there are significant class
and occupational differences among women which in turn affect the concept of
self, beliefs, behavior, and family dynamics. Research into life-cycle transitions
in Japan and elsewhere is fraught with problems unless account is taken not only
of gender differences, but also of the dynamics of relationships of inequality
in general.
7

ITIES OF AGING: JAPANESE MENOPAUSE

RESEARCH METHODS

A cross-sectional survey was administered to 1738 women between the ages
of 45 and 55 inclusively who comprise three major sub-samples. The first sub­
sample consists of 525 middle class women living in the city of Kobe, the
second of 650 farm women who live in Nagano, Shimane, and Shiga prefectures,
and the third group consists of 550 women employed in factories in and around
the city of Kyoto. There is, in addition, a very small sub-sample of 13 Geisha
who live in Kyoto. (Details on sample selection are given in footnote 3). A total
of 1323 usable replies was obtained comprising an 81% response rate to the
questionnaire. The questionnaire results presented in this paper are preliminary
and are based upon 1283 responses since those women who had received
hysterectomies are not included in the analysis. Indepth interviews were carried
out at a later date with 105 of the respondents in their homes. Interviews
were also conducted with fifteen gynecologists, four general practitioners,
three physicians of traditional medicine, and five counsellors for psychosocial
problems. In addition, a survey was carried out of the relevant medical and
popular literature.
One of the major problems to date with comparative studies into menopause
has been the absence of a standardized approach to the collection of data.
This study was designed to overcome this limitation since I was allowed
access to a questionnaire which had been carefully constructed, originally
by Kaufert and McKinlay, and already used with a sample of 2500 Manitoban
women and, in slightly different form, with 8050 women in Massachusetts
(Kaufert 1984). The original 108 item questionnaire was somewhat modified
to suit a culture where extensive use is made of traditional medicine, and
where the organization of medical care, the work force, and the family is
distinctly different from that of Canada and the United States. The revised
117 item questionnaire was translated into Japanese and pre-tested on a small
sample.

80

In order to minimize bias, respondents were asked, as in the Manitoba project,
to report, using a symptom list, what symptoms, if any, they had experienced
during the previous two weeks. This method was used in order to reduce the

26

MARGARET LOCK

AMBIGUITIES OF AGING: JAPANESE MENOPAUSE

problem of inaccurate recall. They were asked, in addition, to recall from
their past life major illness events and life-cycle transitions.
The questionnaire was also designed, as were its North American counter­
parts. so that the attention of respondents was not drawn particularly towards
the topic of menopause. Items relative to the experience of menopause were
embedded in general questions about health and illness, and the word menopause
did not appear in the questionnaire title. This method accomplished two things
firstly, retrospective data could be collected on much of the entire reproductive
history, major illness episodes, physician encounters, and received medication
from each of the respondents, and, secondly, answers in connection with the

27

FROM THE PATH OF BLOOD TO A SYNDROME:

JAPANESE MEDICAL VIEWS OF MENOPAUSE

An investigation into the history of ideas in connection with menstruation
and its cessation in Japan is a demanding task. As early as the 10th century
a concept known as chi no michi appears in the literature. This can be glossed
literally as “the path of blood,” and a priest writing in 1362 states that chi no
michi is contributory to the 36 symptoms which appear only in women. In 1841
a physician named Mizuno published a work in which he claims that chi no
michi is a unique Japanese concept, not found in China, and that it is a term
used to describe organic disorders occuring only in women.5 A contemporary
commentator states that chi no michi was a concept used to describe the occurence of non-specific complaints (futeishuso) and temporary psychological
changes in women such as those that occur during pregnancy, after childbirth,
before and during menstruation, and at the cessation of menstruation (Nishimura
1981). Physicians recall the term being used in medical circles up until the
1940s.

menopause were less likely to reflect a stereotyped response. As Kaufert (1W)
has pointed out, menopause is a culturally constructed event and one to which
people bring preconceived ideas about its nature. Both the Manitoba project
and the present study were able to demonstrate that the actual experience that

women report, and their verbal responses about menopause as a general topicdo not correspond (Kaufert and Syrotuik 1981). highlighting the need for great
care in data collection.
The Japanese symptom list was a particularly long one of 57 items, an
increase of 35 items over the original Manitoba questionnaire. In my previous
research in Japan into the traditional medical system (Lock 1980) 1 had observed
a highly developed sensitivity to minor somatic changes and an appropriate
language with which to describe such changes. For example, terms such as

my head is heavy.' utam^a omoi; "my body is languid." karaduga darui
shoulder stiffness, katakon. and "a feeling of oppression." appakukan. along
with many others, are commonly used in daily conversation and at visits to
the doctor.
Japanese physicians, even more than Western physicians, are used to patients
of all ages and both sexes who can describe complaints for which no organic

origin can be found (fureishuso) in graphic detail. However, the stereotype
presented in the Japanese professional literature on menopause, and given by
the majority of the fifteen gynecologists who were interviewed, is that women
suffenng from '■climacteric" or ‘'menopausal" syndrome are more prone to such
complaints than other patients. The most usual non-specific complaints were
therefore, tncluded in the symptom list. In addition several special categories
which are regularly used in patient surveys done by Japanese gynecologists
were also included, such as "feelings of ants crawling over the skin.’’4
Virtually all our respondents were literate, but approximately fifteen were
given help in filling out the questionnaire.

81

Doctors of the literate and elite schools of Chinese medicine in Japan (kanpd)
used a different concept, that of oketsu (stale blood) which was (and still
is according to some physicians of this school) thought to be the cause of
non-specific symptoms such as dizziness, palpitations, headaches, chilliness
of legs and back, dry mouth and so on. These traditional explanations reflect
a reductionistic approach very characteristic of traditional Japanese medicine
in which emphasis is placed upon a description of symptoms and the selection
of suitable herbal medication (Lock 1980). Women thought to be prone to such
problems were described as being endowed with particular physical constitutions
and possibly, in addition, particular pre-morbid personality types.
Towards the end of the last century these ideas were supplemented by the
concept of kdnenki which is usually glossed as “the change of life” and is
a term which was deliberately created under the influence of German medicine.
Japan had always been a society where life-cycle transitions were marked off
by rituals serving to incorporate one age-set of people into the next segment
of their life span, but these rituals did not necessarily coincide with biological
transitions since they were predominantly markers for status and role changes
(Norbeck 1953), and were associated only in a very general way with the process
of aging. Traditionally there was no ritual associated with the end of menstrua­
tion, and so kdnenki (the change of life) was slotted in between the already
existing concepts of chuncnki (mid-life stage or maturity) and rdnenki (old
life stage). Entry into rdnenki or old age was commemorated by a symbolic
re-entry into childhood,6 a time of rejoicing, and of release from onerous
social obligations. The Chinese character chosen for the kd of kdnenki literally

28

Margaret lock
AMBIGUITIES OF AGING. JAPANESE MENOPAUSE

means the idea of renewal and
regeneration. By themselves these ideograms
would create a {positive image, but they
are very frequently linked with two
more ideograms, shdgai
shogai meaning injury or
bodily harm (see also Rosenberger
in press).
----- ■ of- konenki
• , The
--2 cconcept
shdgai (troubles
--S at menopause) used to
translate the German term, ('*
climacteric disorders, replaced f
those of the “path
of blood” and “stale blood" in the medical
world
and
becameJ associated
w.th tdeas developed in Germany early in this

THE CROSS-SECTIONAL SURVEY: MENOPAUSE AS PROCESS

i. Menopause and Aging

There are a few women who live in relatively isolated areas in Japan today who
believe in the path of blood.” Interviews with seven such women revealed
that they think that when feelings of irritability and depression (yu-utsu) are

P seed upon supposed changes in the autonomic century, where emphasis was
leading to loss of temper (seen in 90% of all womennervous system at menopause
dizziness, perspiration, ringing in the eL^hLTh aCC°rding 10 Yan,ada 1927),
’ ringing in the ears, headachi
word invented to translate hot flash fro 'c
SOgyotek,shakunekkan (a
over the skin, and so on. Treatmen,
u
SenSati°nS °f ants crawling
gland and the administration of hon
a
°f X ray °n the thyroid
•hat women with cert^^

“t rare those °f ~

experienced by women in their late 40’s and 50’s they can be attributed, in
part at least, to a failure to uphold traditional dietary and avoidance taboos
prescribed for post-partum women, or to receiving a fright or shock immediately
post-partum, or to not resting sufficiently after giving birth. One informant
claimed that her own menopausal troubles were due to such a failure.
Most Japanese women no longer believe explicitly in either the “path of
blood” or “stale blood,”8 and the majority of respondents, 65%, report (re­
gardless of whether they are still menstruating or not.) that menopause9 is an
event of little or no importance to them (see Table 1).

w-d,sposed to

TABLE 1
Assessment of the importance of menopause by menopausal status

J., •JU". “ “"■■»«
writer. Okamura 1977) Nervous
'C °
SUffer lnost according to one
sidered highly vulnerable and co^ T
"
are cmentioned. Sympton to 0 v d
S°Cial
3,50 ^querrtly
Physicians as ™e^ex^ Z X 7°PaUSe '

think about themselves too tnucl Other nh"0™"

29

hands

a problem. Hormones, tranquilizers and anti'OneIiness as
as therapy. Although there are detailed descripflonsTh5
menstrual changes, emphasis is nnnn
T P
of hormonal, uterine and
or early forties through to the mid 1X^7°" 7 'b'
‘b"^5

Pre-menopause Peri-menopause Post-menopause Total (%)

N

Of great importance
Of some importance
Of little importance
Of no importance

1.5
35.5
54.6
8.4

5.1
34.1
51.4
9.4

4.5
27.4
51.8
16.3

3
32
53
12

39
340
556
122

Total

100

100

100

100

346

331

380

1057

x2 = 23.8. df= 6, p = 0.0003.

with natural aging and kdnenki shogai (trouble at mT
as inevitable and normal for a laree numb/ r
menopause) are regarded
vary from 50% upwards) InZailv
previous abortions and difficult childbirth "T gyneC°loglsts often associate
and Purported guilt associatedSy"’P‘~logy.

as contributory to kdnenki shdgai ’ The exnerie
f
freqUently ci‘ed
IS thought of by medical nrof«si
t
Perleni-e of menopause therefore
to one’s genetic endownment, persZlhy ^nZ t T'
bnked
mediation Is, nevertheless, readily admired in Zr

82

In the present study, women were asked whether they had menstruated
within the past three months, the past twelve but not the past three months, or
within the last year. Based upon their responses a three-part division was made
between pre-, peri- and post-menopausal groups. Those that had menstruated
within the past three months were assigned pre-menopausal status (33%); those
that had not menstruated within the past three months but within the past
twelve were assigned peri-menopausal status (32%), and those who had not
menstruated for over a year were assigned post-menopausal status (36%). Re­
spondents were also asked, in the section of the questionnaire which deals
explicitly with menopause, to assess their own menopausal status. These two
“definitions” of menopause, one based on a visible biological marker (and the
definition used by epidemiologists, see Kaufert in press) and one based upon

30

MARG/\RET LOC K

AMBIGUITIES OF AGING: JAPANESE MENOPAUSE

self-assessment, provide an interesting comparison in the Japanses case (see Table
2). Among women who are |post- menopausal. 24% state that they have no sign
of menopause and 12.4% state that theyj are just beginning menopause. Among
peri-menopausal women 24.2% respond that they have no sign of menopause.

Of the 72 women who consider kdnenki and heikei to be different, almost
half of them nevertheless consider that the two events are linked and that
heikei is one small part of the larger aging process. The remaining group of
women (38) state explicitly that one can avoid kdnenki (the change of life)
altogether or, alternatively, that one can have passed through kdnenki and
still be menstruating. This last group of women account for the unexpected
responses which appear in Table 2. For these women the menstrual marker
is of very little significance. Instead, they focus upon the presence or absence
of symptoms associated with aging which may appear completely independently
of the end of menstruation, either before it, or, more usually, after it and
sometimes not very noticeably at all. In responding to the questionnaire, there­
fore, a high percentage (50.3%) of pre-menopausal women state that they
are at the beginning or in the middle of menopause and, using a similar logic,
70.8% of peri- and 36.4% of post-menopausal women can respond that they
have no sign of, or are just beginning, menopause.
In the open-ended interviews women were asked to state what symptoms
they associated with their own menopause and with that of their acquaintances.
The symptom which is reported most is headaches, followed equally by shoulder
stiffness, lumbago, irritability, loss of energy, tiredness and general debility,
weakening eye sight, grey hair, and changes in the autonomic nervous system
(this last symptom is part of common parlance in Japan and frequently used
to describe non-specific complaints). The middle class sample is also concerned
about a perceived inability to suppress their feelings (a value held in high regard).
These symptoms will be discussed in detail below, they are introduced at this
point to indicate that general signs of aging are much more prominently noted
than those symptoms commonly associated with menopause in the West, such
as hot flashes and sweating.
Informants very rarely link family relationships, marriage of children, or care
of the sick elderly with a difficult menopause. Of the five women who made this
connection four said that they had learnt these ideas from their physicians
and/or from popular books. This type of association therefore appears to be
infiltrating via professional sources, the mass media, and from translated Western
literature on the subject.

TABLE 2
Self-definition of menopausal status by menopausal status

Self-defined
status
Through with
menopause
Middle of
menopause
Beginning of
menopause
No sign of
menopause

Pre-menopause

Peri-menopause

Post-menopause

Total (%)

N

06.

2.2

34.2

13

136

11.7

27.0

29.4

23

234

38.0

46.6

12.4

32

319

49.7

24.2

24.0

32

328

Total

100

1 00

100

100

/V

324

322

371

1017

.V2 = 332.7. dj = 6. p = 0.0.

If we had translated the word menopause as heikei. that is. as “the end of
menstruation, then 1 am sure that there would have been little or no dis­
crepancy between these two forms of assessment since one is clearly asking
about biological markers in both cases. However, heikei is a technical word
which is very rarely used among ordinary people. In follow-up interviews we
found that several informants had never heard of this term and the word used
both in ordinary conversation and between physicians and patients is kdnenki.
‘‘the change of life.” Kdnenki is viewed predominantly as a life-cycle transition,
as natural and part of the aging process, and hence usually of little importance,
since it is not, and never has been, socially and ritually marked off as have
other more important life-cycle changes.10
When 105 women who had responded to the questionnaire were asked
in the open-ended interviews to describe what kdnenki implies the majority
responded that it is a long gradual transition from one’s late 30’s or early 40's
until the late 50’s. Several women stated explicitly that kdnenki is the beginning
of the process of getting old (rdka gensho). Less than one-third said that for
them kdnenki (the change of life) was the same as heikei (the end of menstrua­
tion), in other words, this group view the event largely as the cessation of
menstruation, and several people stated that they had obtained this information
from medical sources.

31

ii. Attitudes Towards Menopause

83

When asked to assess their feelings in connection with the end of menstruation
46% of the questionnaire respondents indicated that they had mixed feelings
about it, while another 35.1% experienced mainly relief. When interviewed
about their feelings it became clear that most women are pleased to be past
the inconveniences associated with menstruation (in Japan most women do

32

MARGARET LOCK

AML.

not bathe while menstruating), and they are also glad to be beyond possible
pregnancies, but for nearly half the women these feelings of relief are strongly
tempered by concern about aging. Some clearly express sadnecs, some emphasize
a loss of sex appeal and a concern that Japanese men oi y like young and
vivacious (pichi-pichi) women, and most express a fear th; their bodies will
start to “break down" (gata ga kuru) or “slow down." Th feelings of relief,
therefore, are linked directly to the end of menstruation, it concern about
aging leads to mixed feelings and ambiguous and paradoxical sponses.
Respondents to the questionnaire were asked to agree c disagree with the
following statements:
(a)
(b)
(c)
(d)
(e)

iii. Symptom Reporting at Menopause

the first of these
pressed this view
■)ed as a “luxury
ne on her hands,
agreed with the

Slightly more Japanese than Canadians agree
agree that
that w< m worry about
losing their minds (35.9% as compared to 26%). but this \ ; not brought up
at all in the interviews as of great concern. Belief about it eased depression
and anxiety is widely held by both Japanese (71.8%) and ( madians (84.1%).
however, these beliefs are not borne out by the actual experience of women
who are going through menopause, (see Tables 5 and Kaufert and Syrotuik
1981) indicating that the stereotype of menopause does not reflect reality.
Japanese and Canadian women also appear to feel the same as each other
about the fourth statement, since 78.8% and 75% respectively disagreed with
it. However, in this case nearly a quarter ot
of the Japanese women who were
interviewed gave unsolicited comments such as the following: “one becomes
a man. or one “loses one’s sacred function as a woman” or one's “value as
a woman is decreasing” at the time of menopause.
In response to the final statement there is a significant fference between
Japanese and Canadian attitudes. While 78.1% of Canadian agree that menopause does not change a woman in any important way, ily 55.8% of the
Japanese women agree, tending to belie their earlier answ that menopause
is an event of little importance; further analysis is needed on t s point.
..... .«, i .i,

...

.

t

33

personality types or dispositions are vulnerable to a difficult menopause, par­
ticularly those who are “high-strung” (shinkeishitsu) or “nervous.” Others
stressed that certain types of physical constitution can cause trouble. In this
respect their beliefs are similar to the professional gynecological literature,
and also similar to widely held beliefs in Japan about illness and misfortune
in general (Lock in press).

Women with many interests in life hardly notice :
menopause.
Women worry about losing their minds during me )pause.
Many women become depressed and irritable du
I the menopause,
Some women think they are no longer “real’ vomen after the
menopause.
The menopause does not change a woman in any
portant way.

Japanese respondents overwhelmingly agreed (79.2%) wit
statements, and many of the women who were interviewed
equally strongly. Trouble at menopause was frequently des
disease" (zeitaku byo). a problem only for a woman with
Canadian women appear to feel the same way since 72..
statement.11

CITIES OF AGING: JAPANESE MENOPAUSE

84

An interesting problem arose in the creation of the symptom list for the
questionnaire in that there is no word in Japanese used especially to describe
hot flashes. This, despite the fact that there are 20 or more words to describe
the state of one’s stomach and intestines, for example, and an overshelming
vocabulary, as pointed out above, to discriminate between somatic sensations
in general. There are two words commonly used to describe general changes
which resemble a hot flash, both of which are used by physicians and the lay
public: hoten means “glow,” “heat," a burning sensation." This term is also
used to describe the sensation ol flushing that most Japanese experience when
alcohol is consumed. Nobose means “a hot fit." it has emotional overtones
such as “excitement." and “infatuation," but is also used by itself to mean
a hot flash and sometimes in combination with the character for chilly (hie)
to describe the most common form that the menopausal flash apparently takes
in Japan, that of feelings of a hot head together with a cold lower torso, legs
and feet. A third term, kyu na nekkam literally means “a sudden feeling of
fever or heat." This term is associated with an actual rise in body temperature
and has recently emerged in the language of physicians and in popular literature
on the menopause. All three words are used interchangeably to describe a hot
flash, and hence they were all listed together to describe the item “hot flash"
on the symptom list. In addition several women when interviewed simply used
the term atsuku naru (to become hot), to describe sensations which appeared
to the interviewer to be similar to a hot flash.
I predicted that given the sensitivity of Japanese to somatic changes that
there would be an overwhelming reporting of symptoms in general. One person
did report experiencing 32 symptoms in the previous two weeks, and a few
respondents reported between 12 and 20, but most responses were very low.
This is particularly surprising given the tendency of Japanese women to be
embarrassed about appearing flushed after drinking alcohol, and there is also
a general concern about visibly sweating in public. I think it most unlikely,
therefore, that there is under-reporting of hot flashes and sweating.
Complete analysis of the data on symptom reporting is not at present avail­
able. Some preliminary findings are presented below.

34

MARGARET LOCK

At. JGUIT1ES OF AGING. JAPANESE MENOPAUSE

(a) The ‘ ‘Classical' ’ Symptoms of Menopause
Reporting for the characteristic somatic symptoms of hot Hashes, night sweats,
and sudden perspiration is low (see Table 3). There is an increase from 5.7%

among pre-menopausal women to 12.6% and 10.8% respectively among periand post-menopausal women in reporting of hot flashes over the previous
two weeks. Similarly, with sudden perspiration there is a small increase (see
Table 3). Reporting of night sweats is very low and actually drops among periand post-menopausal women (see Table 3). Clearly, in a Japanese population
undergoing normal (not surgical) menopause the prevelance of hot flashes
and sweats is low as compared to that reported in studies from other cultures
(Jaszmann et al. 1969; McKinlay and Jeffreys 1974; Thompson et al. 1973).
TABLE 3
Experience of hot Hashes, night sweats, and sudden perspiration in the previous two weeks
by menopausal status

Presence of
symptoms
Hot flashes*
Night sweats**
Sudden
perspiration

.V

Pre-menopausc

Peri-menopause

Post-menopause

Io tai ('■;)

12.6
4.1

10.8

l()
4

105

3.1

1.1

4.4

7.2

4

47

341

388

I

A

5.7
4.2

353

I

41

1082

* -v2 = 10.4, dj - l.p> - 0.005.
*♦

x2 = 16.465, J/ - 2!. r = 0.0003.
x2 = 0.814. d/ - p = 0.665.

The Manitoba results are also high compared with Japan: 39.7% of perimenopausal women report experiencing hot flashes in the previous two weeks
and 38.6% of post-menopausal women report them. Even the pre-menopausal
Canadians are higher (14.9%) than peri- and post-menopausal Japanese women.
Similarly, with night sweats the Manitoba peri- and post-menopausal women
are higher than the Japanese with 27.1% and 21.7% respectively.
When the Japanese data is broken down according to the sub-samples, that
is. occupational differences, there is very little difference in somatic symptom
reporting, but urban middle class women report slightly less flashes and sweats
than do farmers. This finding, and those reported in the rest of this paper,
belie the stereotype held by medical professionals and lay people in Japan
that middle class women, because they have so much time on their hands,
are likely to pay more attention to and more frequently report menopausal
symptoms.
For some time the hot flash has been regarded within medical circles as the

35

one true symptom of menopause; its etiology is not understood, although it
is generally thought to be linked to lowered estrogen levels. Most basic science
and clinical researchers assume that between 75 and 85% of women suffer
from hot flashes during the peri-menopausal period (McKinlay and Jeffreys
1974; Thompson et al. 1973; Mulley and Mitchell 1976) and often use this
information to justify clinical intervention. In the Manitoba study 69.2% of
the peri- and post-menopausal sample report that they have2 experienced a
hot flash at some C
time, while in the Japanese sample only 20% recall having
had them. A similar figure was obtained by Goodman et al. (1977) with a
Japanese population living on Hawaii, where only 24% of a ssample of 159
menopausal women reported “traditional” menopausal symptoms.
Obviously the implications of these results must be examined more closely
at both the physiological and the cultural levels. There are several hypothesized
physiological models for the hot flash C
at present under consideration including
postulated hypothalamic dysfunction due to low estrogen secretion (Gambone
et al. 1984) and loss of peripheral vasomotor control again linked to estrogen
levels (Brincat et al. 1984). These two mechanisms are not necessarily mutually
exclusive. A third hypothesis suggests the possible blocking of endogenous
opiate receptors leading to withdrawal-like symptoms and hot flashes (Lightman
et al. 1981). Witt and Blethen have demonstrated that estrogen deficiency is
not an absolute requirement for the development of hot flashes (1982), other
researchers emphasize the possible importance of estrogen production in fatty
tissue as a protection against hot flashes; others stress the importance of the
ambient temperature as a contributory factor - hot weather induces more '
flashes (Coope et al. 1978), and still others suggest that dietary factors are
probably important. Most intensive research is at present taking place in con­
nection with the role of the hypothalamus and implicated neurotransmitters
in the hope of uncovering the final common pathway leading to a flash, but
it is apparent that more inductive, epidemiological style models must also be
developed in order to account for why some women experience hot flashes
and others do not.

85

Tulandi et al. (1983) have been able to demonstrate that when the measurable
skin temperature elevation and luteinizing hormone secretion associated with
hot flashes are monitored, subjects do not always report a corresponding sub­
jective experience of a hot flash. This phenomenon is systematically magnified
when the morphine-like substance, clonidine, is administered to subjects. The
implications of this research are many, but one is especially important for
cross-cultural research, since clonidine blocks opiate withdrawal symptoms
including psychological concomitants such as subjective distress (Gold et al.
1980). The hot flash has always been regarded as a “hard” symptom, one that
is not easily missed, under-reported, or subject to intercultural variation

36

MARGARET LOCK

AMutGUITIES OF AGING: JAPANESE MENOPAUSE

As researchers begin to examine hot flashes systematically for the first time
it is gradually becoming clear that there is indeed great variation (Voda. 1981);
moreover, the findings of Tulandi et al. suggest that some w''men, and possibly
some populations, may not experience an objectively similar hot flash in the
same way, that the psychological appraisal system may be subject to biological
variation and obviously, at the same time, to culturally constructed variation.
The striking differences between Japanese and Canadian women suggest that
some sophisticated interdisciplinary research is needed.

In the present study reporting of symptoms of melancholy yu-utsa and
depression (ki ga meiru) are low and actually drop for peri- and post-menopausal
women in both cases (see Tables 4). Depression does not, therefore, appear
to be subjectively associated with the experience of menopause in Japan.

(b) Cultural Construction of Psychological and Psychosomatic Symptoms
A ssociated with Menopause
Turning to the group of symptoms which are usually classified as psychological
and which are frequently associated with the menopausal transition, difficulties
arise once again in translation, and also in the meaning which such words signify.
Two terms were used in the questionnaire to cover the concept of depression:
and ki ga meiru. Yu-utsu includes the idea of grief and sorrow and is
usually translated as melancholy or depression. It has been shown that Japanese
respondents also tend to associate this term with gloomy feelings thought to be
brought about by climatic changes (Marsella et al. 1973). This is the term usually
used by professionals and lay people to describe people who “get down” easily
(a different word, utsu. is used to describe clinical depression); its incidence
is associated with a pre-morbid personality trait,” that of shuchaku kishitsu
(a “sticky” disposition, a character that "adheres” or is highly “tenacious”),
and people who overwork and cannot relax are thought to be particularly
vulnerable. The stereotype of a depressed person in Japan is of a middle class
salaryman, and unconfirmed statistics estimate that the incidence of clinical
depression is equally high for men and women. Depression is not associated
particularly with middle aged women.
The other term, ki ga meiru. which is used by lay people to express feelings
of depression and gloominess, leads us into a very messy arena. Ki is an ancient
Sino/Japanese concept which can be roughly glossed as “pneuma” it is thought
that ki exists both outside and inside the body and that there is a constant
exchange between its two forms (Lock 1980; Porkert 1974). Ki is fairly close
to the Homeric concept of psyche, that is, it is never portrayed as a thinking,
feeling or reflecting entity, as is the Platonic concept of psyche (Simon 1978).
It is closely linked to changes in emotional states but is visualized in a rather
physiological fashion, subject only in a limited way to concious control and
modification (Lock 1982). Many words which express emotional states in
modern Japanese make use of the term ki (Lock 1980), and when such expres­
sions are used they imply natural and temporary fluctuations in emotional
balance.

37

TABLE 4
Experience of depression, melancholy, irritability and nervous tension in the previous two
weeks by menopausal status
Presence of
symptoms

Pre-menopause Peri-menopause Post-menopause Total (%) N

Depression*
Melancholy**
Irritability***
Nervous tension****

6.9
9.6
12.2
4.0

2.3
8.2
11.1
5.3

3.1
5.9
10.8
5.9

N

353

341

388

3
8
11
5

41
85
123
55
1082

* x2 = 3.6, df = 2, p = 0.16.
** x2 = 6.9, df= 2,p = O.O3.
*♦ **

x2 = 0.3, df= 2, p = 0.8.
x2 = 1.5, J/’ = 2, p = 0.5.

Other psychological factors associated with menopausal women by Japanese
informants which were often cited during follow-up interviews were irritability
and nervous tension, but again questionnaire results indicate that the rate varies
very little with menopausal status and is consistently rather low (see Table 4).Reports of difficulty in concentrating are similarly very low. Insomnia increases
a little from 8% in the pre-menopausal group to 12% and 14%- in the periand post-menopausal groups. Insomnia is regarded as a frequently occurring,
frequently reported problem among all age groups and both sexes in Japan.
It has been noted that “psychologization,” that is, the tendency to verbally
report purported changes in affective states, is relatively unusual when examined
cross-culturally (Kirmayer 1984). Many Japanese are aware that they tend to
somaticize rather than psychologize psychosocial problems. A refined discrim­
inatory vocabulary for somatic changes is one reflection of this tendency, and
the somatically oriented form that psychotherapy frequently takes is another
(Ikemi et il. 1980). Serveral psychosomatic symptoms appear in the standard
international menopausal symptom check lists and were included in the present
questionnaire. One symptom usually associated with menopause, dizziness,
is reported by only 7% of all respondents; another, headaches, is higher. Among
the pre-menopausal population 27% report having had a headache in the previous

86

two weeks, but this is only raised to 28% in each of the peri- and post-meno­
pausal groups. Headaches are reported more than any other symptom except

38

MARGARET LOCK

AMBIGUITIES OF AGING: JAPANESE MENOPAUSE

39

J

one. The symptom which is reported most frequently, and nearly twice as
often as headaches, is shoulder stiffness (katakori) (see Table 5). Shoulder
stiffness is regarded in Japan as of frequent psychosomatic origin and is used
almost interchangeably with the word sutoresu, taken from the English term
stress. In the present study its incidence is not shown to be dependent upon
menopausal status, but it does appear to be occupationally dependent and is
considerably higher among farmers and factory-employed women. Lumbago
is the symptom reported third most often, and this is also clearly associated
with farming and to a lesser extent with factory work.

and she does 25 sit-ups a day to keep her muscles in good shape. Mrs. Aoki had two
abortions, about which she feels no regret. She says that she stopped menstruating when
she was 43, and that prior to that, at about 37, she felt for a while as though the blood
in her neck was “curdled.” Her doctor told her that it might be konenki (the change of
life), but Mrs. Aoki now attributes those symptoms, which stopped a few years later, to
high blood pressure which was exaccerbated, she says, because she is an “impatient type.”
She says she has had no problems with menopause, she supposes that she is more or less
through with it, but paid it no attention and adds that in general her health is better than
it was a few years ago.

(2) Mrs. Morita is 45 years old and lives in Nagano prefecture where she runs a farm
with the occasional help of her husband (this is a very common situation in rural Japan
today) who works in the office of the local farm cooperative. She has three children, two
in university and one in high school. The farm is the original Morita family house and Mrs.
Morita’s mother-in-law (who lives with the family and has had a mild stroke) still helps
with light household chores. Mrs. Morita rises at 5:30 a.m. each day except in the winter.
She works in the fields for a while and then makes breakfast and the boxed lunches and
does the laundry, after which she spends much of the rest of the day at farm work including
servicing some of the machinery. In the evenings, after supper, which the children often
prepare, she knits, reads, or watches television, and goes to bed at 11:30 or midnight.
Occasionally she goes on educational/recreational trips with her women’s group. Mrs. Morita
is very happy with her farm, the beautifully rebuilt spacious house that the family lives
in, with her daily life, and with her family, but she is concerned about the future. She
wonders what will happen when her mother-in-law becomes bed-ridden and when the
children finally leave home and cannot help out. She is certain that she will have to give
up most of the farming while she looks after her mother-in-law since there is no senior
citizen’s home for miles around. She and her friends discuss how it might be best to live
in cooperatives, share their resources, and look after the old people and the farms together
as a group.
Mrs. Morita says that right now she is very healthy. In 1977, when she had to run the
farm and look after her father-in-law who had kidney failure and was receiving dialysis as'
an out-patient, she contracted a stomach ulcer. She was hospitalized for a month, received
medication, and made a complete recovery. Her father-in-law was hospitalized at the same
time, and the day that they both came out Mrs. Morita started once again taking him for
his dialysis sessions. Since the death of her father-in-law in 1979 Mrs. Morita’s health has
been excellent. She has had two abortions which saddened her at the time but which she
believes have left no long lasting effects. She is still menstruating regularly and says that
she has not entered “the change of life” which she is not worried about “in the least.”
Mrs. Morita has heard of women having difficult times and becoming very depressed at
konenki but she believes that this is because the women say to themselves that “I am
finished.” She thinks it will not be easy to go through the physical changes involved but
that ai good emotional attitude can overcome all of the difficulties. She thinks she will
enter menopause when she is about 52 and that the end of menstruation is just one sign
of a gradual aging process which is what menopause means to her. She is careful to point
out that she doesn’t understand menopause in medical terms.

TABLE 5
Experience ot shoulder stillness in previous two weeks by menopausal status

Presence of symptoms Pre-menopause Peri-menopause Post-menopause Total (^)

N

Shoulder stiffness

50.1

54.8

50.5

560

Total

353

341

388

.v2 = 1.9, dt = 2, p

52

1082

0.4.

( ASI S 1 UD1ES

(1) Mrs. Aoki is 53 years old. plump, sturdy-looking, and out-going. She works al a cake
factory in the outskirts of Kyoto where she rotates through six types of assembly line
jobs every few weeks. Her tasks include preparing the cake batter, which involves a great
deal of heavy lilting and pouring, squeezing thick cream by hand onto cakes as they pass
along the assembly line at an unvarying and relentless rate, layering cakes, cutting cakes,
boxing cakes, and loading them into trucks. Mrs. Aoki is classified as a part-time worker,
she works from 9 a.m. to 5 p.m. four or five days each week, and she receives 590 yen
an hour ($2.50) after eight years of work for this particular factory. Her situation is not
at all unusual for a Japanese working woman. She says that in the summer the temperature
is often over 40 C. (104 I-.), and everyone is required by law to be covered from head to
foot in protective clothing. Mrs. Aoki complains that the men (the supervisors) at the
factory just play around while the part-time women do all the actual work, but she also
believes that working is good for her health and that it keeps her weight down.
Mr. Aoki has a three hour commute to work and his wife rises at 5:30 a.m. to prepare
breakfast and boxed lunches, do the laundry, and get herself ready for work. Her three
children are all married, she has two grandchildren, and her daughter-in-law has come
to live with her husband of one year in the Aoki household. This means that Mrs. Aoki
can give herself the luxury of going to bed a little earlier at night and leave her daughterin-law to lock up the house and tidy things away after the men have finally gone to bed.
Mrs. Aoki likes extended family living much better than nuclear family living, which she
believes, makes people selfish. She is happy with her life, her family, and her home.
When asked about her health, Mrs. Aoki reports that she gets irritated at work at times
and that about once a week she feels really tired. She attributes the tiredness and the
frequent pain in her neck (which she describes as katakori. shoulder stiffness) to the strain
of the assembly line. She had a herniated disc four years previously as the result of lifting
a pot of chocolate which weighed 35 kilograms (77 lbs.), but she says that it is fine now,

87

(3) Mrs. Ueda is 47, she is a Kobe housewife who lives with her daughter in a small,
slightly shabby home overlooking the ocean. Her husband comes home on weekends from
his job with an electronics company 200 miles away on the island of Shikoku. Until recently
Mrs. Ueda was living with her parents4n-law but they are now both dead (her mother-in-law
was 92) and now she has free time on her hands. She has a dressmaking teacher’s licence,
but she ^oes not want to work and has joined a Buddhist study group. Mrs. Ueda has had
“several’' abortions about which she appears to feel considerable regret. She has had an

42

MARGARET LOCK

AMbiGUITIES OF AGING: JAPANESE MENOPAUSE

43

from a complex biological event such as menopause, which is also shaped by

NOTES

numerous cultural factors. It is particularly in connection with survey research
that I believe the greatest caution must be taken (see also Davis in this issue).
These problems are not new to anthropologists, but as more and more disciplines

i

Convergence theory proposes that those societies with industralization and a welldeveloped technology will come eventually to resemble each other closely in social
organization and structure.
2 The Meiji era commenced in 1867.
3
The middle class urban sample was selected from the register of names and addresses
available at many city halls in Japan. The register used is classified according to residen­
tial areas. Two areas regarded as representative of middle income families were selected
and every women (525) between ages 45 and 55 was noted and mailed a questionnaire.
This was followed up by a reminder postcard and then a second mailing of the question­
naire to those who had not responded. After the first mailing 191 usable questionnaires
were returned, after the postcard 68 more, and after the second questionnaire another
75 were returned giving a total of 324 usable responses. The usual response rate to
Japanese mail questionnaires is between 10 and 15%.
The factory workers were selected by first making contact with the director of
the Kyoto Industrial Health Association who facilitated the distribution of 405 ques­
tionnaires to 15 factory managers who then passed out all of the questionnaires to
women of the appropriate age. Replies were sent back by mail directly to the researchers.
A second group of 145 women working in small silk weaving factories were contacted
by personal distribution of the questionnaire to factory managers after receiving the
support of the local union in the form of a letter of introduction. 377 usable responses
were obtained from this sample.
The final sample of 650 farm workers were mostly selected through the support of
the public health department of a large country hospital. The questionnaires were
distributed by travelling public health workers to the women’s organizations of 45
villages, responses were mailed directly back to the researchers and yielded 434 usuable
responses. A second smaller sample of 176 usable responses were obtained through
the co-operation of the local head of the department of public health who introduced
the researchers directly to the local women’s organizations.
4
This particular symptom of “feelings of ants crawling over the skin’’ came originally from
a German symptom list and was later incorporated into a 1950’s Japanese symptom list
5
This information was obtained from the transcript of a lecture given by Shozo Muroga
to the Kyoto Association of Kanpo physicians, April 1984, entitled ^Konenki shoeai
and chi no michi sho.”
6
This ritual is still frequently enacted and requires the person passing into the role of
elder (at aged 60) to be dressed in red, a color associated with childhood.
7
This style of thinking is perhaps inherited from the traditional concept of chi-no-michi.
8
The concept of oketsu, “stale blood” may have always been a medical rather than a folk
term, whereas the idea of “the path of blood” was used historically by both professional
and lay r ople.
9
The term konenki and not heikei was used in the Japanese translation of this question,
10
The first menstruation of a young girl, for example, is celebrated with the consumption
of boiled rice with red beans by family members.
The, Manitoba cross-sectional sample is comprised of 1326 women between the ages
of 45, and„ 55 inclusively
and------who ahave
not had They are part of a
hysterectomy.
sample of 2500 women aged 40-59 used in the Manitoba Project. The cited figures
were supplied by Dr. Patricia Kaufert.

enter into the field of cross-cultural research into life-cycle transitions I think
that they need to be reiterated. Indiscriminate use of symptom reporting lists,
such as the Blatt Menopausal Index, and psychological scales of various kinds,
even those well tried out in Western settings, can lead to erroneous results.
Questionnaires and interview protocols should be designed and used only in
light of close acquaintance with the culture and language in question. Indepth
“meaning" oriented interivews are essential in order to generate subjective
data, the phenomenological account, rich in itself, but also indispensible in
both the construction and interpretation of survey data.
It still remains to establish the range of normal biological variation involved

tn aging in mid-life, and to understand what symptoms, if any. are likely to
occur at the limits of normality and in cases of pathology. In addition, we
must establish how biological variation is linked to the subjective experience
of menopause. It is also important to use rigorous survey research such as
that of McKinlay and McKinlay (1985) in order to clarify which social and cul­
tural variables, if any, are statistically associated with the occurence of
symptomatology or distress at menopause. Survey research can serve to
establish il menopausal women are at greater risk or not for certain diseases
due either to normal biological change or to prescribed therapies. It can also
be used to combat “received wisdom” on the subject of menopause (see Kaufert
this volume). Furthermore, it is essential to use small-sample, intensive inter­
views, firstly as a basis for the design of any surveys, secondly to establish
individual variation within samples, and thirdly to understand how the subjective

experience of menopause is a product of particular cultures and sub-cultures,
of individual biology, and of a personal history.
ACKNOWLEDGEMENTS
I am greatly indebted to Christina Monde for research assistance in the field,
and to Patricia Kaufert for advice, constructive criticism, and along with Penny
Gilbert, invaluable assistance in computer entry and analysis.
The research on which this paper is based was supported by grant no. 41083-0175R-I from the Social Sciences and Humanities Research Council of
Canada.

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7^n8OQI;UCoalanand Japanese Women Living in Hawaii. Journal of Gerontology

Ikemi, Y. et al.
1980
Psychosomatic Mechanism Under Social Changes in Japan. In Biopsychosocial

eu i u‘ / ay’ F’ L°*as, and M. Kusinitz (eds.). A monograph publication
m Health Communications and Biopsychosocial Health of the International
Foundation for Biosocial Development and Human Health
Jaszmann, L. et al.
1969
Perimenopausal Symptoms. Medical Gynecology and Sociology 4: 268 277.
Kaufert, P.
1982
Anthropology and the Menopause: The Development
of a Theoretical I ramework Maturitas 4: 181-193.
Kaufert, P.
1984
Women and their Health in the Middle Years: A Manitoba Project. Social
Science & Medicine 18: 279-281.
Kaufert, P.
in press The Menopause as a Biosocial Event: The Woman’s Perspective.
Kaufert, P. and Syrotuik, J.
1980
Symptom Reporting at the Menopause. Social Science and Medicine 15: 173-

Kirmayer, L.
1984
Culture, Affect and Somatization Transcultural Psychiatric Research Review
21: 159-188.
Kondo, D.
1985
Cukure Me,rt and
in?pan: Some ,ssues in the Study of Self and Other.

Culture, Medicine and Psychiatry 9: 319-328.

90

JITIES OF AGING: JAPANESE MENOPAUSE

45

Lebra, T.
1984
Japanese Women. Honolulu: University of Hawaii Press.
Lightman, S. L., Jacobs, H. S., Maguire, A. K., McGarrick, G., and Jeffcoate, S. L.
1981
Climacteric Flushing: Clinical and Endocrine Response to Infusion of Naloxone.
British Journal of Obstetrics and Gynecology 88: 919.
Lock,M.
1980
East Asian Medicine in Urban Japan: Varieties of Medical Experience. Berkeley:
University of California Press.
Lock,M.
1982
Popular Conceptions of Mental Health in Japan. In Cultural Conceptions of
Mental Health and Therapy. A. J. Marsella and G. M. White (eds.), pp. 215-233.
Dordrecht: D. Reidel.
Lock, M.
in press Plea for Acceptance: School Refusal Syndrome in Japan. Social Science &
Medicine.
Madoka, Yoriko
1982
Shufushokogun. Tokyo: Bunka Shuppan Kyoku.
Maoz, B., Antonovsky, A., Apter, A., Wijsenbeek, H., and Da tan N.
1977
The Perception of Menopause in Five Ethnic Groups in Israel. Acta Obstet
Gyneco Scand Suppl 65: 69-76.
Marsella, A. J., Kinzie, D. and Gordon, P.
1973
Ethnic Variation in the Expression of Depression. Journal of Cross-Cultural
Psychology 4: 435-458.
McKinlay, S. and McKinlay, J.
1985
Health Status and Health Care Utilization by Menopausal Women. Aging, Re­
production and the Climacteric. New York: Plenum Publishing Co.
McKinlay, S. and Jeffreys, M.
1974
The Menopausal Syndrome. British Journal of Preventive Social Medicine 28:
108-155.
Mikkelsen, A. and Holte, A.
1982
Menstrual Coping Style, Social Background, and ‘Climacteric’ Symptoms.
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Mulley, G. and Mitchell, J. R. A.
1976
Menopausal Flushing: Does Estrogen Therapy Make Sense? Lancet i: 1397 —
1399.
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1981
Josei to Kanpo (Women and Kanpd). Osaka: Sogensha.
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1953
' ’e-Grading in Japan. American Anthropologist 55: 373-84.
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Konenki Shogai. Tokyo: Bunken Shupan.
1977
Pharr, S.
1976
The Japanese Woman: Evolving Views of Life and Role. Japan: The Paradox
of Progress. In L. Austin (ed.). New Haven: Yale University Press.
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1974
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in press Productivity, Sexuality and Ideologies of Menopausal Problems in Japan.
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1978
Mind and Madness in Ancient Greece: The Classical Roots of Modern Psychiatry.
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W-'
46

MARGARET LOCK

Steslicke, W. E.
1984
V0T57, N^lX. 4T-52

P°PUiatiOn: A"

Pacific Affair,

Thompson, B„ Hart, S. A., and Dumo, D.
1973 Menopausal Ageand Symptomatology in
a General Practice. Journal of Biosocial
Science 5: 71-82.
Tulandi, T., Samarthji, L., and Kinch, R. A.
1983
Effect of Intravenous Gonidine on Menopausal Flushing
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Voda, A. M.
1981
Climacteric Hot Flash. Maturitas 3: 79-90
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Witt.M'F. a^Blethtn'r

‘b' Men°PiiUSe- Rinsh6i^U’

91

W 9 • 1095-1102.

Menopause, Power, and Heat

10

Menupause,
Power, and Heat

lier medical and perhaps popular culture may have welcomed
“flushes” as evidence of strength, inner harmony, and balance.
The cultural grammar of hot flashes that we discovered in our in­
terviews reveals something quite different from strength and inner
inner
harmony, accustomed as we are to considering menopause as a com­
bination of broken-down central control and the end of production.
When I began to read about menopause and hear what women said in
the interviews, I had a feeling that my analysis of PMS was going to
repeat itself. For example, consider these two accounts of hot flashes
in popular health books:
I was reading a book and suddenly this wave of heat came over me. I
couldn t believe it was happening to me. I rushed to the mirror, and my face
and neck were as red as a beet. It was my face, but I was so shocked and
while I was looking and touching my face, it started to disappear and in a
minute it was all gone. It wasn’t really scary—but it was.4

During
their
birthing
years
women find many rich ways of re­
sisting medical models and devel­
oping alternative ones that reinte­
grate human experience. What
happens during their later years? Is
there an alternative “cultural gram­
mar” of menopause despite its
public image of atrophy and fail­
ure, a grammar that would belie these public images?
I begin with “hot flashes,” the one true “physical” indication spe­
cific to menopause.1 It must be said at the >tart that there is no good
way of separating the purely “physical” aspects of hot flashes from
their social and cultural context. Researchers have found marked var­
iations in the incidence of this experience and in how it is regarded by
women. In studies using comparable data-^athering techniques, 69.2
percent of a sample of Canadian women report having experienced a
hot flash at some time, while only 20 percent of a sample ofJapanese
women report it.2 Women in a Newfoundland fishing village see
bleeding during “the change” as healthy, for it is the final purge or
cleaning out of the body. “Flashes and flushes are caused by ‘too much
or bad blood’ and [are] welcomed as purifiers.”3 Edward Tilt’s mid­
nineteenth-century account of “flushes” (not “flashes,” but “flushes”)
as “compensating discharges” beneficial to 'he body hints that an ear­

I have heard women compare their
sensations to burning steam rising from
the pit of the stomach. These flushes may
be considered as cases ofpathological
blushing.
—Edward Tilt
The Change ofLife in Health
and Disease (1857)

166

I once had one that lasted ten minutes as I was eating
eating lunch
lunch one
one day.
day. All
All
of a sudden my face got suffused with heat and became all screwed up and
twisted while my jaws got stuck so tight I couldn’t eat another bite. When I
looked in the mirror, I hardly recognized myself, I was so twisted and lined
Butjust as unexpectedly as it had come, the whole thing vanished.5

As in the case of premenstrual syndrome, women experiencing
dramatic transformations in physical and emotional states are not able
to recognize themselves. Could it be, I wondered, that women in
menopause are experiencing the rage and anger associated with PMS?
The more I thought about it, the more it seemed that the culprit in­
volved in hot flashes, which appeared to women as something external
taking over their selves, was not anger, but embarrassment. Consider
Coffman’s description of embarrassment: “blushing, fumbling, stut­
tering, an unusually low- or high-pitched voice, quavering speech or
breaking of the voice, sweating, blanching, blinking, tremor of the
hand, hesitating or vacillating movement, absent-mindedness, and
malapropisms.”6 Not all these factors are present in hot flashes as
women describe them, but many key ones are: turning red, sweating
and confusion.
In Coffman’s classic study of what social situations give rise to em­
barrassment, he focused on events in which the self a person intends
to project to others is confronted with another self he or she would
rather not acknowledge or one that is incompatible with the present
situation. “Because of possessing multiple selves the individual may

72

167

■?

Women’s Vantage Point

Menopause, Power, and Heat
If
Wkrkf? eaker’ °r rellable functionary, these other parts of the
self may be felt to be inappropriate (number i), so much so that men­
tioning them brings on empathic embarrassment (number 5).
One woman’s account incorporates almost all these elements:

find he is required both to be present and to not be present on certain
occasions. Embarrassment ensues: the individual finds himself being
torn apart, however gently. Corresponding to the oscillation of his
conduct is the oscillation of his self.”7 Goffman has in mind situations
such as when a top-level executive and a lowly secretary find them­
selves eating across the table in the same cafeteria.
In a recent review of further efforts to explain what kinds of situa­
tions cause embarrassment, Edelmann identifies several types: (1)
Coffman’s description of failure to confirm the self-image; (2) loss of
poise or failure of social skill such as failure to control bodily func­
tions, stumbling, or spilling things; (3) failure of meshing, such as
when a person realizes that another person is more important than she
thought or has a deformity she did not notice; (4) breaches of privacy,
such as having one’s personal space invaded or becoming the center of
attention because of either praise or criticism; and (5) empathic em­
barrassment, as when one is embarrassed on realizing that someone
else is or should be.8
Nearly all these kinds of interactions can be involved in hot flashes.
Many women’s comments relate to failure of meshing, in that their
judgment about a room being too hot does not mesh with other
people’s. “You just ask, ‘Is it warm in here?’ Then all of a sudden you
get real hot, and ‘Uh oh there it is,’just like a wind, it comes and lasts
maybe a minute” (Regina Hooper). “I can sit here and be real chilly
and the next thing you know I’m coming out of my clothes. It’s weird.
And then you get chilly again. You go back to being chilly. Everybody
thinks you’re crazy!” (Martha Gibson).
Many women mentioned that the hot flashes were embarrassing,
without being able to articulate why. “I can remember being very
embarrassed talking with a fellow worker and my face turned very
red. [This was during work?] I was sure that it was written all over
my face what the cause of that redness was and there was nothing for
me to be blushing about, nothing in the conversation that was embar­
rassing, so I remember those little embarrassing episodes. [How were
you feeling?] Nothing, just praying that he didn’t notice it” (Martina
Ostrov). Insight into these remarks can be gained by using the analy­
ses of embarrassment above: hot flashes make you feel like everyone
is looking at you (number 4); they are an outward public sign of an
inner bodily process associated with the uterus and ovaries, which are
supposed to be kept private and concealed (numbers 2 and 4); they
reveal indisputably that one is a woman and a woman of a certain age;
in situations where one is projecting the aspect of the self as colleague,

168

I am active I am busy and thinking. That is when it would happen But if
you are talking to someone eyeball to eyeball and you are trying to convince
OfTomseT
r
S°methl,n8 and >'OU start sweating, they look at you.
O course if I was talking to a doctor they would understand. But you talk
o someone and they say, “Why are you sweating?" (What did you say’] I
think that in the beginning I used to say that I was hot and I can’t take the
heat or I just had a cold. And after a while I would say that 1 was going
through my menopause, damn it. That is what you should say. That shuts
em up fast. Especially a man. [Were they embarrassed?] Yes, well, let them
be embarrassed. I was tired of being embarrassed. [Were you embarrassed?]
Yes, I was embarrassed. (Gladys Sundquist)
Hot flashes and women’s and society’s responses to them are layered
with levels upon levels of intentionality and interpretation, just as the
same muscular contraction of the eyelid can be a twitch, a wink a
parody of a wink, a rehearsal of a parody of a wink, or a fake wink ’
We have internal and external physical sensations (heat, breathlessness
flushing sweating) that are similar to what happens when we are em­
barrassed; on top of that comes the immediate realization that others
are not hot and that they may see all the outward signs of embarrass­
ment and know the inner state-menopause—that means one should
be embarrassed, even if one isn’t.
One aspect of menopause is not elucidated much by the existing
research on embarrassment: the effect of relative power and status on
interaction. In empathic embarrassment, for example, the feelings of
he person experiencing embarrassment because someone else has lost
face or made a mistake may be similar in some ways to the other
persons embarrassment, but he or she has in fact not lost face or made
a mistake. Weinberg gives the example of a medical intern who is
embarrassed when examining a woman patient’s genitals. •» He may
well be embarrassed, but it is not the intern whose privacy is invaded
whose sexual parts are scrutinized and handled by a stranger I supl
pose nearly any emotion can be felt vicariously—I can feel fear or
error when I see someone else in danger-but it is one thing to be
c Person/hteatened and another to be the person witnessing it
This point is significant because of the greater number of occasions
in which women are in subordinate positions that might increase their
propensity to feel embarrassed. Further research could clarify this At

73

169

Women’s l^anta^e Point
They usually hc._ these factors to be independent of social condi­
tions.18 Yet the Belgium study shows higher socioeconomic classes
having fewer hot flashes. Similarly, on broad indicators of nervous and
vasomotor symptoms, the lowest incidence is found among the high­
est class. When this study measured general satisfaction with life and
degree of alienation, it found they also correlated with class: higher
classes are more satisfied with life and experience less alienation than
lower classes. These patterns replicate the clear positive association
between higher levels of general satisfaction with life and measures of
greater health and longevity found in studies in the United States.19
None of this should be surprising. The 1973 Health, Education,
and Welfare study on work in America found that the single strongest
predictors of longevity were not genetic heritage, physical function­
ing, or use of tobacco but simply one’s general satisfaction with work
and overall happiness.20 These might be important predictors for con­
tentment during menopause also, where the process, even though it
certainly has a physiological aspect, is often accompanied by signs of
aging and changes in family composition, both of which are very dif­
ferently interpreted depending on how much security and satisfaction
one experiences in life generally.
To understand better the links between power, subordination, gen­
der, and the underlying cultural grammar of hot flashes, consider that
our imagery of power and control usually use both space and temper­
ature metaphorically. As Lakoff and Johnson have shown,

any rate, it is clear from my interviews and the literature that women
associate hot flashes with situations where they are “nervous or es­
pecially want to make a good impression: “Worse an emotioncharged situation, such as addressing the chairman of the board, may
bring it on. Women often complain that flushes always seem to creep
up at the worst of all possible times. One patient exclaimed It s hard
to appear calm, cool, collected, and sophisticated when suddenly you
turn red and break out in large drops of perspiration all over your face.
It always throws me when it happens.’”11 “Ahda, 46, 1 dress designer,
was in a conference showing her sketches. ‘Suddenly I became a mass
sensation of hot pricklies. No one said a word, I m not even sure: they
noticed, because I was so excited about the designs
I noticed that
1 was having them mostly at work and not so much on the w^ke"
I attributed it to the fact that 1 have a lot more stress at work (Ruth
Carlson). These might be precisely the occasions on which a person
in a more tenuous, subordinate position would have the most to lose
be the most apprehensive about her performance or appearance, and
hence far more likely to feel the “hot flash” of embarrassment.
If women, generally in more subordinate positions than men, are
likely to suffer embarrassment in connection with hot flashes, are
some women more likely to suffer it than others? Although most
studies of the incidence and perception of menopausal symptoms have
involved only the middle class,1’ a few look at variation among
classes. An early study found that working-class women are more
anxious during menopause than after it, while middle-class women
do not change in anxiety significantly as they move beyond meno­
pause 14 A more recent study based on questionnaires to ascertain
women’s attitudes toward menopause found that in general women do
not have an illness orientation toward menopause. But there was var­
iation by occupation in the extent to which women saw menopause
as an illness: professional women had the highest wellness orientation,
secretarial-clerical second, homemakers third, and blue-collar work-

HAVING CONTROL OF FORCE IS UP; BEING SUBJECT TO CONTROL OR FORCE IS
DOWN

I have control over her. I am on top of the situation. He’s in a superior position.
He’s at the height of his power. He’s in the high command. He’s in the upper
echelon. His power rose.21
HIGH STATUS IS UP; LOW STATUS IS DOWN

He has a lofty position. She’ll rise to the top. He’s at the peak of his career.
He’s climbing the ladder. He has little upward mobility. He’s at the bottom of
the social hierarchy. She fell in status.22

Cr Hwver incomplete, these studies still indicate that the direction

And, key for our purposes:

of distress with menopause runs in the same direction as illness and
death rates generally: the farther down the class hierarchy, the more
suffering and perception of illness there are.16 The most sophisticated
study to date was done in Belgium and corroborates this general find­

RATIONAL IS UP, EMOTIONAL IS DOWN

The discussion fell to the emotional level, but I raised it back up to the rational
plane. We put our feelings aside and had a high-level intellectual discussion of
the matter. He couldn’t rise above his emotions.23

ing. Researchers on menopause usually trace hot flashes, w ic t ey
regard as one of the most invariant accompaniments of menopause
directly to physiological factors such as fluctuating estrogen eve s.

I would add to these metaphors a contrast between hot and cold:24

£
171

170

74

i

Tyumen i minuet. 1 uitu

Menopause, Power, and Heat
RA..ONAL CALCULATION IS COLD; EMOTION, ESPECIALLY ANGER,

IOT

tunng plant dcslgned for production

She is calm, cool, and collected. It was a cold, calculating move. He quit
cold turkey. It was a co/d-blooded murder. She shed the cold light of reason
on the matter.
I lost my cool. I blew my (smoke) stack. She had to let off steam. It burns
me up. Her letter was so angry it burned up the paper. She saw red. He was
inflamed; she was incensed. “This kind of anger would flare up and burn the
innocent.”25 She got hot under the collar. I was boiling mad.

• We considered how
case of the breakdecline
• y
anes tai to resP°nd, and the c----••2 consequence is
aeciine, regression, and decav
•
7
themselves exper.ence and describe the pCss
- —,/ women

the way this evem has'been’hewlt'd Sho"’n rCpeatcdly that despite

most women it does not present a Y • eSCr,b^ ln medical terms, for
most women we interviewed BuT^he'
T' Th‘S W3S tFUe for
sponses to menopause is extrcmelv
hf
they eXpress their re­
describe menopause by Saying Z ,gn,flCanp Over and over, women
had any problem, it just stopped kd nOt,hlng;, “N°thmg. Never

Taken together, there is a certain systematicity, as Lakoff and John­
son term it, among these concepts, such that power, height, rational­
ity, and coolness go together on the one hand and lack of power, low
position, emotions, and heat go together on the other. It is fairly ob­
vious where this leaves women experiencing hot flashes during men­
opause, whether the precipitating circumstances, if any, promote em­
barrassment or anger: it leaves them hot and bothered, down and out.
Perhaps the element of subordination in relationships may lead to
hot flashes and embarrassment in situations where subordination
might otherwise lead to anger. Consider the case of a woman whose
severe night sweats and hot flashes were completely stopped for three
weeks after she decided to try taking vitamin E on her own. “A month
later, after three weeks without a flash, Priscilla went to see her doctor
and told him about this miraculous change. He said it was nonsense.
On the spot, that instant, Priscilla had a huge hot flash. 26 No doubt
she did have a huge hot flash, but if she had not been in menopause,
might she not have simply said she was furious at being so patronized?
Or consider another woman who began to sort out the overlapping
layers in her experience of hot flashes:

■•Nothtng. Just stopped andZSb^'°£ Chap^.
years and whershe^ts^Z^her’bThere’S chlldbear«g
just kind of stops”

was like a light going out It'
“You have y!ur pZd for

Morgan). “My grandmother8stonned
thirty-five. From what I can tell ^hat
nothmg” (Leah Rubenstein).
’

“ St°ps” (Julie
She WaS
' Stopped and absolutely

is described as the cXdon^r^enceTf1CUhr. thr°uble dur,ng

» produ„. .he" * o
working-class, sec this in negative terms No ^°men’ middle-class or
mon in medical parlance: ovaries Gil
N
USCd the terms comduction declining, decreasing se > lng tO 5espond’ hormones’ pro­
breakdown of the feedback system Sp1Vlty
the hyPothalamus, and
explain menopause to someone else^uT en asked how thcy would
They are simply saying mensr
rCpCated’ “k st<>Ps ”

It is frustrating because they look at you in amazement. I would just perspire
from the top of my head and it would just drip down over my eyebrows.
All over my face. The rest of my body was dry. It was my head. In hot
weather it is from my head. It drips down into my glasses and so on. It is
miserable. I can remember many occasions. [As someone who hasn t had
any yet, the interviewer wonders what it feels like.] It is anger. I am angry.
I am angry that my body is doing this to me. I think that that is it. I am
angry. I am annoyed. I didn’t mind if I was by myself but it didn t happen as
much when I was by myself. It was when I was more tense or not even
tense, it would happen at the craziest times. (Gladys Sundquist)
In Chapters 3 and 4 I discussed the dominant metaphors in medical
discourse about a woman’s body—as a hierarchical, bureaucratically
organized system under control of the cerebral cortex and a manufac-

tO bMr cblid— "

M om has just gone through if it
^nhart)

Later we will see whether they miss^^011

women see this perioTa^nY in f h ’
control? It is striking that none oS

scribed it in terms like these Onlv
control,” one to say that an eTt™

a

n°W ’S noL

Organization? Do
PartS get out of

C W°men past menopause de­
W°men
USed the te™

doctor had brought the symptoms sh ” C°mpOUnd Prescribed by her
another that surgery had controlled
eXpenenced under control and
ding contrast, a great man of h
bleeding'28 ,n sta8
3ny °f the y°ung women we interviewed.

172

75

I

173

Menopause, Power, and Heat
looking ahead, saw menopause as a time whe
xe’s body is out of
control. “I guess it’s more of a fear, not of po^ menopause, just the
actual process. You’re not really in control of) ur body. That much
is not predictable, that’s what scares me aboi it” (Tania Parrish),
Describing her mother’s reaction to hormones rescribed by a gynecologist, another woman said, “Her body tern -rature is a lot more
controlled (Rachel Lehman). “The unknown o! menopause, that outof-controlness. That’s one of the biggest things we have to change if
the world is going to be sensible and civilized for women to live in.
As with everything else, we feel out of control \ ith that. I can’t imagine not feeling
1
out of control, because biologicr^y it seems that these
things are out of our control, but some of it ir
is a social overlay too”
(Meg O’Hara). “My grandmother almost we : insane, she almost
didn’t make it through menopause at all” (Ma ia Robbins). “Mom
almost went berserk. I don’t mean she really d, but it was hard”
(Ann Morrison). “Watching my mother go thr igh that. I think that
is why she is kind of whacko” (Gina Billingsly)
There are a number of possible reasons fo this discrepancy bctween young women and menopausal women,
could be that young
women perceive their mothers’ behavior as out 'control just because
children generally fear any unusual behavior i their parents. Or it
could be that the younger women have more t) roughly internalized
the medical model of hierarchy and control.29 V cching their mothers
and grandmothers go through menopause, t y share with some
medical practitioners the interpretation of olde vomen’s behavior as
being out of control: “vacillating and often irrat lal.”30 Some of these
descriptions in medical terms deserve quoting 2 ength.

Giving you the bust years of my life! And you can’t do a simnle little
thing for me. Of all the ungrateful . . The tirade went on and on?’
The author citing this example goes on to describe the woman’s
behavior as being “unable to meet even minor problems Mrs M
couldn t even cope with her daughter's untidiness.” I would reply that
her behavior seems entirely appropriate, especially assuming that she

self re°bn|iyearS °f S1SyPhus-like housework and was now finding her­
self rebelling against being a servant for her nearly grown chifdren
But it is not just that Mrs. M. is in trouble. The author worries most
of all about the effect menopausal women have on their children:

Unfortunately, the adolescent’s personality often parallels the
eing ego<*ntric, vacillating and often irrational. However, for the adoles* m

Another medical practitioner agrees that the characteristics of men
themselves U

°rtUnate

rebounding onto women

I cannot help feeling that the
reason so few women being [sic] found in
leading positions is to 1be at
__ 1least
___rpartly explained by the mental unbalance in
these years around the time of the
menOP^USe- R is arou"d the age of 50 that
men take the final Sten
fstep rn
to the top, a step that women with equal intellectual
capacities rarely take. I know that
many aspects are involved, but the climacteric may well be an important one.
33
P 33

Jn sharing the perspective that women in menopause are out of con­
trol, younger women may be unwittingly perpetuating a bias that

Mrs. M., normally a fairly easy-going person, fo d herself waking up
most mornings with frustrated, rebellious feelings. 5 nehow the usual habits of her family had be<xome maddening.
[The author describes a mutually irritating excha. _• between Mrs. M.
and her husband. |
Their daughter rushed through the kitchen sayinj ‘Hi, Mom, ’by
Mom” and grabbed her jacket from the hall closet. S ■ knocked down a
coat and two sweaters in the process.
Now see what you’ve done—come back here ar pick them up,” commanded Mrs. M.
Look Mom, I’m late, I’ll miss the bus!”
Suddenly Mrs. M. felt herself losing all restraint, zords poured out of
her, bitter hateful words.

n protest, resist, or act in the world, they are defined as sick
and weak (just as women with PMS arc).34
Certainly the vast majority of the older women we interviewed saw

menopause in a positive light. It meant pleasure at avoiding whatever
discomfort they felt during periods and relief from the nJZe of
ha'vi'X
Cedlng’ P3dS’ °r tamP°ns: “J wa* pleased that I didn't
have the inconvenience of the menstruation any more I was verv

sexPuaUy°aactive wU men°PaUSe” (Barbara Heath)-

those women

pregnancy This^ r
“ meant dellght tO nOt Suffer the
°f
pregnancy. This last concern was expressed in vivid terms since for
most women in this age group, abortion was illegal during their re
productive years: “I was glad. It was definite that" wouldn't hX to
glad. It

174

76

175

womens damage ruitu

ruu'ti, ana tieal

worry about pregnancy. I had my last child a. .orty-six, and 1 certainly
didn’t want to rack up any record for having a baby at fifty-five or
sixty" (Claudia Williams). Also on the positive side, many women
asserted that menopause had meant no feeling that they had lost their
womanhood. “I sure didn’t feel deprived or that I was losing my
youth; it really didn’t bother me one bit. I always had bad cramps, I
felt relief from the discomfort, I didn’t sit and weep for any lost worn-

to control yo^ own life, to be independent, take care of yourself as you
need to gives you a great power. (Estelle Hoffman, supervisor in a government agency)
[How did you feel after you finished menopause?] It was just like somebody
injected me with strength and energy and enthusiasm. I started doing more
things. Of course my job had bad hours, so I couldn’t do a lot of things.
(Ethel Jacobsen, retired garment trade worker)

anhood” (Estelle Hoffman).
My research assistants who did interviews with older women often
commented that it was difficult to keep them on the subject of the
from menopause to talk
interview because they wanted to iwander
----about many other aspects of their lives . Taken as a whole, it seems
clear that these women do not experience menopause as if it were a
separate episode in life akin to a stay in the hospital for an illness. They
describe it as a part of all the other events happening in
’ their lives: “It
was
another phase
was just part of life. I had reached that stage. That
that had passed. 1 was glad of it. I wasn’t going to have to worry about
it anymore” (Eleanor Pittman). “So all that [trouble in relationships
with men, her son getting arrested many times freedom-riding in
Mississippi] was mixed up with the menopause” (Ethel Jacobsen).
For some, menopause was a milestone that led them to take stoc
of their lives and reach for greater happiness. “I realized that, boy, I vc
reached another milestone. If I was going to do anything I d better
do it. And I’m talking now about our marriage. When I told my hus­
band I wanted a divorce, he couldn’t believe it. He thought 1 had lost
my mind. You can’t help but realize that time is going by, you know.
And I was healthy, so I figured I wasn’t going to drop dead’ (Claudia
Williams). In this case, her husband saw her as having lost her mind;
she saw herself as having changed: “The way I see it I changed and he
didn’t. And I couldn’t understand why he didn’t.” This suggests that
younger women’s perception of their mothers and grandmothers as
being out of control when they went through menopause might not
be matched by those mothers and grandmothers who see themselves
as taking new steps toward independence, strength, and power.
For at least some middle-class and working-class women, reaching
the other side of menopause can mean greater feelings of energy and

She stored up the anger
for twenty-five years,
then she laid it on the table
like a casserole for dinner.

strength.
I tried to work up some nostalgia because you’re supposed to, but I really
didn’t. Because I did not want any more children, what kind of insanity is
this that I would make a big deal about it, I didn’t want any more children. I
got a job. It’s wonderful to have your own life. Money is power. To be a

“I have stolen back
my life,” she said.
“1 have taken possession
of the rain and the sun
and the grasses,” she said.

176

The general cultural ideology of separation of home and work appears in this material when women are embarrassed at having their
menopausal state revealed publicly through hot flashes. As with the
hassle of menstruation, women are asked to do what is nearly impos­
sible: keep secret a part of their selves that they cannot help but carry
into the public realm and that they often wear blatantly on their faces.
Resistance in the case of menopause does not consist, as it does in the
case of menstruation, in turning private spaces to seditious purposes
It consists in the occasions when women publicly name their state,
claiming its right to exist as part of themselves in the public realm,
and embarrassing their male coworkers at the same time, paradoxil
cally producing in the men our cultural emblems of subordination­
heat and emotion.
Resistance to the medical model runs along a generational line. Al­
though many younger women share the medical view that meno­
pausal women are out of control, women going through menopause
by and large do not see it this way, but instead see it as a release of
new energy and potentiality. Some women, as described in this poem,
even manage to harness the anger provoked by their position in soci­
ety to their desire for a different kind of life.

Mid-Point

77

177

1

5

3

Creating the

Drinking-Driver

117

The Fiction and
Drama of Public
Reality

We live in a forest of symbols on the edge of a
jungle of fact. In understanding the world about
us, we human beings are increasingly drawn
into beliefs about that which we cannot experi­
ence or personally recognize. We have beliefs
about “society” that are public in the sense both
of being shared and of being about an aggregate
of events which we do not and cannot experi­
ence personally. A great many people in the
United States have had direct and personal ex­
perience with automobile crashes and colli­
sions These are personal facts. The total
number of automobile fatalities is not. It is a
public fact. No one observes all the automobile
crashes We are dependent upon an organiza­
tion of special investigators for the factual
world of automobile casualties.
Such public facts constitute an important part
of the belief content of persons. Unemployment
is rising or falling; the nation is threatened by or
threatens a foreign nation; the use of hard drugs
accounts for so many deaths per year. The “so­
cial problem” of the automobile accident is only
one of those factual matters compounded out of
a multiplicity of events and transmitted to the
public arena by scientists, medical practitioners,
experts, policymaking officials, and journalists
Wl?° hdP to create what Walter Lippmann
called the pictures in our heads” that operate
to direct and channel much public action
(Lippmann 1922). The public world is made

of Public Reality

into a consistent reality by this process. In the previous chapter I de­
scribed the structure of this reality. Given a cognitive framework, certain
data appear relevant while other material is implicitly ignored as irrele­
vant. Even the “fact” of choice is not a matter of consciousness since the
selectors are not aware of alternatives. The process is experienced as
normal, natural, and self-evident. The factual world appears as un­
problematic, certain, and devoid of ambiguity.
This chapter is concerned with how such finished and authentic facts
are constituted from raw observations. Were a person to rely solely on his
or her personal knowledge in forming a perception of the impact of
alcohol and the automobile on American life, the shape of the problem
and the demands for public action might be different than they are. But
he also relies on public or societal knowledge, thus imputing both under­
standability and consistency to “society” as an organized and perceived
entity. A “crime wave” is not a matter of personal, private experience.
What is happening to “the community” or “society” enters into the
assessment of the person about the public experience. What is “true”
about society is more than a reflection of individual experiences; it is also
a set of beliefs about the aggregated experience of others.
The style of the National Safety Council’s annual compilation of
statistics is indicative of the process. The title Accident Facts contains a
ring of authority; there really is a consistent and valid body of data about
auto accidents. The format of the report is that of tables and figures
expressed in numbers, often to one decimal point or not rounded (1,123
rather than 1,120 or 1,100). What if it were called “Accident Estimates”
or “Accident Guesses”? What if the format were a narrative instead of
tables and figures, if all the numbers were rounded to the nearest tenth?
To imagine such alternative styles is to reflect on that style which does
convey believability and certainty. Such games of imagination make one
conscious of the problem of how fact is created and certified in the public
arena.
It has been typical of much social and political commentary to conceive
of scientific work as standing outside the culture and society of its time.
To be sure, the nature of scientific institutions and the impact of scientific
theories and findings on technology and thereby on social change have
been a major theme in much social analysis. However, the content of
science, its method and its results, has traditionally been viewed, even by
Marxists, as a process and a product that lie outside the deterministic and
historicist conceptions of social scientists, as “base,” not “superstruc­
ture.” The sociology of science has generally avoided the analysis of the
criteria and content, concentrating instead on either the insitutional

frameworks underlying choice of subject matter or the impact of science
as technology (Ben-David 1971). Scientific thought, the “culture” of sci­
ence, has remained outside the sphere of analysis and study.
In recent years this “preferred status” of science has been under great
criticism. Philosophers such as Michael Polanyi have stressed the tacit
presuppositions which seemingly presuppositionless scientific method re­
quires (Polanyi 1962, esp. pt. 2). Thomas Kuhn’s The Structure of Sci­
entific Revolutions has had a wide influence in directing attention to the
historically specific character of paradigmatic assumptions (Kuhn 1962).
Both social science and specifically Weber’s concept of rationality and
rationalization have been examined as ideologies of technicism by the
“critical theorists” working within a neo-Marxist framework (Marcuse
1968; Habermas 1970, 1975). Others have more directly confronted the
empirical study of how science is done, observing the acts of observation,
presentation, and argument, emphasizing the interpretive acts and pre­
suppositions necessary in the process.1
In this chapter I will show that the body of knowledge about drinking
and driving begins as uncertain, inconsistent, and inaccurate. Almost
from the moment of conception, it is fashioned into a public system of
certain and consistent knowledge in ways which heighten its believability
and its dramatic impact. A dramatic image of the drinking-driver as a
person of evil and blame results. It is not my intention to criticize this
process or hold it up to shame. It is my contention that such processes are
necessary to develop policy actions in a world of limited and flawed
knowledge.

Fiction as the Shape of Fact

118

In borrowing'Terms like “fiction” and “drama” from the world of literary
art, I run the risk of seeming to attack the integrity and validity of
“serion ” scientific work, to hold it and its creators forth to ridicule and
shame. Showing up imputed truth as falsity is not my intention, though
that is probably one way of reading it. My message is both subtler and
cruder; fiction and drama are deeply inherent in the way in which knowl­
edge is presented at several levels of its development. Its presentation as
fact is part of the process by which a real world of substance and sig­
nificance is formed. Kenneth Burke, whose writings are a major source
of ideas in this book, distinguishes between semantic and poetic mean­
ings in human discourse. Semantic meanings are close to what is con­
ventionally accepted as scientific; they have a neutral cast about them and
designate what is clear and devoid of emotion. Poetic meanings involve a

1 UUHL IVCUiliy

operated by analogy, treating the confusion of events and data “as if”
they were analogous to already familiar and understood phenomena.2
The materials I will describe and analyze operate on imperfect, in­
consistent and ambiguous material. They produce an illusion of cer­
tainty, clarity, facticity and authority.

perspective; they take an attitude toward an object. They suggest “what
to look for and what to look out for” (Burke 1957, pp. 121—44).
What 1 am engaged in doing in this chapter is part of an analysis of
how semantic meaning is transformed into poetic meaning, into a real
world of significance; how the “facts” about drinking-driving are con­
verted into the public problem of drinking-driving. Such analysis is a
phase of the kind of rhetorical analysis which the logician Perelman refers
to as the “new rhetoric” (Perelman 1963, pp. 134-42). Thus I include the
analysis of scientific documentation and method as itself a form of
rhetoric under study: it is a system of proof and argument which, like
other arguments, attempts to bring about the adherence of an audience
to what is proposed. In seeing the materials of drinking-driving research
artful
as a species of rhetoric and poetry I am underlining the artistic or artful
character in scientific argument and analysis. This perspective is in con­
trast to the imagery implicit and explicit in much conventional wisdom
about knowledge as a source of authoritative pronouncements about the
real world, an imagery of a world of fact as is covered and reported by a
neutral, objective observer.
The Place of Fiction in Scientific Analysis

I
■

.

0,

f

I

t

Ten Million Alcoholics:
The Social History of a Dramatic Fact

tJi

The world of facts, wrote William James, is a “big, buzzing, blooming
confusion.” To analyze it, human beings have frequently made use of
imaginary situations and types. Mathematicians talk about infinity or
negative numbers or zero as if such concepts had tangible references. 1 he
physicists and chemists use concepts of attraction, repulsion, and pres­
sure as if the physical reality were animate. Sociologists reify ideal types
like community, society, and capitalism as if they described an existing
world. The use of fictions as a unifying and directing vocabulary has long
been recognized as part of legal reasoning (Fuller 1967; Levi 1949; Hall
1952, chap. 1). Its use in scientific language has been overlooked.
In ’examining the corpus of research that constitutes the basis of
drinking-driving policies there are two different kinds of fictions to which
I allude. One is conceptual, as illustrated in the examples above. But there
is another form of fiction, the one involved in reaching conclusions as if
the model of a perfect methodology were applicable. Here my treatment
exemplifies the approach to the understanding of legal and other thought
in the much neglected work of the nineteenth-century German philoso­
pher Hans Vaihinger, whose The Philosophy of “As lf“ contains the
basic analytical framework of this chapter (Vaihinger 1924) Vaihinger
recognized the great extent to which science and other forms of reasoning

119

The morning that I sat down to begin a draft of this chapter, I had heard
and seen the introduction to a television news commentary on the prob­
lems of teenage drinking. The announcer began his introduction by say­
ing “It is a fact that there are ten million alcoholics in the United States”
(italics mine). It was said with an air of gravity and in a context which
made the problems of alcohol worthy of serious consideration by the
audience. “Ten million” was used as a “large” number, accentuating
significance and urgency.
The “fact” of ten million alcoholics in the United States appears in
many places at a variety of levels of informed awareness of alcohol issues.
Figure 3 is an advertisement for a group of community hospitals, part of
outreach programs for alcoholics. Taking up a quarter of a page of the
Los Angeles Times, it announces that “There Are More Than 9 Million
Americans Being Destroyed by Alcoholism.” A series of articles on
alcoholism in the Chicago Tribune begins with the statement that more
than nine million Americans are alcoholics (Chicago Tribune, Oct. 1,'
1972, p. 1). A brochure for the Raleigh Hills Hospital refers to “the nine
million estimated alcoholics in the United States” (Raleigh Hills Hospital,
n.d.). Another brochure, this one from the AFL-CIO Community Service
Activif ?s in cooperation with the National Council on Alcoholism, refers
to the alcoholic as “one of an estimated nine million Americans whose
drinking interferes with his daily life” (AFL-CIO, n.d.). In none of these
cases is any doubt expressed about the certainty of the figure claimed,
although one does use the word “estimated.” No sources or bases are
claimed as justifications for statements. It seems to be assumed that the
figures represent a “true” depiction of the magnitude of alcoholism, that
there is nothing questionable about such a magnitude.
Even literature closer to “experts” in the field conveys the same im­
pression of an unproblematic reality. A brochure published by the Na­
tional Council on Alcoholism refers to the “nearly ten million alcoholics
among our nation’s drinkers” (National Council on Alcoholism 1976).
Another brochure aimed at the public and put out by the National

56

i;*

1 hree

d/

What Is The Third Largest Killer In Our Country?

AlcohoHsm—The Lonely Disease
There Are More Than 9 Million Americans
Being Destroyed By Alcoholism
Jim ia 45. nvamod. haa thna
children, owna Ua own boma.
and la acfferlnj from th* kmnBaat dtomaa ta tbn wrrrid, aloty
laote. Ba ha» aaomod tkei havWflato Bn Oat ■panf the
•octal Mtefrva the pes>b*am
thtakar. Aad now ho to onsht
ta the iSuwotrard qrkal of alcobotam. It ha doan't aeek
baip, Jim wiB beOTine more
lonMy. Icwa lima from woric.
tmcomo tom aflktaaL tom ambidoam and mportanoo probtoota with otlaar acnpioyom and
hto bom. Hla proWenae wiB Incmm at homo m ha Inrrvmm
the amount of alcohol wctm •
■7 to drown hto mtoary. Ha
will drink to ataap bettor, drink
to ewcapo and drink bacaiwe ha
to lonely.
Ha wUl aBemato
frienda, JaapardUa hto job and
daatroy hto family ralationahip.
Jim hm three choicea: death,
inaanlty. or treatment.

Not only to alooholtam a lonaly
dtolim. but it to an axpanatra
ton in doilara, paraonal tra«edy.
brokmt homew juvenile delinquenta and dmtroyed mvriapea.
AJoohoHam to no reepecter of
ape. race or aax. Many do not
realiaa that thia diaeaao to treat­
able. The CAREUNIT pro­
pram provider treatment for
aloohoHam in hoapitala. And
moat group health tnauranca
plana corar the treatment of
alcoholism.

DO NOT LET EXCESSIVE'FrTnKING'KILL YOU OR
SOMEONE YOU LOVE...GET HELP TODAY

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Tel. (213) 3*8-0500
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.California 92621 Tel (714) 5294963 (213) 69IA6I3

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4<m.. 2632 Eau Waa
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1141
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Paaadena, California 91107

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Ontario. California 91764 Tai. (714) 9S4-22OI

d,, 5035CoUeeumSltaet,
Vlewpwk CoananonHy H—»IU1
TH. (213) 295-5314
Loa Anplea, California 90016 7

•y Hoapilal, 31872 Pacific Coeat Hwy.
South Coart Community
ria 92677 Tai. (714) 499-1311 Eat. 160
South Laguna, California

SANTA BARBARA
haaoM Hoaptul. J415 Da La Vina Slreei
Santa Barbara. California V3105 Tel (SOSI 682 2 2 i a

>

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Anaheim California 92B0I Tel. (714) 774-1450

■

Figure 3. “What is the Third Largest Killer In Our Country?” Advertise­
ment, Los Angeles Times, June 2, 1975

120

1 he Fiction and Drama
of Public Reality

Institute on Alcohol Abuse and Alcoholism (NIAAA) features a short
article under the byline of the director which states that “the tragic fact
remains that ten million persons in our country today have severe alcohol
problems” (NIAAA 1976, p. 2; italics mine). Netvstveek magazine, in a
cover story about alcoholism, is more qualified in its language and in
referring to “the fact gathered by NIAAA” states that “about one in ten of
the ninety-five million Americans who drink is now either a full-fledged
alcoholic or at least a problem-drinker (defined by NIAAA as one who
drinks enough to cause trouble for himself or society” (Newsweek, April
22, 1974, p. 39).
Where does the fact of the number of alcoholics (and/or “problem
drinkers”) in the United States come from? If NIAAA has gathered the
facts, where are they? The only census of the entire population of the
United States is conducted by the U.S. government, and it does not con­
tain questions about drinking habits. Several academic discussions of
alcohol problems cite as the source for the fact of nine or ten million the
widely distributed compendium of knowledge about alcohol problems,
the NIAAA’s Alcohol and Health—New Knowledge. The first of those
reports was issued in 1971, the second in 1974, the third in 1978. The
first paragraph of the 1974 issue contains this: “The number of Ameri­
cans whose lives alcohol has adversely affected depends on definition;
those under active treatment for alcoholism ... are probably in the upper
hundred of thousands but there may be as many as ten million people
whose drinking has created some problem for themselves or their families'
or Fiends or employers, or with the police, within the past year” (NIAAA
1974, p. 1; italics mine). Even this highly guarded and qualified statement
is not supported by any cited study or documentation.3
The Congressional hearings on the bill from which emerged the
alcohol abuse and alcoholism legislation establishing the NIAAA are one
clue to how the public reality of the magnitude of the alcohol problem
took form and measurement. In his opening remarks the chairman of the
Subcommittee on Public Health and Welfare of the House Committee on
Interstate and Foreign Commerce referred to the “major health problem”
represented by an estimate that “at the very least 5 million Americans, or
one person in 40, can be considered as an alcoholic” (U.S. House of
Representatives 1970, p. 1). By page 257, the “problem” has grown to
eighteen million. There Representative Rogers of Florida argues that
“with eighteen million people affected” there ought to be more funds and
a larger staff devoted to the issue. Where had this new figure come from?
A few minutes earlier the committee had heard testimony from three
experts: the assistant secretary for health and scientific affairs of HEW,

the director of the National Institute of Mental Health (NIMH), and the
acting director of the Division of Alcohol Abuse and Alcoholism. They
were all physicians, and the latter was a leading auth< rity on problems of
alcoholism. The assistant secretary estimated the nur ber of “alcoholics
at between six and seven million, maintaining that there had been an
increase since an earlier study estimating five milhoi 4 He used the pro­
noun tve to support the estimate and turned to the N 4H
AH director for his
is
view The latter introduced the alcohol expert sayin that “he has spent
twenty years in the alcoholism field” and “can speo knowledgeably to
this issue” (U.S. House of Representatives 1970, p. 24).
The remarks of the acting director illustrate how t n casual and slight
changes in nomenclature have unanticipated results t hough he pointed
time,” he referred
out that “the numbers game has been around for so
showing
that “the
to a recently completed study by a social research u
c
problems"
(U.S.
figure is closer to nine million people with alcob<
He
then
contended
House of Representatives 1970, p. 224; italics mine
.iagnosis until late
that since health care professionals do not make
•led.
Thus five mil­
stages of the illness, the number could be safely do
llion
in less than a
lion alcoholics had been supplemented by thirteen
re
was
drawn of a
day. With the addition of material presented, a pi<
a
new
agency
and
problem of great magnitude and hence worthy c
increased funds.
But where did the nine million figure come n i? At the hearings
reference was made to the American Drinking Pt :tices (ADP) study.
This was the first major national survey of drinking ibits, conducted by
the Social Research Group at the School of Public •alth of the Univer­
stty of California, Berkeley, in 1964-65. That surve was concerned with
drinking practices not drinking problems or alcoho..sm (Cahalan, Cisin,
Crossley 1969). However, the same group conducted another national
survey in 1967 specifically devoted to the investigation of drinking prob­
lems, reported in two later publications (Cahalan 1970; Cahalan and
Room 1974). The findings of the 1967 survey appear to be the basis for
the figure of nine million.5
Treating the nine million figure as establishing the fact of nine million
alcoholics involved a fiction in several ways. First, one category of
analysis was substituted for another. The major thrust of the ADP sur­
veys of drinking problems was to shift attention from chronic alcoholism,
with a pattern of addiction, loss of control, and f equency of intoxica­
tion, to a more diffuse and differentiated concept o ‘problem drinking.
The author of Problem Drinkers identified elev n types of drinking
problems including binge drinking, frequent intox ation, job problems,
spouse problems, and others (Cahalan 1970, cha 2). One of them

121

symptomatic drinking—was close to the traditional concept of the
alcoholic, but even this is misleading since various patterns are possible.
The author of Problem Drinkers is quite explicit about the importance
of the definition, describing his own as “rather arbitrary (but statistically
useful)” (Cahalan 1970, p. 2). Alternative plausible definitions, he stated,
yielded percentages of problem drinkers in the sample ranging from three
percent to thirty percent, compared with nine percent reached by the
author. Nor can these figures be used to estimate alcoholics: “comparing
estimates of alcoholics and problem drinkers is a futile exercise, because
the concepts of alcoholism and problem drinking are not very similar, do
not necessarily apply to the same sufferers, and may have quite different
implications for etiology and preventive public health measures and
treatment” (Cahalan 1970, p. 3). Working with a male sample repre­
senting abstainers, Cahalan and Room found that the rate of classically
defined cases of alcoholism was five percent in that population (Cahalan
and Room 1974, p. 32).
A second source of the fictional character of public fact, the as if
quality of certitude and authority, stems from using the material of these
sample surveys as sources of conclusions on prevalence rates. The interest
of the Social Research Group was not in prevalence but in process. Their
focus was on such matters as correlations betwen problems, social back­
grounds of problem drinkers, stability of problem drinking patterns over
time and the environmental elements affecting problem drinking. The
sampl' ised in the Problem Drinkers study was intentionally “light” on
abstainers and light drinkers and “heavy” on heavy drinkers. It was
necessary to weight the figures in order to make statements about the total population.
Further, as is often the case in panel studies, the sample acutally used
was not a gcfod one from which to make projections to the total national
population. A subsample of the original National Drinking Survey sam­
ple was drawn three years later. In the original sample itself it had been
impossible to get approximately 10 percent of those eligible actually
interviewed. The subsample included 66 percent of those interviewed in
stage 1. The sample actually interviewed was 49 percent of the stage 1
interviewees or 45 percent of the total who had been eligible for the
original probablility sample. While for a panel study this is a fairly good
return, that does not diminish its tenuous quality as a base for certainty
about prevalence rates. Such ambiguities and qualifications are ex­
pressed, but then ignored as conclusions are drawn, and forgotten as they
reach other arenas and other transmitters. A fact is not a near-fact,
maybe-fact, or convenient fact. It becomes reality.
Cahalan and his group produced a series of studies whose thrust was to

of Public Reality
<
r

■}

t
•z ■

I
fc
i

+ir<'

||

II
w'■

The “State of the Art” in Drinking-Driving
Research

substitute a more “realistic” view of alcohol problems by distinguishing a
variety of situations and conditions creative of problems associated with
drinking. They were explicit in reading their materials as showing that
problem drinkers were not subsumed in the stereotvoe of the “alcoholic.”
What resulted in the public arena was an increase in alcoholics—the very
category they thought they were limiting.6
What is the point of all this? My concern is less with the “legitimacy”
of the claim that there are or are not nine or ten million alcoholics. I am
interested in the result of this process of expansion and dramatization for
the character of the knowledge transmitted. At each step in the process,
from data to interpretation to transmission, a more factually authorita­
tive world was made. At each level the problem of alcohol grew. To
present a world of indefiniteness, of interpretation and choice, of more or
less and maybe would diminish the significance of the problem in a con­
text of competing demands for attention, money, and commitment.
Let me illustrate the process with an example which indicates how it
heightens drama and creates support. The following is from the House of
Representatives report on the act establishing the NIAAA: “It is clear
that alcohol abuse and alcoholism constitute one of the most serious
health problems in the country.... Various spokesmen for the DHEW
cited estimates showing that there are possibly eighteen million alcoholics
in the United States” (U.S. House of Representatives 1970, p. 3). Such a
statement of magnitudes, although it creates a factual world of order and
certitude, is in another sense a statement of rhetoric a way of saying:
Look, this is an important problem; it deserves attention and priority.
The two games, that of the scholar and that of the public official, the
journalist, or the maker of opinion, are not the same. The game of the
scholar is decontextualized, it is far removed from a setting in which it
must compete with other demands for attention and commitment. The
game of those of us who use knowledge to persuade to action is not the
same. A former alcohol authority, then in a position of governmental^
critical
activity, put it in this fashion: “When I was a professor I was c.
----- —of
the view that alcohol is a drug. Now that I have to get up in public and
speak to audiences, I always refer to alcohol as a (drug” (from my notes
on an informal meeting, 1973).
This two-sided conception of knowledge and reality must be kept in
clear view as I describe the “state of the art” in drinking-driving research.

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Although laws prohibiting drinking and driving came into the statute
books almost simultaneously with the appearance of the automobile on
highways, the systematic study of alcohol and traffic safety is a product
of the past thirty years and especially of the past twenty. It is with the
perfection of chemical-physical means for detecting and measuring the
level of alcohol in the blood that a proliferation of studies was possible
(Hoffman 1973). The first major papers appeared in the late 1930s in the
Journal of the American Medical Association (Heise 1934; Holcomb
1938). Further work was postponed until the end of World War II.
In 1950 the section on alcoholism of the Swedish Karolinska Institute
held the first international conference on alcohol and road safety in Stock­
holm. As was characteristic of the later conferences on this topic, it was
organized by a research institute and focused on alcoholism rather than
the automobile. This first conference was dominated by experimental
studies of the impact of alcohol on physiological motor performance and
on driving under simulated and experimental conditions (International
Conference on Alcohol and Road Traffic 1950, esp. papers by Leonard
Goldberg and coauthors). These and similar studies in the United States
and ( her countries led to the conclusion that alcohol lowered driving
performance and caused “poor driving.”
During the 1960s three kinds of studies occupied the attention of
researchers and policymakers. The most frequent were studies of the
presence of alcohol in the blood of drivers and pedestrians killed or
injured in automobile accidents. The studies of William Haddon and his
associates were especially influential (Haddon and Bradess 1959,
McCarroll^and Haddon 1961).7 This series of studies was the major
source of statements about the significance and magnitude of the
“drinking-driving problem.” While some studies also reported on alcohol
in passenger fatalities and/or pedestrian fatalities, the emphasis has been
on the driver (Haddon and Bradess 1959; Freimuth et al. 1958; McCar­
roll and Haddon 1961; Waller and Turkel 1966). Although other studies
in the 1960s and later also utilize the analysis of blood level alcohol
among fatalities and/or accident participants, they are focused on other
aspects of the problem in addition to alcohol involvement and utilize
other types of evidence as data.8
A second series of studies concentrated on the drinking-driver and
attempted to locate the demographic and other social, cultural, or medi­
cal characteristics which might differentiate him from the general popu­
lation. These utilized police arrest records for driving under the influence

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of alcohol (DUIA) or fatalities data to compare with a general driver
population (Hyman 1968a, b; Cosper and Moz'^sky 1968). A major
concern of these studies was the role of the problem drinker or alcoholic
as a possible source of disproportionately frequent drinking-driving and
auto accidents (Waller 1967, 1968; Waller and Turkel 1966; Popham
1956; Schmidt, Smart, and Popham 1962). Other studies also analyzed
the accident patterns of treated alcoholics (Selzer 1961, 1969; Selzer and
Weiss 1966). It is this group of studies which formed the basis for the
NHTSA assertion that “alcoholics and other problem drinkers... ac­
count for a very large part of the overall problem” (U.S. Dept, of Trans­
portation 1968, p. 1).
It was recognized that most of the studies of drinking-driving lacked
adequate control groups so that the population at risk—those actually
drinking and driving—could not be ascertained. Thus the increased risk
of accident due to alcohol could not be gauged. Roadside surveys of
stopped vehicles were expensive and difficult to conduct. However, a
major roadside survey was conducted in 1964. The Grand Rapids study
became the most significant drinking-driving research of the decade (Borkenstein et al. 1964). That study compared blood alcohol levels. Data was
collected on approximately nine thousand drivers involved in traffic acci­
dents and from approximately eight thousand drivers in cars stopped at
sites and times identical to those of the nine thousand accidents. This
study has been the major source of statements about the magnitude of
alcohol involvement, the degree to which risk is increased by alcohol use
among drivers and the demographic character of drinking-drivers.
The research outlined above helped to draw attention to the magnitude
of the problem. With the establishment of the NHTSA and its Office of
Alcohol Countermeasures in 1968 (absorbed into the Office of Driver
and Pedestrian Programs in 1973), there was a stable source of funds and
programs. The establishment of the N1AAA in 1970 adds additional
impetus to research and enforcement. These groups constitute the chief
basis for research funding, programs, and publicity in the 1970s.
During the ’70s, research on drinking and driving has deepened the
general pattern of the 1960s. The NHTSA launched a program for in­
creased enforcement of drinking-driving laws in thirty-five cities. In
evaluating the laws, a number of roadside surveys were conducted (Voas,
1975; Wolfe 1975; Perrine et al. 1971). In general the studies of the
1970s have paid greater attention to controls and have compared groups,
with less concern for the magnitude of alcohol involvement than for the
nature of the drinking-driver as a causal agent (Perrine et al. 1971, 1974;
Filkins et al. 1970). As part of this orientation there have been more

careful studies of subgroups other than alcoholics. This is especially the
case in relation to age as a factor in auto accidents (Pelz and Schuman
1974; Pelz and Williams 1975; Zylman 1973). Another concern of such
research has been the issue of causal responsibility for accidents involving
alcohol and driving (Sterling-Smith 1975).
The research of the 1970s has given greater attention to other factors
associated with alcohol than was true of the 1960s research. This grow­
ing recognition of the multivariate perspective toward auto accidents and
alcohol, while not typical of drinking-driving researches, is nevertheless
an increasing characteristic of them. It forms a major basis for the devel­
oping critical literature of such researches (Zylman 1968, 1972, 1974,
1975; Hurst 1973; Cameron 1977).

The Isometric Fiction: Blood-Alcohol Levels

123

I will examine several common fictions in the literature of drinking­
driving with two goals in mind: (1) to indicate the fragility, uncertainty,
and inconsistency of data on which policies and pronouncements are
mad and (2) to examine how, even at the level of primary scholarship,
under the pressure of the need for usable knowledge a facade of certain
and ascertained generalization and fact is built up, removed from the
context of ambiguity and doubt.
My intent is not to excoriate either the materials or the authors, but
rather to understand how a world of reality is constructed as the raw
confusion of a real world takes shape in the arena of public actions.
Having presented the dilemmas of being scientific in a world of un­
scientific data, I will turn later to how the conviction of fact is made
dramatic and even more certain.
The object of drinking-driving research is to ascertain the effects of
alcohol on the driver, but how can it be known that a driver is or is not
under the influence of alcohol? Prior to the use of chromatographic
methods for analyzing alcohol content of the blood and the introduction
of the breathalyzer in 1950, both law enforcement agencies and scientists
had to use direct, clinical observations to make that determination. That
meant a morass of uncorroborated reports, individual judgments, and
criteria difficult to apply to each case in the same manner. Both at law
and in the research “laboratory,” the technology of the blood level sam­
ple and the breathalyzer meant a definitive and easily validated measure
of the amount of alcohol in the blood and, consequently, an accentuated
law enforcement and a higher expectancy of convictions (Hoffman 1973;
Holcomb 1938).

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sistent and organized argument toward the solution of significant ques­
tions. Without such fictions it would be difficult or impossible to reach
conclusions which seem to carry conviction, both for the audience to
whom they are addressed and to the investigator. The fiction that re­
quires acceptance in the case of the B.A.L. is its diagnostic isometric
quality, because the grounds for the assumption of that isometrism are
weak in specific cases. The experience of the driver with drinking, of the
drinker with driving, of the person with both all of these influence the
ability of the drinking-driver to conduct himself or herself at the wheel
(Zylman 1968; Hurst 1973; Cameron 1977). The same amount of
alcohol will have less influence on the driving of a healthy, middle-aged
man who is a heavy drinker, has just finished a meal, is generally over­
weight and has been driving for many years than on that of a teenaged
woman of average height and weight with only one year of driving ex­
perience, four hours after her last meal. What this means is that the
B A.L. is not fully isometric with behavior. There is an ever-present error
ber- use some may be truly DUIA with a B.A.L. below the fixed point and
some not truly DUIA at levels above the fixed point. Legislation has
attempted to get around this hurdle by setting the limits so high as to
encompass many people and many situations, but we do not know how
many escape the net at one end or are erroneously included at the other.
Again, researchers and legislators must treat this problem as if it did not
exist in order to determine if a given person or fatality is or is not DUIA.
Fiction is also involved when experimental data are projected onto
natural settings. Police tell me (see chapter 5) that they sometimes “spot’’
drinking-drivers because they are driving too slowly or too “perfectly”
for the conditions, displaying an anxiety resulting from the realization
that they are DUIA and that there is a risk of accident or arrest. Such risk
was not^part of the design of the experiment; we do not know how
people drive after drinking if they think there is danger of accident and
arrest. Such studies have not been done, again because the frame of
relevance of the experimenters excluded them. The projection of experi­
mental data onto natural settings requires the fiction of isomorphism—
that people behave the same under awareness of conditions as they would
under natural conditions.
What the fiction of isometrism enables the investigator to do is illus­
trated in this excerpt from a recent article on roadside surveys:

All research on drinking-driving of the past thirty years has used the
blood level count as the indication of the fact that a person is or is not
under the influence of alcohol. All legislation in the United States defines
being under the influence in terms of a blood level count (referred to from
now on as B.A.L.—blood-alcohol level). However, the object of concern
is not alcohol in the blood but the effect of alcohol on driving ability. In
other words, a physiological-chemical condition is transformed into a
behavioral one. B.A.L. is considered isometric, similar in measure, to the
psychic state of “being influenced.” This imaginary construction is my
first fiction.
Some description of the B.A.L. is necessary to provide setting. Briefly,
alcohol is metabolized in the human body at a constant rate in the liver.
The liver, even in a healthy state, can convert only so much alcohol into
fat per time unit. The remaining alcohol is deposited in the blood prior to
metabolism. This amount can be ascertained by present chemical proce­
dures and expressed as a percentage. In the United States, it is stated in
terms of milligrams of alcohol per milliliters of blood. Thus a bloodalcohol level of ten hundredths of one percent indicates that each 100
milliliters,of blood contains 100 milligrams of alcohol. A B.A.L. of .10
percent or .10 is the most common legal definition in the United States
of being under the influence of alcohol.9
The breathalyzer is an instrument for determining the B.A.L. in­
directly, through a fixed ratio between alcohol in the breath and alcohol
in the lungs. Urinalysis is a third method but not widely used in either
research or law enforcement. Although not supplanting direct blood
analysis, the breathalyzer has become the most widely used system for
determining DUIA by researchers and police agencies.
I too am adopting a fiction; that scientific analysis of blood and breath
gives a “true” measure of the B.A.L. I treat such test scores as if such
methods yield one hundred percent accuracy one hundred percent of the
time. I do so because I lack the knowledge to assess adequately the theory
or experimental data on which they rest. However, I do recognize that
the matter is by no means a closed question. The breathalyzer results are
particularly under debate. The uniformity of the ratio between alcohol in
the breath and alcohol in the blood is in doubt (see the papers by Curry,
Dubowski, Levett and Karras, Robinson, and especially Harger in Israelstam and Lambert 1975). This fiction is in general useage. The breath­
alyzer is the common tool of roadside surveys, and the B.A.L. the
operational definer of DUIA (Borkenstein et al. 1964; Voas 1975; Wolfe
1975>.
Such fictions are essential if raw data are to be converted into con-

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Almost half of the drivers interviewed said that they had drunk
alcoholic beverages sometime on the day of the interview ... and 22.6
percent registered a BAC [blood-alcohol count] of 0.02 percent.
About one-eighth of the drivers had been drinking to an extent great

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u to impair their driving performance—0.05 percent BAG or
* G considered illegal in
higher—and one out of twenty was at a "BAG
every state (0.10 percent or higher). [Wolfe 1975, p. 46; italics mine]
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The italicized sentence illustrates how fiction has become converted
into fact. No direct evidence is gathered about driving performance. The
inference is drawn that each case with a BAG above .05 involved drunk­
enness and driving impairment and each case below .05 percent did not.
What began as conjecture, as generalization, as a matter of practical
application has been turned into a consistent and certain judgment. The
B.A.L. has been taken as the icon, the model, for the event—impaired
driving.
Once again, this is not a critique of imperfect method. 1 understand
that it is not possible to accomplish research of this nature otherwise.
Research findings are embedded in the assumptions that enable con­
clusions to be drawn and generalizations to be made. To understand and
recognize the blurred and ambiguous character of “fact” in this context is
not the same as presenting a definitive and certain asertion of reliable
and valid knowledge about the amount or frequency of impaired driving.
What 1 am asserting is the usage of the B.A.L. as a measure of impaired
driving as created knowledge—as knowledge which has required the
application of fictional techniques. The B.A.L. has been treated as if it
were impaired driving. Even as I write this I treat the above quotation
from a research document as if it, too, were isomorphic—similar, in
shape, to other DUIA studies. It is not that such usages are poor method.
Rather, it is the realization that fiction has been essential to the creation
of an orderly world of fact.

The Universalistic Fiction: Collecting Data

You, my reader, may be impatient with me at this point. I am demanding
too much of science: a complete census of all cases of alcohol impaired
and unimpaired driving. That is not my intent. My aim is to understand
how knowledge is possible and how it assumes different forms in differ­
ent contexts.
Yet the impossiblility of studying the entire universe of relevant acts
directly has provided the researcher in human behavior with one of the
most troubling issues in social science: sampling. If to study the whole
can be done only by studying the part, how is it possible to make asser­
tions about the whole? The sampling answer has been that the scientist
must be able to assume that the part is like the whole, that it repre­
sents the universe which is the object of concern. The part is taken—to

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use the literary term—as a synecdoche, a representation. How to obtain
valid representations of a universe has been a major concern of research
methods in sociological study.
Drinking-driving research is no exception. Here it is my assertion that
the difficulties and limitations in collecting data representing the universe
of drinking-driving events are glossed over by the fiction that the data
collected are a “true” sample of the universe under examination. This is
the second fiction studied here.
To begin with, what is to be studied? What are automobile crashes and
how can information be collected about them? The complete universe of
auto crashes would encompass everything from “fender-benders” to the
mass carnage of multiple fatalities. Official reporting of accidents as if
report and reality were fused—for example, in Accident Facts the number
of accidents caused by alcohol—or in official statements poses great
problems to the investigator.10
Another use of the synecdoche is in the fiction that arrests for
drink.ng-driving indicate the extent or nature of the event of drinking­
driving or characteristics of drinking-drivers. The variation in the manner
of DUIA arrests from one jurisdiction to another and the diversity of
prosecution policies in forming charges and seeking convictions are dis­
cussed and analyzed in detail in chapter 5. When, where, and whom
officers arrest are as much a function of policy and discretion as of the
event being accorded attention. Studies which make use of arrests and
arrest records to gain knowledge about the phenomenon of drinking­
driving are then operating as if this unrepresentative sample could be
considered an appropriate representation.
These considerations are recognized by many who create the state of
the art in drinking-driving research. For these and other reasons the great
bulk and ’backbone of drinking-driver studies has been done with data
reported on drivers and/or pedestrians who have been killed in auto­
mobile accidents. Ironically, dead men do tell more tales than live ones.
They offer less resistance to the use of blood-alcohol-level analysis, and
their accidents are almost always dutifully reported to authorities. Sadly,
the fact of death, even in this era of biological continuation of “life,”
remains the supreme example of a factual condition among secular
societies.
Here then is at last a land of certainty—where fact rules and fiction is
relegated to the bookshelves? Of course not. To develop knowledge
about the significance of alcohol in traffic fatalities the data derived from
drivers must be treated as if they too represented a universe of drinking­
driving events. At least three such fictions are involved here: (1) that
being killed as a result of auto crash is a clearly ascertained event; (2) that

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Still another element in the complex naming of events as auto casual­
ties is the possibility of natural death, occurring before or during auto
crashes. The only study I know of to discuss this question held that thirty
percent of the automobile deaths were also attributed to natural causes
(Gerber et al. 1966). Again, my point is not that the use of “automobile
fatality” is unwarranted but that it can be used only as a fiction. Reality is
too ambiguous, uncertain, and inconsistent to correspond to categories
which render it unambiguous, certain, and consistent. Data are not col­
lected solely for research purposes; “automobile fatality” is not a natural
category but a human one. We can only presume that auto deaths in­
volving alcohol are as likely to be nondeliberative as are nonalcohol ones.

the test of B.A.L. is equally performed on all cases of fatality or at least
that limits do not affect judgments and conclusions; and (3) that all
drivers are equally likely to be killed in similar circumstances of crash.

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In gathering data on B.A.L. and auto deaths in San Diego County (de­
scribed in chapter 6) I became aware of several matters. The coroner’s
office, the source of the data, considered any death reported to them as
due to automobile crash to be an “automobile fatality.” This included at
least one death occurring two years after the initial accident, several
occurring following accidents in other states, and even one in another
country (Mexico being a half-hour away from San Diego). The location
of the death, rather than the crash, was the criterion for the coroner, since
the jurisdiction of that office is one of geography and not causal agents.
When I asked the research unit of the NHTSA for the criterion they used
in defining an auto casualty, the research personnel to whom I talked did
not know for how long after a crash a death was presumed to be an auto
fatality. We then discussed the issue with personnel closer to the actual
coding of data and were told that they used one year as the cutoff point.
European data reported by the United Nations use, according to a foot­
note, a period of no more than thirty days, although ten countries re­
porting use different time periods varying from scene of accident to one
year afterward (United Nations 1974, pp. 86, 88). Whatever automobile
fatalities are, they do not exist in pristine state, unrelated to the inter­
action of event with observer and the linguistic categories of the nomen­
clature used to clothe them.
In addition, attributing a fatality to the automobile requires an artful
inference. Thus the coroner’s sheets reporting auto deaths occasionally
include statements that the body was found in or next to an auto, and,
given the damaged character of the car, that the death was presumed to
be due to auto crash. Such statements reveal the inferential and selective
nature of the category. A number of studies have raised the distinct
possibility that some auto accidents are results of suicidal intentions (S.
Brown 1968; Tabachnik et al. 1973; D. Phillips 1977). Deliberate suicide
and the less deliberate forms of intended “carelessness” are not consid­
ered in the practical act of naming events as automobile casualties, but
they do introduce an ambiguity in coding or categorizing that is ignored
or neglected as the concept of “automobile fatality” is constructed.
Drinking-driving studies are complicated by the fact that the use of
alcohol in connection with deliberate or semideliberate suicide is a dis­
tinct possibility.

The Fiction of the Adequate Sample

126

The R A.L. is used to determine the presence or absence of alcohol and
the existence of DUIA, but only a portion of drivers are tested. Many
reports, however, treat the tested population as if it is a representation of
the total or the untested is similar to the tested, when there is no indica­
tion that this is so.
Reporting agencies, such as hospitals and morgues, habitually perform
blood alcohol analysis only on corpses. Analysis of the blood is not
reliable four to six hours after death—or the last drink. Even when death
occurs within four to six hours, the possibility that a B.A.L. will be taken
lessens with time. Thus B.A.L. is most likely to be taken where death
occurs at time of accident or shortly thereafter. These are limitations to*
perfect research conditions. As a result, a portion of drivers who die as a
result of automobile crashes are not tested. This is a significant limitation
in research that attempts to assess the frequency of DUIA in automobile
crashes resulting in death. Not only is it the case that the DUIA driver
who has not been killed may not be tested but the driver who is killed
may not be tested.
How large is the untested group? Cameron, in her 1977 review of
DUIA studies, lists twenty-three U.S. traffic driver fatalities studies in
which the percentage of drivers DUIA was reported (Cameron 1977, p.
133).11 In sixteen of the studies, either only the number tested is reported
and used as the base for percentages or, as in five studies, there is no
information on the number untested although the base for calculating
percentage is slightly less than the total number of accidents. In seven
studies, the number of accidents and the number of fatalities tested and
untested are all reported. In two of these latter cases, the total number of
tested cases was less than fifty (Waller and Turkel 1966; Boston Univer­
sity Law-Medicine Institute 1969). In other words, in most cases the

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representative nature of the tested as synecdoche of the total universe
of auto fatalities is assumed. In the two cases just mentioned, a small
number is taken as representation of a larger array of deaths over a
longer period.
In the five studies which report on both tested and untested fatalities,
the highest percentage of total fatalities tested was 72 percent (Davis
1974) . The lowest was 32 percent (Baker et al 1971). The others were 68
percent, 63 percent, and 35 percent (Baker and Spitz 1970; McBay et al.
1974; Filkins and Carlson 1973). In none of these studies, where the
discrepancy between the total number of fatalities and the number on
whom B.A.L. were collected was reported, is there less than 28 percent
for whom a B.A.L. is unavailable. In my analysis of seventeen years of
coroner’s reports in San Diego County, I found that among the 2,616
driver fatalities reported by the coroner, B.A.L. scores were reported for
1,991 or 76 percent. In no one year was the percentage higher than 84
percent.
I will examine the presentation of three different studies of fatalities
and show how they handled the problems posed by the insufficiency of
data. In two of these, the population actually studied is presumed to be
synecdochal to a larger universe. In the third, the issue is clearly rec­
ognized and retained. All of these are major studies in the field, cited
often and utilized by Cameron in her review.
In a study reported to the NHTSA by the Highway Safety Research
Institute of the University of Michigan, the authors summarize findings of
a comparison between fatalities, alcoholics, arrested and convicted
DUIAs, and other court-related offenders (Filkins et al. 1970). Consider­
able analysis of the driver fatalities is reported. The opening page (p. 5)
refers to data from this study which “indicate that alcohol is a charac­
teristic feature in many fatal accidents. Forty-five percent of the total
population of 616 fatalities had blood alcohol levels of 0.10 or above”
(italics mine). The next paragraph informs the reader that fifty-five per­
cent of the 309 drivers were legally impaired. There is no mention of the
total population of traffic fatalities or of driver fatalities. The impression
is left that the universe of fatalities has been studied.12 This is hard to
believe in the light of all else known about studying B.A.L. of traffic
fatalities. No treatment of this issue is presented.
A more complex fiction resulting from the sampling problem is found
in a study of fatalities concerned with the driver fatality judged to be
“most responsible” in different types of fatal accidents (Sterling-Smith
1975) . The author tells the reader that “only six cases collected over the
thirty-month period were found to have insufficient data” (p. 94). Two

pages later, the reader is informed that BACs were available only for 37
percent of the driver fatalities. Presence of alcohol and the incidence of
DUIA were clinically evaluated for the remaining 63 percent (pp. 95-96).
Yet the summary states “122 (46 percent) of the operators [were] in­
fluenced to some degree by alcohol” (p. 105; italics mine). Here even
sketchier (clinical) determinations of DUIA are taken as a “true”
sample of the fatality cases.
The disposition to present qualified, imperfect data as if it were certain
is perhaps inherent in the aesthetic needs for clarity and succinctness.
Haddon and Bradess, in one of the earliest major studies, were acutely
aware of the tested-untested issue (Haddon and Bradess 1959). They
discuss the elements affecting testing in considerable detail. They made a
decision, based on medical understanding of blood alcohol levels, to
resti.vt their sample of drivers killed in single-vehicle accidents to those
who had not survived the crash beyond four hours. Fortunately, as they
remarked, the medical examiner of Westchester County (where the study
was conducted) had a great interest in the alcohol-driving problem, and
the authors had B.A.L. data on 95 percent of the 87 such fatalities; the
summary reports that “postmortem blood levels were studied in a group
of 83 drivers” of single-vehicle crashes. But their tabular data (p. 210)
indicate that there were 117 single-vehicle-crash driver fatalities; thus
their sample is only 70 percent of that universe. Yet when Haddon,
Suchman, and Klein introduce the paper in their classic text, Accident
Research, they state that the results of the study demonstrate “that
alcohol was present in high concentrations in 70 percent of the drivers
killed in single-vehicle automotive accidents” (Haddon, Suchman, Klein
1964, p. 208; italics mine).
What occurs in the fiction of universal representation is that the results
are tested tk if they were either the total universe discussed or as if they
were an adequate representation. The flaws and ambiguities contained in
the data are “dropped out” in the interests of clarity and certainty. Facts
take on a hard, undeniable form and fit into a world of scientific accuracy
and validity. Even though the researchers are aware of the doubts, im­
perfections, and limitations in the data, the results are stated as undeni­
able fact, as the authority of the external world—what Herbert Blumer
refers to as “obdurate facts” (Blumer 1969).

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The Fiction of Association:
Alcohol Involvement

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The 1968 Alcohol and Highway Safety Report states, in its opening
sentence, that “the use of alcohol leads to some 25,000 deaths. . .each
year” (U.S. Congress 1968, p. 1; italics mine). Studies of alcohol and
driving are often much more cautious and refer to alcohol as the largest
single factor involved in fatal crashes” (Perrine 1970, p. 43) or a
“characteristic feature in many fatal accidents” (Filkins et al. 1970, p. 5).
Nevertheless, as Zylman has pointed out, the number of driver fatalities
with B.A.L. above the legal maximum has been emphasized to reach
conclusions of a causal nature (Zylman 1974). The sampling difficulties
resulting from limits in testing, the high percentage of high B.A.L. in
single-vehicle crashes, and the lack of clear evidence from many studies of
who is “at fault” make such conclusions dangerous. All fatal accidents in
which the driver’s B.A.L. is one of legal impairment are not cases in
which the driver can be presumed to have been responsible for the acci­
dent.13 Nor are all, or even most, cases of fatality to alcohol using drivers
instances involving more than a single vehicle. Although studies of
alcohol-involved accidents find approximately two-thirds of them are
single-vehicle ones, such studies of responsibility as have been done study
only multiple-vehicle crashes. Thus they substitute an insurance oriented
view of responsibility for a research oriented one of “cause” (SterlingSmith 1975; Cameron 1977, pp. 179ff).
Studies of alcohol and driving, however, frequently present alcohol as
if it were the only, or the major, cause in drinking-driver accidents. Such
“single-cause” explanations are crucial to the focus on alcohol as a target
of social action. Much of the work on drinking-driving has been con­
cerned to delineate the “fact” that alcohol increases the risk of accident in
driving. In focusing almost exclusively on the factor of alcohol, such
work necessarily turns one element in a complex pattern of “causes into
a single major factor. Zylman, who has been most vocal in criticizing
such studies, puts it succinctly: “People experienced in the study of social
problems will not be surprised to hear that single-cause explanations and
simple one-target programs are inadequate. The slogan that ‘alcohol
causes accidents’ is just as misleading as the counterassertion that it does
not. To conclude that nothing can be done, however, violates our histori­
cal tradition” (Zylman 1968, p. 231).
The issues can be illustrated by the analysis of age as an element in
automobile accidents and fatalities. The disproportionately high fre­
quency of young (16—25) and old (70 and older) drivers among accident

128

victims and fatalities is striking (Carlson 1973; Harrington 1972; Pclz
and Schuman 1974; Zylman 1973). Higher B.A.L. is more frequently
found in both accidents and fatalities among the middle-aged group
(26—69), however. In understanding the role of alcohol in accidents and
deaths in light of these age differences it is necessary to consider a variety
of elements. Alcohol is associated with other characteristics or variables,
so that its presence may lead to false inferences of its causative or
monocausative effects. Thus the overinvolvement of young people in
auto fatalities was seen in Carlson’s study of age, exposure, and alcohol
to be a function of the greater nighttime driving of youth as contrasted to
older persons. Night driving increases the risks of driving and the possi­
bility of drinking in the general population of drivers (Carlson 1973). In
another set of studies, by Pelz and Schuman, the authors conclude that
alienated and socially hostile youth are more prone to accident and also
to drinking. Unalienated youth who drink and drive appear less vulnera­
ble to fatality (Pelz and Schuman 1974).
This is not to maintain that alcohol is not an element, but that it often
appears in association with other and necessary conditions. Cameron
(1977, pp. 158-60) points out that although there are a higher percent­
age of DUIA fatalities among 25-69-year-olds than the young (16—25),
the latter group accounts for more such fatalities than does the former.
This is a result of the greater proportiori'of fatalities among the young
than the old.
Sometimes alcohol becomes significant as it accentuates or catalyzes
some other element in the pattern of driving. Zylman (1973) places great ‘
emphasis on the inexperience of the young in either drinking or driving.
Thus at the same B.A.L., the “new” drinking-driver is affected more than
is the “older” one (Carpenter, quoted in Zylman 1973, p. 220). Carlson
(1973) suggests that the 18—19-year-old is involved in learning to drink
and drive while the older driver has passed through this training experi­
ence. Many conditions are thus involved. The time of day (3—6 a.m.) in
which the highest percentage of drivers with high B.A.L. have been found
is also the “safest” period in terms of death and accident; the traffic
density is then at its lowest.
The structure of presentation of studies makes it difficult to examine
the role of alcohol and yet retain the multiple causal model. Borkenstein
et al. (1964) conducted what has been the major roadside control study
of the drinking-driver literature. It has been very frequently cited as
evidence for the significant effect of alcohol in increasing the risk of
accident. The authors point out, in the opening summary of the study,
that “the summary of results presented is a convenience... for brevity

of Public Reality

the qualifications which must be made in the interpretation of this kind of
data are omitted” (p. xvii). Even so, the text c- ains many summative
sentences like, “Drivers with positive alcohol . els caused more than
one-fifth of all the accidents observed in this study, while constituting
about 11 percent of the driving population” (p. 169). Once alcohol has
been singled out as the factor to be studied, the language of assertion and
summation makes fictional creation possible and probable.
This is the third of the fictions, association is converted into causation.
The discovery that alcohol is associated with an auto accident is turned
into alcohol as the cause of accident. The rapidity with which alcohol
is perceived as villain exemplifies the moral character of factual con­
struction. Without that moral direction the transformation of data into
policy directions is difficult. Multicausality weakens the capacity and
purposefulness which make control seem possible. The assumption that
alcohol isahvays at fault strengthens the certainty that there is a credible
body of knowledge to support what seems only sensible.
An alternative method might well utilize a model of multivariate
analysis (Hirschi and Selvin 1967). Such a model would presuppose a
com plex interaction of variables. It would assess the way in which each
variable, such as time of day, age, road, age of a romobile, etc., combines
with every other variable; the addition each m; es to predictability (the
amount of the variance); and the amount pr iicted by each variable
separately and together. Such results, however may not be very useful
because they are capable of neither persuading | ople to a specific action
nor framing policies. “The major purpose of ie study of accidents,”
wrote Borkenstein et al. (1964) in their classic, >tudy, “is eventually to
develop methods of control” (p. 4).
Knowledge and Authority:
The Ring of Conviction

fytecka (1969) distinIn The New Rhetoric, Perelman and Olbrecl
guish between convincing and persuading (pp. '6—31). Both procedures
are concerned with gaining adherence to an argument. Convincing is a
process in which the validity of the argument is claimed for every rational
human being, a universal audience. Persuasio- is argumentation that
claims validity for a particular audience. Logi
id science are methods
that purport to establish universal truths, one^ vhat cannot be rendered
matters of opinion. All rational people must reach the same conclusions.
Persuasion, on the other hand, is in the realm of the probable, the
opined: “To the person concerned with results, persuading surpasses

129

conviction, since conviction is merely the first stage in progression to­
ward action.... On the other hand, to someone concerned with the
rational character of adherence to an argument, convincing is more cru­
cial than persuading” (p. 27).
The distinction implies divergent audiences, as Perelman and
Olbrechts-Tytecka point out. Convincing involves a form of argument in
which agreement is a matter of the compelling character of reason, a
timeless and absolute validity. The audience such argument assumes, as
in mathematics, logic, or science, is a universal one, because it claims to
be “valid for the reason of every man” (pp. 3 Iff). Persuasion is always an
act ' ..suming a special audience and identifying the character and posi­
tion of the arguers. Where conviction demands objectivity, argument by
persuasion demands impartiality but assumes that the persuader is also
an actor in the events; thus he or she has a commitment: “For the very
reason that argumentation aims at justifying choices, it cannot provide
justifications that would tend to show that there is no choice, but that
only one solution is open to those examining the problem” (p. 62).
The New Rhetoric teaches us to stress the importance of different
contexts in assessing how data and information are used. The scientist
presenting work to a scientific audience is not necessarily impelled to­
ward the same kinds of significance as one attempting to find a solution
to practical problems. The politician and the practitioner in turn operate
within circles of conflict about action, of competing interests and goals,
of differing values and beliefs. In the social history of facts about
alcoholism described earlier, congressmen and bureaucrats are arguing'
for the importance and significance of the alcoholism issue against others
for whom it has less salience and value. A set of already fixed beliefs
about the phenomenon involve investments of emotion, time, aspira­
tions, ancbmoney.
The knowledge of the scientist is knowledge in the abstract. Pre­
supposing a universal audience, it need make little effort to wrest practi­
cal significance from data or conclusions. It need make no concessions
toward persuasion. The knowledge of the practitioner, the political of­
ficial, the bureaucrat, the journalist is knowledge-in-use. If not governed
by such knowledge, we are at least influenced by its consequences. The
political official and former professor quoted earlier who came to refer to
alcohol as a drug, distinguished between how he had used knowledge in
the academic context and how he had used it in the political context.
These considerations of context are salient in understanding the trans­
formations I describe below.
The distinction between conviction and persuasion which Perelman

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and Olbrechts-Tytecka draw fails to delineate how one is used in the
other. My analysis of the “state of the art” in drinking-driving research
has shown how persuasion enters into conviction when research is con­
sidered as if it too were a form of argument. Persuasion, however, makes
use of an agreed upon “reality” in attempting to persuade. In the dis­
cussions about alcoholism, the persuader attempts to place some aspects
of the discussion beyond choice. He refers to “facts as if they compelled
a universal audience to agree, as a basis for further choices about action
to be taken toward alcoholism.
It is important to recognize that much of the public discussion of
alcohol issues and of drinking-driving takes place in an atmosphere of
assumed conflict in which one party is arguing against another, attempt­
ing to induce somebody to do something he is presumed not willing to
do. The character of public dialogue is debate and not demonstration.
The aim is less one of assent to propositions in the abstract than it is one
of action and commitment.
In the remaining part of this chapter I will examine the public arena of
knowledge-in-use: the “facts” of drinking-driving. Two aspects of the use
of knowledge are emphasized. The first is the continuing transformation
of partial, qualified, and fragile knowledge into certain and consistent
fact. The second is the transformation of abstract fact into facts of dra­
matic significance, implying attitudes and commitments, arousing images
and values, having poetic rather than semantic meaning. Both aspects are
important in developing an image or persona of the drinking-driver that
conveys the sense of a cognitive and a moral order in which causal and
political responsibility can be fixed and determined.
The Dramatic Significance of Fact

i

What I am contending is that the apparatus of public media, official
authorities, and professional practitioners acts to build up a sense of an
orderly world in connection with drinking-driving. That world is both
cognitively and morally definitive. It presents an image of authoritative
and unimpeachable fact about drinking-driving which is grounded in
knowledge gained by the scientific method, an image of a moral order in
which the act of drinking-driving is condemned and the campaign against
drinking-driving is a struggle to convince sinners to be virtuous—an
image that claims authority. An institutional order of power is projected
as one of consensus and legitimacy, as if it were compelling and beyond
argument among rational people.

130

To write about the drinking-driver materials as dramatic is to treat
public events as if they are only dramas rather than real events. I am
treating the public presentation of drinking-driving as a drama in three
senses. These emphasize the “as if” or fictional character of this form of
public action (Burke 1968), and its mood of excitement and conflict—its
dramatic value. The dramaturgical is only one way of organizing
experience—in Coffman’s term, one mode of framing (Coffman 1974,
chap. 1' lam not treating it as an alternative but as an addition to a
positivist analysis of action as means to end. It heightens less often rec­
ognized aspects of a complex and multifaceted situation.
The first sense in which a public action is dramatic is that, in keeping
with the metaphor of theater, it is a performance. As performance it is
not to be understood as a response to an objective, detached “reality.” As
with a staged event, the observer utilizes conventions which enable him
or her to sustain an illusion of an orderly world. The performer acts as if
this is a true and actual event, and the observer suspends disbelief. The
actor on the stage is indeed the character represented: a middle-aged
Italian woman singing on a stage in New York City in 1977 is for two
hours Madame Butterfly, a young Japanese beauty in 1868. The per­
formance is a fiction, an illusion of reality.14
The second sense in which a public action is dramatic is that it is
staged; it is a construction of the performers as authors. Plays are written
and planned. The theatre de verite attempts to break with the illusionist
nature of staged performances but runs the risk of being dull. The “make-believe” character of the dramatic is not unexpected. Authors
suppress the circumlocutions, the misperceptions, the uncertainties and
ambiguities of daily conversation, the pauses and lengthy interludes of
natural action. The result is a more concentrated and unambiguous
presentation’Sf experience: “A fundamental transcription practice of ‘disclosive compensation’ is sustained throughout the interaction.... Eaves­
droppers are thus destined to hear fragments of meaningful talk, not
streams of it.... The theater, however, stages interaction systematically
designed to be exposed to large audiences that can only be expected to
have very general knowledge in common with the play characters per­
forming this interaction” (Goffman 1974, p. 142).
The third sense in which events are dramatic is that they take on a
greater excitement and interest. When people speak of “dramatizing” a
problem or idea, the connotation is that of compressing into a visible act
or experience a complex of ideas or events. Elections dramatize the con­
ception of participatory democracy. A boxing match between citizens of

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two different nations, races, or ethnic groups can dramatize intergroup
conflict. The experience is rendered in such a way as to heighten emo­
tional involvement and make complex ideas simpler.
I am asserting that as the raw data of knowledge about drinking­
driving are processed through fictions of scientific research, a step is
taken to convert ambiguity into certainty. That process is carried forward
in the public arenas of government and the mass media. Knowledge
about drinking-driving is dramatized as unambiguous fact in a way
which justifies concentration of attention on the drinking-driver as a
major “cause” of automobile accidents.
Richard Zylman has compiled a number of examples of how research
findings have been “twisted,” the numbers of drinking-drivers re­
sponsible for auto fatalities increased and reported as assured and certain
“fact” (Zylman 1974a, b). Zylman has been engaged in a critique of such
statements as “inadequate fact.” From my perspective they are actions in
a context of argument, attempts to persuade others to support a pro­
gram, back a law, or refrain from drinking and driving. As Zylman puts
it:
Public relations agents, administrators and volunteer safety work­
ers as well as researchers and action program functionaries engage in
these semantic gynmastics regularly. Words are used that mean dif­
ferent things to different people. Findings regarding specific and
unique segments of the traffic crash problem are applied across the
board as though they applied to the whole problem, and some re­
search findings are ignored while others arc distorted. [Zylman
1974a, p. 8]

Two of Zylman’s examples are taken from a Congressional hearing
and from a public information brochure of the Alcohol Safety Action
Projects (ASAP). In the first, the director of the National Highway Traffic
Safety Administration in 1972, justifying the large expenditure in the
alcohol countermeasure field, took the official position that “alcohol is
involved in 50 percent of all highway fatalities” and cited several studies
to support this position (Zylman 1974b, pp. 165-66). In the second, a
brochure on the countermeasures program cites the 1968 Alcohol and
Highway Safety as authority, for “as a matter of fact. . . drinking drivers
contributed directly to more than half of all traffic deaths and injuries”
(italics mine). As Zylman points out, even that 1968 report said that
“almost half the drivers” rather than “more than half” (Zylman 1974b,
p. 164). In both cases the illusion of certainty is conveyed in the effort to
persuade.

131

These “semantic gymnastics,” as Zylman calls them, are common
usage in public materials. One frequent fiction is to use the 50 percent
“involved” figure to dramatize drinking as a “cause” of many accidents
without reference to the different proportions of DUIAs among drivers in
single-car and multiple-car crashes or driver-pedestrian crashes. Even so
“fa.vUal” appearing an item as an article used in the drinking-driver
course for convicted DUIAs of the University Extension of the University
of California at San Diego and entitled “The Facts about Drinking and
Accidents” leaves the impression that it is unambiguously the case that
fifty percent of auto fatalities are due to drinking and driving: “Many
studies reveal drinking to be a factor in a great number of traffic acci­
dents. Studies in Wisconsin and California of accidents causing fatalities
show that drinking was involved in more than 50 percent of those acci­
dents” (Traffic Safety Magazine, n.d., p. 1; italics mine).
The same fiction, sometimes with the term “alcohol-related” instead of
“involved,” occurs in Alcohol Safety Action Project public brochures
with studies quoted or cited. A public information pamphlet of the
Addiction Research Foundation of Canada, one of the world’s leading
research organizations in this field, even blurs the distinction between
“accidents” (in which one or two drivers are by definition involved) and
deaths, which include pedestrians and passengers as well. “Traffic deaths
make up 43 percent of all accidental deaths in Ontario. According to
recent studies, about 50 percent of such deaths involved ‘more than a
trace’ of alcohol” (Addiction Research Foundation 1975).
The implications of this body of constructed fact are found in the easy
slippage from the drinking-driver to the “drunk driver,” as newspapers
frequently refer to him. The conclusion is readily drawn in public discus­
sion as seen in the following letter to a metropolitan newspaper: “Your
article (Oct. 1) on highway deaths failed to mention the principal cause of
highway deaths—the drunken driver. If the drunken driver could be
removed from the highway, the number of traffic deaths would decline by
50 percent” (Los Angeles Times, Oct. 16, 1973, pt. 2, p. 7).
But my point is not a critique, as Zylman’s is. The various statements
alleged as “fact,” as certain knowledge, have a status also as rhetoric.
They attest to the serious character of the issue through its facticity. They
command attention and require the listener to accept the significance of
the DUIA problem both because the magnitudes are high and because
there is an authoritative account of an orderly world in which it is possi­
ble to say that alcohol is a cause of many fatal accidents. In the effort
to persuade skeptical, recalcitrant, and indifferent people to a way of
action involving cost, inconvenience, and displeasure, the appearance of

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certainty is an essential rhetorical device. The numbers dramatize concern.
Summarizing research in ways which eliminate qualifications and un­
certainties maintains the smoothness of the story line. The world of
objective reality is, like much of natural behavior, confused, ambiguous,
and unobtainable; it must be organized, interpieted, and compressed to
create a clear message, to form an understandable but objective reality.
The image of the world of science is not that of the world of action.
The seminar constitutes the arena of science as the factory does the arena
of industrialization. The scientist faces an audience whose hostility is
presumed neutral, whose skepticism is not partisan but Olympian. Scien­
tists, it is presumed, do not have a passionate commitment to one or
another conclusion. Qualifications and partial results, gaps in knowledge
and areas of ignorance can be admitted. This image is, to be sure, also far
from an exact description of a real world of acting scientists. It does,
however, underscore the contrast with the arena of an audience already
committed to a line of action and needing to be persuaded to an opposite
line.
The argument in drinking-driving cannot utilize the language and at­
mosphere of the seminar. Facing a hostile audience whose behavior is to
be controlled, the argument must present a state of affairs beyond dis­
pute. To admit to the audience that the “facts” are not clear, that choice
is necessary to translate them into certainty, is to shore up the target that
the speaker is passionately devoted to knocking down. One must not
look too closely at the referee while trying to punch the opponent. The
public approach to drinking and driving is not a report on research; it is a
call to action. Even the reports on research, I have been asserting, are not
unaffected by the arena in which they will eventually star. Such consid­
erations however shift the sources of compelling authority and conviction
away from scientific method and toward mor.’i or political interest or
both.

convert him from sin to virtue is a salient element in the public drama of
the auto and American society.
W’ at I am doing in this analysis of the drinking-driver as public pre­
sentation is treating public pronouncements as forms of drama similar
to those in other situations and historical periods. Following Kenneth
Burke’s provocative analysis I look for a sacrificial principle as a dramatic
theme in creating social order. That is, when an image of social order is
conveyed, its opposite—disorder—is also portrayed. The drama consists
in seeing some players as victims, others as villains. Order is obtained
through sacrifice so that unity is derived. This universal theme is not
absent from modern life.15 In the drama of drinking-driving the drinker is
portrayed as villain and others, including himself, as victims. The “acci­
dent” is not a result of random, blind fate but of human beings who fail
to observe the moral order of sober work.
The very fictive facticity described above enables the drama to be
performed. It renders the events closer to the imagined model of villainy,
and in this fashion serves to organize attitudes of condemnation. Burke
again is pertinent:
The “perfection” of a secular enemy is the clearest observable in­
stance of ways whereby the intermediate absolutizing step is involved.
Given the vast complexities of the modern world, it would be hard to
find a “perfect” material victim for any of our ills. ... [people] are
eager to tell themselves of victims so thoroughgoing that the sacrifice
of such offerings would bring about a correspondingly thoroughgoing
cure. The “fragmentary” nature of the enemy thus comes to take on
the attributes of an absolute. [Burke 1954, p. 293]

The Moral Drama of the Drinking-Driver
Is it “accident” that I have used the language of conflict and combat to
describe public campaigns, laws, and information on the problem of
alcohol? My intent is to bring out the way in which the presentation of
the issue takes the form of a dramatic confrontation between the in­
formed and the ignorant. In this section I want to describe that con­
frontation as a confrontation between good and evil. The drinking-driver
is the leading protagonist in the moral drama of automobile accidents.
He supplies a major explanation for a source of death and destruction. To

132

Consider the following headlines from news stories: “CHP Plans
Drunk Driver Crackdown” (Los Angeles Times, Nov. 27, 1977, pt. 1, p.
23); “Stronger Laws Are Needed to Curb Drunken Drivers” (Los
Angeles Times, Oct. 27, 1973, pt. 2, p. 1); “Crackdown on Drunk Driv­
ers in L.A. Begins” (Los Angeles Times, July 2, 1976, pt. 2, p. 1); “Study
Defends Drinking Drivers” (San Diego Union, Sept. 1, 1974, Bl-5). Such
terminology carries with it the sense of battle, of a conflict in which
drinking-driving is one side: the enemy. “You’ll Be the Death of Me
Yet!... If You’re a Drunken Driver,” proclaims an ASAP information
borchure on its cover (Greater Tampa Alcohol Safety Action Project,
n.d.). It portrays the drinking-driver as an active agent whose actions are
socially hostile and irresponsible. Another ASAP brochure quotes from a
Congressional message of then-President Nixon: “Our highway death
toll is a tragedy and an outrage of unspeakable proportions. It is all the
more shameful since half of these deaths involved drivers or pedestrians

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under the influence of alcohol” (U.S. Department of Transportation,
National Highway Traffic Safety Administration, n.d.).
Two aspects of these presentations, and others already described, yeed
comment. First, the drinking-driver is portrayed as “drunk. The sin
of drinking and driving is almost a microcosmic and symbolic enactment
of the sources of disorder, the unwillingness to respect controls and
boundaries in social life (this is discussed at length in chap. 6). Drunken­
ness has its own imagery and definition varying from group to group. I
have shown above that while some drinking-drivers are drunk, many
do not demonstrate the loss of ability to drive or of self- or motor control
to the degree that such a term implies.
The second aspect of the presentation needing comment is the term
“drunken driver.” Here the implication, examined in greater detail in the
next chapter, is that of a permanent attribute of the person. Not the event
“drinking-driving” but the person “drunken driver” is described. The
personalization of the event keeps alive the sense of a drama of conflict
against disordered persons, a performance of deviance. It is a drama of
agents in which the individual is prime mover.
These same dramatic attributes occur as well in the personification of
automobile design as “villain.” In Ralph Nader’s presentation, it is the
auto industry that serves as “victim” of sacrificial rites. Just opening
Unsafe at Any Speed “at random” I find: “For decades the conventional
explanation preferred by the traffic safety establishment and insinuated
into laws, with the backing of the auto industry and its allies, was that
most accidents are caused by wayward drivers (Nader 1972, p. xiii).
Here, too, a possible drama of scene, of environment, is converted into
one of agent, of auto industry directors as villains, by such expressions as
“explanation preferred,” and “insinuated into.
All the presentations put together into a concentrated image o
drinking-driving add up to a drama of morality and order in the expla­
nation of auto accidents and deaths. They are not random inescapable
events before which we must bow, sacrifices made to the avenging ange
for the gift of technological Progress. It is not the natural order that is
largely “responsible” for the tragedy and destruction wreaked by the
auto. It is the irrationality, venality, and even greed of humans; evil
people who do evil to themselves and to others. “In contrast to scientific
communication, which attempts to find an hypothesis that fits a situa­
tion, dramatization creates a situation that predetermines the hypothe­

Prologue

r

It has been customary to distinguish efforts to
persuade through language—the activity of the
artist—from those through logic, the activity of
the scientist. Albert Hofstadter has made this
difference between scientific and literary uses of
language the crux of his distinction between the
two functions of art and science. The literary
artist, maintains Hofstadter (1955), uses lan­
guage as a significant vehicle for his or her ac­
tivity. Ho tv objects and events are described or
explained is more important than the subject
matter of the narrative or poem. For the scien­
tist this is not the case. Language is only a
medium by which the external world is re­
ported. That which is described and analyzed is
not itself affected by the language through
which it is reported.
Put generally, the scientist searches for
items involved with each other in patterns of
dependence ... the scientist’s language is not
one of these items ... he must not allow his
language to become part ot the content ot
his assertion.
The character of the imaginative object
achieved by the artist depends on the charac­
ter of the language he employs, whereas the
language of the scientist does not operate
within the involvement pattern he formu­
lates. [Hofstadter 1955, pp. 294-95]

sis” (Young 1965, p. 151).

III-.

Pathos in
Drinking-Di
Research

This is what I call the “windowpane” theory.

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Introduction

The Culture of
Public Problems

The use of the automobile is a microcosm on a
large scale of the problems created by the con­
flict of restraint and release in American life.
The issues embedded in the use of alcohol and
the auto present the tensions and complements
of a world at once at work and at play. Driving
has accentuated the difficulties in keeping the
borders between self-control and self-release
closed. The contemporary motorcar is a piece
of mechanical equipment inherently dangerous
and yet relatively unsupervised in its use. Driv­
ing requires a high degree of motor coordina­
tion, rational judgment, and a level of skill that
must be maintained by constant practice and
attention, qualities of mind calling for a rational
attitude and a serious intent. But this area of
rational existence intersects day and night,
work and play. Unlike the airplane, the rail­
road, or mass transit it is not in the care of
highly trained, paid, and certified personnel.
The automobile is available as an accesory
to the gamut of our moods, our arenas of liv­
ing, and our daytime and nighttime tasks and
adventures.
This book is about how situations become
public problems, but it is also about drinking
and driving. The particular case informs us
about the macrocosm, the more general case. In
general, this is a book about culture—public
meanings—and social structure—authority,
control, and deviance. It is about consistencies

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and inconsistencies between public ceremony and routine behavior. In
particular, it is also a book about motorists, police, judges, lawyers,
scientists, journalists, doctors, and government officials, about how and
why driving an automobile under the influence of alcohol is an act pub­
licly condemned yet privately observed.
The introduction is a ritual of transition which permits the reader to
become acquainted with the writer—his style, his outlook, his intent. It is
a literary device that enables me to ease you into this study. If I have
written well and you have read well, it will outline what is to come and
foreshadow the thrust and significance of the work.
The phrase “research essay” conveys both what this book is and what it
is not. It is a book of general ideas developed and expressed in the context
of a particular subject matter and experience. The phenomenon con­
stituting the public issue of alcohol and auto safety—the “drinking4??^ prQblem”—is the occasion for creating a theoretical perspective
with which to examine public problems. This is neither a conventional
report on research nor an essay seTting forth an abstract system of
theoretical ideas or propositions, not grounded in specific subject matter.
Perhaps it is both. In the word research 1 call attention to the ground­
ing of my ideas in the experience of performing a detailed analysis and
description of a specific body of data on a particular issue—drinking­
driving. Some of the data are original with me; some are the result of
reading, activity, and exposure to the field. By the word essay I point to
the effort to create a theoretical perspective, grounded in the particular
phenomenon of the empirical research, but reaching for a general and
wider application. I am less bound by data here than in the research
report; more constrained by them than in the essay of abstract theory.
The door of my book is now opened. Let us move into the foyer.

welfare, the angel demanded that every year 5,000 Americans be put
to death on the steps of the Capitol. Having posed the question, the
philosopher then asked the class what answer should be given to the
angel. After the ethical dilemma had been discussed for some time,
the professor pointed out that every year many more than 5,000 were
killed in automobile accidents in the United States.
Of course, public issues seldom emerge in such clear-cut fashion. Only
in seminars can a philosophical problem be posed in so hypothetical and
deliberate a manner. The problems connected with most public issues
emerge long after events and processes have~Eeen set~in motion. No
seminars on the ethical consequenceFoFtechnological change were held
in Henry Ford’s shop to decide if the venture was a wise public action and
worthy of continuation. Technological assessment comes later.
The Plurality of Possible Realities

The Construction of Social Problems: How
Phenomena Become Real

There is an apocryphal tale about the American philosopher Morris
Raphael Cohen. He was reputed to begin a course in ethics with the
following problem for his students:
Suppose an angel came down from Heaven and promised the people
of the United States a marvelous invention. It would simplify their
lives; enable the injured to receive quick treatment; decrease the time
of transportation by a large magnitude; bring families and friends
closer together and create a life of far greater ease and convenience
than exists today. However, in grateful return for this boon to human

Introduction:
The Culture of Public
Problems

106

9

At the outset I have had the problem of naming the problem. To talk
about the “drinking-driving problem” is already to assume the character
of the phenomenon (automobile safety) and to define it as having such
and such a shape. Human problems do not spring up, full-blown and
announced, into the consciousnes£lQlZbystanders7~Even to recognize a
situation as painful requires a system for categorizing and defining
events. All situations that are experienced by people as painful do not
become matters of public activity and targets for public action. Neither
are they given the same meaning at all times and by all peoples. “Objec­
tive” conditions are seldom so compelling and so clear in their form that
they spontaneously generate a “true” consciousness. Those committed to
one or another solution to a public problem see its genesis in the neces­
sary consequences of events and processes; those in opposition often
* point to “agitators” who impose one or another definition of reality.
The existence of a “drinking-driving problem” is the result of a proce­
dure by which the automobile and fatalities have been construed as a
problem of societal concern, to be acted upon by public officials and
agencies. Alcohol has already been perceived as important in the genesis
of such fatalities and accorded an importance as a target in the resolution
of the problem. That target character is not a given, is not in the nature of
reality as a Ding an sich (a thing in itself), but represents a selective
process from among a multiplicity of possible and potential realities
which can be seen as affecting auto fatalities and injuries. Before thg
nineteenth. cenwryLdriiiking and drunkenness were seldom used to ac­
count for accidents or crime (H. G. Levine 1978). The problematic

4
3 ■?

The Culture of Public
Problems

accept it as given in the nature of things.
The sociologist has come to recognize that many human situations and
problems have histones; they have not alwaysbeenconsnuedandrectoday or will be in the future. Whales now labeled
was Zd S
in whlch the «me behavior
was accorded dif erent statuses in different historical periods, and somemes seen as valued, sometimes as condemned and irremediable Its
tMk6"1 h306
SpeCtrU[n of medical “illnesses” is another way of
talk ng about it. Recent criticisms of the concept of “mental illness” have
196S ROrVhlS ^eQ^e ° ltS h,stoncal diversity (Rosen 1968; Foucault
now5labe<|tdmanA
Same haS occurred with the phenomenon
ern h ? d k AmenCan Society as “Poverty.” At some periods in West­
ern h stops the poor were objects of reverence; at others they were the
objects of condemnation. In the 1950s the issue of poverty was a minor
HthTltT'^ Publ'.“onsclousness. In the 1960s, with little changed
m the levels and distribution of income, it became a significant part of
pu he actions. W ere poverty had once been a term foA margXow

define a putative condition as a problem-.s the distinctive subject matter

T- ProblemS ’” Pressed
the wall to solve the
problem of drmking-dnving I can only shout “Why do you ask’”
The Public Character of Social Problems

a8°A 1 ,PaSSed 3 movie marquee with the title Marnage Is a
A
jnd
‘S *n Amencan life today. Much attention, time
and money are devoted to problems of marital relationships. Divorces are
da ly lamented, accepted, or exulted over in public communications, bu
the sttuanons, percetved as painful or problematic or even immoral, do
parent chiid P
f
tO
resolutions- Manta! happiness,
p ent-child satisfactions, sexual frustration, unrequited love, disap-

107

pointment in friendships are among the most keenly felt of human ex­
periences and their joys and sorrows the occasions for some of the
deepest and most profound aspirations. Yet no public agency exists to
provide for their quick or beneficent satisfaction. Only in musical com­
edies do political parties campaign on platforms that promise to bring
everyone love and sexual fulfillment.
It is useful to distinguish public problems from private ones. That is
why I prefer the term “public problems” to that of “social problems.” All
social problems do not necessarily become public ones. They do not
become matters of conflict or controversy in the arenas of public action.
They do not eventuate in agencies to secure or in movements to work for
their resolution. Whether or not situations should be public problems is
itself often a major issue. The abortion question is today a source of great
and bitter political conflict in the United States. It poses the question as to
the place of public authority in accepting responsibility for providing
sanction to private abortions and entitling citizens to facilities for
achieving abortions. It is not straining the imagination to perceive a
somewhat similar destiny in store for sexual pleasure. In the past decade
sexual dissatisfaction has become the source of a new, growing
occupation—sexual therapist. I can imagine in the next quarter-century
the movement to define sexual disappointment as illness and a govern­
mental program to provide sexual therapy as part of medical insurance.
What may be visible and salient in one period of time may not be so in
another. Issues and problems may wax and wane in public attention, may
disappear or appear. How is it that an issue or problem emerges as one
with a public status, as something about which “someone ought to do
something”?
In analyzing the public character of a problem it is vital to recognize
again the mukiiHe possibilities of resolution. Who and what institution
gains or is given the responsibility for “cloing something” about the
issue? As phenomena are open to various modes of conceptualizing them
as problems, so too their public character is open to various means of
conceiving their resolution. It is only in the past ten or fifteen years that
automobile safety has been seen as a matter of responsibility for the
federal government and the automobile industry through the develop­
ment of public standards for safe automobiles. 2 Income security in old
age has ceased to be left largely to personal and familial obligations.
Social security legislation has established a public, governmental
responsibility.
The problem of responsibility has both a cultural and a structural

Problems

(

dimension. At the cultural level it implies a way of seeing phenomena.

and it seemed the task of this sociologist to develop it and to understand
how the existing consciousness persisted.
The people whom I talked with in the course of that original study
presented a fairly uniform view of the problem. Alcohol leads to impaired
driving and increases the risk of accident, injury, and death. Since drink­
ing coupled with driving “causes” auto accidents, solutions lie in strate­
gies which diminish either drinking or driving after drinking. The
available strategy is to persuade the drinker not to get behind the wheel of
the car. Law enforcement and punishment perhaps supplemented by edu­
cation are the most useful and acceptable means to diminish auto accidents
due to drinking. Some people thought in longer range terms and wanted
drinking-drivers screened for alcoholism and treated for their illness.
This homogeneous consciousness of alcohol and automobile use ap­
pears to the sociologist as a salient form of social control. It eliminates
conflict or divergence by rendering alternative definitions and solutions
unthinkable. This subtle, unseen implication of cultural ideas is perhaps
the most powerful form of constraint. Unlike the conflict of power it goes
unrecognized. What we cannot imagine, we cannot desire.
Earlier in my academic career I had studied the American temperance
movement and Prohibition (Gusfield 1963a). That study had sensitized
me to other modes of seeing issues of alcohol. It made me critical of the
intensively individualistic character with which the auto safety problem
and the drinking-driver problem were seen by those I studied and met in
the San Diego courts research in 1971-72: it was taken for granted by
those I studied that the problems of auto safety and alcohol use were
chiefly problems of individuals, of motorists. Institutional explanations
and loci of responsibility were eloquently absent from the consciousness
of officials, observers, and offenders.
Two thingsstruck me as especially significant by their absence: thejack
of involvement of alcohol beverage distributors—bartenders, sellers,
manufacturers—and the inability or unwillingness of people to see the
problem of drinking-driving as a problem of transportation. The pro­
ducers and distributors of liquor and beer were almost never represented
in the conferences, meetings, classes, and committees which fill the or­
ganizational agenda of local alcohol agencies. But so, too, was there little
representation from medicine, government, planning, or other possibly
interested groups. In speaking to audiences throughout the country as a
presumed “alcohol studies expert” I often pointed out that the city of San
Diego had developed an area of hotels alongside a major interstate high­
way. The hotels all had public bars which provided part of their income
and depended on more than their temporary residents for clientele. Autos

fe7m
inA7tht
el’
ferent institutions and different personnel who are charged with obliga­
tions and opportunities to attack the problem. Here, too, change from
one set of causal definitions, of cognitive conceptualizations, to another
carries .mphcations for institutions. The relation of causal responsibility
to pohtical responsibility is then a central question in understanding how
public problems take shape and change.
In the case of drinking-driving this has involved such institutions as the
church, the courts and police, government, medicine, and the world of
engineering. That there is transition or conflict between institutions
of ddnkin' 7eCt7 rmS tO authonty in contro^lng the phenomenon
of drinking-driving leads us to a recognition of the categories in which
the phenomenon is conceptualized, thought about, becomes a matter of
consciousness. For example, to see alcohol problems through the
metaphor of medicine, as diseases, has consequences for efforts to utilize
law enforcement measures in their resolution. Such modes of conceiving
of the reality of a phenomenon are closely related to the activities of
esolution. They affect the claims to authority over the area and over rhe
persons connected with the phenomenon.
-------- ' )

The Structure of Public Problems

F
ik'

My obsession with the uses of knowledge as a basis for authority in
studvC 1^ 9771 Wa.S aTed7 an «rller phase of what has become this
to undirt k l0Cal|tra£fi7tfet>«°fficiais in San Dieg° County asked me
o undertake an analysis of the effectiveness of court sentencing practices
(Gusfield 197/"wt J6518 7 driV'n8 Under the influen« of alcohol
(Gusfield 1972). While completing that initial study, it seemed to me that
a 1 the parties with whom I came in contact—police, offenders, judges,
rneys, academic colleagues, Department of Motor Vehicle
officials—were locked into a consciousness of drinking-driving which
narrowly shut out possible alternative conceptualizations and solutions
There were other ways of “seeing” the phenomenon, other resources that
might
have beenk explored
the
nrnhle™
u
35 solutions to the problem. The definition of
the prob em, which participants to. the process took for granted, was to
me problemauc. This situation became something that required my ex­
planation and understanding. An alternative consciousness was possible

108
I

•?
A/o '

i

Problems

parto'f ?hOentht
transPortation
from such bars in a
pan of the United States where the spatial spread n ade taxis expensive
Research on dnnking-dnvers was similarly silent
alternative means

definition of the reality of the problem, or to assume legitimate power to
regulate, control, and innovate solutions. To describe the structure of
public problems is to describe the ordered way in which ideas and ac­
tivities emerge in the public arena.
The concept of “structure” lends itself too much to a distorted sense of
public events as having a fixed, permanent, unchanging character. I do
not want to convey that interpretation. At any moment the “structure”
itself may be fought over as groups attempt to effect the definitions of
problems and authority to affect them. At any moment the structure is
itself problematic in its implementation. Structure is process frozen in
time as orderliness. It is a conceptual tool with which to try to make that
process understandable. What is important to my thought here is that all
is not situational; ideas and events are contained in an imprecise and
changing container.4

drmkm Sd ““
,ranSPortation- L’«le was ....own about where
dnnking-dnvers were going or had come from. Although such questions
were part of the standard arrest form in these cases, fhe item was no
deemed important and answers were inconsistent and poorly asked 3

alternative""0"
th‘S W3y
tO the realizatlon that there were
ternative ways of being conscious of the drinking-driving problem I

tm! U
" 'n
raihei- ih.n c.u.e, (Gu,field
976). It was possible to drop attention to drinking and to think only
about the injury or fatality incurred, concentrating only on preventing

e’;± ”d '

L“'r 1

. Xi!

'h“'

?d| ,Ure 3nd a set^ programs and movements since the mid-1960s that
had done exactly that (cf. chapter 2, below).
nlpCaarUrSiirnputati°n in itself> of course, is ambiguous and open to multi­
ple attributions and trnputations. The absence of alternative modes of
transportation is logically as much a cause of' drinking-driving
'
as is the
use of alcohol. To see public problems as
the application of values to an
objective set of conditions puts the car in front <
the motorist. The
conditions are themselves part and parcel of the pr.
ess through which
problems are attacked. There was a structure of th<
ight and action, of
institutions and groups within which the problem
vas contained and
alternatives were excluded.
The idea of structure implies an orderliness tc
Kings. Ideas have
structure insofar as they follow from generalized n
es of thought. Behavior has structure when it, too, is orderly. Analyz
g public problems
as structured means finding the conceptual and inst
tional orderliness
m which they emerge in the public arena. The public
•rena is not a field
on which all can play on equal terms; some have <
eater access than
others and greater power and ability to shape the
finition of public
issues. Nor do all ideas have public problems as the
consequences.
1 he social construction of public problems implies
i historical dimenston. The same “objective” condition may be defied
—1 as a problem in one
time period, not in another. But there is more to
i™.s
the ide. „<
■>'
' experience w h the initial study
suggested, there is a pattern to how issues and prol
-I ns arise, emerge,
and evidence a f
---* any specific moment, all
structure.
At
possible parties to
the issue do not have equal abilities
to influence the public; they do not
oossess the same degree or kind of authority to be legitimate
? sources of
b n'ltro

zi

_

Cognitive and Moral Judgments

*

109
j

As ideas and consciousness public problems have a structure which in­
volves both a cognitive and a moral dimension. The cognitive side con­
sists in beliefs about the facticity of the situation and events comprising
the problem—our theories and empirical beliefs about poverty, mental
disorder, alcoholism, and so forth. The moral side is that which enables
the situation to be viewed as painful, ignoble, immoral. It is what makes
alteration or eradication desirable or continuation valuable.
The moral side of a problem suggests a condemnable state of affairs
from the perspective of someone’s morality. Even medical conceptions of
illness contain the moral admonition that sickness is not preferable to
health, that the patient should want to be well. Someone who elects to
continue an unhealthy occupation because of the value of its rewards
may decide, however, that illness is preferable to health. Issues of equal­
ity, of justice, of economy all involve judgments of goodness, badness,
and morality.
But events and situations are also cognitively assessed. A world of fact
is posited. Crime may be seen as a result of broken homes, poverty,
genetics, community disorganization, or any number and type of vari­
ables. Significantly there are beliefs about the alterability of phenomena.
They are, but need not be. The aging process is seen as physiologically
painful and unwelcome in contemporary societies, but it also is seen as
inevitable and unalterable. Inequality between races is also seen by many
as painful and unwelcome but believed to be alterable. In that is its status
as a problem.

The Culture of Public
Problems

Without both a cognitive belief in alterabflity and a moral judgment of
its character, a phenomenon is not at issue, not a problem. In recent years
iologists have begun to take the aging process as potentially alterable
and have begun to study it. It may become a problem and the reality of
aging itself a center of public controversy. At present it is not. The reality
of a problem is often expanded or contracted in scope as cognitive or
moral judgment shifts. The composition of the criminal has been open to
considerable argument over such phenomena as “war crime,” "white
collar crime,” “victimless crime,” and “juvenile delinquency” (Quinney
1971; Cressey 1953; Platt 1969; Schur 1965).
7

The Ownership of Public Problems
The concepts of “ownership” and “responsibility” are central to this
work and are used in a very particular manner. Much of the study
examines the fixation of responsibility for public problems, and the concepts must be discussed with care.
At
’ W111 seParate three aspects of the phenomenon of re­
sponsibility. The first will be given the term “ownership” and the other
two discussed as different types of “responsibility.” The concept of
ownership of public problems” is derived from the recognition that in
the arenas of public opinion and debate all groups do not have equal
power, influence, and authority to define the reality of the problem The
ability to create and influence the public definition of a problem is what I
refer to as ownership.” The metaphor of property ownership is chosen
to emphasize the attributes of control, exclusiveness, transferability, and
potential loss also found in the ownership of property.
I have pointed out that the status
ot aa phenomenon
as aa jproblem is
status of
phenomenon as
itself often a matter of conflict as interested
interested parties
parties struggle
struggle to
to define
define or
prevent the definition of a matter as something that public action should
do something about.” At any time in a historical period there is a
recognition that specific public issues are the legitimate province of
specific persons, roles, and offices that can command public attention
trust, and influence. They have credibility while others who attempt to
capture public attention do not. Owners can make claims and assertions
They are looked at and reported to by others anxious for definitions and
so utions to the problem. They possess authority in the field. Even if
opposed by other groups, they are among those who can gain the public
ear Thus the American Psychiatric Association has been the owner of the
problem of homosexuality, and their support or opposition to the defini­
tion of homosexuality as a psychiatric problem has been significant.

w

110

What the Chamber of Commerce does about homosexuality is far less
significant in its influence on others.5
Different groups and institutions have authority and influence for dif­
ferent problems and at different times. The orbit in which religion has
control over health has greatly diminished while that of medicine has
expanded in Western countries. At one stage in the history of the social
organization of health, ecclesiastical authorities possessed great power
and influence; today they do not.
The history of the control of alcohol problems illustrates the concept of
ownership in an area central to this study. During the nineteenth and
early twentieth centuries in the United States, the Protestant churches
wielded a heavy club over alcohol problems, providing by themselves, or
through allied organizations, much of the public, persuasional material
on temperance and Prohibition. When they defined the legitimate cogni­
tive and moral approaches toward alcohol use, many listened. The
churches, the Woman’s Christian Temperance Union, the Anti-Saloon
League all acted to place and keep alcohol high on the public agenda.
The churches came to “own” the problem of drinking in American
society. They set the pace and much of the framework of the debates,
Other possible sources of competing ownership were absent. The medical
profession was poorly organized and unable to gain a loud voice in
suggesting alternative perceptions of the problems of drinking and
drunkenness. The same was true of the universities. They were far from
autonomous from religious influences. The sciences were less well orga­
nized and equipped to play a role in public affairs than at present. The
effort of the Committee of Fifty, a group of private citizens, to be arbiters
of fact in the area was short-lived. Government was less the initiator than
the recipient of alcohol policies.
With Repeal, the authority of the churches to be judges of public tastes
was “disowned.” Whatever the desires and attempts of temperance and
Prohibitionist organizations, theirs was no longer the authoritative voice.
Their pronouncements no longer commanded attention but were the
“kiss of death” for proponents of alcohol control policies. Ownership
passed to the universities, the medical profession, and the problem
drinkers themselves. In recent years government has entered the field as
federal agencies have been charged with solving alcohol problems (Room
1979).

The Culture of Public
Problems

Disowning Public Problems
Some groups, institutions, and agencies are interested in defining, affect­
ing, and solving public problems. Others may be especially interested in
avoiding the obligation to be involved in the problem creating or problem
solving process, lliey deliberately seek to resist claims that the phenome-

and PmhV
mUCLh °f the aCtive Penod of the temperance
and Probation movements the liquor and beer industries made little
effort to counter temperance assertions, took little notice of the issue and
derogated the importance of alcohol as a cause of suffering, crime or
other public woes. Today theirs is a similar, though unstated, aloofness
rom attempts to provide definitions or solutions to the problems as“The?
a Ckh°L The Sl°gan °f the alc°ho1 leverage industry is
The fault .s m the man, not the bottle.” Little
Little money is spent by the
alcohol beverage industry in research on problems connected with its use
m worSnd iTTt °
' “ °WnershiP of the alcoh°l Problem and,
m word and deed, disown it.
charactered h3t I™'11"
u°n’
automob^ safety problem has been

HiXav Trlffi i

1

y a 'eSS than benign nCgleCt‘ The Nationa'

wS P
rf k
AdmL1"lstration (NHTSA) came into existence in
Ip' P. bV Mik aUtOm0blle safery on a ^deral level was the purview
of the Public Health Service. At the state level it was usually an arm of the
5ileThant
7r °f mrOtOr VehiC'eS' The aut°™bi|e industry,
while has sponsored some safety research, has not devoted much of its
sn OrrkeSAtO qUestlons of safet? improvement. Prior to 1966, the total
rac" onyofThTrCan a"bi'e “mPanies on
research was a small
dusril h
H expended on style research? Similarly the insurance inin de^ I
thC
°S (CL Chapter 2 below)’ P,ayed a minor role
m developing or supporting research or education on auto safety The
sourcTof S
d,SCUSS!d at length 'n cbaPhas 'been a
nrnv J J
lnf°rmatlon and a source of agitation chiefly for imuntiHhe iTlS 'idutat'on- Tbe major research on automobile safety,

sXu s’.K? -r

Responsibility: Causal and Political

Ownership constitutes one piece of the structure of public problems. It
indicates the power to define and describe the problem. It tells us who but
not what: it does not specify the content of description and solution.
Here we need to add two other concepts: causal responsibility and politi­
cal responsibility.
The Dual Meaning of Responsibility

U.S. a™, .„d t„e us. P„Mic

The question of ownership and disownership is very much a matter of
oubhc WCr a"d a“th|°nty grouPs and institutions can muster to enter the
public arena, to be kept from it, or to prevent having to join. The power
Doliti!"6"^ r
cn'tiC>n °f th£ rea'ity °f Phenomena is a facet of a

du ring theSen.r^
A
R,bic°ff Stated thls ,n one form
d thinkDetrn th f
Traffic Highway Act in 1966:
bL^d the wheep35
k
tHat thC Wh0'e Pr°blem W3S the ‘nUt
• •. and they brainwashed Americans into thinking that

the automobile did not have a real role to play in the safety field (U.S.
Senate 1966, p. 47).
Ribicoff’s remarks imply a set of empirical assertions and a theory of
how public consciousness is formed. Without judging those assertions
and that theory at this point, the implications of the remarks are perti­
nent. Public problems have a shape which is understood in a larger
context of a social structure in which some versions of “reality” have
greater power and authority to define and describe that “reality” than do
others. In this sense—of responsibility—the structure of public problems
has a political dimension to it. The existence of overt conflict and debate
makes the politics of an issue manifest. The lack of such conflict may hide
the very features of the structure which make for its absence, which
prevent the opposite forms of consciousness from being observed. They
contribute to “what everyone knows,” what is “common sense”—the
taken-for-granted by which the objective world is made into experienced
life. This absence of alternative modes of consciousness is also the subject
of analysis of the structure of public problems. Acceptance of a factual
reality often hides the conflicts and alternative potentialities possible.
Ignoring the multiplicity of realities hides the political choice that has
taken place.

Ill

V

To say that “cancer was responsible for someone’s death” is to use the
term responsibility in a manner different from saying that “parents are
responsible for preventing their children from making noise.” The first
usage looks to a causal explanation of events. The second looks to the
person or office charged with controlling a situation or solving a prob­
lem. The first answers the question, How come? The second answers the
question, What is to be done? The first—causal responsibility—is a mat­
ter of belief or cognition, an assertion about the sequence that factually
accounts for the existence of the problem. The second—political
responsibility—is a matter of policy. It asserts that somebody or some

1 he Culture 01 i uduu
Problems

office is obligated to do something about the problem, to eradicate or
alleviate the harmful situation.
The second usage is close to the legal use of “responsible” in much of
Anglo-Saxon law:

are looked to for liability and repair. The Prohibition movement owned
the alcohol problem during the early part of the twentieth century. What­
ever the causal theory of alcohol problems, the movement tried, suc­
ceeded, and later failed to fix responsibility for solution on the beer and
liquor industries. Government and law intervened but not as solvers of
the problem. The definition of alcohol problems, their cause, and their
cure were given by the programs of the movement.7
The unique position of the state makes it a key figure in fixing re­
sponsibility. In some historical periods and for some issues it may be a
processing machine, taking in inputs in the form of demands and pro­
cessing them into policies that meet the demands, serving as a broker ot
inconsistent and equally powerful demands.8 This was the case in the
Prohibition period, but seems less and less so in many areas of contempo­
rary life. Today the state appears more often as an active agent, the
owner of the problems it seeks to solve. Governmental officials and
agencies operate to define public issues, develop and organize demands
upon themselves, and control and move public attitudes and expecta­

Usually in discussions of law and occasional!; in morals, to say
that someone is responsible for some harm mea is that in accordance
with legal rules or moral principles it is at least permissible, if not
mandatory, to blame or punish or exact compensation from him. In
this use ... the expression “responsible for” does not refer to a factual
connection between the person held responsible and the harm but
simply to his liability under the rules to be blamed, punished or made
to pay.... There is no implication that the person held responsible
actually did or caused the harm. [Hart and Honore 1959, p. 61]
The political, or policy, concept of responsibility has a wider scope
than the legal one but is similarly distinguished from causal explanation.
In my usage the responsible office or person is the one charged with
solving the problem and open to reward or punishment for failure to do
so. To look to government agencies and actions to diminish inflation is to
hold governmental officials politically accountable, subject to electoral
and other responses for the continued or curtailed existence of the eco­
nomic problem, although government may not be seen as its cause. The
medical profession and medical science are not seen as causes of cancer,
but they are seen as sources of potential solution. Priests, astrologers,
civil engineers, and sociologists are not responsible for curing cancer or
nephritis in American society although they may be in some others.

tions:
To explain political behavior as a response to fairly stable individ­
ual wants, reasoning, attitudes, and empirically based perceptions is
therefore simplistic and misleading....
Government affects behavior chiefly by shaping the cognitions ot
large numbers of people in ambiguous situations. It helps create their
beliefs about what is proper; their perceptions of what is fact; and
their expectations of what is to be done. [Edelman 1971, pp. 2, 7]

-!

Ownership and the Fixation of Responsibility
A primary question of this study is the relation between these three
aspects of structure—ownership, causation, and political obligation.
While all three may coincide in the same office or person, that is by no
means necessarily the case. Quite often those who own a problem are
trying to place obligations on others to behave in a “proper” fashion and
thus to take political responsibility for its solution. The environmental
“lobbies,” operating under a theory of causal responsibility which finds
the source of “impure air” in the automobile, have used their ownership
of the pollution problem to fix political responsibility on the automobile
industry. Government shares that responsibility through undertaking to
determine standards of gasoline fume emission.
In the example of clean air, causal and political responsibility are
related. The design of the automobile is seen as cause, and the designers

112

Knowledge and Responsibility
The structure of public problems is then an arena of conflict in which a
set of groups and institutions, often including governmental agencies,
compete and struggle over ownership and disownership, the acceptance
of causal theories, and the fixation of responsibility. It is here that knowl­
edge and politics come into contact. Knowledge is a part of the process,
providing a way of seeing the problems, congenial or contradictory to
one or another way in which political responsibility is fixed. It may
emerge from religious institutions, from science, from folklore. Whatever
its source, the appeal to a basis in “fact” has implications for the practical
solutions sought to public problems.
In analyzing drinking-driving, I am examining the theoretical and sci­
entific perspectives which have emerged from universities and technical
institutes and which have operated in attributing causal responsibilities.
These perspectives constitute the “state of the art in explanations of

The Culture of Public
Problems

nrohr k
*eS tnd prov,de the Piousness of the auto safety
problem. The ownershtp of that problem in different and someth
confhcnng ctrcles of alcohol occupat.ons and engineering and legal
agencies provides the arenas within which the drama takes8 place The
spectatonsm and occasional participation of the liquor beer auto' and

XTained Th:7

causal hZl

generated, and supported by human interests located within the di­
versities and hierarchies of social structure, of group life and position.
“Our primary aim,” wrote Robert Merton in his classic paper on non­
conformity, “is to discover how some social structures exert a definite
pressure upon certain persons to engage in nonconformist rather than
conformist conduct” (Merton 1949, pp. 125—26).
This is not to maintain that I am uninterested in the social structural
side of the coin of behavior. How culture and social structure affect one
another is a significant piece of the puzzle of social life, and in a complete
analysis both must be explored (A. Cohen 1976). I am, however, ap­
proaching the phenomenon of drinking-driving and the public actions
connected with it while keeping their status as cultural forms uppermost
in my bifocals. Only after I have viewed them as cultural products can I
analyze the structural relationships.9
There are then two levels of social life: that which is constructed in the
act of talking about it, defining it, and organizing our thought about it;
and that which exists in social action itself. The former presents an
ordered, consistent, understandable set of rules—a social structure. It is
what sociologists and others construct in describing a “society.” The
latter is the raw data of existence, the initial acts which we, as human
beings, cast into types in order to think about them. Edmund Leach, in
his classic work on highland Burma, has made us aware of the sharp
discontinuity between these:

wh°Se

rT betWeCn tHeSe e,ementS of ownership,

studv Th
r 7.
reSP°nsibilitles the central focus of tWs
dy. The crux of the political issue of drinking-driving lies in the
choices of one or another theory of cause and one'or another locus of

L\rmyrXct ty' The COnSCiOUSneSS Of the Sinking-driving probcrimeththr?se0f0frdfOULd ‘T"- °f

hUman equalit^’ and violent

crime, the case of dnnking-dnving may seem too prosaic and un
timPe°rtadnt tO mer,tfthe attention of the sophisticated reader let alone the
time and energy of a mature sociologist. But that very prosaic and un
bXse'of^s th °f drinf in8-dr'v,ng “ itself the incitement for curiosity,
because of its theoretical importance. If drinking-driving seems not to
occursPThataa matt0”5’ ”
SOmeth|ng about how dissensus
occurs. 1 hat a matter seemingly connected with so many deaths and
VieVNam0^65
lcSsdemand for ^tion or resolution than did the
X Thusd
7s SOmething ab°Ut h°W Pub,ic Stands do
arise. Thus do we by indirections, find directions out.”

social structure in practical situations (as contrasted with the
sociologist’s abstract model) consists of a set of ideas about the dis­
tribution of power between persons and groups of persons. Individu­
als can and do hold contradictory and inconsistent ideas about this
system. Thoy are able to do so because of the form in which their
ideas are expressed. The form is cultural form; the expression is ritual
expression. [Leach 1954, p. 4]
In practical field work situations the anthropologist must always treat
the material of observation as if it were part of an overall equilib­
rium, otherwise description becomes almost impossible. All I am
asking is that the fictional nature of this equilibrium should be
frankly recognized. [Leach 1954, p. 285[

The Cultural Perspective toward Public
Actions
The perspective which informs this study represents a departure from the
oubhcTfWiayk'n Wh'Ch SOciol°gists bave approached the study of
public acttons. It has more in common with the orientations that have

that h USC ambOn|8 C“ tUira anthroPol°glsts and literary critics than those
that have marked socological studies until recently.
anil e VIeW °f PUbl‘C aCtiO"S 38 CU,tUral forms can be introduced by
analyzing two terms used in this book: rhetoric and ritual. The terms are
~andmd l,teratUTr.eand anthropology. They describe behavior as lan­
guage and drama. Their usage thus appears as an aspect of culture—of
(Sahhn^97? S’!mbols
whicb meaning is constituted and conveyed
(Sahhns 1976; Geertz 1973a). “A symbolic system of meanings is an

iTrl fS lmPfJSef a7t

°n the rea'istic situati°n” (Parsons

hL ’ k 1 •’ 7 3 8enerall2ed perspective on human behavior sociology
has emphasized the cultural realm as “superstructure, ” as implicated^

113
w

The two terms—rhetoric and ritual—will appear here in contexts of
incongruity. Each will be used as a primary term of reference to describe
an area in which the term is unfamiliar and even contradictory. They
emphasize the nonutilitarian, uninstrumental quality of the products of
science ai.d law. It is precisely this noninstrumental quality, the cultural
character of these products, that lends such areas of life their potent

The Culture of Public
Problems

J
5 ’’

moral consensus. It presents a public version of the ethical and social
character of drinking-driving which has its own existence as a public
performance. The public drama creates a public culture whose relation to
private culture is as problematic as the relation of the stageplay to the life
of the audience. In part 2 the issue of law and deterrence becomes the
occasion for analysis of public performance as an effort to establish a
public authority among private people.

Part 1 treats the product of science—fthe “state of the art” in
dnnking-driving reSearch_as a form of rhetorjc To descrjbe 'sci;
------------ science as
rhetoric diminishes or ignores its status as a means to an end—a way of
eterminmg a factual reality. It emphasizes the research document and its
Potation in communities of science and in the public arena as a form
nresent"1’
C°mP
metaPhor’ 1 analyze documents and public
drinkint d°nSPerformanees-as materials which dramatize the
drmking-dnvmg phenomenon as both a cognitive and a moral matter.

Zd'thrTui i"

The Illusions of Authority

a^"Xam^de"

stood through literary analysis.
The significance of this cultural analysis for social structure lies in
thorltv^f^1"8 7 7 COnStrUCtion of 3 factua> ^ality rests on the au­
thority of research and scientific study. That “reality” has a definitive
consistent facticity which enables the social control of drinking and

SildX " ”1"d’ app"'s

”d

»h“

rhem'in2
'h'>»d dram,. ,h„ llme p|acmg
them in the arena of aw. It is a story of contradiction^-of the gap
an7rr7Orma? Stated lntentions and aspirations of law and legislation
and the day-to-day routines of courts and police. It is a story of moves to
decrease automobile accidents and deaths that prove to be ineffectve and
nconsequennal. In law drinking-driving is a delinquency which differs
from ,ordinary traffic violations in its moral status and its prescribed
Ecr^ThVTday.aCt,°n’ ir aPPears more
traffic violation
and 7 Jmu68. pUn‘shmentsexa«ed are far below those prescribed
deterrmel
k6 " °f
ha* only a limited" effect in
deterring the phenomenon of driving while under the influence of
of aiironT
* ’n PreVentlng the accidents which are the objects

'I

as?^ 77 'n P/rt c.are myth and r,tual~^ consideration of law
as a stylized form of public drama whose impact is not only in its instramental consequences as a utilitarian means to an end. As a cultural
performance at levels of both formal and routine activity, law embodies

coirXhror^rjA88’ 7reates a day-to-day authority and leginmates
control through building the image of a social and natural order based on

114

In the chapters to come I make some assertions about the modes of
authority and develop a general theory of public acts as carriers of
meaning. These can only be foreshadowed in this introductory chapter,
but it is essential to sketch them out at this point so that the substantive
material can be visualized in the framework which the author has in­
tended.
In describing authority as illusory I am intentionally creating an am­
biguity of meaning. In one sense authority is illusory in that its sources
are illusory. The base of knowledge about drinking and driving is not so
certain, consistent, and constant as is claimed when experts speak in a
voice of authoritative wisdom. The analogy between alcohol problems
and disease is a metaphor, and their affinity to other medical ailments is a
matter of discretion and choice—not scientific truth. The claim of techni­
cians to moral neutrality hides ethical and political values at work.
There is still another meaning to the illusion of authority, in which the
fact of authority is illusory. The effectiveness of legal sanctions as
methods for deterring drinking-driving and for preventing accidents is
more limited than the legislative and judicial acts that fill libraries will
lead one
think. The medical model of alcohol problems, so carefully
nurtured over the past thirty years, has not given medicine a dominant
voice in the healing of this sickness or convinced more than a slim sliver
of the body politic of its validity.
There is a third side to the problem of authority, especially in relation
to knowledge but also relevant to the issues of law and deterrence. This
point of view is derived from sociological perspectives which place at the
center of human action the image of the actor interacting with his social
and natural surroundings—selecting, choosing, typifying, generalizing.
The seminal theorists here are George Herbert Mead (1934) and Afred
Schutz (1967). What this perspective does is to emphasize the activity of
the human actor in creating and constructing the world in which he lives,
in carving out of the “big, buzzing, blooming confusion” (William

Hill UUUVUVli.

The Culture of Public
Problems

James s phrase) a consistent and orderly universe in which to act. The
concept of “ethnomethodology ” contains in its etymology an entire
theory of human behavior. It suggests that ordinary people^-the ethnos,
the folk—also follow a methodology, make the world logical , consistent,
and operative in theoretical terms. Thus Garfinkel: “Every feature of
sense, of fact, of method, for every particular case of inquiry without
exception, is the managed accomplishment of organized settings of prac­
tical actions” (Garfinkel 1967, p. 32).
Translated from the abstract pages of theory into the particular acts of
men and women this leads us to ask how it is that the illusions of
certainty, consistency, effectiveness, or political and ethical detachment
are constructed into realities. It is a one-sided version of human activity
which sees only an external stimulus and a responding animal. That is
not what is happening in the public arenas—the media of communica­
tion, the courts, the experts’ professional endeavors, the scientists’
studies—in which auto safety, alcohol, dunking, and driving are topics of
analysis and targets of policy. Knowledge and law are not shiny marbles
lying on the beach and awaiting only the sharp eyes of skilled men and
women to be found. The “facts” of alcohol are picked out of a pile,
scrubbed, polished, highlighted here and there, and offered as discoveries
in the context of the particular and practical considerations of their
finders.
The Artful Realm of the Public
The last of the illusions is that public authority is only a bridge to private
behavior, a mechanism through which control is attempted. That illusion
is the premise, as I will show, behind the disappointment with law as a
deterrent device. It has been the incitement for much of sociology in its
use of empirical study to establish the great divide between official ver­
sions of what is and what really is. A great deal of modern sociological
work has been debunking writ large, showing that the clean face of
organizations, movements, governments, forms of social organization
hides from public view the dirty backside of hierarchy, narrow interests,
and group antagonisms.
The hiatus between the public and private <sides
’ of reality is interesting
or shocking or provocative only as the observer expects or demands> a
closer fit, assumes that public authority is a means to a private end—
control of the behavior of persons. Suppose that instead, or in addition,
public acts—-laws, legislation, official speeches, mass media descriptions,
brochures, and the other mechanisms of public action—can be consid-

115

ered sui generis, as events in and of themselves without reference to
possible functions as means to ends? If we drop the premise that
drinking-driving knowledge, as portrayed in the policies of governments
and the opinions of experts, conveys much about drinking-driving, and
operate on the premise that it tells us much about how public actors
behave toward this phenomenon in public arenas, what then? If we
assume that the legislation and appellate court decisions about
drinking-driving are dramas for the consumption of an audience and not
a technique for controlling alcohol abuse and automobile use, what
would law and legislation look like?
Like any methodological device, this form of study, now called
dramaturgical analysis, says more than it can frequently show.11 But
using it uncovers more than was there without it. I will retreat to less
radical conclusions than implied above but will still find that the analysis
of drinking-driving knowledge and policies as forms of literary art casts a
strong footlight on some of the problems of policy implementation. It
helps reveal the otherwise unrecognized political and moral conflicts that
public presentations disguise and camouflage.
Although the dramaturgical perspective has not been well developed in
social science or applied to social behavior by literary analysts, its use is
not unique or new. Erving Coffman’s development of it in analyzing
interaction has been the major source of its introduction into social sci­
ence (Coffman 1956, 1974). I build on the past work of several writers
who have used it in analyzing politics, including Murray Edelman (Edel­
man 1964, 1971). In my own earlier work I distinguished between in­
strumental and symbolic political acts (Gusfield 1963a). Instrumental
acts, such as social security legislation, effect behavior in a direct fashion.
Symbolic acts “invite consideration rather than overt action” (Wheel­
wright 1954, p. 23). I interpreted the temperance movement and Pro­
hibition less as politically significant through controlling alcohol use than
as ceremonial actions which affected the social status of those who sup­
ported or rejected an abstinent style of life and a moral condemnation of
alcohol. In this study I am more conscious of the mix of the instrumental
and the symbolic and much more aware of the complexity of symbolic
actions as modes by which public consciousness is itself constructed and
defined.
Kenneth Burke, the literary critic who has been the seminal figure of
dramaturgy, has taught us to be attentive to the language of metaphors
by which phenomena are presented, and in this study I am concerned
with knowledge, law, medicine, and technology as cultural patterns, as
metaphors by which a reality is presented.12 This method of analysis is

The Culture oi Public
Problems

itself dependent on a metaphor, that of the theater. 1 see public actions
and public policies as theatrical is to emphasize th< ritual, ceremonial,
and dramatic qualities of actions. It is to see public a ions, like plays, as
artistic, as constructed within conventions particular to that genre of
actions, just as dramas are staged within conventional understandings
between audience and performers.13
To see public actions as performances does not nerate group interests
in the character of those performances, as I stressed. iin finding social
status interests in the temperance issue. Nor d< *s it absolve the
sociologist from looking for self-serving and instru icntal elements in
otherwise symbolic and ceremonial behavior. Metap ors are important
for what they ignore as points of difference as we as for what they
include as marks of similarity.
I am also better informed about language and at ut the social construction of reality than was the case when I dev iped the view of
symbolic politics more than a decade ago. The belie •hat language and
logic are analyzable only as means of making statem ts about a factual
world has undergone much criticism in recent years ider the influence
of J. L. Austin and other linguistic philosophers, as -*11 as rhetoricians
and linguists (Austin 1962, 1971; Perelman and )lbrechts-Tytecka
1969; Jakobson 1966). To see that language can be it If action is crucial
to how I interpret the theater of public life—as mode )f presentation of
the speaker. To say that “there are nine million alco •lies in the United
States” is more than a statement about numbers; it is
expression of the
concern of the speaker with alcohol issues and his c< amitment to their
seriousness.
Public consciousness is then drawn into the actio of policymakers,
experts, and journalists. The rules of public perforn ice “front stage’’
are not those of private behavior “backstage.” In tl r behavior in the
public arena they create the order and consistency w i which “society”
is endowed. Public authority is engaged in preservit the illusion of a
predictable, consistent, and morally controlled univer , one in which the
facts about drinking and driving are clear. Consensus xists about heroes
and villains, and policy can be made because the aral and rational
grounds of authority are discoverable and evident. Ja k D. Douglas has
phrased my viewpoint well:

In such an uncertain and conflictful society, the bel; f in an absolutist
set of moral rules is important not only because it i reassuring and
because it helps one to control his nightmares of social chaos and
violence, but also because it helps the individuals involved in political

action to solve the fundamental problems of constructing or­
der ... the belief that a rational and ordered society is both possible
and already existing gives individuals the belief that their attempts to
construct social order will be successful. [Jack D. Douglas 1971, p.
308]
In its utilitarian and rational emphasis, social science has sought to
replace mysticism, irrationality, and blind conflict in public policy with
reason, knowledge, and scientific method. This study is less than en­
thusiastic about the success of this Enlightenment attitude. Peter Gay’s
description of the confidence of and “ideological myopia” of the En­
lightenment philosophes is appropriate: “They never wholly discarded
that final, r ^st stubborn illusion that bedevils realists—the illusion that
they were free from illusions” (Gay 1966, p. 27).

116

1/

e
c

The Seven Countries Study
A scientific adventure in

cardiovascular disease epidemiology

Editors:
Daan Kromhout, Alessandro Menotti and Henry Blackburn

Investigators and Contributors:
Ancel Keys, Christos Aravanis, Henry Blackburn, Frans SP van Buchem’,
Ratko Buzina, Bozidar S Djordjevic*, Anastasios S Dontas
Frederick H Epstein, Flaminio Fidanza, Martti J Karvonen
Noboru Kimura’, Daan Kromhout, Alessandro Menotti, Srecko I Nedeljkovic
Aulikki Nissinen, Maija Pekkarinen , Vittorio Puddu’, Sven Punsar
Leena Rasanen, Henry L Taylor', Hironori Toshima
’ deceased

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The Sevei^
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cardiovasc

Editors:
Daan Krom bout
Daan Kromhout
Professor, Director Division of Public Health Research
National Institute of Public Health and Environmental Protection
P.O. Box 1, 3720 BA Bilthoven, The Netherlands
Alessandro Menotti
Professor, Director
Laboratory of Epidemiology and Biostatistics,
Istituto Superiore di Sanita
Viale Regina Elena 299,1-00161 Rome, Italy
Henry Blackburn
Mayo Professor, Division of Epidemiology
University of Minnesota
Suite 300,1300 South Second Street, Minneapolis,
MN 55454-1015, USA

4

I
Ancel Keys, Christos A
Ratko Buzina, 1
Frederick H Ep
Noboru Kimura*, Daan K
Aulikki Nissinen, M
Leena Rasan

14
Major results of
THE SEVEN COUNTRIES STUDY
H. Blackburn and A. Menotti

Demonstration of Feasibility

Prior to the Seven Countries Study (SCS) no one had attempted to compare cardiovascular disease (CVD) frequency and risk between defined populations in a
systematic manner. The SCS demonstrated that with goodwill, planning, and hard
work, leadership and collaboration could be found, funding obtained, and research
carried out, despite many difficulties.

Population Differences: Cross-sectional

The SCS was the first to establish credible data on CVD prevalence rates in contrasting populations, with differences found on the order of five to 10 fold in coronary
heart disease (CHD). The SCS was the first to document'poputation-differenresTn
the means and distributions of serum cholesterol, with the dramatic example of the
almost non-overlapping values between men of the same age in Japan and eastern
Finland of the 1960s. The SCS demonstrated remarkable differences in composition
of diet in otherwise similar rural, stable, agricultural-pastoral populations: between
and 22% for saturated fatty acid calories daily and 9 to 40% total fat calories.
Detailed, deciled distributions were reported for the first time of skinfolds;
height, weight and relative body weight; systolic and diastolic blood pressure, and
serum cholesterol for all areas of all seven countries.
The concentration of blood serum cholesterol at entry showed greater differ■ nces among the 16 cohorts than any other risk factor. The mean ranged from 160
nig/dl or less in Serbia and Japan, to 260 mg/dl in Finland. There was a low order
individual correlation of serum cholesterol with age, blood pressure, and body
mass index.

Entry surveys found lack of individual correlation between electrocardiologic
’indings of left axis deviation and major risk characteristics, and strong correlations
between: high amplitude R waves on ECG and systolic blood pressure; negative
1 -waves and systolic blood pressure; post exercise ST depression and sum of skin159

folds and systolic blood pressure. There were negative associations of exercise ST
changes and cigarette smoking; strong positive associations of left ventricular
hypertrophy and heavy work; and strong relationships of infarct Q waves to serum
cholesterol and systolic blood pressure.

Population Differences: Follow-up

The SCS was the first to establish credible data on CVD incidence rates in contrast­
ing populations, with differences on theorder of six to eightfold in CHD. The 5-year
follow-up found favorable all-cause death rates in Greece, Japan, and Italy com­
pared with the other areas, as well as a lower incidence rate of coronary disease and
new electrocardiographic findings in those areas.
A remarkable excess was found of 5-year deaths among those with an old infarc­
tion, in the order of 10- to 20-fold.
Ecologic correlation was weak between CHD incidence and the proportion of the
population sedentary, overweight, or obese, or with elevated systolic pressure >160
mmHg. Diastolic pressure >95 showed, however, a strong relationship with CHD.
The strongest consistent relationship was between the population prevalence of
entry serum cholesterol values greaterthan 250 mg/dl and CHD incidence. There
was also a strong correlation of CHD incidence with saturated fatty acid intake at
entry.
Low CHD rates in a cohort were not compensated by an excess of other death
causes. Total, all-causes death rate reflected well the death rates from CHD.
There was an indication overall of the importance of blood pressure and serum
cholesterol in individual prediction of 'hard criteria' of coronary death and infarc­
tion, a lack of significance of body weight, significance of smoking habits in U.S. but
not in European cohorts, and weak relationships of CHD with physical activity.
In the 10-year follow-up experience, among the 12,000-man cohort free of CVD
at entry, the 10-year total death rate was less than 75/10,000 in Crete, Japan, and
Croatia and was 250 or greater for Finland, U.S. Railroad, Zutphen, and Serbia.
Correlation of CHD death rates in Seven Countries cohorts with WHO vital sta­
tistics on coronary deaths was 0.98; for all-causes death rates the correlation was
0.86, indicating that SCS cohort data have generalizability to regional and national
experience.
A higher death rate from neoplasms in northern Europeans was due to a three­
fold excess of lung cancer.
It was found that age standardization by single years of age is required in analysis,
due to the strong influence of age on incidence of CHD. For example, the difference
of one year of age in 10-year CHD incidence was 5 to 6%.
The individual correlation of age with major risk factors was trivial, but age was
160

the strongest risk predictor for CHD incidence and death from all-causes. However,
despite the great difference inCHDTates, the force of age itself, in regard to the

incidence of hard CHD, was similar between northern and southern Europe.
In all areas,, meu in the top 20% of the age-specific distribution of blood pressure
at entry had twice the incidence of CHD, and this was similar for all areas.
All-causes death rates were only slightly correlated with average serum choles­
terol level, while there was a highly significant correlation of cholesterol level with
10-year CHD deaths and a negative correlation with all causes of death other than
CHD combined. Thus, the SCS was one of the first studies to demonstrate the
inverse relationship between serum cholesterol level and non-cardiovascular dis­
ease risk.
Serum cholesterol concentration was a particularly important individal risk factOr for CHD at levels greater than 220 mg/dl, while at less than 200 mg/dl, decreas­
ing cholesterol concentrations tended to be associated with increasing rates of non­
coronary death.
Strong prognostic power was found of the ECG, particularly for ischemic and
junctional type ST depression after exercise, for negative T waves independent of ST
depression, and for post-exercise arrhythmias. The prognostic importance was
shown of major Q and QS waves, and of negative T waves and atrial fibrillation.
A remarkable finding was that in Italy, Greece, and Japan cigarette smoking was
a minor risk factor for all-causes and CHD deaths, in part due to few CHD events.
In the other cohorts there was a strong individual relationship of smoking to coron­
ary and non-coronary causes of death, and the risk of cancer rose linearly with cig­
arette smoking dose.

Weight and Physical Activity

Cohort differences in 10-year CHD death rates were not significantly related to
average relative weight or obesity. Within none of the areas was relative overweight
or obesity associated with excess risk of all-causes death. In fact, total deaths were
mrcrseh/ related to relative body weight and obesity in Finland, Croatia, Italy,
Greece, Serbia, and Japan. Ten-year incidence of coronary heart disease was not sig­
nificantly related to body mass, and the probability of death (all cause) in 10 years
was least for men with greater than average relative weight or fatness.
Distributions of physical activity of occupation did not explain cohort differ­
ences in the incidence of CHD. Where physical activity was important in predicting
individual risk of coronary disease or early death, it seemed to be due to interrela­
tions with other risk factors. However, few of the occupations represented in the
SCS involved heavy, anaerobic work.

161

Other Characteristics

Resting heart rate was significantly lower in men active physically, and 10-year
death rate was linearly related to the entry pulse rate.
An increase of one year in age was associated with an average decrease of 1% in
vital capacity and 1.4% decrease in 3/4 second FEV. Timed vital capacity was signifi­
cantly and inversely related to all-causes deaths, though CHD was unrelated to entn
vital capacity. Timed vital capacity was more prognostic than total vital capacity.
For diet, within-individual variation in the same cohort was of the same order as
between-individual variation. This provided another demonstration of statistical
theory: under such conditions, individual serum cholesterol and nutrient composi­
tion of diet cannot be found correlated without repeated surveys to reduce the
effects of intra-individual variation.

Multivariate Analyses

Partial correlation analysis, including dietary saturated fatty acid content, found no
significant correlation between dietary sucrose and CHD incidence. Cohort compar­
isons showed the strongest correlation of milk and cheese with CHD incidence.
Only two entry risk variables were significantly related to differences in CHD
incidence among cohorts: blood pressure and blood cholesterol, accounting for 40
and 42% of the variance in CHD death rate. Together, they accounted for about
two-thirds of the variance.
The risk of 10-year deaths from all-causes was least for men above average in
relative body weight and skinfolds in multivariate analysis, including other major
risk factors.
In multivariate analysis, habitual physical activity and resting heart rate at entry
were significant predictors of all-causes death and coronary death in Europe.
Systolic and diastolic blood pressure were highly significant risk factors for
death and CHD incidence in multiple logistic analyses, but neither was superior.
Multivariate discriminatory power of risk factors for CHD death was far superi­
or to their prediction of all-causes death.
Multivariate solutions from experience in one area gave generally good predic­
tion of relative CHD risk in other areas but gross errors in prediction of absolute
risk. The 'southern solution', for example, greatly underestimated the absolute risk
of coronary deaths in northern European cohorts. These multivariate analyses
across cultures lead to two possible conclusions: 1) at entry, measurements were not
representative of long-term characteristics of men in the different areas, or 2)
unidentified variables, unrelated to those considered in the SCS, contributed to the
increased risk of Americans and northern Europeans, or alternatively, were
'protective' in southern Europeans and the Japanese.
162

In all European areas there was a significant rise in mean serum cholesterol in
the first 10 years of the SCS. This trend upward in cholesterol was more marked in
southern than in northern Europe, more marked in the younger men than in the
older and was presumably based on dietary changes on-going in Europe.
The specter that a low incidence of CHD necessarily involves a trade-off with
other, less acceptable causes of death, was laid to rest. The SCS gave clear demon­
stration of the contrary that CHD deaths are generally unrelated to death rates from
other causes in these relatively developed countries. The conclusion is that effective
prevention of CVD does not necessarily lead to enhancement of other causes of
death, but rather, can result in lower age-specific death rates overall!

Design and Method Innovations

The SCS was probably the first, and certainly the first in cardiovascular disease
(CVD) epidemiology, to carry out cross-sectional surveys of populations contrasting
in diet, in samples adequate to demonstrate differences in prevalence and early\ ear incidence, as well as to combine this with cohort follow-up for incidence and
mortality, for up to 30 years in many areas.
The SCS demonstrated the validity of dietary survey methods to characterize the
diets of whole populations, and made important contributions to the measurement
of individual and population diets.
The SCS made basic contributions, as well, to the methodology of population
studies with respect to electrocardiographic classification, clinical procedures, risk
factor measurement, blood lipid analyses, and skinfold measurement.
In addition, contributions were made to sampling for epidemiological surveys.
Less than perfect response rates do not necessarily mean biased samples in regard
to physical characteristics. Moreover, complete responses in rural villages may re­
present the generality of rural men of an entire country.
Many contributions were made, as well, to the practicalities of fieldwork, includ­
ing the number of people per day examined, number of days or number of weeks in
the field, timing of the field work in regard to local conditions, establishing a roster,
engaging local assistants, transportation, and training and organization of the field
team.

Methodological deficiencies were found of occupational classifications in respect
to physical activity.

Population Correlations

• he SCS was the first to compute population (ecologic) correlations between risk
factors and disease incidence, demonstrating significant population correlations as
163

well as thresholds for atherosclerotic diseases and establishing the precision with
which CHD death rates can be predicted by knowledge of the average serum cho­
lesterol level of a population, and the increasing precision of that prediction over a
15-year follow-up.
It also demonstrated the remarkable departure from the prediction line for par­
ticular populations such as East Finland, where CHD rates were greater than pre­
dicted by the mean serum cholesterol values and the island of Crete, where the rates
were less than predicted by those values, opening important new questions about
causation.

The Force of Risk Factors

The SCS was the first CVD study to apply partial correlation coefficients derived
from relationships between risk and disease incidence found in one country or
group of countries to those in another. This showed the universality of risk factors
as predictors of individual relative CHD risk in widely contrasting cultures. But the
SCS was also the first to demonstrate the different force of a risk factor in popula­
tions and in individuals, finding the slope of the individual risk factor-CHD rela­
tionship approximately twice as great in the United States as in Europe, and in

northern as in southern Europe.

Risk Factor Changes

The SCS was among the first to demonstrate dramatic changes in a decade in both
directions (in means and distributions of risk characteristics in whole populations),
confirming the overwhelming role of culture and environment in determining dif­
ferences and changes in chronic disease risk, particularly cardiovascular diseases.
The SCS was among the first to demonstrate the predictive importance of change
in risk characteristics, suggesting the particular importance of population change in
cholesterol and blood pressure levels in the risk of cardiovascular diseases.

Long-term Prediction

The SCS was one of the first to examine, in prolonged cohort follow-up study/ the
relationship between baseline risk characteristics during health and subsequent lon­
gevity, variously defined as survival for 25 years, or to age 75, or 85. It showed the
importance of cigarette smoking in long-term survival, the lesser contribution of
blood pressure, and the very little contribution of serum cholesterol and body mass
index.

164

The SCS was one of the first to illustrate the variety and complexity of the rela­
tionship between body weight, body mass and obesity, and disease rates, including
total mortality and survival. The shape was highly different between cultures, from
absolutely flat relationships, for example, of weight measures with CHD, to
U-shaped or inverted U-shaped, to monotonic linear positive relationships, and in
occasional cases, even inverse relationships. The more recent findings of Keys sug­
gest that in some cultures longevity and survival are actually greater in those who
gain weight in middle age than in those who do not gain, or who lose weight.
Fifteen-year mortality follow-up confirmed the experience of the 10-year follow­
up in all regards: risk functions of northern Europe and the U.S. overestimated the
coronary mortality of southern Europe, and half of the area differences in CHD
death rate were explained by average blood total cholesterol level alone, with little
added contribution from the other major risk factors.
Population (ecologic) correlations among the 16 cohorts of the ratio of monounsaturated to saturated fatty acids were inversely related to CHD, cancer, and
all-cause mortality.

Twenty-year follow-up mortality revealed that 81% of the difference among
cohorts in CHD deaths could be explained by mean saturated fatty acid intake.
Individual correlations revealed that age and blood pressure were the only con­
sistent universal predictors of individual risk of CHD and all-causes death. An in­
verse correlation was found between blood cholesterol levels and stroke mortality.
The time integral of the changing level of risk factors during the first three sur\ eys, largely independent of the initial level, enhanced prediction of subsequent
mortality.

Twenty-five year follow-up revealed a reduced predictive power of entry choles­
terol level for long-term CHD mortality. This long-term follow-up found re­
ordering among the cohorts' ranking of coronary mortality rates, with Zrenjanin
' Vojvodina) eventually achieving the highest rates. Absolute and relative increase in
coronary mortality was greatest in Zrenjanin and Velika Krsna (Serbia), ac­
companied by very large increases in average cholesterol levels, especially in
Zrenjanin, far greater than in other southern European cohorts. This contrasted to
no change, or to decreased cholesterol levels, in northern Europe and the U.S.

Public Health Implications

• rederick Epstein has, in this volume, summarized elegantly the public health
■mplications of these SCS results. It is fitting that this be done by a person outside
'•He investigators group, yet a person having a longstanding professional interest
■’’id a supportive role in Seven Countries undertakings.

Clearly, a major result of the SCS has been the concept of population causes and
phenomena involved in mass diseases such as CHD, hypertension, and stroke. We
have come to appreciate that we are dealing with mass cultural phenomena that
influence already widespread individual susceptibility and lead to the heavy popu­
lation rates of disease. This concept has played the central role in development ot
the population strategy of prevention, complementing the individual medical strat­
egy. It has stimulated the research on population causes and on community-wide
preventive strategies which characterizes the on-going work of Seven Countries
investigators.

166

15
Public health implications
OF THE SEVEN COUNTRIES STUDY
F.H. Epstein

Ancel Keys never wrote or talked much about public health as
such but rather contributed to its mission and success. However, it is interesting
and important that 'public health' is part of the title of a historical paper, based on a
lecture presented in 1953, in which he presented, for the first time, his views on the
relationship between cholesterol and the diseases due to atherosclerosis (1). In the
introduction, he points out that the frequently narrow concept of public health
should be extended to wider horizons, 'to prevent or decrease the incidence of all
forms of illness and disability, not merely those that are infective or occupational in
origin'. Keys states that major public health attention is required when there are
large numbers of the population suffering disability and death from diseases for
which private medical practice is making little headway, and when there is hope
that measures applicable to the general population can be found to alter the inci­
dence of these diseases; he adds that coronary heart disease fulfills these conditions.
It is clear, therefore, that Keys had the public health implications of his work in
mind from the very beginning. The Seven Countries Study is, as Keys states in his
own contribution to this book, the culmination of work which began in Minnesota
m 1947. But it took some 10 years for the major project to get under way after com­
pletion of the many exploratory investigations in the intervening years.
The definition of public health is not as evident as it might seem. One proposal is
that it'... consists of all the things we as a society do collectively to assure the condi­
tions in which people can be healthy' (2). This definition has the sanction of a spe­
cial committee of the Institute of Medicine of the National Academy of Sciences of
the U.S.A.; it is appealing in being broad, broad-minded, and functional. It will
x-rve the present purpose very well. Under this definition, it is unnecessary to
debate to what extent research into the causes of disease falls within the domain of
public health, or whether the application of the results of this research is entirely
w ithin its realm. All that matters is how the targets can be reached most effectively
•md efficiently! Along this road there is a continuum from observational studies,
hke the Seven Countries Study, to testing the results for causality between predis169

posing factors and disease risk by means of intervention studies, and applying the
knowledge and understanding gained toward prevention. The Seven Countries
Study stands at the beginning of this chain but has had a decisive influence all the
way along its course. The present assessment is concerned with the final link, trying
to evaluate the impact of the study at the public health level.
Before proceeding further, it goes without saying that no study is an island, like
'no man is an island'. The role of each study must be viewed within the context of
the contributions of all the investigations which, over the years, have helped to
build up the available knowledge on, in this case, cardiovascular disease epidemi­
ology. An attempt has been made to summarize the saga of this success story (3). In
the case of the Seven Countries Study the task is somewhat simplified by the fact
that, among the studies which permit international comparisons, it really has no
equal. In part, it is an ecological study which makes it possible to relate disease inci­
dence, not just mortality from national statistics, to risk factors and lifestyles, meas­
ured by comparable methods; this ecological component has a partial counterpart in
the MONICA Project. There is no counterpart to the prospective component
because, in no other study, have incidence as related to lifestyles and risk factors
been measured according to the same study protocol by the same, standardized
methods. There are many separate prospective investigations of coronary heart dis­
ease in a number of countries which attest to the universal validity of the risk factor
concept in regard to cholesterol, blood pressure, and smoking, but the incidence
data are not comparable as the diagnostic criteria are not the same. Another unique
feature of the Seven Countries Study is that it combines the advantages of ecological
and cohort studies, while largely avoiding the pitfalls of the 'ecological fallacy' since
data based on individuals are available at the same time.
No finding from the Seven Countries Study had a greater impact than the
sequence leading from dietary habits, especially in terms of dietary fats, to the lipid
content of blood, in particular cholesterol, and from there to coronary heart disease
risk. In most epidemiological investigations, data on diet are lacking and, if avail­
able, are limited in their usefulness for characterizing individuals, on account of
measurement error and variability. In the Seven Countries Study, ecological dietary
comparisons of groups are supplemented by the dietary investigations of individu­
als under controlled conditions, carried out independently by the Laboratory of
Physiological Hygiene. Drawing on all sources of data, the study has provided the
strongest existing evidence that the risk of coronary heart disease is linked to the
consumption of saturated fat, and that this relationship is mediatecTby serum cholesterolCThis, of course, is the basis for the current”conviction that reduction of saturated fat intake will lead to a reduction of coronary heart disease risk. Firm support
comes from preventive trials, but these are confined to high-risk groups and mostly
use drugs rather than dietary modification for lowering serum cholesterol. The
170

results from the Seven Countries Study permit, more than any other data singly or
collectively, important though they are, the extrapolation from high-risk groups to
the population at large. They are a cornerstone, therefore, of the population strategy
of prevention related to diet and serum lipids.
Beyond serum cholesterol and its determinants, the Seven Countries Study has
contributed important cross-cultural data on blood pressure which is related to dis­
ease risk in all the areas. The same does not apply to smoking or physical activity.
This does not in any way suggest that they are not important, but indicates that the
constellations of risk factors which add up to total coronary heart disease risk may
not be exactly the same in different parts of the world. Furthermore, evidence from
other studies must be taken into account, as well as the statistical power inherent in
different studies. No single study can answer all questions, but there are few if any
studies which have contributed at the same time to as many answers, definite or
tentative, as the Seven Countries Study. In the present context, from the all-impor­
tant point of view of coronary heart disease prevention, the outstanding finding is
the demonstration that countries can be graded along a scale of disease risk, and
that this risk is related to a series of lifestyles and risk factors. Without the Seven
Countries Study, this knowledge would have to be pieced together from a variety of
sources which often lack comparability or reliability. These studies also give each
participating country a measure of its own risk status and the factors which influ­
ence it. From this, high-risk countries can draw the lesson how to become a low-risk
country and low-risk countries can learn how to become or not to become a highrisk country. Examples of the former are the U.S.A., Finland, and the Netherlands
that showed large decreases in CHD mortality during the last two decades. An
example of a low-risk population that became a high-risk population is the Serbian
cohort Zrenjanin (Vojvodina). The latter lesson is of prime importance to the devel­
oping part of the world. It would be very unfortunate if the Seven Countries Study
were viewed only within its own confines, without realizing that its findings can be
extrapolated to countries resembling those which are included in it. This is one of
its great strengths!
The bearing of the study on the population strategy of prevention has already
been pointed out. For optimal prevention on the community level, the high-risk
strategy must supplement it. While practicing physicians must be involved in both
strategies, their immediate role is the protection of people at high risk. Ancel Keys
had striking success in enlisting the collaboration of clinicians, many of them lead­
ers in their own countries, both in the Seven Countries Study and, importantly, in
the field studies which preceded it in the late 1940s and in the 1950s. Through them,
the seeds of thinking in terms of epidemiology and prevention, and of becoming
’■ngaged in these fields, were planted in a good many countries, both within and
'‘utside the Seven Countries Study. It would be impossible to gauge the influence of
171

these physicians and their publications, separately and with the Minnesota team,
but, empirically, the 'spirit of prevention' seems to be, on the average, more alive in
their countries. A certain international halo-effect of these activities also appears to
be evident. Perhaps one of the messages of the Study is that medical people support
epidemiology and prevention more strongly if they get themselves involved in their
pursuit. One of the obstacles to public health action in coronary heart disease pre­
vention is the frequently passive or negative attitude of the medical profession.
Practicing physicians are essential 'agents of change' in promoting prevention and
the Seven Countries Study has had an impact on these developments.
The influence of the Seven Countries Study, along with the total effort of the
Laboratory of Physiological Hygiene, on research into the causes and prevention of
atherosclerosis and its consequences is immense. In his introduction to the first
Ancel Keys Lecture, Blackburn has tersely and impressively addressed this point
(4). It is not only a matter of the huge amount of work done but having opened, in
many ways, a new world which stimulated an immeasurable amount of work car­
ried out by others. To this must be added the leadership which Ancel Keys and his
senior associates assumed nationally and internationally to further epidemiological
research, and to apply the results in the cause of prevention. There is no doubt that
all of this dedicated and successful effort played a major role in initiating and inten­
sifying epidemiological research, including the big intervention studies, and the
development of national programs for the prevention and control of cardiovascular

diseases, both in the United States and some other countries.
How does research lead to action on the public health level? Cardiovascular dis­
ease, being a health burden of epidemic proportions, demands preventive action
encompassing the whole population. The required action needs collaboration of all
people in the population, whether or not at elevated risk, the physicians in the com­
munity, the health agencies from the local to the national level, professional so­
cieties, the media, research workers and organizations, and policy makers. This
chapter is concerned with the public health implications of the Seven Countries
Study. Has it influenced preventive action on all of these levels? Most likely it has,
but it would be hard to arrange the targets in order of the impact which the Study
had on them. Does it matter? Can we do more than give our best in doing good
research and see to it that those in a position to turn it into action are aware of the
scientific evidence and its implications? In the Seven Countries Study, all of this has
been done!
The Seven Countries Study has not only provided crucial evidence for the poten­
tial of coronary heart disease prevention; it has also created a new model and
approach for studying geographical differences in the frequency of non-communi­
cable diseases and searching for their causes. In his review of Ancel Keys's book on
the Seven Countries Study, Stallones writes: 'Keys's contributions to the epidemi-

172

ology of coronary heart disease are enormous, but this report suggests that what he
has begun may be far greater even than what he has done.' (5) The public health
implications of this monumental work, therefore, will in all probability, extend to
horizons which cannot yet be seen.

173

< Health promotion, in the perception of WHO, can, for the above reasons,
] only succeed if it is:
* integral, i.e. covering the health problem with various policy in­
terventions which should be tuned to each other;
*
intersectoral, i.e. involving many sectors from different societal, gov­
ernmental and private spheres in a coordinated effort;
I
*
comprehensive',
I *
participatory,
*
mobilizing resources for health, i.e. enabling and empowering indi­
viduals, groups, communities and organizations to improve health
and health determinants;
*
in pursuit of healthy public policy, i.e. advocating policies to advance
health or hinder policies with detrimental effects on health.
Reformulated into five major principles, health promotion:
* involves the population as a whole in the context of their everyday
lives, rather than focusing on people at risk for specific diseases.
* is directed towards action on the determinants or cause of health, not
on individual behavioral change.
* combines diverse, but complementary, methods or approaches.
* aims particularly at effective and concrete public participation.
* Health professionals -particularly in primary health care- have an
important role in nurturing and enabling health promotion.
Five subject areas have been stated;
* Access to health ?
j * Development of an environment conducive to health — )
Ch
Strengthening of social networks and social supports
*
Promoting positive health behavior and appropriate coping strategies - a
key aim in health promotion
Increasing knowledge and disseminating information related to health.
A model has been developed in order to position this notion in its societal
context (figure 3). The shaded area on the left is called ‘problem definer
field . On the basis of certain data, using information which is transferred to
and from all the participants in the ‘problem definition process', the prob­
lem is formulated, and preferred options and interventions put forward;
this is a intersectoral process, which should result in an integral and in­
tersectoral policy choice to be filtered through the cultural, social, econom­
ic, organizational and societal ‘intermediate determinants’. Ito (1982),
finding the foundations for his approach in the works of among others
Mechanic (1974), Heidenheimer, Heclo & Adams (1975) and Wilensky
(1975) has called the two fields on the left of the model (‘problem definer
field’ and ‘intermediate determinants’) the ‘policy-making environment'.
We will expand on policy-making matters in paragraph 3.3.2, and suffice to
say here that the exact policy options, interventions, work types to be
involved, budgets, interests to be protected etc. are developed in the
shaded area on the left of the model, and then formulated through the

22

HUMAN
BIOLOGICAL

PRESSURE GROUPS
ADVOCATING STATUS QUO

SERVICES

I

CULTURAL

HEALTH
PROMOTION

SOCIAL

HEALTH
EDUCATION

POLITICS

ECONOMIC

BEHAVIOR

EQUITY

HEALTH

ORGANIZA­
TIONAL

♦
SOCIETAL

PRESSURE GROUPS ADVO­
CATING HEALTHY PUBLIC
POLICY

f

PROBLEM DEFINER FIELD

J I

SUPPORT
SYSTEMS

BIOSPHE RICAL
INTERMEDIATE
DETERMINANTS

DETERMINANTS

Figure 3: A model to position health promotion in the societalcontext.

Co—<

constraints and stimuli of the cultural, social, economic, organizational and
societal intermediate determinants into factual operational terms. It ap­
pears that there is very little research done on the subject of exact processes
of problem definition and operationalization on this scale (cf. Ito (1982), de
Leeuw (1985) and Milio (1987)).
The interventions which have been chosen will influence the ‘determinants'-column, that is, scope and scale of services to be rendered are
determined, individual and collective behavior may be influenced (cf. our
definition of‘policy' given above!), and support systems (general needs and
prerequisites, food, shelter, a ‘monetary social minimum income', etc.) are
shaped by the options considered in the policy-making environment. A
better distribution of these may result in a more equitable distribution of
health and risk, and therefore, in a more favorable health situation in a
given population.
< In chapter five we will further illustrate the above notions related to this
1 approach chosen for health promotion.

I

24

SUMMARY AT

NTRODUCTION

components of cardiovascular disease and cancer have constituted a very
small portion of the research effort in these fields.
Philanthropic foundations can play a path-breaking role, but they cannot
take primary responsibility for progress in this sphere. Similarly, contri­
butions from industry, except for drug development, are modest and are
unlikely to increase greatly in the near future, except where applications
of biotechnology are foreseeable. Altogether, there is a remarkable dis­
crepancy between unprecedented scientific opportunities on the one hand
and diminishing suppott for research on the other.

Concluding Perspective

Given deep national concern and strong data on the contribution of be­
havioral factors to the national burden of illness, do scientific opportunities
exist to form the basis of a logical response to this great challenge? The
bulk of this report examines various lines of potential scientific inquiry.
Many substantial opportunities for research do in fact exist. They offer the
promise of revealing the linkages of behavior to health and the potential
of suggesting more effective therapeutic and preventive interventions in
the future. This being the case, the present low level of funding for research
in this sphere deserves serious reexamination. It would be tragic to allow
a prolonged decline in support at a time of expanding scientific opportunity.
A principal opportunity for health science policy today is to find ways to
bring support of the promising lines of research described in this report
into more rational alignment with costs to society of the heavy burden of
behavior-related illnesses.

7

Summary

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SEI E MCE B

health

This report assembles the informed assessments of more than 400 leaders
in the biomedical and behavioral sciences on problems of great importance
to the health of people everywhere. These scientists participated in a series
of novel studies and conferences convened by the Institute of Medicine
over the past few years to consider thoroughly the linkages between health
and behavior. They examined the extent of behavior-related disease and
disability and evaluated scientific approaches to understanding, treating, and
preventing such illnesses. Each chapter of this report highlights especially
promising lines of inquiry. These research directions, selected from the
large array of possibilities considered, have great potentiality for future
progress and deserve vigorous pursuit.

Nature and Scope of the Problem
The heaviest burdens of illness in the United States today are related to
aspects of individual behavior, especially long-term patterns of behavior
often referred to as “lifestyle.” As much as 50 percent of mortality from
the 10 leading causes of death in the United States can be traced to lifestyle.
Known behavioral risk factors include cigarette smoking, excessive con­
sumption of alcoholic beverages, use of illicit drugs, certain dietary habits,
reckless driving, nonadherence to effective medication regimens, and mal­
adaptive responses to social pressures.
One important advance of the twentieth century is recognition that it is
possible to employ scientific methods to gain a better understanding of
3

SUMMARY AND II

ODUCTION

auman behavior. The task is difficult and complex, but human behavior
can be observed systematically, reliably, and reproducibly. As knowledge
progresses, observations can become increasingly quantitative and have
considerable predictive power. Human behavior is sufficiently regular to
permit dependable, specific propositions about patterns and themes. Under­
lying causes will be identified with more certainty when the intimate in­
terplay between genetic and environmental factors and the rich variability
of individuals and societies are taken into account.

The Health and Behavior Project
Over the past few years, the Institute of Medicine, National Academy of
Sciences, has been responding to the heightened awareness of behavioral
factors in health in a variety of ways. This study, Health and Behavior: A
Research Agenda, was a natural extension of such interests. The Assistant
Secretary for Health of the Department of Health, Education, and Welfare
asked the Institute of Medicine to collaborate with the National Institutes
of Health and the Alcohol, Drug Abuse, and Mental Health Administration
to (1) clarify the behavioral aspects of selected major public health problems;
(2) delineate the biobehavioral sciences’ contributions to and future pros­
pects for improving the diagnosis, treatment, and prevention of serious and
widespread illnesses; and (3) facilitate strengthening of the biomedical and
biobehavioral sciences in these areas.
The two and one-half year project had two components, both conducted
by a broadly interdisciplinary steering committee. The first part of the study
consisted of six invitational conferences. At each, a small group of scientists
and health practitioners from a range of relevant disciplines considered
biobehavioral research issues relating to a major health problem. Summaries
of highlights and promising lines of inquiry for each conference were pub­
lished (Appendix A).
This volume constitutes the second part of the Health and Behavior
project. Drawing on conference summaries, related Institute of Medicine
reports, and other recent major studies, the committee has attempted to
integrate available information into a perspective of the frontiers of the
biobehavioral sciences, of their relevance for public health, and of impli­
cations for science policy. Coverage is broad but not exhaustive. Rather,
this monograph describes briefly many promising research directions at the
interface of health and behavior. Still, we have tried to include represen­
tative samples of the many components of the biobehavioral sciences that
can contribute to effons to improve the health of people in the United
States and throughout the world.

Summary

5

Scope of the Biobehavioral Sciences

The term biobehavioral sciences is used in this volume to refer to the panoply
of basic, applied, and clinical sciences that contribute to an understanding
of behavior. Thus, the term includes not only the behavioral sciences that
conduct experimental analyses of animal and human behavior but also such
basic sciences as neuroanatomy, neurology, neurochemistry, endocrinology,
as well as the fields of psychology, psychiatry, ethology, sociology, and
anthropology. Broadly inclusive, this term transcends the many changes in
specialties and subspecialties that currently characterize the area. Fields of
overlapping interests are emerging constantly, with such names as behavioral
genetics, psychoneuroimmunology, immunohistochemistry, physiological
sociology, or behavioral medicine. All are part of the biobehavioral sciences.
The Contribution of Behavior to the Burden of Illness

Many measures have been employed to assess the societal and personal
impact of disease, including disease prevalence, death rates, economic costs,
drain on health care resources, and activity restrictions such as lost work.
Regardless of the measure used, diseases in which behavior may play a
significant role constitute a major component of the current burden of
illness in the United States and other developed countries (Table 1).
Research has confirmed that some behaviors are major risk factors of
disease. For example, people who smoke cigarettes expose themselves to
risk as surely as does someone who ventures unprotected into a swamp
known to harbor malarial mosquitoes. To be termed a risk factor, the
behavior must be present before the disease begins, rather than constituting
an early disease symptom, for example, as coughing is an early indication
of lung disease. However, a risk factor need not cause the disorder. It may
be closely associated with some underlying process that eventually produces
the disease state. Once a behavior is identified as a risk factor, additional
studies are needed to determine whether changing the behavior is of any
value in preventing or treating the disease.
Mortality and Morbidity

Almost two million deaths each year in the United States are caused by
cardiovascular diseases, cancers, accidents, violence (including homicide and
suicide), diabetes mellitus, cirrhosis of the liver, and respiratory diseases.
Premature mortality”—death before the usual life expectancy—is an im­
portant aspect of the burden of illness. To assess the relative impact of
different disease categories, potential years of life lost can be calculated

TABLE 1

Burden of Illness in the United States in 1974
Percent of the Total

Accidents,

Cardio­

Total

Poisoning,

vascular

Mental

Measure

(millions)

Violence

Cancer

Diseases

Disorders

Deaths
Potential years of life lost
Short-stay hospital days
Long-term care days
Physician office visits*
Work loss days
Bed days
Social Security Disability benefit days
Causes of major activity limitations
Direct cost dollars'

2
33
255
616
521
461"
1,783"
561
34"
99,000

8
17

19
18
10
1
2
2
4
9
2
5

53
37
19
27
11
8
13
27
23
16

11

3
9
18
9
7
4
7

Other

1

19
27
54
29
72
69
71
37
67
62

1
6
40

6
3
3
20
4
10

" More than one condition may cause a work loss day, a bed day, or a limitation in major activity. Days or limitations thus may be counted more than
once. For the 22 million persons reporting major activity limitations, there were ani average of 1.5 chronic conditions per person. There were an
estimated 1,392 million bed days; each bed day was counted about 1.3 times. There were
’
414 million work loss days; each loss day was counted an
average of 1.1 times.
* For the year 1973.
' For the year 1975.
SOURCE: See Chapter 2, Table 2.1.

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i

SUMMARY AND INlKUDUCliUN

,s and overeating to obesity are present disproportionat
among pa­
ints’with high hospitalization costs. In a recent hospital survey, from 31
1 to 69 percent of the high-cost patients had at least one of these habits,
compared with 20 to 45 percent of lower-cost patients.
A variety of specific behaviors have been implicated as risk factors of
certain major physical and mental disorders. Behavioral factors identify
high-risk populations that might benefit especially from early disease de­
tection and intervention efforts. For diseases in which behavior has a caus­
ative role, interventions may be appropriate. However, it has become clear
that individuals often find it very difficult to change their lifestyles, even
in the face of known risks to health. Thus, research on prevention must
determine not only which behavioral changes are potentially beneficial but
also how such changes can be adopted and maintained.

Cigarette Smoking In the United States in 1979, one third of people over
19 years of age were current smokers—25 million men and 23 million
women; 3 to 4 million teenagers (about 12 percent of that age group) also
were current smokers. In a 12-year follow-up of one million men and
women in the United States, mortality rates were greater for smokers than
for nonsmokers regardless of age or sex. Risk consistently increased for
both men and women with increasing daily doses of cigarettes. Mortality
from respiratory tract cancers, emphysema, and cardiovascular disease is
especially prevalent among cigarette smokers. About 320,000 deaths an­
nually probably are linked to cigarette smoking. General morbidity mea­
sures also are considerably higher for smokers than for nonsmokers. For
example, in 1974 smoking resulted in 81 million excess workdays lost and
145 million excess days of bed disability.
Trends in the pattern of cigarette use by women of childbearing age are
of special concern. Since 1965, current smokers among women 20 to 44
years of age decreased from about 43 percent to 34 percent, but the pro­
portion of heavy smokers increased. Cigarette smoking during pregnancy
doubles the risk of having a low birth weight infant; about one third of the
incidence of low birth weight is attributable to cigarette smoking. Death in
the first year of life is 20 times more likely for low birth weight infants
than for heavier infants. There also is suggestive evidence of lower scores
on tests of intellectual function and higher frequencies of minimal cerebral
dysfunction, neurological abnormalities, and behavior problems among chil­
dren of mothers who had smoked during pregnancy.

Excessive Alcohol Consumption In 1979, 10 million adult men and women
in the United States were heavy drinkers, consuming an average of four

Summary
drinks per day; anoth. 3.5 million teenagers were heavy drinkers, con­
suming five or more drinks per drinking occasion. Overall mortality rates
are higher for heavy drinkers than for lighter drinkers or nondrinkers. In
a study in the United States, mortality was 2.5 times greater than expected,
with the greatest increase among younger alcoholics. Cirrhosis of the liver
accounts for 60 to 80 percent of alcohol-related deaths. Alcohol use also
contributes to many accidents, suicides, and homicides. In 1975, the direct
and indirect cost of alcoholism was estimated to be about $43 billion.
Pregnant women are at special risk of problems from alcoholism. Heavy
drinkers are more likely to deliver babies who have the fetal alcohol syn­
drome, characterized by certain physical abnormalities and often associated
with mental retardation. Possible adverse effects even of moderate drinking
during pregnancy are being studied. There are reports of lowered viability
at birth, poor sucking ability, heart rate abnormalities, and various other
behaviors associated with poor functioning of the central nervous system.

Unhealthful Dietary Habits Major dietary inadequacies can seriously im­
pair health. Much current research focuses on adverse consequences of
excess consumption, for example, of calories and fats. Several studies have
shown a higher mortality rate for those markedly above average weight.
For people who are 20 to 30 percent overweight, mortality is 20 to 40
percent greater than for people of average weight; for those 50 to 60 percent
overweight, it is 150 to 250 percent greater. Obesity increases the risk of
hypertension, diabetes, and hyperlipidemia—each a risk factor for heart
disease. Also, obesity may be an independent risk factor of cardiovascular
disease. In addition, there is strong epidemiological evidence that high blood
levels of cholesterol are associated with increased rates of cardiovascular
disease and death; in part, this may be reflective of dietary intake of cho­
lesterol and saturated fats.

Scientific Opportunities: Major Disorders and Conditions
Certain behavior patterns such as cigarette smoking and excessive use of
alcohol contribute gready to many components of the current burden of
illness. For that reason, it is useful to focus directly on ways of helping
people not to engage in health-risky behaviors. For several important dis­
eases, including cardiovascular disease and some mental disorders, behaviorrelated factors appear to be closely associated with the production of the
disease or play a major role in aspects of preventing or treadng it. This
section examines issues about such behaviors and diseases that the biobehavioral sciences can usefully address.

1
•7

SUMMARY AND INTF

AUCTION

Stress, Coping, and Health

systems through which stress affects bodily function and studies of how
individuals cope with stress.
Major advances are being made in understanding the nervous system,
with recognition and detailed study of a rapidly expanding numbe.: of neu­
roregulators, the chemicals that control communication among nerve cells.
Increasingly sophisticated research is examining coordinated responses of
the nervous and endocrine systems to stressors. Genetic and environment^
factors pertinent to individual responses are being specified. Such research
offers the promise of establishing the steps between being exposed to a
stressor and developing a disease consequence. That knowledge is directly
relevant to devising better ways to treat and to prevent health-damaging

nhvsical and emotional stress responses.
Much has been learned about successful and unsuccessful coping patterns,
and there have been effons to apply existing concepts to prevention of
disease and promotion of health. One direction of inquiry involves early
adolescence—a major but neglected phase of human development that lends
itself to analysis of developmental tasks and coping strategies. Also impor­
tant is research on health-related decisions. For example, studies have shown
chat a sense of personal control helps people cope with stressful experiences
and affects their commitment to health-enhancing behavior patterns. In
addition, there is great interest in learning why some individuals cope bette
than others and in discovering ways to help people improve their coping
strategies. Further applications of such basic learning principles as operan
conditioning, social learning, and cognitive problem solving merit pursuit
in the years to come.

Alcoholism, Alcohol Abuse, and Health

person in the etiology of problem drinking and assoc.ated adverse hed h
effects. An individual’s physiological predisposinons are shaped by genetic
endowment and affected by fanuly, school, work place, and other social

Summary

11

It still is unclear exacts ^hich of alcohol’s many effects are most relevant
to alcoholism. Among promising lines of research are studies of acute and
chronic effects of alcohol and its metabolites on cell membrane fluidity and
neuroregulator function. Animal and human evidence of a genetic contri­
bution affirms the value of a continued search for specific genes that place
an individual at higher risk for alcoholism. In conjunction with psychological
and social approaches, basic physiological research may suggest ways to
identify people at high risk for becoming alcoholics.
Relationships among the stress of life events, social supports, and various
styles of coping are a rich area of research opportunity. Young adolescents
are a high-risk group deserving special attention. Interest in research on
alcohol-related problems among the elderly also is growing. Another im­
portant research focus is social influences such as work settings. Factors
affecting remission of alcoholism merit more attention; new research should
provide a better understanding of how to design effective and appropriately
targeted prevention and therapy programs.

Smoking and Health

Most cigarette smokers begin the habit as adolescents or young adults.
Because smoking is so difficult to give up, we should learn why young
people start smoking and what methods are most effective in helping them
not to do so. Successful prevention programs have in common the active
involvement of young people in developing strategies to avoid pressures
to smoke from peers, media, and adults.
Of everyone in the United States who regularly smokes, about 60 percent
have tried to quit, and another 30 percent want to quit. A combination of
biobehavioral science disciplines is needed to explore pharmacological,
physiological, neurochemical, behavioral, psychological, and social factors
that contribute to this powerful addiction. Nicotine may be a major phar­
macological reinforcer for cigarette use, but behavioral factors appear to be
crucial in initiation of the smoking habit and in day-to-day fluctuations in
smoking.
A key research issue about quitting is better understanding of why some
can stop smoking on their own; belief in self-efficacy may predict success.
Methods are needed to help large portions of the population to quit smoking
if they wish to do so. For those wanting to use formal programs, more
effective and safer techniques are needed, as are ways to match interventions
to the person. Studies of factors that predispose to relapse and of ways to
maintain abstinence also are important.

influences.

i

SUMMARY AMD IMKUUULilUlM

jleep. Biological Clocks, and Behavior
' Currently, about 27 percent of U.S. employees have work schedules that
shift regularly from day to evening or night. Also, several hundred million
times each year people fly across time zones to an environment to which
their internal biological clocks are not adjusted. The best documented health
consequences of shift work are disorders of sleep and digestion. There are
also potential hazards in operating complex equipment, monitoring safety
indicators, or making important decisions while affected by a disrupted
routine. People differ greatly in their ability to tolerate working or sleeping
on abnormal schedules. One frontier area of biobehavioral research attempts
to clarify the nature and extent of such changes and factors that influence
them.
Over the past decade, investigators have made considerable gains in
understanding the physiological and behavioral processes that affect the
sleep-wake cycle and its relation to the day-night cycle. Basic research is
beginning to define both the characteristics of biological clocks and some
of the neural systems that regulate them. A specific area of the brain
hypothalamus now is known to be the central pacemaker for many circadian
rhythms. Further research on pacemakers and control systems is highly
appropriate.

Cardiovascular Disease and Behavior

Among established risk factors for cardiovascular disease are hypercholes­
terolemia, hypertension, cigarette smoking, advanced age, being a male,
diabetes, and marked obesity. Several of these have clear behavioral aspects.
Thus, strong evidence of an association between atherosclerosis and ele­
vated blood cholesterol has led to studies to find if reducing cholesterol
concentrations by various means will alter cardiovascular disease rates. Sim­
ilarly, an association between cardiovascular disease and Type A behavior
has created interest in helping people to change that type of behavior,
characterized as harsh competitiveness, unusual aggressiveness, intense work
orientation, and a persistent time urgency. Behavioral aspects of smoking
were discussed earlier; those of diabetes are discussed later.
Sudden cardiac death is of special interest to the biobehavioral sciences.
Although the heart is almost invariably diseased in such deaths, the type
of disease typically is compatible with many years of active and satisfactory
life. Identification of factors that lead to sudden cardiac death may be useful
in designing programs to reduce its incidence. Areas that must be explored
in order to better understand neural controls of the heart relating to sudden
cardiac death include describing the neural pathways involved, delineating

summary

13

the influences of ini. J and external stimuli, and finding ways to prevent
or reverse pathological responses to psychosocial stressors.

Diabetes and Behavior
Diabetes results from a variety of causes of abnormal glucose utilization.
Recent research has revealed multifactorial regulation of glucose utilization;
many of the regulators are responsive to stress. In diabetes, emotional stress
and other psychosocial influences affect disease complications and treatment
adherence. Only recently have systematic, interdisciplinary studies begun
to address those issues.
The treatment of diabetes typically entails diet modification, insulin re­
placement, and adherence to a demanding medical regimen. Techniques
are needed to identify individuals and families who are unlikely to meet
such demands. It still is unclear how handling of early episodes affects a
patient’s ability to accept diabetes as a tolerable routine of daily life. How
best to help patients and families cope with the complications of diabetes
is another key area for study. Also, innovations in self-care, medical service
delivery, and use of community resources may lead to better metabolic
control, decreased hospitalization, and substantial cost savings.
About 90 percent of diabetics are overweight. Some effects of excessive
caloric intake are beginning to be understood, as are ways to help patients
lose weight. One successful approach to weight loss uses an interdisciplinary
team to evaluate and educate patients and provide continuous follow-up
care. Continuity of care is critically important, as is a stepped-care approach
that is responsive to the needs of individual patients. Much more remains
to be learned about helping people lose weight and maintain the weight
loss.
Major Mental Disorders and Behavior

The population in psychiatric hospitals increased for many years and then
peaked in 1955. Since then it has declined steadily, coinciding with increased
use of drug therapies and improved psychosocial treatments. Despite great
progress, mental disorders continue to impose major burdens on individ­
uals, their families, and society. The biobehavioral sciences still have much
to offer in the search for a permanent solution to these illnesses.
In the 1950s, investigators discovered effective drug treatments for major
depression, mania, and schizophrenia, as well as antianxiety agents used for
a variety of physical and mental problems. Research into the actions of such
drugs has greatly enriched concepts about brain function, leading in turn
to biochemical hypotheses about major mental disorders that have influ-

I

research M>d pr^. Jhe ^J^^nlvation
enced clinical has been fostered y
neurosciences
one new Ulocalized changes

dth

normai human bem^

ZXX- .to to^Xto/XXeX/’Z

ZS s—P"ta’““ ‘>f

vention and treatment. Program
tension detection and trea
.
introduced in many setting
be valuable, for instance,^couses

X"otoe»i »a

have
success Other programs also might
tQ retire However, the
undesirable side effects

rX'S:XX. toee yet » to ^..ed

pSyjhoJOcW

BeazS-

r.da.
«
'TtlO% J to other
forms
of progress X
efforts add to
of mental. disorders.
eventual prevention c. -

*' ■“»“ “■

Scientific Opportunities: Special LlfeJ^

of spedfic settings in

Agi„g and Health

challenge5

The rising numbers and special pro
deliveryi and social orgamto basic sciences, clinical
the elderly must consider not only
zation. Studies of health and beha
related physical and psychoenvironmental and social Jactor
esentation response, and complilogical changes that can affect, disease P« senta ,
po
s
steps

X.. Fo, .«»p>«, .«>«• “’X, X™ «. tomes ™ «>>*
that promote independence amo g

^“‘T fotsinTon environmental influences or beha
Ps
ZS ^remarkable and
'nmrventions that may be

W--

relationships, treatment re-

*'
rf.be .Uert, rf

Research is needed to specify th ^‘Xcial processes. A growing
historical events and of biological “P ?
available for such research
number of longitudinal studies are
integration of biomedical

Such research holds the promise ofugge^ng

ufe

Work and Health
Much remains to be learned about t e eff

employee health of the
characteristics that define

many administ^

io J™, todsh
l&TXis

hSonS

!nJ

a £;!S toP*ton;~XXZieXSvXX..« the mt^e,

provide r —

age and those who are much less resistant.

to health

Social Disadvantage and Health

nn the socially disadvantaged.

The burden of illness rests d‘sProI^°"^j^^enting disease among the
A growing body of researc goes
f
differential exposure to and
poor and looks at the effects of such.^aCJ^ji^s of
cumulative effects of
treatment by health care Professl°^
of identifying mechanisms
psychosocial and economic stress show promise

'~!X "J

F

/?
COR^S TsZed ’in’all of these types of prevention. Efforts continue

advantage and of targeted
J^td effective inter­
should focus on identifying preyentabie causal

i» I-..
and ethnic groups. Studies of ^nne^
lation, bereavement, an cumu a

«"■
especially relevant, di­
effects of racial and social factors

“'7^2—»-

on diagnosis and treatme
tt-parment of hypertension in
geted interventions such « ‘krecuo
jn_
designated subpopulations
mixture of health care personnel,
elude measures of the type,
lass on management
their attitudes toward patients, and the ettects ot
of minorities and the poor.

to develop techniques for earlier, safer, and more reliable detection of
abnormalities and new vaccines against dangerous infections. In addition,
there is strong interest in finding ways to make early interventions that will
diminish risks associated with low birth weight and prematurity. Attention
also must be given to ways of engaging parents in disease prevenuon and
health promotion for their children.
Research is needed into developmental problems of ear y childhood,
including mental retardation and clinically apparent emotional disturbance.
Additional research on infants and families with multiple sources of high
risk for developmental dysfunction is likely to enhance both basic under­
standing and provision of care. Sound intervention programs already have
shown the interdependence of research and practice, of evaluation and
treatment, and of assessment and counseling in the service of children in
the first months of life. Progress in this area holds promise of yielding
substantial gains, both in decreasing the burden of illness and in increasing

the quality of life.

Crosscutting Themes: Prevention and Treatment
Reg^dless of .he he^.k, beh.,« ». .he

Prevention Efforts in Adolescence

eendon should he mior

In recent years, greater attention has been given to adolescence as an
important, lengthy, and developmentally complex part of the life course.
One feature of adolescence is behavioral experimentation, some of it dam­
aging to health. Some behaviors affect health immediately, as in contracting
venereal disease or having a severe accident related to alcohol use. OthJrs
produce deleterious effects only later in life, as seen with lifelong habits
that can contribute to adult cardiovascular disease. Naturally, adolescence
also is a time for adopting healthful habits, with correspondingly good short-

^[ering ,he burden erf illness by

be learned, be. .he exisung re««h toe Peeles
.”X «— .he

„
burden el

illness in this country.

Prevention Efforts in Early Life

ur. P^e. .
many of which may have _hfe g
dominant role in the
disease, behavior-related disorders have taken a mo
burden of illness in early life. Recognitionx>f th>s sh f^

recently for a number of et e

d di

neOnatal metabolic screens,

and long-range effects.
The need for more adolescent-oriented research on prevention and on
behavioral issues pertinent to health and disease recently has become widely
recognized, and many issues have been identified. Studies of the antecedents
of adult disease, particularly such chronic ones as cancer and cardiovascular
disease, would be directly relevant to prevention. Also needed are better
strategies to promote health-enchancing behaviors in adolescents and to
prevent adoption of such habits as cigarette smoking and drug use. A special
area of concern is teenage pregnancy. The complexity of that issue creates
a formidable research agenda, including evaluation of current and preferred
roles of such institutions as schools and hospitals in adolescent pregnancy

pregnancies or provide ways of improving the lives of
. their infants.

age mothers
mothers and
and
age

Prevention Efforts in Adult Life: Cardiovascular Risk Factors
For most diseases considered in this volume, interventions constitute pre­
venting or altering such behaviors as smoking or unhealthful dietary habits.
Common experience makes it clear that many individuals are unable to
change these habits readily. Yet change is possible. In the past decade, real
shifts have occurred in the lifestyles of many people in the United States,
arguing against the pessimism that often clouds prevention efforts. The
evidence demonstrates that, at least for cardiovascular disease, effective
large-scale interventions are feasible. Encouraging results of smoking pre­
vention and cessation programs have positive implications for prevention
of some prevalent types of cancer, chronic lung diseases, and cardiovascular
diseases.
Much remains to be learned about the most cost-effective methods of
conducting prevention efforts. For example, studies are needed about se­
lecting the best communication medium for specific kinds of health mes­
sages. Much is known already about the learning process, but it needs to
be applied systematically in prevention programs. Some prevention ef­
forts—particularly those that can be expressed in simple, short, and clear
messages—may be especially suitable for the mass media Others such as
helping people to stop smoking may require more individualized and smallgroup attention. But the task now seems to be determining how to do it
best, rather than whether it can be done at all.

The Interface of Drug and Psychosocial Treatments
For many chronic diseases, drugs alone are not enough. Social and psy­
chological influences also affect the disease course and prognosis. Broadly
speaking, psychosocial interventions involve either clinical management or
specific therapies. Clinical management refers to issues that arise during
the course of treatment of any type, for example, explaining a diagnosis or
warning about side effects. Specific psychotherapies are designed to relieve
the symptoms of disease. Thus, relaxation techniques might be used to
reduce mild hypertension, or cognitive therapy could be used to treat
depression. Psychotherapy need not be a competitor of drug treatments.
At times, it may be more effective than drug treatments, or it may be a
useful adjunct, so that patients receiving both types of therapy do much
better than those who receive only one of them. Thus, counseling often is

esSexUi'ai (or
ad/icrcuce to a treatment regimen in diseases such as hypei
ion and diabetes.
Needed studies at this interface are beginning to emerge. An under­
standing of the psychological and social factors that influence attitudes about
illness, seeking help, and deciding whether medical advice is reliable would
be of value for individualizing treatment regimens. Also, comparative data
are needed to enable physicians and patients to select rationally between
drug and psychotherapeutic treatments of the same illness or to choose
efficacious combinations of them. In some cases, psychosocial interventions
require skills for which health practitioners lack training, time, or interest.
Incorporation of such treatments into health care may necessitate innova­
tions in the delivery system.
M.ental Health Care in General Health Care Systems
The primary care sector has a major role in caring for 60 percent of the
adults and a large proportion of the children who have a discernible mental
disorder. A concerted effort is needed to overcome serious deficiencies in
communication between mental health and general health services. Bene­
ficial health results can be achieved from increased primary care commit­
ment to identification of mental disorders in the patient population, more
effective counseling, improved drug-prescribing regimens, and better re­
ferral mechanisms to mental health care professionals. Primary care prac­
titioners must be able to convey to patients an interest in health-related
behavioral issues as a vital link in prevention or recovery processes.
Research could facilitate collaboration between primary care and mental
health services in several ways. For example, primary health care providers
need simple and precise methods for identifying mental disorders, deter­
mining whether or not to refer a patient, selecting the best treatment for
patients not referred, and monitoring side effects. Also needed are tests of
alternative ways of providing well-integrated mental health care in primary
health care settings. Such studies should include assessments of the effec­
tiveness of various types of manpower in dealing with carefully differen­
tiated problems in various treatment settings.

Changes in Human Societies, Families, Social Supports, and Health

The human species is intensely social. This fact is so much a part of daily
life that it is easy to overlook its significance in human adaptation. People
everywhere are organized in societies and therefore are inevitably tom
between serving individual interests and those of the group. Modern in­
dustrial societies have made rapid and drastic changes in social relations.

ianges and the effects on health remain to be asses
idequately.
’ Many research opportunities exist for probing relatio..mips among stre
illness social support, and utilization of medteal services. For example it
should be possible to examine ways in which support systems can buffer
or mediate effects on health, either through physiological effects or by
reducing health-damaging behaviors. Also of interest is whether ^inds
of social support protect against specific types of stressors. It will be im
portant to examine the relative merits of various levels of
including removing or moderating stressors, teaching coping skills to mdiviudalf, and strengthening social supports. With respect to sociJ suppons
studies are needed of ways to foster attachment behavior and s m ate
development of support networks where they are ‘"^ate _ As such
experimental networks are formed, their effects on health should be com­
pared with those of naturally occurring networks.

Health Science Policy Considerations
In recent years, several Institute of Medicine study groups have examined
!he entire gamut ofsc.ence policy pertinent to health. Baste potnts germane
to the present report emerged with a high degree of consensus from a
range of biomedical and other scientists participating in that analysis. Those
points are summarized in Table 2. The present report is repute. with spec.fie
suggestions about scientific and institutional opportunities, but the steering
Ze explicitly decided not to undertake detailed prescriptions. Rather
policy makerTin different settings may flexibly consider how best to proceed

in light of the framework and suggestions provided.

Role of Basic Research Relating to Health and Behavior
Examination of this nation’s burden of illness helps to point up the impor­
tance of behavioral factors for health. As noted throughout thls reP°«’
cardiovascular disease, cancer,
£^^“3
other violence constitute major drams on life and health. Such disorde
have substantial behavioral components, so approaches to preventing
managing them must include a strong biobehavioral perspective. As the
burden of illness changes, the sciences needed to lessen it alsc’
Increasingly it will be in the public’s interest to foster progress in the fu
range of health sciences. Discovering how best to achieve this go wi
require cooperation and innovation within and among the scientific com-

with multiple interacf
elements as smoking,

'isk factors, which prominently include such behavioral
2 <
.Jiol, exercise, diet, and response to stress.

The definition of health sciences must be expanded beyond biomedical fields to
include the biobehavioral sciences.
The biobehavioral sciences have a major role to play in elucidating and alleviating
many components of the current burden of illness.

Biobehavioral sciences already have made significant contributions to improved
health and hold great promise for further progress.
The science base in the biobehavioral sciences should be strengthened, and adequate
support should be provided for such research.

Multidisciplinary, collaborative programs are a valuable and needed component of
some types of health research^

BrowTs. S. Policy Issues in the Health Sciences Washington, D.C.: National Academy of
Sciences, 1977.
K.
Institute of Medicine DHEWs Research Planning Principles: A Review Washington, D.C.: Na­
tional Academy of Sciences, 1979.
Institute of Medicine DHEW Health Research Planning, Phase II Washington, D C.: National
Academy of Sciences, 1980.
munity; the health professions; and policy makers in government, philan­
thropies, industry, and academic institutions.
The biobehavioral and other health-related sciences share several fun­
damental needs: (1) greater interdisciplinary collaboration within the sci­
entific community and more communication between it and clinical prac­
titioners, medical educators, public and private policy makers, and the general
public; (2) productive allocation of resources in an era of economic con­
straints; (3) better understanding of the impact of research discoveries and
science policy decisions on individuals and society, and concomitant ethical
dilemmas; (4) strengthened data collection, epidemiology, and other sup­
porting sciences to improve disease prevention and health promotion ef­
forts; and (5) improved research methods.

Interdisciplinary Cooperation and Collaboration
Interdisciplinary collaboration is not an end in itself but rather a means to
a higher goal—solving a problem. Collaboration is achieved only when the
CcpwCcpf of

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cCtrbiArc

?.4$k demands itproductivity of cooperation among disciplines. Thk port suggests ways
in which factors such as communication, institutional structure, and study
review committees can be influenced constructively.
In a substantial number of major research awards, funding agencies should
acknowledge explicitly the role of biobehavioral factors in disease. In the
areas considered in this report, agencies should review the nature and extent
of their support for research on biobehavioral factors in pathogenesis, clinical care and rehabilitation, and primary and secondary prevention. Consideration should include ways to foster interdisciplinary activities between
the neural and behavioral sciences and the biomedical disciplines.
Universities or medical centers with appropriate capabilities may find it
useful to establish centers in which goals of funded research can be met
only through sustained collaboration across disciplines. A focus for such a
center could be the study of biobehavioral factors in disease. Academic
medical centers could encourage active involvement of departments of
medicine, family medicine, geriatrics, pediatrics, and psychiatry. Similar
links to basic science departments of genetics, biochemistry, pharmacology,
and neurobiology also can be helpful. Such cooperative ventures could be
fostered by joint grants, given only for research requiring cooperative links
between biobehavioral and biomedical disciplines.
Strengthening Research Capabilities in Health and Behavior

The dynamic interplay of clinical and basic research can be profoundly
beneficial over time, in this field as in others. The fruits of basic research
can grow into valuable applications, and the stimulus of clinical observations
can lead to basic discoveries. This circumstance poses important questions
for agencies that sponsor research and for institutions that engage in it.
How can programs be formulated, applications reviewed, grants made, and
research organized in ways that foster the interplay of basic and clinical
research? What institutional arrangements are most conducive to such link­
age? Such basic policy questions deserve sustained attention from govern­
ment, industry, philanthropies, and research institutions.
Essential to the success of the mission described in this report is attraction
of talented and dedicated young people to health and behavior research.
The first step is wider recognition of the importance of these problems,
the burden of illness they impose, their human impact, and the urgency of
progress. The second is awareness that scientific opportunities exist for

grappling with the problems.
Interdisciplinary research depends first on training young investigators
to expand the scope of inquiry beyond their primary discipline. Professional

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research training effort in this area is essential to bring young investigators
into the field and provide settings in which they can make significant con­
tributions. Several requirements of research training must be met:
1. M.D.-Ph.D. training programs in biobehavioral sciences This approach
has been highly successful in biological sciences and urgently needs to be
broadened now to include such fields as psychology and sociology.
2. Appropriate research training stipends It must be feasible for young
scientists to learn their craft well, and this takes considerable time.
3. Targetedfunding to institutions supporting postdoctoral training programs
on the design and conduct of biobehavioral research Such training should be
available to both physicians and nonphysicians. Programs for the former
could emphasize basic science, and those for the latter, pathology and aspects
of clinical medicine, helping to build bridges between the laboratory and
clinic.
4. Stipends for students to do biobehavioral research Such projects could
spark interest at a crucially formative stage of career development; stipends
for appropriate medical students or graduate students in biological and
biobehavioral sciences could be a valuable asset for developing the essential
scientific cadre.
When young people have completed research training in health and
behavioral sciences, they must be able to find acceptable career pathways,
if their skills are not to be wasted. Relevant agencies and institutions must
consider long-term career pathways through which the problems delineated
in this report can be addressed effectively. In the decade ahead, the time
will be ripe for appointing more behavioral scientists to medical school
faculties. One encouraging prospect is the emergence of departments of
behavior in schools of medicine that emphasize research. Such depanments
provide a fundamental resource for many fields of medicine and a powerful
stimulus for research advances in health and behavior.

Allocation of Resources for Research on Health and Behavior
Available figures indicate that research into health and behavior is not
funded at a level commensurate with the costs that behavior-related illness
and disability impose on society. Federal funding of research on alcoholism
and mental illness is modest indeed compared with funding for cancer and
heart disease. Yet the burden of illness in terms of human suffering and
economic costs is heavy in all these cases. By the same token, the behavioral

B

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Unit 7
Introduction to Public Health
I ‘
1

■Sd

CONTENTS
Page
Introduction

3

Case 1
Health

6

Case 2

9

Public Health

Case 3

10

Training for public health

Case 4

11

Determinants of health

Case 5

17

Public, Health, and Science

Case 6

18

Health Promotion; a concept to remember?

Case 7A

21

Differences in health issue perceptions

Case 7B

22

The construction of public (health) problems

Case 7C

23

Primary prevention of aids

? f

)

/

Unit 1

MPH 1995/1996

r

©

University of Limburg
Faculty of Health Sciences, 1995

-2 -

Unit 1

MPH 1995/1996

INTRODUCTION
I. Title of the Unit
Introduction to Public Health

II. Theme of the unit
This module will introduce you to the field of public health. You will have to
unravel a number of mysteries in the realm that neither academia nor praxis has
been able to tackle unequivocally.
For instance, what is health? Is it the absence of disease, a numerical indicator, the
output of the medical-industrial complex?
Clearly, public health does not have anything to do with individual health or illness;
it has a societal and social dimension. But how far do we wish to go in the inclusion
of societal and social issues in the public health domain?
Further, training for public health has been conceptualized in different parts of the
world in different ways. Even in a small country like The Netherlands there are two
Schools of Public Health which seem to diametrically oppose each other in
perspective. One tends to have a medically, somewhat traditional, perspective,
whereas the other claims to present innovative solutions to new public health
problems. Where, then, do you stand?
Public health has acquired definite political and societal status in the last quarter of
the twentieth century. The World Health Organization, European Union and many
non-governmental organizations play a role in the definition of public health
priorities. How has that position come about?
This module does not claim to give definite answers. It merely introduces you to a
field with its own traditions, language, and strategies. By the end of this module you
are expected to make an elementary public health analysis, to be able to recognize
and tentatively use public health jargon, to appreciate developmental lines in public
health history and its current manifestations, and to be able to distinguish between
various public health specializations and their interventions.

1

Public health studies
Are public health studies in Maastricht different? Yes, certainly when it comes to
educational approaches. But we are also different regarding the contents of the
programme. We invite you to discover for yourself (through work on cases 3 and 5)
which different models for public health training and research exist. Such a
realization is important for your self-identification as a public health professional.

III. Objectives of the Unit

□
□
□
□
□

To be able to make an elementary public health analysis;
Mastering public health jargon;
To appreciate developmental lines in public health history;
To appreciate approaches to new public health;
To be able to analytically distinguish between public health intervention
types.

-3 -

MPH 1995/1996

Unit 1

IV. Timetable
Monday, September 18, 13.30 - 15.30
Opening of the unit
Lecture: Health___________________
Monday, September 18, 16.00 - 18.00
Discussion Case 1

Wednesday, September 20, 09.00 - 11.00
Reporting Case 1
Discussion Case 2___________________
Friday, September 22, 09.00 - 11.00
Reporting Case 2
Discussion Case 3___________________
Monday, September 25, 13.30 - 15.30
Lecture: International health____________
Monday, September 25, 16.00 - 18.00
Reporting Case 3
Discussion Case 4___________________
Wednesday, September 27, 09.00 - 11.00
Reporting Case 4
Discussion Case 5___________________
Friday, September 29, 09.00 - 11.00
Reporting Case 5
Discussion Case 6___________________
Monday, October 2, 11.00 - 13.00
Question hour_______________________
Monday, October 2, 16.00 - 18.00
Reporting Case 6
Discussion Case 7___________________
Wednesday, October 4, 09.00 -11.00
Reporting Case 7
Evaluation Unit

Group 1 and 2: 0.420 UNS50
Group 1 and 2: 0.420 UNS50

Evelyne de Leeuw
Evelyne de Leeuw

Group 1: 1.201, UNS50
Group 2: 1.164, UN$50

Evelyne de Leeuw
Mustaq Kahn

Group 1: 1.202, UNS50
Group 2: 1.164, UNS50

Evelyne de Leeuw
Mustaq Kahn

Group 1: 1.237A, UNS50
Group 2: 1.164, UNS50

Evelyne de Leeuw
Mustaq Kahn

Group 1 and 2: 0.420 UNS50

Evelyne de Leeuw

Group 1: 1.201, UNS50
Group 2: 1.164, UN$50

Evelyne de Leeuw
Mustaq Kahn

Group 1: 1.202, UNS50
Group 2: 1.164, UNS50

Evelyne de Leeuw
Mustaq Kahn

Group 1: 1.201, UNS50
Group 2: 1.164, UNS50

Evelyne de Leeuw
Mustaq Kahn

Group 1 and 2: 0.124, DEB1

Relevant Staff

Group 1: 1.201, UNS50
Group 2: 1.164, UN$50

Evelyne de Leeuw
Mustaq Kahn

Group 1: 1.201, UNS50
Group 2: 1.164, UNS50

Evelyne de Leeuw
Mustaq Kahn

Because of the relatively small group of student you are encouraged to request
lectures on specific issues. We will do our utmost to arrange such special lectures.

V. Literature
Each case is concluded with a number of suggested readings (most of which are
included in the reader accompanying the module). Please remember, however, that
these are suggestions, and by no means the ultimate texts on the subject.
Depending on your own interests and emphases you are encouraged to undertake
expeditions in the Learning Recources Centre and find your own material. In that
way, you may also find small treasures that we could use in rewritten versions of
this module in coming years.

-4-

*

Unit 1

MPH 1995/1996

VI. Assessment
This module will be tested by means of three essay questions. Such a test mode
requires you to write an essay on the required issue. An essay is a short story with a
clear structure: problem statement, inventory, alternatives, opinion, conclusion.
Essays enable students to show that they have not only ’acquired academic
knowledge, but that they are also able to apply that knowledge to a specific
situation. The latter is explicitly appreciated in the programme you will be studying.
Deadline submission essay: Friday October 13th, 1995
VII. Coordination
Evelyne de Leeuw, Department of Health Ethics and Philosophy, tel.: 881235

- 5-

MPH 1995/1996

Unit 1

CASE 1
HEALTH
Health and illness are notions so widely used that they seem to have a clear and
unequivocal meaning. Nothing is less true than this; just check the many books that
have been devoted to these issues.
In this case you will be confronted with several perspectives.

A physician's perspective (?)
A physician (P) and a pregnant woman (W) meet for a check-up. This is part of
their conversation:
P
Everything's all right, the only thing is you're a bit overweight, so I'd say try
to loose some of it.
W
But I feel fine, doctor.
P
OK, good for you, but that's not the issue. The issue is that you are
overweight and that's not good for you in your condition. You have a chance
of high blood pressure. Remember you're not in an ordinary situation, you
must think about the child.
W
But I'm quite satisfied with my weight, so why start slimming? On top of
that, I feel really good and believe me, I watch my nutrition real carefully.
P.
Anyhow, your weight indicates that you are in a risk group for complications
during pregnancy, so I do regard you as not entirely healthy. That's fully
independent from how you or anyone feels.
W
But doc, if I feel OK, I must be healthy, don't I?

An academic perspective (?)
The Minister of Public Health considers it very important to establish clear and
empirically useful criteria for health. In his first memo he suggests to describe health
as statistically normal functioning, that is, the capacity to carry out tasks specific to
humans on a certain level. A bureaucratic working group is installed. Their purpose
is to develop a list of bodily functions with their respective functional degree of
'normality'.
One bureaucrat suggests to regard people with one common cold a year as healthy.
In the end, each adult on average catches a cold once a year.
A capacity perspective (?)
The effectiveness of medical interventions is often measured in terms of quantity of
life (years gained). Some investigators find this an insufficient criterium; they try to
measure quality of life.
Some people argue for the use of such information in financing and budgeting of
health care services.
Various proposals for such an approach have been developed, one of them by
Rosser. She focuses on physical mobility and distress as relevant dimensions of
health. Two scales have been developed (figure).
It looks like a great idea, but questions remain: is this a valid approach? How about
intersubjectivity? Can policy consequences be based on such scales?

- 6-

Unit 1

MPH 1995/1996

Disability

Distress

I

No disability

II

Slight social disability

A
No distress

III

Severe social disability and/or
slight impairment of performance at
work

B
Mild distress

C
Moderate distress

Able to do all housework except very
heavy tasks

IV

Choice of work or performance at
work very severely limited

Housewives and old people able to do
light housework only but able to go
out shopping
V

Unable to undertake any paid
employment
Unable to continue any education

Old people confined to home except
for escorted outings and short walks
and unable to do shopping

Housewives able only to perform a
few single tasks

*

VI

Confined to chair of wheelchair or
able to move around in the house
only with the support from an
assistant

VII

Confined to bed

VIII

Unconscious

-7 -

D
Severe distress

MPH 1995/1996

Unit 1

References
Bayles, M. (1978) The price of life. Ethics, 89, pp. 20-34

Boorse, C. (1977) Health as a theoretical concept. Philosophy of Science, 44, pp.
542-573
Harris, J. (1987() QALYfying the value of life. Journal of Medical Ethics, 13, pp.
117-123.

Kind, Rosser & Williams (1982) Valuation of quality of Life: Some Psychometric
Evidence. In: M.W. Jones-Lee (ed.) The Value of Life and safety. North Holland
King, L.S. (1954) What is disease? Philosophy of Science, 21, pp. 193-203
Williams, A. (1985) Economics of coronary artery bypass grafting. BMJ, 291, pp.
326-329
Wulff, H.R., S.A. Pederson, R. Rosenberg (1986) Philosophy of Medicine. Oxford
(pp. 46-60)

*

-8-

Unit 1

MPH 1995/1996

CASE 2
PUBLIC HEALTH
Public health historians place the birth of public health at various points in the past.
They refer to Indian Ayur Veda, papyrus writings of ancient Egypt, Hippocrates, or
Galenus. Modern public health, the myth goes, starts with Lord Snow taking the
handle off the Broad Street pump in a London neighbourhood where cholera
seemed to be pandemic. More clinically oriented public health historians mention
Koch, Pasteur, Virchow and Semmelweis as the fathers of the profession.
However, public health is not a matter of individuals, but of society. The individuals
mentioned have definitely played a role in the emergence of modern public health
but could only do so because society gave them opportunity to act.
Britain may certainly be called the cradle of modern public health as it was the first
nation to embark on an industrial revolution in the 19th century. New (health)
problems emerged, and new solutions had to be found.
References
Coleman, W. (1982) Death is a social disease. University of Wisconsin Press,
Madison

Eyler, J. (1979) Victorian social medicine. The ideas and methods of William Farr.
The John Hopkins University Press, Baltimore
Rosen, G. (1974) From medical police to social medicine. Essays on the history of
health care. New York

Wohl, A.S. (1983) Endangered lives: public health in Victorian Britain. HUP,
Cambridge, Mass.

-9-

Unit 1

MPH 1995/1996

CASE 3
TRAINING FOR PUBLIC HEALTH
THE LANCET
University of medicine

University

University

University
QD

If

is

0
Type 1

berth

Ministry of health

° 0)

81

4Z Q0

Sa

Type 2

Type 3

o c
cn <d

Type 4

Ministry of health

University
Research institute

a

Type 6

Type 7

Type 5
•oO

is S.I
° 4>

O
o 2 ■C
O o
w E cn
<n

Type 8

Figure: Eight types of school of public health

References
Leeuw, Evelyne de (1995) European Schools of Public Health in a state of flux. The
Lancet, 345, 1158-1160
Sorensen, A.E. & R.G. Bialek, eds. (1994) The Public Health Faculty/Agency Forum Linking Graduate Education and Practice. Final Report. Health Resources and
Services Administration, Washington DC / Centers for Disease Control, Atlanta

WHO/EURO (1994) Training and Research in Public Health. Policy perspectives for
a 'New Public Health'. Training and Research in Public Health Dialogue Series No
7, January 1994. WHO Regional Office for Europe, Copenhagen / Centre for Public
Health Research, Karlstad

WHO/EURO (1994) Training in Public Health. Strategies to achieve competences.
Training and Research in Public Health Dialogue Series No 2, April 1994. WHO
Regional Office for Europe, Copenhagen / Centre for Public Health Research,
Karlstad

-10 -

Unit 1

MPH 1995/1996

CASE 4
DETERMINANTS OF HEALTH
Public health is concerned with the art and science of promoting health. We have
seen that health may be conceived as a vague notion. Nevertheless, there are factors
which promote health and illness. In different cultures, these factors may be
perceived differently. Among indigent people in Central America, for instance,
diarrhoea is felt to be caused, among others, by the 'evil eye1.
In this case, however, we will focus on various western ideas about the
determinants of health. Two different perspectives abound. Read the fist chapter of
Healthy People: The Surgeon general's Report On Health Promotion and Disease
Prevention, the USA national public health policy document:

INTRODUCTION AND SUMMARY
The health of the American people has never been better.
In this century we have witnessed a remarkable reduction in the life­
threatening infectious and communicable diseases
Today, 75 percent of all deaths in this country are due to degener­
ative diseases such as heart disease, stroke and cancer (Figure 1-A). Ac­
cidents rank as the most frequent cause of death from age one until the
early forties. Environmental hazards and behavioral factors also exact
an unnecessarily high toll on the health of our people. But we have
gained important insights into the prevention of these problems as well.
It is the thesis of this report that further improvements in the health
of the American people can and will be achieved—not alone through
increased medical care and greater health expenditures—but through a
renewed national commitment to efforts designed to prevent disease
and to promote health. This report is presented as a guide to insure
even greater health for the American people and an improved quality
of life for themselves, their children and their children's children.

Americans Today are Healthier Than Ever
Since 1900, the death rate in the United States has been reduced from
17 per 1,000 persons per year to less than nine per 1,000 (Figure 1-B). If
mortality rates for certain diseases prevailed today as they did at the
turn of the century, almost 400,000 Americans would lose their lives
this year to tuberculosis, almost 300,000 to gastroenteritis, 80,000 to
diphtheria, and 55,000 to poliomyelitis. Instead, the toll of all four dis­
eases will be less than 10,000 lives.
We have seen other impressive gains in health status in the past few
years.
• In 1977, a record low of 14 infant deaths per 1,000 live births
was achieved.
• Between 1960 and 1975, the difference in infant mortality rates
for nonwhites and whites has cut in half.
• Between 1950 and 1977, the mortality rate for children aged one
to 14 was halved.
• A baby born in this country today can be expected to live more
than 73 years on average, while a baby born in 1900 could be
expected to live only 47 years.
• Deaths doe to heart disease decreased in the United Stales by 22
percent between 1968 and 1977.

- 11 -

MPH 1995/1996

Unit 1

HGURE 1-A
DEATHS FOR SELECTED CAUSES AS A PERCEKT
OF ALL DEATHS: UMTED STATES,
SELECTS YEARS, 1M0-1E77
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• During l he past decade the expected life span for Americans has
increased by 2.7 years. In the previous decade it increased by
only one year.
For this, much of the credit must go to earlier efforts at prevenpoo,
based on new knowledge which we have obtained through research.
Nearly all the gains against the once-great killers—which also included
typhoid fever, smallpox, and plague—have come as the result of im­
provements in sanitation, housing, nutrition, and immunization. These
are all important to disease prevention.
But some of the recent gains are due to measures people have taken
to help themselves—changes in lifestyles resulting from a growing
awareness of the impact of certain habits on health.

Caa We Do Better?
To be wre, as a Nation we have been expending large amounts of
money for health care.
• From 1960 to 1978 our total spending as a Nation for health
care mushroomed from $27 bdlion to $192 bdlion.
• In 1960 we spent less than six percent of our GNP on health
care. Today, the total b about nine percent Almost 11 cents of
every Federal dollar goes to health expenditures.
• In the years from 1960 to 1978 annual health expenditures in­
creased over 700 percent
Yet our 700 percent increase in health spending has not yielded the
striking improvements over the last 20 years that we might have hoped

to treatment of dhease and disability, rather than prevemkn.

- 12 -

*-

Unit 1

MPH 1995/1996

FIGURE IB
DEATH RATES BY AGE: UNITED STATES,
SELECTED YEARS 1900-1977
70.000 J—
60.000 —
50.000 —
40.000 —

JO.OOO —
20.000 —

65 ymn and owr

BE
6.000 —
5.000 —
4.000 —

<

3.000 —

I

2.000 —

§
8
Sau
141

2

Under 1 year

1.000mo —
MO —
TOO —
too

2S44yoen

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500 —
400 —
XX) —

MO —

15-24 yam
100 70 —
M i—
90 —

1-14 yaan

30^

|

|

I

I

I

|

1

1900

1910

1920

1930

1940

1960

1990

1970

NOTE

IMO

I»77 MU M
MU to *11 Mto Mn M to*. SMMtM vMn ar« IMO. 1W5. IMO. IMO
(to
FMa I *-24 yMn aMy). M 1977

SOURCE: National Carmr tor Haafth StMMtos. Dwidon of Vital Statdtia.

Though, particularly in recent yean, we have made strides in preven­
tion, much is yet to be accomplished.
For example, recent figures indicate that we still lag behind several
other industrial nations in the health sums of our citizens:
• 12 othen do better in preventing deaths from cancer,
• 26 othen have a lower death rate from circulatory disease;
• 11 othen do a better job of keeping babies alive in the first year
of life; and
• 14 othen have a higher level of life expectancy for men and six
othen have a higher level for women.

Prevention • An Idea Whoae Time Has Come
Clearly, the American people are deeply interested in improving their
health. The increased attention now being paid to exercise, nutrition,
environmental health and occupati'^ial safety testify to their interest
and concern with health promotion and disease prevention.
The linked concepts of disease prevention and health promotion are
certainly not novel. Ancient Chinese texts ditamed ways of life to
maintain good health—and in classical Greece, the followers of the
culapius but with his two daughters, Panacea and Hygeia. While Pana­
cea was involved with medication of the sick, her sister Hygeia was
concerned with living wisely and preserving health.

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In the modern era, there have been periodic surges of interest leading
jo major advances in prevention. The sanitary reforms of the latter half

of the 19th century and the introduction of effective vaccines in the
middle of the 20th century are two examples.
But, during the 1950s and 1960s, concern with the treatment of
chronic diseases and lack of knowledge about their causes resulted in a
decline in emphasis on prevention.
Now, however, with the growing understanding of causes and risk
factors for chronic diseases, the 1980s present new opportumties for
major gains.
Prevention is an idea whose time has come. We have the scientific
knowledge to begin to formulate recommendations for improved
health. And, although the degenerative diseases differ from their infec­
tious disease predecessors in having more—and more complex—causes,
it is now clear that many are preventable.

Challenges for Prevention
We are now able to identify some of the major risk factors responsi­
ble for most of the premature morbidity and mortality in this country.

Cigarette Smoking

Cigarette smoking is the single most important preventable cause of
death. It is clear that cigarette smoking causes most cases of lung
cancer—and that fact is underscored by a consistent decline in death
rates from lung cancer for former male cigarette smokers who have ab­
stained for 10 years or more.
Cigarette smoking is now also identified as a major factor increasing
risk for heart attacks. Even in the absence of other important risk fac­
tors for heart disease—such as high blood pressure and elevated serum
cholesterol—smoking nearly doubles the risk of heart attack for mou
Though the actual cause of the unprecedented decline in heart dis­
ease in the last 10 years is not entirely understood, it is noteworthy that
the prevalence of these three risk factors also declined nationally during
this same period.

AlcoM aad Drugs
Misuse of alcohol and drugs exacts a substantia] toll of premature
death, illness, and disability.
,
Alcohol is a factor in more than 10 percent of all deaths m the
United States. The proportion of heavy drinkers in the population grew
substantially in the 1960s, to reach the highest recorded level shoe
1850.
,
Of particular concern is the growth in use of both alcohol and drugs
among the Nation’s youth.
Problems resulting from these trends are substantial—but preventable.
Our ability to deal with them depends, in many ways, more on our
Ailk m mobilizing individuals and groups working together in the
schoob and communities, than on the efforts of the health care system.
Oceupadaual Risks

Abo more widely recognized as threats to health are certain
tional hazards. In fact, it is now estimated that up to 20 percent of tow
cancer mortality may be associated with these hazards. The true dimob
sions of the asbestos hazard, for example, have become manifest only
after a latency period of perhaps 30 years.
And rubber and plastic workers, as well as workers in tome coke
oven jobs, are exhibiting significantly higher cancer rates than the gen­
eral population.
Yet, once these occupational hazards are defined, they can be controUed. Safer materiab may be substituted; manufacturing processes
may be changed to prevent release of offending agents; hazardous mate­
rials can be isolated in enclosures; exhaust methods and ocher engineer­
ing techniques may be used to control the source; special clothing and
other protective devices may be used; and efforts can be made to edu­
cate and motivate workers and managers to comply with safety proce­
dures.
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Injuries

Injuries represent still another area in which the toll of human life is
great.
Accidents account for roughly 50 percent of the fatalities for individ­
uals between the ages of 15 to 24. But the highest death rate for acci­
dents occurs among the elderly, whose risk of fatal injury is nearly
double that of adolescents and young adults.
In 1977, highway accidents killed 49,000 people and led to 1,800,000
disabling injuries. In 1977, firearms claimed 32,000 lives, and were
second only to motor vehicles as a cause of fatal injury.
Falls, burns, poisoning, adverse drug reactions and recreational acci­
dents all accounted for a significant share of accident-related deaths.
Again, the potential to reduce these tragic and avoidable deaths lies
less with improved medical care than with better Federal, State, and
local actions to foster more careful behavior, and provide safer environ­
ments.
Smoking, occupational hazards, alcohol and drug abuse, and injuries
are examples of the prominent challenges to prevention, and there are
many others.
But the clear message is that much of today's premature death and
disability can be avoided.
And the effort need not require vast expenditures of dollars. In fact,
modest expenditures can yield high dividends in terms of both lives
saved and improvement in the quality of life for our citizens.

A Reordering of our Health Priorities
In 1974, the Government of Canada published A New Perspectrve on
the Health of Canadians. It introduced a useful concept which views ail
causes of death and disease as having four contributing elements:
• inadequacies in the existing health care system;
• behavioral factors or unhealthy lifestyles;
• environmental hazards; and
• human biological factors.
Using that framework, a group of American experts developed a
method for assessing the relative contributions of each of the elements
to many health problems. Analysis in which the method was applied to
the 10 leading causes of death in 1976 suggests that perhaps as much as
half of U.S. mortality in 1976 was due to unhealthy behavior or life­
style; 20 percent to environmental factors; 20 percent to human biologi­
cal factors; and only 10 percent to inadequacies in health care.
Even though three data are approximations, the implications are im­
portant Lifestyle factors should be amenable to change by indivirtnah
who understand and are given support in their attempts to change.
Many environmental factors can be altered at relatively low costs. In­
adequacies in disease treatment should be correctable within the limits
of technology and resources as they are identified. Even some biologi­
cal factors (e.g., genetic disorders) currently beyond effective influence
may ultimately yield to scientific discovery. There is cause to believe
that further gains can be anticipated
The larger implication of this analysis is that we need to re-examine
our priorities for national health spending.
Currently only four percent of the Federal health dollar is specifical­
ly identified for prevention related activities. Yet, it is dear that im­
provement m the health status of our citizens win not be made pre­
dominately through the treatment of disease but rather through its pre­
vention.
Thte is recognized in the growing conaensm about the need for, and
value of, disease prevention snd health promotion.
Several recent conferences st me national level have been devoted So
the health sector are re-evahtating the rote of preveatioa in their wort.
The President and the Secretary of Health, Education, and Wettnu
have made strong public endorseanents of prevention. And a rapiiSy
growing interest has emerged in the Congress.

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The notions o_f individual risk are quite pervasive in the Healthy People document.
Other North American authors have arguecTfor a more society-based approach of
interventions.

References
Blum, H. (1981) Planning for Health. Human Sciences Press, New York

Labonte, R. (1991) Econology: integrating health and sustainable development. Part
one: theory and background. Health Promotion International, 6 (1), 49-66

Labonte, R. (1991) Econology: integrating health and sustainable development. Part
two: guiding principles of decision-making. Health Promotion International, 6 (2),
147-156
Lalonde, M. (1974) A New Perspective on the Health of Canadians. Government
Printing Office, Ottawa

Surgeon-General of the Public Health Service (1979) Healthy People: The Surgeon
Generals Report on Health Promotion and Disease Prevention. US Department of
Health, Education and Welfare/Public Health Service, Washington DC

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CASE 5
PUBLIC, HEALTH, AND SCIENCE
Public health has to do with anything and everything (cf. also Labonte's references
for case 4). What, then, is a public health professional?
It is plausible that a civil engineer could be working on public health issues. It is
possible that someone working in the alcohol industry says to have public health
commitments. Any primary school teacher should be involved in public health
education.
What is a public health professional?
Obviously, the public health practitioner does not exist. In the past, workers in this
field have been identifying themselves as epidemiologists, community health
physicians, sanitary engineers, and the like.
Under the aegis of the WHO Health for All strategies there is a growing awareness
that anyone working in the public health realm should have some basic
competences as well as advanced competences in specific fields. These fields could
for instance be labelled as biological health sciences, psycho-social health sciences,
and societal health sciences.
Clearly, there is some sort of relation between the public health professional,
science, and academic/praxis competences.

References
Garcia-Barbero, M., J. Bury, & E. de Leeuw (eds.) (1994) Training in Public Health.
Strategies to achieve competences. Training and Research in Public Health Dialogue
Series No. 2, WHO regional Office for Europe/Centre for public health research,
Copenhagen/Karlstad, ISBN 91-971559-4-2

/Hamburg, D.A., G.R. Elliott, D.L. Parron (1982) Health and Behavior: Frontiers of
Research in the Biobehavioral Sciences. National Academy Press, Washinton DC
x/Terris, M. (1985) The public health profession. Journal of Public Health Policy, 6
(1), 7-14

Terris, M. (1985) The changing relationships of epidemiology and society: The
Robert Cruikshank Lecture. Journal of Public Health Policy, 6 (1), 15-35

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CASE 6
HEALTH PROMOTION; A CONCEPT TO REMEMBER?
Nairobi (Kenya), December 1992
In the Ministry of Health and Welfare in Kenya a taskforce is formed. The main
reason to establish this taskforce is the exceptional number of people killed in traffic
accidents over recent years. By the end of 1991 two thousand persons were killed,
one year later this figure had increased up to 2900 annually. For this reason the
prime goal of the first meeting is to find a way to reduce this huge rate by the year
2000 to 1500 fatal accidents. At the meeting a physician, a community health
worker and a staff member of the Ministry are present. In the corner of the room
there is a smart, young junior bureaucrat who just returned from studies in Canada.

The Physician starts off the confrontation: "We'll have to buy more ambulances to
make sure the wounded people will be in the hospital sooner. The sooner we start
our treatment, the better the curation will be, the less people will die.'
The community health worker sighs and says that having more ambulances surely is
important but that it should be more effective to look for the real causes. However,
he has to admit that he can not say were to start any intervention.
The staff member raises disappointedly.
'Well ladies and gentlemen, we have a problem. I've got to go to the minister to give
a possible solution and we don't have a good one.'
That was the moment the junior bureaucrat starts, shy and hesitatingly taking a
paper out of her pocket. On the paper there was one sentence: Health promotion; a
combination of integral intervention mixes, community participation and
intersectoral cooperation.
'Maybe we should read this paper to find a new way of looking at this particular
problem.'

References

Goodman, R.M., Steckler, A. (1989). A model for the institutionalization of Health
Promotion Programs. Family and Community Health 11, 63-78
Kok, G.J., Green, L.W. (1990). Research to support Health Promotion in practice: a
place for increased cooperation. Health Promotion International, 5, 303-08
Leeuw de, E. (1989) The Sane Revolution. Health Promotion: Background, scope,
prospects. Van Gorcum Assen/Maastricht

■V

WHO, Health and Welfare Canada, Canadian Public Health Association (1986)
Ottawa Charter for Health Promotion. An international Conference on Health

Promotion- The move towards a new Public Health, nov. 17-21, Ottawa.

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The following cases constitute an introduction into various public health
specialization. You may want to split up the group according to your preferences;
you can pick the one case that suits your interests most.

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CASE 7A
DIFFERENCES IN HEALTH ISSUE PERCEPTIONS
An American woman tells how she experienced 'hot flushes' during menopause:
It is frustrating because they look at you in amazement. I would just perspire from
the top of my head and it would just drip down over my eyebrows. All over my
face. It drips down into my glasses and so on. It is miserable. I can remember
many occasions. I am angry that my body is doing this to me. I didn't mind if it
was by myself but it didn't happen as much when I was by myself. It was when I
was more tense or not even tense, it would happen at the craziest times'.

Maya women do either experience physiological nor psychological complaints
during menopause. The only symptom that is related to transition is the fact that
menstruation becomes irregular and finally stops. In Maya culture menopause is
considered to occur when a women has used her blood, i.e. her menstrual blood.
Transition starts early for a woman who has had many children, because she has
used a lot blood due to frequent pregnancies and deliveries. A woman who has few
or no children will start later with menopause. Generally, Maya women are glad
when menopause starts. This phase is associated with being 'young' and 'free'.

References

Martin, E (1987). The women in the body. A cultural analysis of reproduction.
Boston: Beacon Press (chapter 3, Medical metaphors of women's bodies:
menstruatbrigand menopause (pp. 27-53) and Chapter 10. Menopause, power and

Lock, M. (1986). Ambiguities of aging: Japanese experience and perceptions of
menopause. Culture, Medicine and Psychiatry, 10, p. 23-46).
Beyene, Y. (1986). Cultural significance and physiological manifestations of
menopause. A biocultural analysis. Culture, Medicine and Psychiatry, 10 p. 47-71
^es|m1ag' C K‘ (1983)- Women and Medicalization. A new perspective Social Policy,

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CASE 7B
THE CONSTRUCTION OF PUBLIC (HEALTH) PROBLEMS
Every year thousands of people are killed in automobile-accidents. In many of these
cases alcohol is involved. This phenomenon can be defined as a problem in several
ways. According to the specific definition of the problem both the supposed causes
as the proposed solutions differ.
A.

It is a well-known fact that drinking alcohol diminish the capability to drive
and, as a result of that, increases the risk on fatal accidents. Therefore policy
should be directed at preventing people to drive after drinking alcohol, for
example by education and legal measurements. The car-driver should be
confronted with alcohol-cheQttSs regularly. If an automobile-accident has
occurred, the police should always test the blood of the driver on the
presence of alcohol.

B.

The current types of cars are unsafe at any speed. They demand a kind of
attention which can only be produced by people who have been trained
extensively and who have been supervised continuously, like pilots. Instead
everyone who has ever passed one's driving test is allowed to drive a car,
even when he is moody in the morning or is fatigued by spending the
evening out. Automobile-manufactures should be obliged legally to produce
cars which really are designed for daily use - being safe even after a fight with
your wife or after a party with alcohol.

C.

The amount of automobile-accidents as a result of alcohol should be laid on
the account of the alcohol-industry. If the profits an -apart from human
sorrow- the costs would have been calculates, this branch of industry which
introduce onto the market and intrinsically unsafe product, would have been
closed down.

With regard to driving under influence of alcohol the problem is defined very clear
at the moment. Causes and responsibilities have been lay down and policy is
directed at that specific problem definition.

References
J. Gusfield, The Culture of Public Problem: Drinking-driving and the Symbolic
Order, Chicago, 1981, p. 1-27, 51-82

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CASE 7C
PRIMARY PREVENTION OF AIDS
Mid 1992 the estimation of the number of people infected with aids in different
continents is:
Africa
7.000.000
America
2.000.000
Asia
1.000.000
Europe
500.000
Oceania
50.000
In the developing countries, both sexes are equally affected.

We know how the virus is transmitted, the primary channels of infection being
unprotected sex or blood-blood contact, both with infected persons. Therefore
primary prevention of aids is theoretically possible by changing people's behaviors
However, in practice the prevention of aids is still far from optimal.
The field of public health has traditionally taught us much of what we need to know
to prevent epidemic disease, i.e. inoculation. With regards to aids, with its significant
behavioral components, traditional public health approaches are not enough. The
most hopeful approach to the prevention of aids is health education/health
promotion and the modification of behaviors.
In the realm of health education health promotion is defined as 'the combination of
educational and environmental supports for actions and conditions of living
conducive to health' (Green & Kreuter, 1991, p. 4). There is a strong tradition in
health education/health promotion theories and models, research methodologies
and techniques, that can be applied the problem of aids. However there is still a lack
of knowledge about people who are infected, determinants of safe and unsafe
behaviors, cultural barriers, the best way to implement educational programs, etc.
Nevertheless, more knowledge is available than presently is used in health
education/health promotion programs.

References

Green, L.W.& Kreuter, M.W., 1991. Health Promotion planning; an educational and
environmental approach. Mountain View, Cal.: Mayfield.
Glanz, K„ Lewis, F.M. & Rimer,, B.K. (Eds.), 1990. Health behavior and health
education; theory, research and practice. San Francisco, Cal.: Jossey Bass.

Kok, G., 1991. Health education theories and research for aids prevention. Hygie,

Mays, V.M., Albee, G.W. & Schneider, S.F. (Eds.), 1989, Primary prevention of aids;
psychological approaches. Newbury park, Cal.: SAGE

O'Reilly, K.R. & Higgins, D.L., 1991. Aids community demonstration projects for
HIV-prevention among hard-to-reach groups. Public Health Reports, 106, 714-720

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NOTES

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