PUBLIC HEALTH BRIEFS
The American Journal of Public HealthRelevance to the Nation's Public Health Problems? RICHARD N. PODELL, MD, MPH KATHRYN KELLER, MSW Recently the senior author participated in a major conference on preventive medicine.* In one of the task force meetings he was challenged to delineate a practical public health strategy appropriate for the United States in the 1970s. In developing the proposal, he naturally sought guidance and information from the official journal of the American Public Health Association. However, his initial impression and then hypothesis was that the content of the Journal only moderately overlapped what seemed to be the major public health problems confronting the people of the United States. Therefore, the authors undertook the study to analyze and classify the substantive focus of each article appearing in the American Journal of Public Health from January, 1973 to June, 1975 (Vols. 63, 64, and half of 65).
Method Each published article was read at two sittings six weeks apart. At the fIrsi reading each author independently classified each article as to primary and secondary substantive concerns. These topics were grouped into fortyeight common themes, and a nomenclature was developed. Six weeks later each article was reread and reclassified by each author independently and without reference to notes taken on the first reading. When the articles were grouped according to the 48 major themes, there was agreement on identification of the primary focus for all but 14 of the 319 articles. For the articles on which there was disagreement, classification was negotiated by a process which was partly arbitrary. In retrospect, alternative choices in these few cases would not have affected the study's conclusion.** For
*National Conference on Preventive Medicine cosponsored by the American College of Preventive Medicine and The Fogarty International Center, June 9-11, 1975, Washington, D.C. **An example of an article which was difficult to classify is Backscheider, J. Self-Care Capabilities, and Nursing Systems in the Diabetic Nurse Management Clinic, AJPH 64:1138-1146, 1974. It's primary classification could reasonably have been either "health education" or "diabetes mellitus". ("Nurse-manpower" was clearly a secondary concern). It seemed to us that health education was "more primary" than diabetes. From the Division of Family Practice, Overlook Hospital. Address reprint requests to Dr. Podell, Associate Director, Overlook Family Practice Associates, 193 Morris Avenue, Summit, NJ 07901. This paper was submitted to the Journal October 15, 1975, and accepted for publication October 29, 1975.
AJPH January, 1976, Vol. 66, No. 1
ease of presentation, the 48 topics were further aggregated to
27. Each article was also classified according to a second scheme. It was noted that no matter what the substantive concern, almost all articles focused also at one of two levels: (1) directly at a disease (threat to health) or the object of that threat (patient/consumer); and (2) at the characteristics or operation of the health care delivery system or health professional provider. For convenience the first level (patient/ consumer/disease) was designated P/C/D. The second (system-professional) was designated S/P. For example, "The Role of House Dust in Human DDT Pollution"' was clearly P/C/D. In contrast "Some Trends in Schools of Public Health"2 and "Who Should Administer School Nursing Services?"3 were examples of S/P. Again, in greater than 95 per cent of cases there was agreement between each author and on two readings. All entries appearing as articles were analyzed; other entries such as editorials or public health briefs were excluded. It is recognized that inferences made on the basis of the articles do not necessarily apply to these other sections of the
Journal.
Results Table 1 details the primary substantive themes of Journal articles during two and one-half years. Articles primarily concerned with the organization of health care delivery systems or with health manpower issues together account for almost one-third of all titles. Next most common are articles on various aspects of human reproduction and family planning (12 per cent). Following are three more almost equally prevalent topics: environmental health; infant, child, and adolescent health; and infectious disease. Together, these six leading topics comprise 65 per cent of the total articles during the period studied (See Table 1). In contrast, many of the diseases which are among the most important contributors to severe physical illness and to death4' 5(including heart disease, cancer, stroke, diabetes, chronic lung disease, and renal disease) are the primary focus of less than four per cent of the articles; five per cent concentrate on behavior change techniques or the relation between behavior and chronic diseases; one per cent concern atherosclerotic risk factors such as cigarette smoking, hypertension, or hyperlipidemia; and other major causes of morbidity and mortality-such as accidents, homicide, and suicide-are also represented to a small degree. Table 2 summarizes the Patient/Consumer/Disease versus Systems/Professional orientation of articles according to 67
PUBLIC HEALTH BRIEFS
TABLE 1-Primary Subject of Articles in AJPH, January 1973-June, 1975 %ofTotal(N=319articles) Subject Matter
Per Cent
Organization of Health Care National/Regional Organization (8%) Institutional forms, politics and policy (4%) Quality of Service/Evaluations (3%) Micro-Organization and Administration (2%) International (2%) Statistics/Economics (2%) Other (2%) Human Reproduction and Family Planning Health Manpower
22
Discussion 12 10
Public Health Manpower (including history of public health, A.P.H.A.) (3%) Environmental Health Health of Infants, Children, and Adolescents (includes school health, excludes drug addiction) Infectious Disease (includes veterinary medicine) Addictions and Drug Abuse (includes alcoholism) Health of Low Income or Minority Groups Mental Health Health Education, Behavior Change, and Behavioral Causes of Diseases Geriatrics and Nursing Homes Heart Disease, Cancer or Stroke Accidents (including automobiles) Occupational Health Dental Disease
7 7
7 6 5 5 5
3 3 2 2 1
Cigarettes
1
Homicide and Suicide Sickle Cell Anemia Diabetes Mellitus, Chronic Lung Disease, Renal Disease or Cirrhosis Other Chronic Diseases and Chronic Disease Risk Factors (includes screening for chronic disease)
1 1 1
1 102%*
TABLE 2-Proportion of Articles Oriented to System/Professional (S/P) vs. Patient/Consumer/Disease (P/C/D) Concerns by Primary Substantive Topic Primary Topic
Per Cent
S/P Human Reproduction and Family Planning (N = 39) Health Manpower (N =32) Environmental Health (N=22) Health of Infants, Children, Adolescents (N=23) Infectious Disease (N=21) Addiction and Drug Abuse (N =20) Health of Low Income or Minorities (N- 16) Mental Health (N= 15) Health Education, Behavior Change and Behavioral Causes of Disease (N=15) Geriatrics and Nursing Homes (N=9) Chronic Disabling Disease and Risk Factors (Heart, Cancer, Stroke, Diabetes, Renal, Lung, Cirrhosis, Cigarettes) (N= 13) 68
There seem to be major discrepancies between the concerns of public health professionals as reflected in the Journal and the actual health problems affecting Americans today. For example, the review demonstrated minimum attention devoted to such important problems as heart disease, cancer, and stroke. In fact, far less space was devoted to these topics than to issues such as human reproduction, family planning, and infectious disease. This allocation of concerns does not, in the writers' opinion, reflect the actual importance of these problems in the United States. We do not assert a precise priority among public health problems. However, as a first approximation, it seems reasonable that the situations contributing most to death, suffering, and disability should receive priority attention. Table 3 lists the most prevalent causes of death in the United States. As these are also important causes of suffering and disability,* one might expect their importance to be reflected in TABLE 3-Fifteen Leading Causes of Death, United States,
19705
Causes of Death
exceeds 100% because of rounding off to nearest %
Organization of Health Care (N=70)
substantive topic categories. In most categories both levels of concern are found. However, there are several categories in which the orientation is exclusively at one level. Particularly, none of the articles about heart disease, cancer, stroke, or related risk factors focused at the Systems/Professional level, e.g., how should intervention be organized and by whom?
77 71
P/C/D 23 29
100 14 13
0 86 87
0 35 64 60 20
100 65 36 40 80
11 0
89 100
Annual Death Rate Per Cent (per 100,000 persons) Of All Deaths
Diseases of Heart Malignancy Cerebrovascular Disease Accidents Motor vehicle All other Influenza and Pneumonia Certain causes of mortality in early infancy Diabetes Arteriosclerosis Cirrhosis Bronchitis, Emphysema and Asthma Suicide Homicide Congenital Anomalies Nephritis and Nephrosis Peptic Ulcer All Other TOTAL
362.0 162.8 101.9 56.4 26.9 29.5 30.9
38.3 17.2 10.8 6.0 2.8 3.1 3.3
21.3 18.9 15.6 15.5 15.2 11.6 8.3 8.3 4.4 4.2 108.3 945.3
2.3 2.0 1.7 1.6 1.6 1.2 0.9 0.9 0.5 0.4 11.5 100%
*The chronic conditions most often responsible for inability to carry on major activity include heart conditions (17 per cent), arthritis and rheumatism (10.1 per cent), cerebrovascular disease (6.1 per cent), impairment of lower extremities and hips (5.1 per cent), mental and nervous conditions (5.0 per cent), emphysema (3.7 per cent), paralysis (3.2 per cent), other musculoskeletal disorders (3.2 per cent), visual impairment (3.2 per cent), diabetes (2.6 per cent), malignant neoplasm (1.9 per cent).4
AJPH January, 1976, Vol. 66, No. 1
PUBLIC HEALTH BRIEFS
made for other risk factors and for major chronic diseases. the writing and reading of public health professionals as However, their importance has not been reflected in the promeasured in their main professional journal, The American Journal of Public Health. This was not found to be the case. fession's leading journal. Similarly, the lack of articles on the One might object at this point: a health problem need systems or manpower aspects of these problems reflects the not be a public health concern simply because it is highly generally low level of concern. prevalent. Thus, DNA molecular biology may be critical to Why have important public health problems been relathe conquest of cancer, but public health journals need not tively neglected in the publications of the Journal? One devote much space to its research. The question really is might analyze the professional priorities of the editorial which of the major health problems of America should be board. However, it is our personal opinion that any exconsidered also to be problems of public health? planation based on "personalities" would be misleading and We propose a rule of reasonableness and precedent. If superficial. Instead, we believe the findings reflect a genuine the disciplines and methods by which a health problem is and profound identity crisis in the public health profession, studied, prevented, or treated derive substantially from the one which is shared by the body politic. Traditionally, there disciplines and methods of public health, then these probhas been a clear distinction between problems for which the lems ought to be the concern of the public health profession. individual patient and physician were responsible and those, By this rule, the adult killer diseases and attendant risk facsuch as infectious disease and family planning, in which the tors certainly must be included among our major public public had the "right" and effective ability to intervene. In health problems. recent years the objective relevance of public health interFor example, consider -the problem of cigarette smokventions to such "personal" conditions as heart disease, caning. Its relationship to major diseases was defined first cer, and stroke has been established. However, the subthrough the public health discipline of epidemiology. In turn, jective "right" or "legitimacy" of the profession's interest understanding the relationship of the cigarette to the smoker (i.e. of the public's interest) in this area remains equivocal. requires expertise from the social and behavioral sciences, The question is still open as to whether the public health prowhich have interfaced with medicine most often through the fession will be asked to assume responsibility for the full public health profession. Effective programs against the spectrum of the nation's public health problems. Whether harmful effects of smoking will require action by legislative the profession will seek or be prepared to accept such rebodies, public regulatory agencies, and the executive branch sponsibility also remains to be seen. of government-all traditional concerns of public health. There will be health education strategies and, of course, fiREFERENCES 1. Davies, J., Edmundson, W., Raffonelli, A., the role of house dust nancial, organizational, and manpower issues relating to the in human DDT pollution, Am. J. Public Health 65:53-57, 1975 provision of preventive and therapeutic services. Screening 2. Mathews, M., Some trends in schools of public health, Am. J. and case-finding of high-risk individuals is important. Again, Public Health 65:291-292, 1975 these pursuits lie in the domain of public health. Finally, 3. Humes, C., Who should administer school nursing services?, Am. J. Public Health 65: 394-396, 1975 there should be quality control and evaluation of inter4. Limitation of Activity and Morbidity Due to Chronic Conditions, vention programs as well as assessment of the ratio of beneUnited States, page 37, 1972, DHEW Publication No. (H.R.A.) fit to cost, both of which are public health methods. 75-1523, Rockville, Maryland, November, 1974 Thus, the cigarette smoking problem is a major problem 5. Vital Statistics of the United States, 1970, Volume II, Part A, in health and in public health. A similar analysis could be Table 5-6, U.S. Department H.E.W., Washington, D.C., 1972 (Briefs continued next page)
INDUSTRIAL HYGIENE CONFERENCE SET FOR MAY The American Industrial Hygiene Conference will be held on May 16-21, 1976 at the Marriott Hotel, Atlanta, GA. The Conference is cosponsored by American Industrial Hygiene Association and American Conference of Governmental Industrial Hygienists. For further information, contact American Industrial Hygiene Association, 66 S. Miller Rd., Akron, OH 44313 (216) 836-9537.
AJPH January, 1976, Vol. 66, No. 1
69
The American Journal of Public HealthRelevance to the Nation's Public Health Problems? RICHARD N. PODELL, MD, MPH KATHRYN KELLER, MSW Recently the senior author participated in a major conference on preventive medicine.* In one of the task force meetings he was challenged to delineate a practical public health strategy appropriate for the United States in the 1970s. In developing the proposal, he naturally sought guidance and information from the official journal of the American Public Health Association. However, his initial impression and then hypothesis was that the content of the Journal only moderately overlapped what seemed to be the major public health problems confronting the people of the United States. Therefore, the authors undertook the study to analyze and classify the substantive focus of each article appearing in the American Journal of Public Health from January, 1973 to June, 1975 (Vols. 63, 64, and half of 65).
Method Each published article was read at two sittings six weeks apart. At the fIrsi reading each author independently classified each article as to primary and secondary substantive concerns. These topics were grouped into fortyeight common themes, and a nomenclature was developed. Six weeks later each article was reread and reclassified by each author independently and without reference to notes taken on the first reading. When the articles were grouped according to the 48 major themes, there was agreement on identification of the primary focus for all but 14 of the 319 articles. For the articles on which there was disagreement, classification was negotiated by a process which was partly arbitrary. In retrospect, alternative choices in these few cases would not have affected the study's conclusion.** For
*National Conference on Preventive Medicine cosponsored by the American College of Preventive Medicine and The Fogarty International Center, June 9-11, 1975, Washington, D.C. **An example of an article which was difficult to classify is Backscheider, J. Self-Care Capabilities, and Nursing Systems in the Diabetic Nurse Management Clinic, AJPH 64:1138-1146, 1974. It's primary classification could reasonably have been either "health education" or "diabetes mellitus". ("Nurse-manpower" was clearly a secondary concern). It seemed to us that health education was "more primary" than diabetes. From the Division of Family Practice, Overlook Hospital. Address reprint requests to Dr. Podell, Associate Director, Overlook Family Practice Associates, 193 Morris Avenue, Summit, NJ 07901. This paper was submitted to the Journal October 15, 1975, and accepted for publication October 29, 1975.
AJPH January, 1976, Vol. 66, No. 1
ease of presentation, the 48 topics were further aggregated to
27. Each article was also classified according to a second scheme. It was noted that no matter what the substantive concern, almost all articles focused also at one of two levels: (1) directly at a disease (threat to health) or the object of that threat (patient/consumer); and (2) at the characteristics or operation of the health care delivery system or health professional provider. For convenience the first level (patient/ consumer/disease) was designated P/C/D. The second (system-professional) was designated S/P. For example, "The Role of House Dust in Human DDT Pollution"' was clearly P/C/D. In contrast "Some Trends in Schools of Public Health"2 and "Who Should Administer School Nursing Services?"3 were examples of S/P. Again, in greater than 95 per cent of cases there was agreement between each author and on two readings. All entries appearing as articles were analyzed; other entries such as editorials or public health briefs were excluded. It is recognized that inferences made on the basis of the articles do not necessarily apply to these other sections of the
Journal.
Results Table 1 details the primary substantive themes of Journal articles during two and one-half years. Articles primarily concerned with the organization of health care delivery systems or with health manpower issues together account for almost one-third of all titles. Next most common are articles on various aspects of human reproduction and family planning (12 per cent). Following are three more almost equally prevalent topics: environmental health; infant, child, and adolescent health; and infectious disease. Together, these six leading topics comprise 65 per cent of the total articles during the period studied (See Table 1). In contrast, many of the diseases which are among the most important contributors to severe physical illness and to death4' 5(including heart disease, cancer, stroke, diabetes, chronic lung disease, and renal disease) are the primary focus of less than four per cent of the articles; five per cent concentrate on behavior change techniques or the relation between behavior and chronic diseases; one per cent concern atherosclerotic risk factors such as cigarette smoking, hypertension, or hyperlipidemia; and other major causes of morbidity and mortality-such as accidents, homicide, and suicide-are also represented to a small degree. Table 2 summarizes the Patient/Consumer/Disease versus Systems/Professional orientation of articles according to 67
PUBLIC HEALTH BRIEFS
TABLE 1-Primary Subject of Articles in AJPH, January 1973-June, 1975 %ofTotal(N=319articles) Subject Matter
Per Cent
Organization of Health Care National/Regional Organization (8%) Institutional forms, politics and policy (4%) Quality of Service/Evaluations (3%) Micro-Organization and Administration (2%) International (2%) Statistics/Economics (2%) Other (2%) Human Reproduction and Family Planning Health Manpower
22
Discussion 12 10
Public Health Manpower (including history of public health, A.P.H.A.) (3%) Environmental Health Health of Infants, Children, and Adolescents (includes school health, excludes drug addiction) Infectious Disease (includes veterinary medicine) Addictions and Drug Abuse (includes alcoholism) Health of Low Income or Minority Groups Mental Health Health Education, Behavior Change, and Behavioral Causes of Diseases Geriatrics and Nursing Homes Heart Disease, Cancer or Stroke Accidents (including automobiles) Occupational Health Dental Disease
7 7
7 6 5 5 5
3 3 2 2 1
Cigarettes
1
Homicide and Suicide Sickle Cell Anemia Diabetes Mellitus, Chronic Lung Disease, Renal Disease or Cirrhosis Other Chronic Diseases and Chronic Disease Risk Factors (includes screening for chronic disease)
1 1 1
1 102%*
TABLE 2-Proportion of Articles Oriented to System/Professional (S/P) vs. Patient/Consumer/Disease (P/C/D) Concerns by Primary Substantive Topic Primary Topic
Per Cent
S/P Human Reproduction and Family Planning (N = 39) Health Manpower (N =32) Environmental Health (N=22) Health of Infants, Children, Adolescents (N=23) Infectious Disease (N=21) Addiction and Drug Abuse (N =20) Health of Low Income or Minorities (N- 16) Mental Health (N= 15) Health Education, Behavior Change and Behavioral Causes of Disease (N=15) Geriatrics and Nursing Homes (N=9) Chronic Disabling Disease and Risk Factors (Heart, Cancer, Stroke, Diabetes, Renal, Lung, Cirrhosis, Cigarettes) (N= 13) 68
There seem to be major discrepancies between the concerns of public health professionals as reflected in the Journal and the actual health problems affecting Americans today. For example, the review demonstrated minimum attention devoted to such important problems as heart disease, cancer, and stroke. In fact, far less space was devoted to these topics than to issues such as human reproduction, family planning, and infectious disease. This allocation of concerns does not, in the writers' opinion, reflect the actual importance of these problems in the United States. We do not assert a precise priority among public health problems. However, as a first approximation, it seems reasonable that the situations contributing most to death, suffering, and disability should receive priority attention. Table 3 lists the most prevalent causes of death in the United States. As these are also important causes of suffering and disability,* one might expect their importance to be reflected in TABLE 3-Fifteen Leading Causes of Death, United States,
19705
Causes of Death
exceeds 100% because of rounding off to nearest %
Organization of Health Care (N=70)
substantive topic categories. In most categories both levels of concern are found. However, there are several categories in which the orientation is exclusively at one level. Particularly, none of the articles about heart disease, cancer, stroke, or related risk factors focused at the Systems/Professional level, e.g., how should intervention be organized and by whom?
77 71
P/C/D 23 29
100 14 13
0 86 87
0 35 64 60 20
100 65 36 40 80
11 0
89 100
Annual Death Rate Per Cent (per 100,000 persons) Of All Deaths
Diseases of Heart Malignancy Cerebrovascular Disease Accidents Motor vehicle All other Influenza and Pneumonia Certain causes of mortality in early infancy Diabetes Arteriosclerosis Cirrhosis Bronchitis, Emphysema and Asthma Suicide Homicide Congenital Anomalies Nephritis and Nephrosis Peptic Ulcer All Other TOTAL
362.0 162.8 101.9 56.4 26.9 29.5 30.9
38.3 17.2 10.8 6.0 2.8 3.1 3.3
21.3 18.9 15.6 15.5 15.2 11.6 8.3 8.3 4.4 4.2 108.3 945.3
2.3 2.0 1.7 1.6 1.6 1.2 0.9 0.9 0.5 0.4 11.5 100%
*The chronic conditions most often responsible for inability to carry on major activity include heart conditions (17 per cent), arthritis and rheumatism (10.1 per cent), cerebrovascular disease (6.1 per cent), impairment of lower extremities and hips (5.1 per cent), mental and nervous conditions (5.0 per cent), emphysema (3.7 per cent), paralysis (3.2 per cent), other musculoskeletal disorders (3.2 per cent), visual impairment (3.2 per cent), diabetes (2.6 per cent), malignant neoplasm (1.9 per cent).4
AJPH January, 1976, Vol. 66, No. 1
PUBLIC HEALTH BRIEFS
made for other risk factors and for major chronic diseases. the writing and reading of public health professionals as However, their importance has not been reflected in the promeasured in their main professional journal, The American Journal of Public Health. This was not found to be the case. fession's leading journal. Similarly, the lack of articles on the One might object at this point: a health problem need systems or manpower aspects of these problems reflects the not be a public health concern simply because it is highly generally low level of concern. prevalent. Thus, DNA molecular biology may be critical to Why have important public health problems been relathe conquest of cancer, but public health journals need not tively neglected in the publications of the Journal? One devote much space to its research. The question really is might analyze the professional priorities of the editorial which of the major health problems of America should be board. However, it is our personal opinion that any exconsidered also to be problems of public health? planation based on "personalities" would be misleading and We propose a rule of reasonableness and precedent. If superficial. Instead, we believe the findings reflect a genuine the disciplines and methods by which a health problem is and profound identity crisis in the public health profession, studied, prevented, or treated derive substantially from the one which is shared by the body politic. Traditionally, there disciplines and methods of public health, then these probhas been a clear distinction between problems for which the lems ought to be the concern of the public health profession. individual patient and physician were responsible and those, By this rule, the adult killer diseases and attendant risk facsuch as infectious disease and family planning, in which the tors certainly must be included among our major public public had the "right" and effective ability to intervene. In health problems. recent years the objective relevance of public health interFor example, consider -the problem of cigarette smokventions to such "personal" conditions as heart disease, caning. Its relationship to major diseases was defined first cer, and stroke has been established. However, the subthrough the public health discipline of epidemiology. In turn, jective "right" or "legitimacy" of the profession's interest understanding the relationship of the cigarette to the smoker (i.e. of the public's interest) in this area remains equivocal. requires expertise from the social and behavioral sciences, The question is still open as to whether the public health prowhich have interfaced with medicine most often through the fession will be asked to assume responsibility for the full public health profession. Effective programs against the spectrum of the nation's public health problems. Whether harmful effects of smoking will require action by legislative the profession will seek or be prepared to accept such rebodies, public regulatory agencies, and the executive branch sponsibility also remains to be seen. of government-all traditional concerns of public health. There will be health education strategies and, of course, fiREFERENCES 1. Davies, J., Edmundson, W., Raffonelli, A., the role of house dust nancial, organizational, and manpower issues relating to the in human DDT pollution, Am. J. Public Health 65:53-57, 1975 provision of preventive and therapeutic services. Screening 2. Mathews, M., Some trends in schools of public health, Am. J. and case-finding of high-risk individuals is important. Again, Public Health 65:291-292, 1975 these pursuits lie in the domain of public health. Finally, 3. Humes, C., Who should administer school nursing services?, Am. J. Public Health 65: 394-396, 1975 there should be quality control and evaluation of inter4. Limitation of Activity and Morbidity Due to Chronic Conditions, vention programs as well as assessment of the ratio of beneUnited States, page 37, 1972, DHEW Publication No. (H.R.A.) fit to cost, both of which are public health methods. 75-1523, Rockville, Maryland, November, 1974 Thus, the cigarette smoking problem is a major problem 5. Vital Statistics of the United States, 1970, Volume II, Part A, in health and in public health. A similar analysis could be Table 5-6, U.S. Department H.E.W., Washington, D.C., 1972 (Briefs continued next page)
INDUSTRIAL HYGIENE CONFERENCE SET FOR MAY The American Industrial Hygiene Conference will be held on May 16-21, 1976 at the Marriott Hotel, Atlanta, GA. The Conference is cosponsored by American Industrial Hygiene Association and American Conference of Governmental Industrial Hygienists. For further information, contact American Industrial Hygiene Association, 66 S. Miller Rd., Akron, OH 44313 (216) 836-9537.
AJPH January, 1976, Vol. 66, No. 1
69
