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.

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.

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.

Health and human rights: old wine in new bottles?

It is one of the remarkable and significant consequence of the AIDS epidemic that out of the context of enormous suffering and death there emerged a forceful set of ideas linking the domains of health and human rights. At first, the effort centered on the observation that protecting individuals from discrimination and unwarranted intrusions on liberty were, contrary to previous epidemics, crucial to protecting the public health and interrupting the spread of HIV But in fairly short order, the scope of the health and human rights perspective expanded dramatically to focus on the ways in which the most fundamental social arrangements rendered individuals and communities vulnerable to HIV Racial and ethnic minorities, those who were marginalized, and women were at risk because of their subordinate status. In the face of such an understanding, nothing short of social change could be adequate to the challenge posed by the AIDS epidemic.

Paradigm lost: race, ethnicity, and the search for a new population taxonomy

The Institute of Medicine (IOM) recently recommended that the National Institutes of Health (NIH) reevaluate its employment of "race," a concept lacking scientific or anthropological justification, in cancer surveillance and other population research. The IOM advised the NIH to use a different population classification, that of "ethnic group," instead of "race." A relatively new term, according to the IOM, "ethnic group" would turn research attention away from biological determinism and toward a focus on culture and behavior. This article examines the historically central role of racial categorization and its relationship to racism in the United States and questions whether dropping "race" from population taxonomies is either possible or, at least in the short run, preferable. In addition, a historical examination of "ethnicity" and "ethnic group" finds that these concepts, as used in the United States, derive in part from race and immigration and are not neutral terms; instead, they carry their own burden of political, social, and ideological meaning.

Public health nihilism vs pragmatism: history, politics, and the control of tuberculosis

Tuberculosis (TB) began to decline in the Western world in the mid- to late 1800s. In the United States, the disease receded until the mid-1980s, when that trend was reversed. Although the TB epidemic in the United States subsided in response to public health interventions, it sparked a controversy regarding the relative value of targeted public health measures vs broad social reform. That controversy, which echoed earlier debates calling for structural reform over public health programs, was further strengthened by the historical and demographic studies of Thomas McKeown. His influential thesis maintains that clinical and primary prevention efforts had little effect on TB mortality. In this paper, the historical literature is used to examine whether public health had a significant impact on the decline of TB mortality rates in several countries. Specifically, the paper describes the arguments for and data affirming the efficacy of 2 major public health interventions over time: segregation of those infected with pulmonary TB and eradication of bovine TB. This review finds support for the hypothesis that public health measures, along with other factors, led to falling rates of TB mortality beginning in the late 19th century.

Prematurity as a public health problem: US policy from the 1920s to the 1960s

During the 1920s and 1930s, a number of physicians created model premature infant stations in select hospitals, arguing that medicine could successfully treat premature infants, most of whom could be expected to live normal lives. Most hospitals and doctors, however, remained indifferent to the special medical needs of premature infants. Subsequently, public health officials, beginning in Chicago, took up the cause of the medical management of newborn premature infants, defining the problem and finding the resources for a community-wide solution. The latter included multiple, high-quality premature nurseries, infant transport, regionalization, and public financing. The "Chicago model" was adapted by many state and municipal departments of health, particularly after World War II, to create community-based programs, the largest of which was in New York City. As premature infant care became of greater interest to pediatricians and hospitals, in part because of the success achieved by public health officials, the earlier, prominent role of the latter was increasingly diminished and historically forgotten.

The $147,000 misunderstanding: repercussions of overestimating the cost of AIDS

The increasing incidence of AIDS in the 1980s prompted inquiry into the resources required to meet projected needs. In the first economic study to appear on the illness, the Centers for Disease Control (CDC) estimated that the costs of inpatient care were $147,000 per AIDS patient, heightening concern that the health care system would be overwhelmed by the epidemic. However, every study published subsequently has produced much lower cost estimates. As a result, many have concluded that treatment costs declined due to improved delivery of AIDS care. We offer an alternative interpretation, based on evidence demonstrating that the CDC's methods and assumptions yielded a figure about three times too high. The CDC's erroneous estimate had significant policy repercussions. Using the $147,000 figure, the health insurance industry lobbied successfully for the right to screen applicants for HIV. Next, when a study of San Francisco AIDS patients found local hospital costs per case to be $27,571, many concluded that billions of dollars could be saved if the "San Francisco model" of care (emphasizing home and community-based services and case management) were universalized. Since then, most programs for AIDS services have provided funds for community care. While such programs improve access to vital services, they are unlikely to guarantee "better care for less money." A more informed understanding of the cost of AIDS should lead to programs that also strengthen inpatient care.

AIDS: the risks to insurers, the threat to equity

The AIDS crisis poses a special challenge for American health care, which depends heavily on private insurance to pay medical bills. Can we provide adequate health care to all who need it and still meet the financial requirements of the private health insurance industry? More insurance carriers are turning to antibody testing in order to eliminate poor risks from non-group, direct-pay pools. Some cost-conscious employers have attempted to fire AIDS patients summarily or to exclude AIDS coverage from group insurance policies. Various remedies are available for spreading the financial risks of the epidemic, such as covering persons with AIDS under Medicare or in state-sponsored health insurance pools. Ethical questions about cost and access may also rekindle the debate about the need for national health insurance.