AMERICAN JOURNAL OF
Public
Editorials Health August 1979 Volume 69, Number 8
Established 1911
State Registries and the Control of Rheumatic Fever
EDITOR Alfred Yankauer, MD, MPH EDITORIAL BOARD Michel A. Ibrahim, MD, PhD (1980), Chairperson Ruth B. Galanter, MCP (1980) George E. Hardy, Jr., MD, MPH (1981) David Hayes-Bautista, PhD (1981) C. C. Johnson, Jr., MSCE (1980) Selma J. Mushkin, PhD (1981) George M. Owen, MD (1979) Doris Roberts, PhD, MPH (1980) Pauline 0. Roberts, MD, MPH (1979) Ruth Roemer, JD (1981) Sam Shapiro (1979) Robert Sigmond (1979) Jeannette J. Simmons, MPH, DSc (1981) David H. Wegman, MD, MSOH (1979) Robert J. Weiss, MD (1980)
The information provided by Rice and Kaplan in the current issue of the Journal will not surprise those who have been responsible for state rheumatic fever programs, for there is no reason to believe that other states have a better record than is described in the Minnesota study.' Drs. Rice and Kaplan tell an important story that has ramifications for many public health programs. It is disappointing that 35 years after Dr. T. D. Jones established the criteria to be used in making the diagnosis of rheumatic fever,2 the Minnesota study shows that many physicians are not applying the criteria. It is also disappointing that although the Council on Rheumatic Fever and Congenital Heart Disease of the American Heart Association has, with great care, determined the type of prophylaxis that results in the lowest recurrence rate of rheumatic fever, few physicians in the study seem to recommend that form of prophylaxis, and fewer patients seem to take the recommended type of prophylaxis for long periods of time.3 Although a number of states have rheumatic fever registries, they are not actively supervised by a physician and are likely to contain inaccurate information. So in spite of a major effort to create a national standard for the diagnosis, prevention of recurrences, and reporting of rheumatic fever, the field of rheumatic fever would appear to be in disarray.
STAFF William H. McBeath, MD, MPH Executive DirectorlManaging Editor Allen J. Seeber Director of Publications Doyne Bailey Assistant Managing Editor Michelle Horton Production Editor Monica Pogue Administrative Assistant Ann Profozich
Classified Advertising CONTRIBUTING EDITORS
William J. Curran, JD, SMHyg Public Health and the Law Barbara G. Rosenkrantz, PhD Public Health Then and Now Jean Conelley, MLS Book Corner
AJPH August 1979, Vol. 69, No. 8
Some will disagree with that conclusion and will point to studies conducted in medical centers that show evidence of careful diagnosis, high compliance rates, and low recurrence rates. However, many patients receive their care outside of medical centers and the article shows that their care falls far short of the recommended standards. Moreover, the information in the article suggests that the clinical course of the disease in these people was not adversely affected by that care in any remarkable way.
The article by Rice and Kaplan raises two critical questions. First, "Are the current national standards for prophylaxis to prevent the recurrence of rheumatic fever so unpleasant, so expensive, so long-term, so inflexible, as to be self-defeating?" Those who are responsible for establishing these national standards are in a difficult position. They are understandably reluctant to recommend any program other than one which can be shown to result in the lowest recurrence rate. However, that recommendation does not recognize the pleomorphic nature of the disease. All would agree that long-term prophylaxis is important for the patient who has evidence of chronic rheumatic heart disease, but many would question whether it is indicated for the great majority of patients who have mild signs of rheumatic fever and no evidence of residual rheumatic heart disease. There is, therefore, a need to conduct clinical studies of rheumatic fever (as have been conducted for other diseases) to establish the criteria to identify those patients at greatest risk for having a recurrence of the disease. On the basis of those results, reasonable recommendations for prophylactic therapy can be developed. I suggest that it is the blanket nature of the current recommendation for prophylaxis that has limited its acceptance and resulted in the low compliance rate reported in the Minnesota study.' 761
EDITORIALS
The second question raised by the article is, "Should state rheumatic fever registries be continued?" This question can be asked about the Minnesota RF Registry unless it is reorganized. The reporting forms used by a state registry must be carefully designed to request established criteria by which the registry staff can screen the reported cases. Information that does not meet the criteria can then be directed to the monitoring physician. A state rheumatic fever registry that is not actively monitored by a physician qualified to respond to questions about rheumatic fever is of limited value and may do more harm than good by collecting erroneous material. State registries can no longer function as passive recipients of incomplete and inaccurate information. They must now be designed to actively process the data they receive so they can provide complete and accurate information because Health Systems Agencies are now using the information to determine the adequacy of current programs and the need for new programs.
Drs. Rice and Kaplan are to be commended for conducting a needed study of a state registry that identified an unpleasant, but important, problem.
JOHN C. MACQUEEN, MD Address reprint requests to John C. MacQueen, MD, Professor, Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, IA 52242.
REFERENCES
1. Rice MJ, Kaplan EL: Rheumatic fever in Minnesota: II. evaluation of hospitalized patients and utilization of a state rheumatic fever registry. Am J Public Health 69:767-771, 1979. 2. Jones TD: Diagnosis of rheumatic fever. JAMA 126:481-484, 1944. 3. Committee on Prevention of Rheumatic Fever and Bacterial Endocarditis of the American Heart Association. Prevention of rheumatic fever. Circulation 55:1-4, 1977.
Controversy and Publication Since its infancy, almost a century and a half ago, public health has been associated with social reform and challenges to accepted ways and standards. Those on the far left interpret these reformist tendencies as futile efforts to bolster an inherently inequitable social system. Those on the far right take a "blame-the-victim" approach and equate reform with education of the public. Most public health workers believe in both social reform and health education but try to judge each issue on its merits. During the past century the biomedical, laboratory and mathematical sciences have created new tools with which to control many of the old health hazards and to monitor, if not control, many other hazards which new technologies have unleashed. Although the relationship of the public health profession to the health of the public may seem more complex and uncertain than it was in the days of Virchow, Chadwick and Shattuck, its associations with social reform remain the same. One of the missions of this Journal is to bring divergent interpretations of data to the attention of its readership while firmly eschewing rhetoric and redundancy. This mission often poses an editorial problem, some of whose ramifications have been discussed in prior editorials.' 2 When there is a clear difference between two referees of a manuscript as to what the data really mean, an editor usually feels able to decide what to advise the author and whether publication is merited, making the disposition either on his own or with the help of additional referees. Nevertheless, when an important public health issue is at stake, and a serious attempt has been made to document a case that challenges the existing system, it seems reasonable to consider exceptions to a general rule and allow a paper to be published even though informed consensus goes against the author's interpretations. These exceptions must, of necessity, be 762
rare; some will question the editor's judgment, since publication itself may be taken as tacit endorsement. However, publication together with the criticism of peers allows counter-arguments to be made which may have even greater impact than the article which is criticized; furthermore, the publication of a controversial piece foils the dead hand of censorship,'which some have claimed contaminates the peer review process. We have had two such exceptions to the "general rule" in recent months.3'4 In both cases, critiques were solicited to accompany the controversial article, one as an editorial,S the other as a more detailed review.6 In the current issue of the Journal we publish another exception to the general rule, a paper that relates unemployment to heart disease mortality trends in Australia.7 We publish Dr. Bunn's paper together with two critiques, one which looks at its statistical techniques,8 the other which views the issues within a broader social and epidemiological framework. Why cardiovascular mortality has begun to decline after rising for several years remains, for many observers, an important public health phenomenon, yet to be explained satisfactorily. If the mortality curve reflects the ups and downs of gainful employment in a capitalist system, then reform of the system is as legitimate a measure of primary prevention as Rudolph Virchow's suggestion in 1848 that the abolition of poverty was the most important way to prevent typhus fe-
ver.I0 However valid Virchow's suggestion was at the time, epidemics of typhus fever are no longer to be feared, although poverty and its attendant health problems is still with us. Dr. Bunn's critics point out that the association of heart disease mortality and the business cycle is not all that it seems to be. Similar notes of skepticism were sounded in a
AJPH August 1979, Vol. 69, No. 8
Public
Editorials Health August 1979 Volume 69, Number 8
Established 1911
State Registries and the Control of Rheumatic Fever
EDITOR Alfred Yankauer, MD, MPH EDITORIAL BOARD Michel A. Ibrahim, MD, PhD (1980), Chairperson Ruth B. Galanter, MCP (1980) George E. Hardy, Jr., MD, MPH (1981) David Hayes-Bautista, PhD (1981) C. C. Johnson, Jr., MSCE (1980) Selma J. Mushkin, PhD (1981) George M. Owen, MD (1979) Doris Roberts, PhD, MPH (1980) Pauline 0. Roberts, MD, MPH (1979) Ruth Roemer, JD (1981) Sam Shapiro (1979) Robert Sigmond (1979) Jeannette J. Simmons, MPH, DSc (1981) David H. Wegman, MD, MSOH (1979) Robert J. Weiss, MD (1980)
The information provided by Rice and Kaplan in the current issue of the Journal will not surprise those who have been responsible for state rheumatic fever programs, for there is no reason to believe that other states have a better record than is described in the Minnesota study.' Drs. Rice and Kaplan tell an important story that has ramifications for many public health programs. It is disappointing that 35 years after Dr. T. D. Jones established the criteria to be used in making the diagnosis of rheumatic fever,2 the Minnesota study shows that many physicians are not applying the criteria. It is also disappointing that although the Council on Rheumatic Fever and Congenital Heart Disease of the American Heart Association has, with great care, determined the type of prophylaxis that results in the lowest recurrence rate of rheumatic fever, few physicians in the study seem to recommend that form of prophylaxis, and fewer patients seem to take the recommended type of prophylaxis for long periods of time.3 Although a number of states have rheumatic fever registries, they are not actively supervised by a physician and are likely to contain inaccurate information. So in spite of a major effort to create a national standard for the diagnosis, prevention of recurrences, and reporting of rheumatic fever, the field of rheumatic fever would appear to be in disarray.
STAFF William H. McBeath, MD, MPH Executive DirectorlManaging Editor Allen J. Seeber Director of Publications Doyne Bailey Assistant Managing Editor Michelle Horton Production Editor Monica Pogue Administrative Assistant Ann Profozich
Classified Advertising CONTRIBUTING EDITORS
William J. Curran, JD, SMHyg Public Health and the Law Barbara G. Rosenkrantz, PhD Public Health Then and Now Jean Conelley, MLS Book Corner
AJPH August 1979, Vol. 69, No. 8
Some will disagree with that conclusion and will point to studies conducted in medical centers that show evidence of careful diagnosis, high compliance rates, and low recurrence rates. However, many patients receive their care outside of medical centers and the article shows that their care falls far short of the recommended standards. Moreover, the information in the article suggests that the clinical course of the disease in these people was not adversely affected by that care in any remarkable way.
The article by Rice and Kaplan raises two critical questions. First, "Are the current national standards for prophylaxis to prevent the recurrence of rheumatic fever so unpleasant, so expensive, so long-term, so inflexible, as to be self-defeating?" Those who are responsible for establishing these national standards are in a difficult position. They are understandably reluctant to recommend any program other than one which can be shown to result in the lowest recurrence rate. However, that recommendation does not recognize the pleomorphic nature of the disease. All would agree that long-term prophylaxis is important for the patient who has evidence of chronic rheumatic heart disease, but many would question whether it is indicated for the great majority of patients who have mild signs of rheumatic fever and no evidence of residual rheumatic heart disease. There is, therefore, a need to conduct clinical studies of rheumatic fever (as have been conducted for other diseases) to establish the criteria to identify those patients at greatest risk for having a recurrence of the disease. On the basis of those results, reasonable recommendations for prophylactic therapy can be developed. I suggest that it is the blanket nature of the current recommendation for prophylaxis that has limited its acceptance and resulted in the low compliance rate reported in the Minnesota study.' 761
EDITORIALS
The second question raised by the article is, "Should state rheumatic fever registries be continued?" This question can be asked about the Minnesota RF Registry unless it is reorganized. The reporting forms used by a state registry must be carefully designed to request established criteria by which the registry staff can screen the reported cases. Information that does not meet the criteria can then be directed to the monitoring physician. A state rheumatic fever registry that is not actively monitored by a physician qualified to respond to questions about rheumatic fever is of limited value and may do more harm than good by collecting erroneous material. State registries can no longer function as passive recipients of incomplete and inaccurate information. They must now be designed to actively process the data they receive so they can provide complete and accurate information because Health Systems Agencies are now using the information to determine the adequacy of current programs and the need for new programs.
Drs. Rice and Kaplan are to be commended for conducting a needed study of a state registry that identified an unpleasant, but important, problem.
JOHN C. MACQUEEN, MD Address reprint requests to John C. MacQueen, MD, Professor, Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, IA 52242.
REFERENCES
1. Rice MJ, Kaplan EL: Rheumatic fever in Minnesota: II. evaluation of hospitalized patients and utilization of a state rheumatic fever registry. Am J Public Health 69:767-771, 1979. 2. Jones TD: Diagnosis of rheumatic fever. JAMA 126:481-484, 1944. 3. Committee on Prevention of Rheumatic Fever and Bacterial Endocarditis of the American Heart Association. Prevention of rheumatic fever. Circulation 55:1-4, 1977.
Controversy and Publication Since its infancy, almost a century and a half ago, public health has been associated with social reform and challenges to accepted ways and standards. Those on the far left interpret these reformist tendencies as futile efforts to bolster an inherently inequitable social system. Those on the far right take a "blame-the-victim" approach and equate reform with education of the public. Most public health workers believe in both social reform and health education but try to judge each issue on its merits. During the past century the biomedical, laboratory and mathematical sciences have created new tools with which to control many of the old health hazards and to monitor, if not control, many other hazards which new technologies have unleashed. Although the relationship of the public health profession to the health of the public may seem more complex and uncertain than it was in the days of Virchow, Chadwick and Shattuck, its associations with social reform remain the same. One of the missions of this Journal is to bring divergent interpretations of data to the attention of its readership while firmly eschewing rhetoric and redundancy. This mission often poses an editorial problem, some of whose ramifications have been discussed in prior editorials.' 2 When there is a clear difference between two referees of a manuscript as to what the data really mean, an editor usually feels able to decide what to advise the author and whether publication is merited, making the disposition either on his own or with the help of additional referees. Nevertheless, when an important public health issue is at stake, and a serious attempt has been made to document a case that challenges the existing system, it seems reasonable to consider exceptions to a general rule and allow a paper to be published even though informed consensus goes against the author's interpretations. These exceptions must, of necessity, be 762
rare; some will question the editor's judgment, since publication itself may be taken as tacit endorsement. However, publication together with the criticism of peers allows counter-arguments to be made which may have even greater impact than the article which is criticized; furthermore, the publication of a controversial piece foils the dead hand of censorship,'which some have claimed contaminates the peer review process. We have had two such exceptions to the "general rule" in recent months.3'4 In both cases, critiques were solicited to accompany the controversial article, one as an editorial,S the other as a more detailed review.6 In the current issue of the Journal we publish another exception to the general rule, a paper that relates unemployment to heart disease mortality trends in Australia.7 We publish Dr. Bunn's paper together with two critiques, one which looks at its statistical techniques,8 the other which views the issues within a broader social and epidemiological framework. Why cardiovascular mortality has begun to decline after rising for several years remains, for many observers, an important public health phenomenon, yet to be explained satisfactorily. If the mortality curve reflects the ups and downs of gainful employment in a capitalist system, then reform of the system is as legitimate a measure of primary prevention as Rudolph Virchow's suggestion in 1848 that the abolition of poverty was the most important way to prevent typhus fe-
ver.I0 However valid Virchow's suggestion was at the time, epidemics of typhus fever are no longer to be feared, although poverty and its attendant health problems is still with us. Dr. Bunn's critics point out that the association of heart disease mortality and the business cycle is not all that it seems to be. Similar notes of skepticism were sounded in a
AJPH August 1979, Vol. 69, No. 8
