Viewing Psychiatric Epidemiology Within a Global Historical Framework to Shape Future Practice.

This Viewpoint discusses the benefits of rethinking the history of psychiatric epidemiology from a global perspective.

Is Moderate Drinking Protective Against Heart Disease? The Science, Politics and History of a Public Health Conundrum.

Policy Points For more than 40 years, most research by epidemiologists, social scientists, and alcohol policy experts found that moderate alcohol consumption was cardioprotective. In the early 2000s, that consensus was shaken by new critics who subjected the previous research to vigorous methodological and empirical analysis, precipitating a bitter controversy, seemingly unresolvable despite numerous observational epidemiological studies. The effort to finally put that debate to rest through a large, multiyear randomized controlled trial under the aegis of the National Institute on Alcohol Abuse and Alcoholism, generated external criticism and adverse newspaper coverage, particularly because the trial was largely funded by the alcohol industry, forcing National Institutes of Health leadership to abruptly terminate the study shortly after it started. In the absence of definitive evidence and given the contentious debate over the risks and benefits of moderate alcohol consumption, those who formulate health policy have a responsibility to clearly acknowledge to the public the existence of evidentiary uncertainty when making recommendations.

If the Framingham Heart Study Did Not Invent the Risk Factor, Who Did?

Most historians, epidemiologists, and physicians credit the Framing-ham Heart Study for introducing the term "risk factor" to public health and medicine. Many add that the term came from life insurance companies. This familiar history is incorrect. Taking advantage of the expanding availability of digitized and full-text searchable journals, textbooks, newspapers, and other sources, we have uncovered a deeper and broader history. Antecedent concepts (such as risk, factor, predisposition) have ancient roots. "Risk factor" began to appear in the late 19th and early 20th centuries in many industries, not just in insurance but also in finance, agriculture, and manufacturing. The term appeared in the occupational health literature in 1922. It reappeared in the 1950s in many different areas of medicine including psychiatry, surgery, cardiology, epidemiology, and aerospace medicine. Furthermore, despite the influential appearance of "risk factor" in a 1961 Framingham Heart Study publication, the term did not gain momentum in medicine and public health until the mid-1970s. While our analysis is not exhaustive, our findings are extensive enough to require a substantial revision to the history of the risk factor.

Social disorder and diagnostic order: the US Mental Hygiene Movement, the Midtown Manhattan study and the development of psychiatric epidemiology in the 20th century.

Recent scholarship regarding psychiatric epidemiology has focused on shifting notions of mental disorders. In psychiatric epidemiology in the last decades of the 20th century and the first decade of the 21st century, mental disorders have been perceived and treated largely as discrete categories denoting an individual's mental functioning as either pathological or normal. In the USA, this grew partly out of evolving modern epidemiological work responding to the State's commitment to measure the national social and economic burdens of psychiatric disorders and subsequently to determine the need for mental health services and to survey these needs over time. Notably absent in these decades have been environmentally oriented approaches to cultivating normal, healthy mental states, approaches initially present after World War II. We focus here on a set of community studies conducted in the 1950s, particularly the Midtown Manhattan study, which grew out of a holistic conception of mental health that depended on social context and had a strong historical affiliation with: the Mental Hygiene Movement and the philosophy of its founder, Adolf Meyer; the epidemiological formation of field studies and population surveys beginning early in the 20th century, often with a health policy agenda; the recognition of increasing chronic disease in the USA; and the radical change in orientation within psychiatry around World War II. We place the Midtown Manhattan study in historical context--a complex narrative of social institutions, professional formation and scientific norms in psychiatry and epidemiology, and social welfare theory that begins during the Progressive era (1890-1920) in the USA.

McGovern's Senate Select Committee on Nutrition and Human Needs versus the meat industry on the diet-heart question (1976-1977).

For decades, public health advocates have confronted industry over dietary policy, their debates focusing on how to address evidentiary uncertainty. In 1977, enough consensus existed among epidemiologists that the Senate Select Committee on Nutrition and Human Need used the diet-heart association to perform an extraordinary act: advocate dietary goals for a healthier diet. During its hearings, the meat industry tested that consensus. In one year, the committee produced two editions of its Dietary Goals for the United States, the second containing a conciliatory statement about coronary heart disease and meat consumption. Critics have characterized the revision as a surrender to special interests. But the senators faced issues for which they were professionally unprepared: conflicts within science over the interpretation of data and notions of proof. Ultimately, it was lack of scientific consensus on these factors, not simply political acquiescence, that allowed special interests to secure changes in the guidelines.

Framingham Heart Study: the first 20 years.

The Framingham Heart Study remains the most famous and influential investigation in cardiovascular disease epidemiology. To generations of epidemiologists, it is a model for the cohort design. Here we revisit the origins of the Framingham Study before it became an accomplished and famous investigation whose existence and success are taken for granted. When in 1947 the Public Health Service initiated the study, knowledge of the distribution and determinants of coronary heart disease was sparse. Epidemiology was primarily focused on infectious disorders. Framingham's pioneers struggled to invent an appropriate epidemiological approach to this chronic disease and to establish support for a new kind of research within a community. Thereafter they had to convince skeptical medical professionals that the results of epidemiological investigations of heart disease were applicable to their clinical practices.

Invited commentary: The context and challenge of von Pettenkofer's contributions to epidemiology.

Max von Pettenkofer is largely remembered for swallowing cholera vibrio, trying thereby to falsify the claim of his rival, the contagionist Robert Koch, that the bacillus he had isolated was cholera's sufficient cause. In this issue of the American Journal of Epidemiology, Alfredo Morabia reminds us that von Pettenkofer was more than this futile gesture. He was a 19th century public health leader whose multifactorial theory of cholera etiology deeply influenced the dominant anticontagionist school of disease transmission. His authority was undercut by the massive 1892 cholera epidemic in Hamburg, Germany. As it took off, the German government sent in Koch, who successfully contained the epidemic through interventions that von Pettenkofer regularly repudiated-quarantine, disinfection, and the boiling of water. The authors situate the antagonism between these two individuals within a broader scientific and political context that includes the evolution of miasma theory and debates over the role of governments confronted by epidemic disease. They also note that Koch's approach, which focused narrowly on the agent and its eradication, was missing key elements required for applying germ theory to public health. As scientists later incorporated biologic, host, and environmental factors into the germ theory paradigm, they reintroduced some of the complexity that had previously characterized the miasma model.

Scale-ups, scarcity, and selections: the experience of doctors in South Africa.

OBJECTIVES: To present the ethical and clinical experience of public sector physicians during the post-Apartheid period in South Africa, who were faced with poverty, medical scarcity and unexpected government resistance in treating individuals with HIV infection. METHODS: Oral history interviews with 73 physicians from major cities, mine company clinics, and rural hospitals selected because of their long-standing commitment to treating people with AIDS. CONCLUSION: The onset of the government's 'rollout' of antiretroviral therapy (ART) in 2003, providing drugs to public sector patients, has not put an end to the rationing of care that characterised the pre-ART period. Subsequently, rules were established to guide such rationing in an equitable fashion. But there are occasions when doctors override their own rules, demonstrating the complex interplay between principles of equity and the claims of moral duty to patients, especially in instances of life and death.

Profiling risk: the emergence of coronary heart disease epidemiology in the United States (1947-70).

This historical study examines the development of coronary heart disease (CHD) research and its role in the evolution of post-1945 chronic disease epidemiology in the United States. To give the examination greater salience, it compares the pathway represented by CHD epidemiology with that of lung cancer. Historians have paid less attention to the differences between the two, which later merged into what we now call 'risk factor epidemiology'. This study assesses why CHD epidemiology in the post-war period almost uniformly began with cohort studies and primarily stressed clinical variables as putative aetiological factors. It describes how CHD epidemiologists sought to justify the creation of a non-infectious chronic disease epidemiology, a position reinforced by the relative swiftness with which they obtained important results. It also follows the emergence of 'risk factor thinking' within CHD epidemiology. CHD epidemiology critically differed from its lung cancer counterpart in that it identified multiple factors of risk, each producing relatively small effects, rather than a single factor producing a strong and evident outcome. Consequently, it was difficult for CHD epidemiologists to demonstrate causality and to confirm scientifically that reducing risk factors would lower CHD rates. This had significant consequences for primary prevention and public health policy.

Becoming the Framingham Study 1947-1950.

In the epidemiological imagination, the Framingham Heart Study has attained iconic status, both as the prototype of the cohort study and as a result of its scientific success. When the Public Health Service launched the study in 1947, epidemiological knowledge of coronary heart disease was poor, and epidemiology primarily involved the study of infectious disease. In constructing their investigation, Framingham's initiators had to invent new approaches to epidemiological research. These scientific goals were heavily influenced by the contending institutional and personal interests buffeting the study. The study passed through vicissitudes and stages during its earliest years as its organizers grappled to define its relationship to medicine, epidemiology, and the local community.