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 Population Health:
Concepts and Methods,
Second Edition

T. Kue Young
M.D., M.Sc., FRCPC, D.Phil.

OXFORD UNIVERSITY PRESS

Population Health
This page intentionally left blank
Population Health
Concepts and Methods
Second Edition

T. Kue Young
M.D., M.Sc., FRCPC, D.Phil.
Professor of Public Health Sciences
Faculty of Medicine
University of Toronto

3
2004
 3
Oxford New York
Auckland Bangkok Buenos Aires Cape Town Chennai
Dar es Salaam Delhi Hong Kong Istanbul Karachi Kolkata
Kuala Lumpur Madrid Melbourne Mexico City Mumbai Nairobi
São Paulo Shanghai Taipei Tokyo Toronto

Copyright © 2004 by Oxford University Press, Inc.

Published by Oxford University Press, Inc.

198 Madison Avenue, New York, New York 10016
www.oup.com

Oxford is a registered trademark of Oxford University Press

All rights reserved. No part of this publication may be reproduced,

stored in a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, recording, or otherwise,
without the prior permission of Oxford University Press.

Library of Congress Cataloging-in-Publication Data

Young, T. Kue.
Population health : concepts and methods / T. Kue Young.—2nd ed.
p. cm.
Includes bibliographical references and index.
ISBN 0-19-515854-7
1. Public health. 2. Epidemiology. I. Title.
RA425.Y68 2004
614.4—dc22 2004050095

123456789
Printed in the United States of America
on acid-free paper
 Preface

Why the term population health was chosen as the title of this textbook is
explained in some detail in Chapter 1. The book is intended for introduc-
tory and intermediate courses in epidemiology, community health, or
related course work given primarily in schools or graduate programs
of public health. It arose from a graduate course on the principles of epi-
demiology that I have taught for over 10 years, first at the University of
Manitoba, and more recently at the University of Toronto. Despite the
proliferation of epidemiology texts, I have had surprising difficulty find-
ing one that suits the needs of students who intend to work in public
health, health planning, or program management. These students should
be exposed to the excitement of both research and practice. Numerous ed-
itorials and articles in recent years have lamented the “drifting away” of
epidemiology from its roots in public health. Indeed, there are books on
epidemiology where “population” does not matter, and where “health” is
not even a focus. It is also increasingly evident that epidemiology as a
quantitative science alone is an inadequate tool to understand or to inves-
tigate the full complexities of the health of populations.
In writing this book, I have had an ambitious aim: to spark the develop-
ment of a new type of interdisciplinary, broadly based foundation course in
population health. Such a course would, for sure, have epidemiology as its
core, but this would be integrated with the methods and concepts of rele-
vant social sciences and the humanities, including demography, sociology,
anthropology, history, and ethics. The course would focus on defining and
measuring population health status, determining health risks and infer-
ring causation, and planning and evaluating interventions.
This book does not intend to replace the standard encyclopedic texts in
public health. It is not meant to be a reference text, and I would actually rec-
ommend that it be read from cover to cover. Doing so is not to indulge the
author in his delusion, but to enable students to take a guided tour of the
entire field (with some detours) and to get a good grasp of its key features.
Extensive use is made of boxes throughout the text. These provide ex-
planations of technical terms—etymology, nuance, and usage; worked ex-
amples of computations using actual data; supplementary information to
vi Preface

illustrate the text; and useful lists, figures, and tables. At the end of each
chapter are case studies, which provide short summaries of the methods
and results of published studies relevant to the concepts discussed in the
chapter. Many of these cases are historical. This represents a deliberate at-
tempt to impress on students entering the field that what we know today
has accumulated from what others have learned in the past, and that what
we see as “new” issues often are actually recycled old ideas.
The chapters also contain exercises, which mainly involve numerical
computations but also deal with the interpretation of graphical and tabular
data. Actual data from the published literature are used whenever possible,
with examples from the full spectrum of health problems—infectious dis-
eases, chronic diseases, environmental and occupational health, injuries,
mental health, dental health, and more. While there is a North American
bias, a conscious effort has been made to choose examples from around the
world.
Since the first edition was published in 1998, the term population health
has become much more widely accepted and the field has advanced. For
this second edition much new material has been added to the text, boxes,
and exercises reflecting changes in contemporary public health concerns
and our response to them, as well as new research directions. In addition,
many sections have been expanded, reorganized, or clarified, and I am
grateful to the many readers, students, and colleagues who have pointed
out errors and weaknesses in the first edition.
The topics that are new to this edition or are discussed in greater depth
include: achievements of public health in the twentieth century (Chapter 1);
confidence intervals for commonly used rates, and the impact of popula-
tion aging on mortality trends (Chapter 2); health survey questionnaires,
summary measures of population health, the new International Classifica-
tion of Functioning, Disability and Health, and the epidemiological investi-
gation of bioterrorism (Chapter 3); migrant studies, race and ethnicity,
health in the life course, psychoneuroendocrine pathways, and more exten-
sive coverage of genetics and social epidemiology (Chapter 4); expanded
coverage of risk perception, and communicating the SARS epidemic (Chap-
ter 5); expanded discussions of ecologic studies, the odds ratio and interac-
tions, participatory research, and Durkheim’s classic studies on suicide
(Chapter 6); evidence-based community interventions (Chapter 7); and
more detailed coverage of evaluation methods and health economics, the
Cochrane Collaboration, and systematic reviews (Chapter 8). Chapter 9 is
still a student project, but with additional guidance and examples from ex-
isting populations.
In writing this book, I have ventured far afield into areas in which I am
not expert. There is no better way to understand a subject than to try to ex-
plain it to others, and I hope the readers will share my enthusiasm for
learning and exploring new ideas about population health.
 Preface vii

Jeffrey House of Oxford University Press has actively supported and

encouraged the development of this book and its second edition. The
highly competent editorial staff (Nancy Wolitzer and Bruce Cleary for the
first edition, and Lynda Crawford and Gail Cooper for the second edition)
guided the book through its production process. They made the task of
the author almost enjoyable. The continuing demand for this book is
cause for some optimism for a broad-based multidisciplinary approach to
studying population health.

Toronto T.K.Y.
This page intentionally left blank
 Contents

1 Introduction, 1
Defining Health, Population, and Population Health, 1
Objectives and Uses of Population Health Studies, 6
The Arts and Sciences in Population Health, 7
Historical Antecedents and Future Prospects, 10
Summary, 12
Case Study 1.1. James Lind and Scurvy among Sailors, 14
Case Study 1.2. John Snow, Cholera, and the Broad Street Pump, 15
Case Study 1.3. Ignaz Semmelweis and Puerperal Fever, 17
Case Study 1.4. Joseph Goldberger on Diet and Pellagra, 18
Guide to Resources, 19
Notes, 21

2 Measuring Health and Disease in Populations (I), 25

Measures of Disease Occurrence, 25
Population Structure and Dynamics, 31
Comparing Health Events in Populations, 44
Demographic and Health Transition, 49
Summary, 54
Case Study 2.1. Cancer Incidence in Five Continents, 54
Case Study 2.2. Contribution of Population Aging to Changes in
Cancer Mortality, 56
Notes, 59
Exercises, 62

3 Measuring Health and Disease in Populations (II), 67

Health Indicators and Indices, 67
Sources and Quality of Health Data, 71
Summary Measures of Population Health, 81
Diagnosis and Classification of Diseases, 82
x Contents

Accuracy of Screening and Diagnostic Tests, 90

Surveillance and Epidemic Investigations, 96
Cultural Concepts of Health and Disease, 99
Summary, 102
Case Study 3.1. Are Death Certificates Accurate? 103
Case Study 3.2. Diphtheria in Russia—Return of a
Vanquished Foe? 104
Case Study 3.3. Is Schizophrenia Universal? 106
Notes, 107
Exercises, 111

4 Modeling Determinants of Population Health, 115

Models and Pathways of Health, 115
Genetic Susceptibility, 117
Physical Environment, 126
Personal Lifestyles and Behaviors, 135
Social, Cultural, and Economic Factors, 148
A Life Course Approach to Health, 156
A Biopsychosocial Model of Health, 157
Contributions to Global Disease Burden, 158
Summary, 161
Case Study 4.1. The Sickle Cell Trait and Protection from
Malaria, 162
Case Study 4.2. Chernobyl: Aftermath of an Environmental
Catastrophe, 163
Case Study 4.3. Social Medicine in Pre–World War I Germany, 166
Notes, 168
Exercises, 173

5 Assessing Health Risks in Populations, 177

Risks in Population Health, 177
Concepts of Causation, 181
Measures of Association and Effect, 188
Competing Risks, 194
Risk Perception and Communication, 196
Summary, 200
Case Study 5.1. Is British Beef Safe? 201
Case Study 5.2. Do Heart Attacks Prevent Cancer Deaths? 204
Case Study 5.3. Communicating SARS Risk with Numbers, 205
Notes, 207
Exercises, 210
 Contents xi

6 Designing Population Health Studies, 215

A Matter of Measurement, 215
Types of Research Design, 219
Validity and Reliability, 230
Error and Bias, 232
Confounding and Confounders, 233
Interaction or Effect Modification, 236
Qualitative Methods, 238
Ethical Concerns, 241
Summary, 245
Case Study 6.1. Age-Period-Cohort Analysis of Traffic
Accident Mortality, 247
Case Study 6.2. Durkheim’s Studies on Suicide, 250
Case Study 6.3. The Causal Trail: Cigarette Smoking
and Lung Cancer, 252
Case Study 6.4. Tracking Heart Disease among World War II
Airmen, 256
Notes, 257
Exercises, 261

7 Planning Population Health Interventions, 264

Promoting Health, Preventing Disease, 264
Population Health and the Health Care System, 266
Types and Levels of Interventions, 267
Criteria for Screening, 272
Behavioral Models for Health Promotion, 277
Cross-Cultural Considerations, 280
A Broader View of Prevention, 281
Summary, 284
Case Study 7.1. The Global Eradication of Smallpox, 284
Case Study 7.2. Is Mammography Good for Women? 288
Case Study 7.3. Community-Based Heart Disease
Prevention in North Karelia, 290
Notes, 293
Exercise, 295

8 Evaluating Health Programs for Populations, 296

A Framework for Evaluation, 296
Technology Assessment, Diffusion, and Transfer, 299
Evaluation Methods, 302
xii Contents

Economic Appraisal, 306

Decision-Making in Health Care, 310
Summary, 312
Case Study 8.1. Nurse-Practitioners in Primary Care, 312
Case Study 8.2. Fluoridation of Community Water Supply
to Prevent Dental Caries, 314
Case Study 8.3. Economic Evaluation of Neonatal
Intensive Care, 317
Case Study 8.4. A Meta-Analysis of Adolescent Smoking
Programs, 319
Notes, 320
Exercise, 321

9 Improving the Health of Populations, 324

Guide to Resources, 327

Bibliography, 331
Answers to Exercises, 365
Index, 381
Population Health
This page intentionally left blank
1
Introduction

Defining Health, Population, and Population Health

This is a book about the health of populations. Health and population are
fundamental concepts that need to be clearly defined. While most people
seem to know when they are healthy or when they are not, there is no
universal consensus on the definition of health. The World Health Orga-
nization’s (WHO) definition of health—that health is a state of complete
physical, mental and social well-being, and not merely the absence of disease or
infirmity—first appeared in the preamble to its constitution, which was
signed in 1946 and ratified in 1948.1 It reflected the yearning for a world
full of peace and harmony after the global catastrophes of World War II.
The definition has been quoted innumerable times and is hailed for its
comprehensiveness and emphasis on the broader, “positive,” and psy-
chosocial aspects of health, beyond the traditional “biomedical,” “nega-
tive” aspects such as death, disease, and disability. (Together with discomfort
and dissatisfaction these constitute the so-called five Ds). The European Re-
gion of WHO provided an update of the definition of health in a 1984 doc-
ument on health promotion:

[Health] is the extent to which an individual or group is able on the one

hand to realize aspirations and satisfy needs, and, on the other hand, to
change and cope with the environment. Health is therefore seen as a re-
source for everyday life, not the objective of living; it is a positive concept
emphasizing social and personal resources as well as physical capacities.

There have been numerous other attempts at a definition.2 Certain re-

current themes and key words can be found in these definitions; for ex-
ample, coping with and managing stress, achieving functional capacity
and structural integrity, ability to make valued contributions to the com-
munity, and maintaining equilibrium.
Writers on health issues, such as René Dubos (1901–1982) and Ivan Il-
lich (1926–2002), have also offered their views on the matter. These are
generally more forceful and less convoluted than those composed by
2 Population Health

committees. Dubos, a distinguished microbiologist, championed the eco-

logical view of the relationship between microbes and humans. A rarity
among scientists, he wrote several books for the general public and even
won the Pulitzer Prize in 1969. In his 1968 book Man, Medicine and Envi-
ronment, Dubos called health

a modus vivendi enabling imperfect men to achieve a rewarding and

not too painful existence while they cope with an imperfect world. . . .
Health and vigor can be achieved in the absence of modern sanitation
and without the help of western medicine. Man has in his nature the po-
tentiality to reach a high level of physical and mental well-being with-
out nutritional abundance or physical comfort.3

Illich, a theologian by training, was a noted critic of advanced indus-

trial societies and their social institutions, such as medicine and educa-
tion. In 1975, he published his highly provocative Medical Nemesis in draft
form, a book that was circulated worldwide in nine languages and created
a heated debate in medical circles. In it, he described health as

an autonomous yet culturally shaped reaction to reality. It designates

the ability to adapt to a changing environment, to growing up and to ag-
ing, to healing when damaged, to suffering and to the peaceful expecta-
tion of death. Health embraces the future as well, and therefore includes
anguish and the inner resources to live with it.4

The U.S. Surgeon General’s landmark 1979 report on health promotion,

Healthy People, did not offer a definition of health. Yet its first sentence de-
clared, “The health of the American people has never been better.” This
and subsequent updates established detailed health goals and age-related
objectives for Americans. (Devotees of “positive health” may find the
overall tone and approach still too “disease-oriented”).5
In 1986, the Canadian Department of National Health and Welfare pub-
lished a report titled Achieving Health for All, in which “a new vision of
health” was proposed:

a concept which portrays health as a part of everyday living, an essen-

tial dimension of the quality of our lives . . . the opportunity to make
choices and to gain satisfaction from living. Health is thus envisaged as
a resource which gives people the ability to manage and even to change
their surroundings. This view of health recognizes freedom of choice
and emphasizes the role of individuals and communities in defining
what health means to them.

While a broad and “positive” definition of health serves to orient

health professionals to think in terms of health promotion and not just the
 Introduction 3

BOX 1.1. Words and Origins

That health is more than just physical health but mental/emotional as

well is not a modern concept.6 The Latin word sanitas (adj. sanus) gave
rise to both “sanity/sane” and “sanitation/sanitary.” The famous say-
ing by the Roman satirist Juvenal—mens sana in corpore sano (“a sound
mind in a sound body”) sums it up very well. There is a recent trend to-
wards the use of the word wellness in place of health. This is a particular
favorite of health ministry bureaucrats, as if “health” were still too
disease-oriented and not “positive” enough. The English word health is
quite old, as one can trace it back to the hal of the Anglo-Saxons in the
eleventh century, which ultimately gave rise also to heal, hale, and whole.
Wellness, despite its trendiness, is in fact also quite old, and can be
traced back to the mid–seventeenth century. The word sick and its vari-
ants have been used since at least the ninth century. Although ill and
evil were not related etymologically, the two have been used synony-
mously from the twelfth century on—no doubt in people’s minds the
two were related etiologically. Disease, or dis-ease, is of Anglo-French
origin from the early fourteenth century.

treatment of disease, the rhetoric can be carried too far. The WHO defini-
tion has its critics and supporters, and indeed has been wryly observed to
be “honored in repetition, rarely in application.”7 Health may become so
inclusive that all human endeavors, up to and including the pursuit of
happiness, are considered within its domain. Ministries of health will then
become ministries of everything! In day-to-day population health practice
and research, there remains a need for an “operational” definition.
In everyday usage, population means the number of people in a given
area. This can be defined geographically or politically, as in a country, al-
though physical boundaries are not always necessary, such as when refer-
ring to groups of people sharing common characteristics (e.g., ethnicity,
religion, etc.) who are scattered throughout a particular geographical or
political unit. When counting individuals and deciding on membership,
distinction is sometimes made between de facto and de jure criteria, based
on the premise that a person can only be at one place at any one time and
should be counted only once. The former category includes individuals
who are actually there at the time and place of counting, whereas the lat-
ter refers to those who usually belong to a specific locale from which they
may be temporarily absent.8 Temporary visitors such as students, diplo-
mats, military personnel, and tourists may not be counted in the place
where they happen to be, but “charged back” to where they came from.
Statisticians use population in a special sense, especially when dis-
cussing sampling. It is sometimes referred to as the universe, the total num-
ber of units (animal, vegetable, or mineral) from which a sample is drawn.
4 Population Health

Sampling is necessary since obtaining information from all members of the

population may be too cumbersome, inefficient, or not feasible. (Sampling
is discussed in more detail in Chapter 6.) The characteristics of a universe
or population (such as its mean and standard deviation) are referred to as
parameters. Much of statistics is concerned with estimating population pa-
rameters from a sample.
Populations also have specific meaning for geneticists, who define them
in terms of the sharing of genes. The collection of genes of all the individu-
als in a population is referred to its gene pool. Deme is often used to refer to
small and isolated populations. Because small and non-industrialized pop-
ulations have been the subject of study by anthropologists, the term anthro-
pological populations is sometimes also used.
The term population health has been used for some time as a less cumber-
some substitute for the “health of populations.” In the 1990s the phrase
took on a new connotation, especially in Canada and the United Kingdom.
The Canadian Institute for Advanced Research established a program
in population health alongside other leading-edge “hard” sciences. The
Canadian Institutes of Health Research, established in 2000, include also
an Institute of Population and Public Health among its 13 institutes. Popu-
lation health can be regarded as a conceptual framework for thinking about
why some people are healthier than others and the policy development, re-
search agenda, and resource allocation that flow from this. The difference
between it and terms such as community health and public health, which
have been around a long time, is subtle.
In North America, public health usually refers to the array of programs
and services organized primarily, but not exclusively, by various levels of
governments to protect, promote, and restore the health of citizens. The
Institute of Medicine’s 1988 report on the future of public health in the
United States defines the mission of public health as:

fulfilling society’s interest in assuring conditions in which people can be

healthy. Its aim is to generate organized community effort to address the
public interest in health by applying scientific and technical knowledge
to prevent disease and promote health. The mission of public health is
addressed by private organizations and individuals as well as by public
agencies. But the governmental public health agency has a unique func-
tion: to see to it that vital elements are in place and that the mission is
adequately addressed. The committee finds that the core functions of
public health agencies at all levels of government are assessment, policy
development, and assurance.

In the same year, the Acheson Report was released in England, and it
also pondered the future of public health. It defined public health simply
as “the science and art of preventing disease, prolonging life, and promot-
ing health through organized efforts of society.”9
 Introduction 5

Terms such as social medicine and preventive medicine were once popular
and are still in use, but the use of medicine rather than health may be
viewed by some as too “biomedical” in orientation, locating these fields
within the medical profession (albeit often as poor cousins). On the other
hand, social medicine is sometimes confused with socialized medicine,
which is anathema in certain political circles. The British have now adopted
the term public health medicine to refer to the medical specialty. While not
quite an oxymoron, it certainly encompasses within the same term two
very different perspectives on health.
Proponents of the concept of population health envision something
more than traditional public health. Population health supposedly “in-
creases our understanding of the determinants of health and reaffirms the
need for public health professionals to examine critically social inequities
and policies that maintain them.”10 In 1994 the Canadian government re-
leased a document entitled Strategies for Population Health, in which the
population health approach is ascribed these characteristics:

1. Addresses the entire range of factors that determine health, rather

than focusing on risks and clinical factors related to particular dis-
eases;
2. Affects the entire population rather than only ill or high-risk indi-
viduals.

This approach claims to be able to provide benefits in increased pros-

perity, since a healthy population contributes to a vibrant economy with
reduced health and social service expenditures and increased overall so-
cial stability and well-being. The term “population health” is still rela-
tively new in the United States but is catching on, and a commentary in a
2003 issue of the American Journal of Public Health clarified the distinction
between population health as a concept of the health status of a group of
people and its distribution within the group, and as a field of study that
focuses on both health outcomes and health determinants, as well as the
policies and interventions that link them. “Population health” is not with-
out its critics, especially among social scientists of the “critical” school,
who consider its analytical framework as flawed in lacking a significant
“class” and social structural perspective.11
In the United Kingdom, the 1993 Leeds Declaration proposed 10 prin-
ciples for action on population health research and practice. It urged
health authorities to turn away from an exclusive focus on individual
risk and toward social structures and processes, and to investigate the
causation of health rather than disease. In research, it urged the need for
interdisciplinary approaches, integrating qualitative and quantitative
methods, and recognition of the importance of lay knowledge and partic-
ipatory research.12 It is in the spirit of this new “population health” that
this textbook is written.
6 Population Health

Objectives and Uses of Population Health Studies

While one is entitled to study any subject for its own sake and for the in-
tellectual challenge it presents, there are four practical reasons why one
should engage in studying the health of populations:

1. To describe;
2. To explain;
3. To predict; and
4. To control.

This book is indeed structured around these four objectives. As a first

step, one should describe the state of health of the population and identify
the prevalent health problems. With a firm foundation of such knowl-
edge, one can then seek explanations of why the state of health is what it
is and why certain health problems occur. Based on the results of studies
of disease patterns and their determinants, one can offer individuals and
communities predictions of health effects and strategies for risk avoidance.
Ultimately, knowledge from population health studies must be translated
into public health policy (or better still, healthy public policy) to prevent
disease and promote health.
The chapter headings of Jerry Morris’s influential Uses of Epidemiology13
provide a useful listing:

1. Community diagnosis: assessing the health status of a population;

2. Working of health services: evaluating health programs;
3. Individual chances and risks: practicing clinical preventive medicine;
4. Completing the clinical picture: describing the natural history of dis-
ease;
5. In search of causes: establishing etiology of diseases or associations
with risk factors.

There are numerous examples of how our everyday life is increasingly

affected by the results of population health studies. Safe sex, electromag-
netic fields, pesticides, seatbelts, low-cholesterol foods, cigarette taxes—
all are public issues that require some knowledge of the arts and sciences
of population health. Scarcely one day goes by without the media in-
forming us of yet another risk factor that is harmful to our health. The
public demands to know the safety and health risks of specific industrial
and commercial products and processes, and courts are frequently called
upon to decide on liability and damages. Epidemiologists have been
called in to solve serial murder cases and are indispensable in the inves-
tigation of acts of bioterrorism, such as the anthrax outbreak in the United
States during 2001.14
 Introduction 7

The Arts and Sciences in Population Health

The core scientific discipline in the study of population health is epidemiol-

ogy. A concern with population phenomena, however, is not unique to
epidemiology. Several social sciences, notably demography, sociology, geogra-
phy, economics, and anthropology, also study human populations. There are
specific branches within these disciplines that have acquired the qualifier
“medical” or “health,” as in “medical sociology” and “health economics.”
Not all health phenomena are analyzed at the level of the population,
though. Many medical anthropologists, for example, study the cultural
aspects of healing, sickness, and medical knowledge at the individual
level.15
Demographers are concerned with the quantitative analysis of popula-
tion size, structure, and change, as well as the social, economic, and politi-
cal factors that affect population trends, processes, and events.
The contribution of the social sciences in applied population health
programs has long been recognized and advocated. Milton Terris (1915–
2002), an ardent advocate of the important social role of epidemiology,
simply stated that epidemiology is “by definition a social science.” There
has also been a resurgence of social epidemiology in recent years.16 This
book attempts to integrate the social and biological, the quantitative and
qualitative, and recognizes the importance of social and cultural factors in
assessing health and planning interventions.
The humanities—history, philosophy, ethics, art, and literature—
contribute to a broader understanding of the health of populations by
inculcating core human values in their practitioners, encouraging non-
dogmatism, and developing critical thinking.17
The term epidemiology reflects the science’s earlier preoccupation with
epidemics of infectious diseases. As a result of changing disease patterns
in the industrialized, developed countries, the scope and definition of epi-
demiology have also changed. There is, however, no reason why epidemi-
ology should not still be regarded as the study of epidemics and their
prevention, if we extend epidemics to not just those caused by microor-
ganisms, but also drugs, diet, workplace, and environmental hazards.18
A current definition of epidemiology can be found in every textbook of
epidemiology. The Dictionary of Epidemiology defines epidemiology as

The study of the distribution and determinants of health-related states

or events in specified populations, and the application of this study to
control of health problems.

From this definition one can discern three components to the current
understanding of what epidemiology is. There is descriptive epidemiol-
ogy, which describes the distribution of diseases and health conditions;
analytical epidemiology, which finds out “causes” or determinants; and
8 Population Health

experimental or interventional epidemiology, which is concerned with

the prevention and control of health problems.
David Lilienfeld scoured the literature and found 23 definitions of epi-
demiology dating from 1927 to 1976. In response to his paper, Alfred
Evans (1917–1996) tabulated the different features of these definitions and
the frequencies of various key words. The word disease appeared in over
90% of the definitions, and the older ones tended to specify “infectious
disease.” Terms such as health, physiological condition, and injuries were
also used. Other key words used include some sort of group, usually pop-
ulation, but also mass and community. Almost 40% mentioned distribution,
and less frequently spread, incidence, and occurrence. Etiology and similar
concepts such as causes, determinants, and factors were used in over one-
third of the definitions. Only a few mentioned natural history or prevention
and control at all.
Among the definitions unearthed by Lilienfeld is this amusing por-
trayal of an epidemiologist, vintage 1942:

The epidemiologist is the fellow who gets to town at the peak of an epi-
demic and coasts to glory on the down or eastern leg of the epidemic
curve. He goes around town with a sheaf of case cards in his hand and
knocks on front doors, asking impertinent questions. When he has
drained the community dry of what he calls pertinent information, he
then goes into a huddle with a Monroe machine and comes out with a
paper for the Epidemiological Society (by invitation!). When he is too
old to walk from car to door, he becomes a statistical or armchair epi-
demiologist, or in extreme cases, a professor.19

Few of us know what a “Monroe machine” is, but most of us can recog-
nize a professor when we see one!
As disease ultimately is mediated through biological processes in the
human body, population health cannot be isolated from various “basic”
biomedical sciences that study disease at the organismic, cellular, and mo-
lecular level (e.g., physiology, biochemistry, toxicology). The rapid ad-
vances of molecular biology in the second half of the twentieth century,
culminating in the Human Genome Project, hold promise for population
health. The techniques of molecular epidemiology have proven to be par-
ticularly powerful tools in such diverse areas as tracking the origin and
spread of epidemics of infectious diseases and in studying genetic suscep-
tibility to chronic diseases. Investigations into the links between the ner-
vous, endocrine, and immune systems offer insights into the biological
pathways between social environmental influences and health and dis-
ease.20
Because they are practical-minded, specialists in population health
have not been preoccupied with issues relating to the philosophy and
logic of science, although most would consider their own methods as
 Introduction 9

BOX 1.2. More Words and Origins

It is worth knowing that the word epidemic comes from the Greek roots
epi, meaning “upon,” and demos, meaning “people,” which conjures up
the image of the angel of pestilence knocking on one’s door. An epi-
demic among animals (i.e., animals other than human beings) is more
correctly called epizootic. Nevertheless, epidemiology of diseases in ani-
mals is called veterinary epidemiology rather than epizoology. The term
epidemiologist was first used in the 1860s, shortly after the formation of
the London Epidemiological Society.
Variations on the theme of epidemics include pandemic and endemic.
A pandemic is an epidemic that affects large swaths of land and multi-
tudes of people, even the entire world.21 Examples of pandemics are the
Black Death in mid–fourteenth century Europe, caused by bubonic
plague, which is believed to have decimated one-fourth to one-half of
the population. In the twentieth century the “Spanish flu” pandemic of
1918 killed several times more people than the carnage of World War I
that preceded it. A disease is endemic if it is constantly present in an
area or population—it is usually when such a “baseline” or “back-
ground” level is exceeded that an epidemic is said to occur.
Demos shows up again in demography, a sister discipline of epidemi-
ology, both being concerned with human populations. Anthropology, of
course, is the study of anthropos, or man. The word population is derived
from the Latin populus, meaning “people.” It was used in French as
early as the fourteenth century. In English, philosopher Francis Bacon
(1561–1626) is credited with being the first to use both the terms popu-
lation and depopulation.

“scientific.” In epidemiological circles, the work of the philosopher Karl

Popper (1902–1994) has evoked considerable debate.22 His influential
Logic of Scientific Discovery was originally published in German in 1934.
Many scientists believe that science operates by induction, which in logic
is a process of inferring a general law or principle from the observation of
particular instances, according to the Oxford English Dictionary. Induction
operates on the assumption that if something is true in a few observa-
tions, it will be true also in as-yet-unobserved instances, and hence true
“in general.” This approach can be traced back to the book Novum Or-
ganum, published in 1620 by philosopher Francis Bacon (1561–1626).
Popper argues that science is primarily deductive; that is, conclusions are
inferred from general premises. Observations are generally made to test
a hypothesis that is already in mind, a product often of one’s imagina-
tion. Knowledge advances only by disproving (or “falsifying”) an exist-
ing hypothesis.
10 Population Health

Historical Antecedents and Future Prospects

Much of current thinking in population health, as well its methods and

practices, can be traced back to antiquity. Many contemporary issues
have, in fact, old historical roots.23 History is always instructive and hum-
bling. A few examples are selected for illustration in the case studies at the
back of this chapter: James Lind and scurvy, John Snow and cholera, Sem-
melweis and puerperal fever, and Goldberger and pellagra.
In his Structure of Scientific Revolution, first published in 1962 and a ma-
jor modern work in the philosophy of science, Thomas Kuhn (1922–1996)
describes how a scientific paradigm comes to dominate the thinking and
approaches to knowledge by prescribing the work that scientists can do,
the questions they can ask, and the methods they can use. Paradigms are
defined as “universally recognized scientific achievements that for a time
provide model problems and solutions to a community of practitioners.”24
When enough unsolved problems under a particular paradigm accumu-
late, increasing doubts ultimately spark a scientific revolution and the ap-
pearance and dominance of a new paradigm.
In their review of the modern development of epidemiology, Mervyn
and Ezra Susser identified three major eras, each with its own paradigm.25
The era of sanitary statistics began in the early nineteenth century. This is
the era of the Victorian epidemiologists (more about them in Chapter 2)
who avidly collected statistics on births and deaths, which allowed them
to draw conclusions about disease causation. The major paradigm of that
era is miasma, that of diseases being caused by the foul emanations from
the “airs, waters, and places.” This is in fact the title of a book by Hip-
pocrates, who lived in the fourth and fifth centuries BC, an indication of
the antiquity of the idea. The word malaria, for example, comes from mal
(meaning “bad”) and aria (meaning “air”).
During the latter part of the nineteenth century, at the dawn of modern
bacteriology, the “miasmatists” were challenged by the “contagionists,”
who believed that diseases were caused by tiny organisms passed from
person to person. The miasma school was aligned with political radicals
and social reformers of the day, including the noted German pathologist
Rudolf Virchow (1821–1902). Virchow’s view of the close links between
society and health is reflected in his famous saying, “Politics is nothing
but medicine on a grand scale.”26 The contagionists, on the other hand,
were mostly political conservatives. They eventually won out, as more
and more bacteria were discovered—tuberculosis, diphtheria, cholera,
and a host of others. The germ theory became the dominant paradigm in
both clinical medicine and public health during the late nineteenth and
first half of the twentieth century. It led to major advances in the develop-
ment and deployment of vaccines and antibiotics.
While the miasmatists-sanitarians were proven wrong, their conception
of social and environmental causation is still valid, and their prescription
 Introduction 11

for control—improving water and sanitation—has been responsible for the

major advances in population health in the industrialized countries, and
still holds the key in the developing countries today.
While correct for the infectious diseases that dominated much of the
world at the time, proponents of the germ theory conceived of diseases
as having single causative agents. By the second half of the twentieth
century, the disease pattern, at least in the developed countries, has
shifted to one dominated by the chronic, noninfectious diseases such as
heart disease and cancer. As the germ theory is no longer up to the task,
another paradigm shift occurred. From the 1950s onwards, there has
been an explosion of knowledge about risk factors for chronic diseases,
built on advances in epidemiological and biostatistical methods. The
Sussers called the paradigm of the era of chronic disease epidemiology
the black box. (Think of a black box as a computer or telephone: we only
need to know what goes in and what goes out, and do not need to worry
about how the “thing” actually works. Since we know that smoking in-
creases the risk of lung cancer, effective action does not have to wait un-
til all the hundreds of noxious chemicals in cigarette smoke have been
isolated.)
A prime example of the contributions of this era is the Framingham
Heart Study, launched in 1950 in a community near Boston, which has
contributed substantially to our understanding of the causes, incidence,
clinical spectrum, and prognosis of cardiovascular diseases. Indeed, it in-
troduced the term risk factor into everyday vocabulary and established the
significance of smoking, hypertension, plasma cholesterol, and being
overweight, among others. The control of such factors has occupied a cen-
tral place in the health promotion and public policy agenda during the
second half of the twentieth century.27
While the black box approach has allowed public health action to occur
without waiting for disease mechanisms to be fully elucidated, at some
point it is useful to know what is inside the box; i.e., the cellular and mo-
lecular mechanisms of disease pathogenesis. The black box, indeed, also
exists at the “macro” level. To say that “poverty causes disease” is helpful
up to a point, but one also needs to delve inside the box to investigate and
understand the complex of social interactions and political and economic
forces that are at work.
There is no shortage of critics of the direction epidemiology has taken
in the latter half of the twentieth century. A major theme is that modern
epidemiology has overemphasized methodology and the identification of
an ever-increasing number of risk factors in individuals. It lacks credibil-
ity among the “hard” scientists and bewilders the impressionable gen-
eral public with its claims. A special news report in the prestigious
journal Science, based on interviews with noted scientists in the field, was
headlined “Epidemiology Faces Its Limits” and generated considerable
controversy.28
12 Population Health

In an introduction to a conference on the future of epidemiology,

Rudolfo Saracci identified four major tensions that permeate contempo-
rary epidemiology: between the focus on methods and substantive issues
in health, between biological and social orientations, between specializa-
tion and integration, and between curiosity-driven and targeted research.
The charge that epidemiology is atheoretical and merely a collection of
methods is longstanding, not helped by the penchant of some methodolo-
gists to engage in “overindulgence in refinements of little practical im-
pact.”29 The biological/social divide goes beyond the different research
interests in “micro” and “macro” determinants of health, to issues of
whether population health scientists should concern themselves solely
with research or engage in influencing public policy and social change, es-
pecially in redressing inequities in health. Sub-specialization has occurred
at a rapid pace. We now have “epidemiologies” based on diseases (e.g., can-
cer, cardiovascular), risk factors (e.g., occupational, genetic), and methods
(e.g., molecular, spatial).
Another division within epidemiology is that between practitioners of
“classical” population-based epidemiology and the newer species of
“clinical” epidemiologists. While there is no doubt that clinical epidemiol-
ogy has made a major impact on clinical medical practice and research, it
is perceived by some to divert attention and resources from population
health issues, especially prevention, to individual patient care and treat-
ment. It is indicative of the strength of clinical epidemiology that some see
the need to designate a separate term: public health epidemiology.30
The diversion of epidemiology, the basic science of public health, from
a primary concern with the occurrence of disease in populations and pop-
ulation factors as causes of disease, needs to be stemmed and reversed.
Perhaps the new “population health,” by integrating research and prac-
tice, and taking advantage of the full range of tools from molecular biol-
ogy to the social sciences, will ultimately achieve the aim of improving the
health of populations.

Summary

This chapter introduces different definitions and usages of the terms

health, population, and population health. Population health studies serve
the objectives of describing the health status of a population, explaining
the causes of diseases, predicting health risks in individuals and commu-
nities, and offering solutions to prevent and control health problems. To
achieve these aims, population health requires collaboration between the
core science of epidemiology, several social sciences that are also con-
cerned with population phenomena, the humanities, and laboratory-based
biomedical sciences. Several case studies are presented to illustrate the
historical roots of many contemporary health issues.
 Introduction 13

BOX 1.3. Public Health Achievements of the Twentieth

Century and Challenges for the Twenty-first

In a series of fin-de-siècle reviews, the Morbidity and Mortality Weekly Report

(MMWR), published by the Centers for Disease Control (CDC), identified
ten great public health achievements in the United States during 1900–
1999.31 These are as follows, not arranged in the order of importance:
• Vaccination—the eradication of smallpox; elimination of polio in
the Americas; and control of measles, rubella, tetanus, diphtheria,
and Hemophilus influenzae type b;
• Motor-vehicle safety—reduction in motor vehicle–related deaths
due to engineering improvements in vehicles and highways and
change in personal behaviors (use of safety devices and reduction
in drinking and driving);
• Safer workplaces—control of pneumoconiosis and silicosis; reduc-
tion in fatal occupational injuries;
• Control of infectious diseases—control of typhoid and cholera
through improved water and sanitation; and of tuberculosis and
sexually transmitted diseases (STDs) by antibiotics;
• Decline in deaths from coronary heart disease and stroke—from risk-
factor modification (especially smoking cessation and blood pres-
sure control) and improved access to early detection and treatment;
• Safer and healthier foods—decrease in microbial contamination
and increase in nutritional content; nutritional deficiency diseases
(rickets, goiter, pellagra) almost eliminated;
• Healthier mothers and babies—from better hygiene and nutrition,
availability of antibiotics, access to health care, and technological
advances in neonatal and maternal medicine;
• Family planning—altered socioeconomic role of women, reduced
family size, increased birth intervals, and improved maternal and
child health; barrier contraceptives also reduced unwanted preg-
nancies and transmission of STDs;
• Fluoridation of drinking water—resulted in reductions in tooth de-
cay and tooth loss;
• Recognition of tobacco use as a health hazard—resulted in changes
in social norms, reduced prevalence of smoking and mortality
from smoking-related diseases.
During the same period, important changes also occurred in the
public health system, which provided the infrastructure necessary for
these interventions to succeed. These included advances in epidemio-
logical methods, the systematic collection and analyses of health data
at the national and regional levels, establishment of schools of public
(continued)
14 Population Health

health and other training programs, and the involvement of both

governmental and nongovernmental organizations in program plan-
ning and service delivery.
Also looking ahead, the CDC identified 10 challenges for the future:
• Institute a rational health care system;
• Eliminate health disparities;
• Focus on children’s emotional and intellectual development;
• Achieve a longer “healthspan”;
• Integrate physical activity and healthy eating into daily lives;
• Clean up and protect the environment;
• Prepare to respond to emerging infectious diseases;
• Recognize and address the contributions of mental health to over-
all well-being;
• Reduce the toll of violence in society; and
• Use new scientific knowledge and technological advances wisely.

Case Study 1.1. James Lind and Scurvy among Sailors

Scurvy is a disease characterized by bleeding gums, sore limbs, and

general debility, which may ultimately be fatal. It once devastated
sailors on long sea voyages. James Lind (1716–1794), a British Navy
doctor, performed a classic epidemiological study that examined
both causation and intervention.32 He selected 12 patients with simi-
lar clinical features, all having been subjected to the typical horren-
dous Royal Navy diet:

• Breakfast: water gruel sweetened with sugar

• Dinner: fresh mutton broth with pudding, boiled biscuits with
sugar
• Supper: barley, raisins, rice, currants, sago, and wine

Lind divided his patients into 6 groups of 2, who received treatment as

follows:

Group 1: A quart of cider a day;

Group 2: 25 drops of elixir vitriol (sulfuric acid, diluted!) three
times a day, and gargle;
Group 3: Two spoonfuls of vinegar three times a day mixed with
food, and gargle;
Group 4: Half a pint of sea water a day;
Group 5: A potion consisting of garlic, mustard seed, balsam of
Peru, and purged 3 times a day;
Group 6: Two of the worst cases were given two oranges and one
lemon a day, which lasted for only six days.
 Introduction 15

Group 6 recovered in dramatic fashion, compared to the other treat-

ment groups.
This early example of an experimental study would probably not
pass any present-day peer review committee (“sample size too
small!” “not double-blind!”) or research ethics committee (“where is
the informed consent?”). Nevertheless, Lind showed that citrus
fruits cured scurvy. He published his findings in 1753 in a book enti-
tled A Treatise of the Scurvy in Three Parts, Containing an Inquiry into
the Nature, Causes and Cure of That Disease. It took another 40 years
before the Royal Navy finally adopted the policy of issuing citrus
fruits on its ships and the problem of scurvy disappeared. British
seamen, and by extension all Britons, have since been nicknamed
“limeys.”
Lesson: One can eliminate a health problem without having to
know the exact cause first (an example of “black-box” epidemiol-
ogy). Another lesson: Great ideas do not always get adopted right
away!
Vitamin C, or ascorbic acid, is the ingredient in citrus fruits whose
deficiency causes scurvy. The crystalline form of ascorbic acid was
isolated in 1928 and the substance synthesized in 1933. Research into
vitamin C led to the award of the Nobel Prize for medicine to the
Hungarian biochemist Albert Szent-Györgyi (1893–1986) in 1937,
and for chemistry to the English chemist Walter Haworth (1883–
1950) in the same year.

Case Study 1.2. John Snow, Cholera, and the Broad Street
Pump
In the mid–nineteenth century, cholera devastated London and many
European cities. Cholera is an infectious disease characterized by se-
vere vomiting and diarrhea, which may result in death from dehy-
dration. The first pandemic began in 1817 in Calcutta. The second
pandemic reached Europe in the 1830s and swept through all the ma-
jor cities, taking civil and medical authorities by surprise. By the
twentieth century, cholera had broken out of India and circled the
world six times. A seventh pandemic began in the 1960s in Asia, and
spread to Europe, Africa, and finally to Latin America in the 1990s. It
is still ongoing.
London experienced cholera epidemics in 1831–1832, 1848–1849
and 1854–1855. The Industrial Revolution had resulted in massive ru-
ral–urban migration. Many Londoners lived in conditions of squalor,
overcrowding, and lack of sanitation. A key figure in the group
of Victorian “sanitary physicians” was John Snow (1813–1858), an
anesthetist by profession whose other claim to fame was admin-
istering chloroform to Queen Victoria during childbirth. Snow
16 Population Health

suspected a waterborne route of transmission from his experience

with the 1849 epidemic and published a monograph entitled On the
Mode of Communication of Cholera.33 During the summer of 1854, he was
able to test his ideas by calculating the death rates from cholera ac-
cording to the source of water supply. The cholera death rate in
houses supplied by one water company (the Southwark and Vaux-
hall Co.) that obtained its water from the Thames in central London
greatly exceeded that observed in houses supplied by its competitor
(the Lambeth Co.), which had earlier moved its water supply further
upstream, where the river was visibly less polluted. In this analysis,
Snow was assisted by William Farr of the General Register Office
(more about him in Chapter 2), who provided him with the raw data.
Snow also investigated a local outbreak in St. James Parish and
presented a dot-map showing a heavy clustering of cases around the
water pump on Broad Street. Snow concluded that cholera was
caused by a contaminated water supply. He persuaded the local au-
thorities to remove the pump handle, although by then the outbreak
had already subsided. Snow was a contagionist at a time when mi-
asma was still the dominant theory of disease causation, and his
views were not widely accepted in his lifetime. The bacteria respon-
sible for cholera—Vibrio cholerae—was not discovered until 1883, by
Robert Koch (1843–1910).
Snow recognized, and took advantage of, a “natural experiment”
and presented his data in a statistical manner that allowed the ap-
propriate conclusions to be drawn. While the pump has long since
gone, Broad Street still stands in central London under a different
name. The Broad Street pump has acquired the status of a metaphor
(and even myth), and Snow is today revered as a pioneer and hero in
public health.

Cholera Mortality in London, 7 Weeks July–August, 1854

350

300
Deaths/10,000 houses

250

200

150

100
50

0
Southwark & Lambeth Co. Rest of London
Vauxhall Co.
Water Company
 Introduction 17

Case Study 1.3. Ignaz Semmelweis and Puerperal Fever

Ignaz Semmelweis (1818–1865), a Viennese obstetrician, attempted

to explain and control the devastation of childbed or puerperal fever
among patients in the maternity hospital. In 1840, by imperial de-
cree, the hospital was divided into two wards for the purpose of ed-
ucating health professionals: Klinik 1 (K1 in the graph below) was
reserved for medical students (all male), while Klinik 2 (K2) was
used for the training of midwives (all female). Admissions to these
wards alternated from day to day. On reviewing the records, Sem-
melweis noted that K1 had consistently higher maternal mortality
(graph below) as well as neonatal mortality than K2.
Semmelweis investigated this phenomenon and made several im-
portant observations. Women whose cervix had been dilated for
more than 24 hours during labor almost invariably developed fever.
Such women died if they were on K1, but not on K2. The disease
seemed to spread from bed to bed, but again only on K1 and not on
K2. Attempts to reduce pelvic examinations by students, and bar-
ring foreign students who were believed to be “too rough,” did not
eliminate the discrepancy between the wards. In 1847, the professor
of pathology died after his finger was pricked by a student’s knife
during an autopsy. What was remarkable was that the clinical
features—that of overwhelming sepsis—were very similar to those
of puerperal fever. This led Semmelweis to suspect that “cadaverous
particles” were responsible. Medical students went directly from the
autopsy room in the morning to making rounds on the wards and
examining all women in labor. Midwives, on the other hand, were
not privileged to learn pathology. Hand-washing was unheard of.
Semmelweis instituted an intervention: all students were required
to wash their hands with chlorinated lime solution. Mortality rate
18 Population Health

declined dramatically compared to the preintervention period, to a

level even slightly below that of K2.
Semmelweis published his observations in a book in 1861, enti-
tled The Etiology, Concept, and Prophylaxis of Childbed Fever.34 Unfortu-
nately for Semmelweis, and especially for Viennese women, his ideas
were ridiculed by the medical profession. After years of unequal
struggle, Semmelweis was driven mad. He died several days after
having been committed to an asylum. The cause of death? A septic
wound of the finger, the very disease he had striven so passionately
to prevent. A sad day for medicine and public health indeed. It was
not until several decades later, with the discovery of staphylococci
and streptococci by Louis Pasteur (1822–1895) and the innovations
in antiseptic surgery by Joseph Lister (1827–1912) that Semmelweis
was vindicated.

Case Study 1.4. Joseph Goldberger on Diet and Pellagra

Toward the end of the nineteenth century and the beginning of the
twentieth century, pellagra was rampant in the southeastern United
States. The disease is characterized by dermatitis, diarrhea, and de-
mentia, the last often leading to the victim’s being admitted to a
mental hospital. The disease has been known in southern Europe
since the eighteenth century. The word itself is of Italian origin (pelle,
skin, and agra, sour). Initially pellagra was believed to be an infec-
tious disease. In 1914, Joseph Goldberger (1874–1929), a U.S. Public
Health Service medical officer, was assigned to investigate this epi-
demic. Over the next decade and half, Goldberger conducted a se-
ries of observational and experimental studies and concluded that
pellagra was not infectious but dietary in origin.35
Goldberger observed that while inmates of institutions such as
prisons, orphanages, and insane asylums suffered from pellagra,
none of their keepers suffered from it. In an early example of social
epidemiology, he conducted community surveys and noted that pel-
lagra was primarily a disease of the rural poor. For example, the in-
cidence of the disease in 1916 in seven South Carolina villages
varied according to family income.
To prove that pellagra was not infectious, he and his friends in-
jected themselves with, or consumed, preparations containing body
fluids of pellagra patients and lived to tell the tale (thankfully it was
the pre-AIDS era). He conducted diet experiments in two orphan-
ages and showed that supplementation with milk, eggs, meat, and
legumes reduced the disease. He also induced the disease among
prisoners in Mississippi by restricting their diet to an unsavory mix
of corn, refined carbohydrates, and not much else. (Such studies
would be unethical and unthinkable today.)
 Introduction 19

Pellagra Incidence by Income Group in 7 South Carolina Villages, 1916

45
40
35
Cases/1000/Yr

30
25
20
15
10
5
0
<$6.00 $6.00–$7.99 $8.00–$9.99 $10.00–$13.99 >$14.00

Half-month Family Income

It was not until 1937 that niacin, or vitamin B3, was identified as
the active substance whose deficiency causes pellagra. Among ani-
mals, only primates and guinea pigs are unable to synthesize the
substance. Supplementation of flour and cereals has all but elimi-
nated this disease. Goldberger reputedly was nominated for the No-
bel Prize five times but was never awarded it.

Guide to Resources

Comprehensive, encyclopedic textbooks of public health should be con-

sulted and browsed;* for example, the Oxford Textbook (Detels et al.,
2002). The Oxford Handbook (Pencheon et al., 2001) is a pocket-sized com-
pendium of important tasks and skills required by public health practi-
tioners. Epidemiology must be a growth industry, as there is no shortage
of textbooks published in recent years, ranging from the introductory
(Lilienfeld and Stolley, 1994), the intermediate (Kahn and Sempos, 1989;
Kelsey et al., 1996), to the advanced (Selvin, 1996; Rothman and Green-
land, 1998). While not intended to be a textbook, Stolley and Lasky (1995)
is a thoroughly enjoyable and richly illustrated book that, when read
from cover to cover, will probably give one a better understanding of
what epidemiology is all about than many textbooks. There are also self-
instruction manuals, such as Norell (1995) and Abramson and Abramson
(2001). The Dictionary of Epidemiology (Last, 2001), now in its fourth edi-
tion, is indispensable. The more rigorous methodologist will want to con-
sult the Encyclopedia of Epidemiologic Methods (Gail and Benichou, 2000).
For those who want to go to the source, an excellent collection of original
reports from classic epidemiological studies is the PAHO reader (Buck

*For full references, see the Bibliography.

20 Population Health

et al., 1988). Greenland’s (1987) selections trace the evolution of key con-
cepts and methods.
For demography texts, there is the condensed edition of Shryock and
Siegel (1976), which is a standard classic, and more recent ones such as
Weeks (1995) and Preston et al. (2001). Substantial materials relevant to
population health can be found in texts in medical sociology, such as
Armstrong (1994), Cockerham (1997), and Albrecht et al. (2000); medical
anthropology texts such as Helman (2000) and McElroy and Townsend
(1996); and medical geography texts such as Meade and Earickson
(2000).
Aficionados of Internet surfing should be interested in the following
web sites that provide useful information on population health. A good
starting-off point is various “virtual libraries” that provide direct links to
other relevant web sites in government, academe, and industry. Examples
include:

• Epidemiology (http://www.epibiostat.ucsf.edu/epidem/epidem.html)
from the University of California School of Medicine at San Francisco
• Demography and population studies (http://demography.anu.edu.
au/VirtualLibrary) from the Australian National University in Can-
berra
• Statistics (http://www.stat.ufl.edu/vlib/statistics.html) from the Uni-
versity of Florida at Gainesville

Useful web sites include the following:

International:
• The Global Health Network (http:/ /www.pitt.edu/~super1)
• World Health Organization (http://www.who.int)
• Pan-American Health Organization (http://paho.org)
• International Agency for Research on Cancer (http:/
/www.iarc.fr)

United States:
• U.S. Bureau of the Census (http:/ /www.census.gov)
• Centers for Disease Control and Prevention (http://www.cdc.gov)
• National Center for Health Statistics (http:/
/www.cdc.gov/nchs)
• National Institutes of Health (http:/
/www.nih.gov)
• National Library of Medicine (http:/ /www.nlm.nih.gov)
• U.S. Environmental Protection Agency (http:/ /www.epa.gov)
• Office of the Surgeon General (http:/ /www.surgeongeneral.gov)
• Institute of Medicine (http:/
/www.iom.edu)
• American Public Health Association (http:/ /www.apha.org)
 Introduction 21

Canada:
• Statistics Canada (http://www.statcan.ca)
• Health Canada (http:/ /www.hc-sc.gc.ca)
• Canadian Public Health Association (http://www.cpha.ca)

Notes
1. While it is quoted by many, few people have read the original Constitution
of the WHO. The definition and relevant historical documents can be found on the
WHO web site: www.who.int/about/definition/en.
2. See the entry “Health” in the International Epidemiological Association’s
Dictionary of Epidemiology (Last, 2001:81).
3. This particular quotation is from Man, Medicine and Environment (Dubos,
1968:69). His other books include Mirage of Health (1959), Man Adapting (1965), and
So Human an Animal (1968).
4. The quotation is from Illich (1975:167). Illich founded the Center for Inter-
cultural Documentation (CIDOC) in Cuernavaca, Mexico, which lasted from
1961–1976. Among his other books are Deschooling Society (1970), Tools for Convivi-
ality (1973), and Energy and Equity (1974). A definitive version of Medical Nemesis
was published in 1976 under the title Limits to Medicine.
5. The latest version is Healthy People 2010, available at www.health.gov/
healthypeople. It also provides links to other documents such as the Final Review
of Healthy People 2000, a rich compendium of U.S. health statistics.
6. I am indebted to the weekly column “Word Play” by Robertson Cochrane
of the Toronto Globe and Mail: “Is ‘Health’ Unwell?” (11 Feb. 1995); and “A Healthy
Choice of Synonyms” (18 Feb. 1995).
7. The quotation is from Evans and Stoddart (1990:1347). Hanslukwa (1985)
provided a sampling of various views on the WHO definition expressed by re-
searchers and expert committees. Breslow (1972) defended the WHO definition
and quantified it in a health survey in California.
8. The Romans seemed to merge the de jure and de facto methods. It was
written in the Gospel According to St. Luke (Chapter II) that Caesar Augustus de-
creed that all his subjects return to their place of origin to be counted in order to be
taxed. Hence Joseph and Mary traveled back to Bethlehem, where the inns were
all full, and the rest we know.
9. See Institute of Medicine (1988:7). The definition provided by the Acheson
Report can be found in the Dictionary of Epidemiology (Last, 2001:145).
10. The quotation is from Frank (1995), who defended the need for such a term.
The phrase “population health” appears in the title of several books, such as Dean
(1993), Kindig (1997), Kawachi et al. (1999), Green and Ottoson (1999), Tarlov and
St. Peter (2000), and Weinstein et al. (2002).
11. See the commentary by Kindig and Stoddart (2003). For a critical social
science perspective, see Poland et al. (1998) and Coburn et al. (2003). Among the
criticisms is the absence of any mention of capitalism as a root cause of ill health.
12. The Leeds Declaration originated from a conference organized by the
Nuffield Institute of Health in Leeds in 1993. An editorial in Lancet (19 Feb. 1994)
promotes it to a wider audience. “Upstream” refers to the story of the hero who
saves one drowning man after another from the river, but never discovers that
someone upstream is pushing people into the water!
22 Population Health

13. Morris and Uses of Epidemiology have had a profound impact on the disci-
plines of epidemiology and public health. The book was first published in 1957,
with new editions in 1964 and 1975. For a celebratory essay on the author, his pre-
science, and the current relevance of his book, see Davey Smith (2001).
14. See, for example, Lilienfeld and Black (1986) on the epidemiologist in court.
The Centers for Disease Control was called in to investigate a series of unexplained
deaths at the Toronto Hospital for Sick Children in the 1980s, using the approach
and technique of a disease outbreak investigation (Buehler et al., 1985). This study
is included as a case study in Exercise 5.2. To date, the case remains unsolved—in
the criminal justice sense, if not in the epidemiological sense. During the months of
October and November 2001, a total of 22 cases of anthrax—an infection by the bac-
teria Bacillus anthracis—were identified in seven states and the District of Colum-
bia. For an account of the anthrax outbreak, see Jernigan et al. (2002) and Exercise
3.5. The UCLA School of Public Health web site contains a wealth of information
on bioterrorism: www.ph.ucla.edu/epi/bioter/bioterroism.html.
15. Hahn (1995), a CDC epidemiologist, provided an anthropological perspec-
tive on sickness and healing. The impact of cultural concepts of health and dis-
ease on the assessment of population health status is discussed in more detail in
Chapter 3.
16. See Terris (1985). For a comprehensive review of the “re-engagement” of
epidemiology and social science, see Krieger (2000). The resurgence of “social epi-
demiology” as a branch of epidemiology is attested to by the appearance of books
such as Marmot and Wilkinson (1999), Berkman and Kawachi (2000), and others
in recent years. Works by Janes et al. (1986), Swedlund and Armelagos (1990), and
Hahn (1999) demonstrate the increasing confluence of anthropology and epidemi-
ology. Elsewhere I have used the term biocultural epidemiology to emphasize the
need for an integrated approach to the study of population health (see Young,
1994), a view shared by McElroy (1990). Inhorn (1995) noted that studies demon-
strating true collaboration and integration between epidemiology and anthropol-
ogy were rare and pointed out several stereotypes that anthropologists had of
epidemiology.
17. See Weed (1995) and editorial comments by Oppenheimer (1995).
18. See Kuller (1991). By concentrating on the study of epidemics—broadly
defined—the drifting away of epidemiology from its roots in public health may
perhaps be corrected.
19. See Lilienfeld (1978). Evans’s addendum appeared as a letter to the editor
of the American Journal of Epidemiology (1979; 109:379–82). The caricature of the epi-
demiologist is quoted from an unnamed editorial in the American Journal of Public
Health (1942; 32:868–69).
20. See Hunter (1999) and the text by Carrington and Hoelzel (2001) on some of
the uses of molecular epidemiology. The confluence of interests in the brain, behav-
ior, and hormones can be seen in the title of the journal Psychoneuroendocrinology.
21. For an account of the major epidemics in history, see Karlen (1995). Lilien-
feld (1979) discussed the development of epidemiology in nineteenth-century En-
gland. Bacon spoke of “depopulation of towns and homes of husbandry” (cited in
Thomlinson, 1976:5).
22. The Austrian Popper spent the war years in New Zealand and moved to En-
gland after World War II, where he was eventually knighted. The German title of
his book is Die Logik der Forschung. Buck (1975) first introduced Popper in the pages
of the International Journal of Epidemiology, and the debate has continued ever since:
 Introduction 23

see, for example, Jacobsen (1976), Maclure (1985), Pearce and Crawford-Brown
(1989), Karhausen (1995), and Greenland (1998), and the considerable volume of
letters to the editor that they generated. Susser (1986) concluded that there was a
need for both induction/deduction and verification/falsification in research and
practice. Weed (1986) provided a good general introduction to the logic of science
and its relevance to epidemiology. For the scientifically trained, but philosophically
challenged, an excellent primer to the philosophy of science is Ladyman (2002).
23. A few histories of public health, as distinct from histories of medicine, do
exist; for example, the classic by George Rosen, originally published in 1958 and
reprinted in 1993. The book of readings published by the Pan American Health
Organization (PAHO) (Buck et al., 1988) provides excerpts from the original re-
ports of many historically significant studies.
24. This quotation is from the preface to the third edition (1996). For an appli-
cation of Kuhn’s ideas to an analysis of epidemiology textbooks, see Bhopal
(1999).
25. See Susser and Susser (1996) and the accompanying editorial in the Ameri-
can Journal of Public Health (1996; 86:621–22).
26. Rosen (1947) provides the English translation.
27. See Kannel (1995). The Framingham Study has generated numerous re-
search papers. For more background, see the monograph by Dawber (1980).
28. See Taubes (1995), and other critiques by Skrabanek (1992), Pearce (1996),
and Krieger (1999). Several of the epidemiologists interviewed by Taubes re-
sponded in a letter to correct the impression that “evidence based on epidemiol-
ogy is not usually credible” (Science 1995; 269:1325–28).
29. See Saracci (1999). The views of those against broadening the role of the
epidemiologist can be sampled from Rothman et al. (1998), and Savitz et al. (1999).
30. Last (1988) considered the term clinical epidemiology itself an oxymoron,
and its effect on health detrimental. Naylor et al. (1990), in response, emphasized
the complementarity of the two approaches and urged collaboration. Mackenbach
(1995) suggested qualifying epidemiology as “public health epidemiology.”
31. For the achievements, see MMWR 1999; 48:241–43; 243–48; 369–74; 461–69;
621–29; 649–56; 849–57; 905–13; 933–40; 986–93; 1073–80; and 1141–47. Koplan and
Fleming (2000) discussed the challenges.
32. Excerpts of Lind’s book can be found in the PAHO reader (Buck et al.,
1988:20–23). Lind was credited with other naval and novel practices such as de-
lousing sailors, the design of hospital ships, and the distillation of sea water.
33. Snow’s Report on the Cholera of 1849 and the second (1855) edition of On the
Mode of Communication of Cholera were reprinted as Snow on Cholera: Being a Reprint
of Two Papers in the United States by the Commonwealth Fund in 1936. The editor
was Wade Hampton Frost (1880–1938), the first professor of epidemiology at the
Johns Hopkins School of Public Health, who was responsible for rescuing Snow
from relative obscurity and initiated the tradition of teaching Snow in introductory
courses of epidemiology. Excerpts of Snow’s writings can be found in the PAHO
reader (Buck et al., 1988:42–45; 415–18). For an analysis of the historical context
of Snow and other “sanitary physicians” of his era, see Lilienfeld (1979). Ralph
Frerichs created a comprehensive web site devoted to the life and work of John
Snow, including relevant historical documents, www.ph.ucla.edu/epi/snow.html.
Vandenbroucke et al. (1991) traced the revival of Snow to Frost. McLeod (2000) ex-
amined the various versions of Snow’s map and sets the record straight for much
of the myth that has sprung up around the Broad Street pump. A new biography of
24 Population Health

Snow was produced by Vinten-Johansen et al. (2003). For an up-to-date report of

the current global cholera pandemic, check the WHO web site: www.who.int/
health-topics/cholera.html.
34. An excerpt of Semmelweis’s book can be found in the PAHO reader (Buck
et al., 1988:46–59). See Rosen (1993:293–94) for an account of his last days. Nuland
(2003) provides a biography for the general readers.
35. Goldberger published a series of papers in Public Health Reports, the official
journal of the U.S. Public Health Service. Three of these, published in 1914, 1920,
and 1923 are reprinted in the PAHO reader (Buck et al., 1988:99–102, 584–609,
726–30). Additional background information can be found in Stolley and Lasky
(1995:45–49). Roe (1973) has written a social history of pellagra, dubbed “a plague
of corn.”
2
Measuring Health and
Disease in Populations (I)

Measures of Disease Occurrence

The two basic measures of disease occurrence in populations are incidence

and prevalence. They are generally discussed in textbooks of epidemiology
within the first two chapters, although the depth of discussion varies con-
siderably. The two are often confused in everyday usage, in the media,
and in clinical circles.
Incidence is the rate at which new events occur in a population in a de-
fined time period. The numerator is composed of a count of the events of
interest. “Events” may be new episodes of disease or the number of peo-
ple becoming sick; “mortality rate” is a special kind of incidence where
the event is death. The key concept is a change in status, from healthy to
sick, from alive to dead, over a period of time.
The denominator is the population “at risk” for the event. Ideally, it
should consist only of people who do not already have the disease and
of those among whom it is possible for the disease to develop (e.g.,
women who have had hysterectomies are not “at risk” for cancer of the
cervix).
There are two kinds of incidence: cumulative incidence and incidence den-
sity. The cumulative incidence is the proportion of an initially disease-free
group of individuals who develop the disease within a specified period of
observation. An example is the so-called attack rate used in epidemic in-
vestigations. For example, if 100 people attended a wedding reception
and 20 of them came down with diarrhea within 24 hours, this is referred
to as an attack rate of 20%. According to the definitions in Box 2.1, the cor-
rect term should be attack proportion rather than rate.
It is important to specify the period of observation. The cumulative in-
cidence of death in a cohort of newborn infants is 100% if the period is,
say, 130 years—in the long run, we are all dead! Comparing one cumula-
tive incidence with another using a different period of observation is
therefore meaningless.
 Another Random Document on
Scribd Without Any Related Topics
The Project Gutenberg eBook of Down the
Scale or Up...
This ebook is for the use of anyone anywhere in the United States
and most other parts of the world at no cost and with almost no
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you are located before using this eBook.

Title: Down the Scale or Up...

Author: Barbara Abel

Author of introduction, etc.: W. W. Bauer

Release date: September 22, 2020 [eBook #63264]

Most recently updated: October 18, 2024

Language: English

Credits: Produced by Stephen Hutcheson, Lisa Corcoran and the

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Distributed Proofreading Team at https://www.pgdp.net

*** START OF THE PROJECT GUTENBERG EBOOK DOWN THE

SCALE OR UP... ***
 Down the Scale
Or Up...
by
BARBARA ABEL

Copyright 1939—Revised 1948

NATIONAL DAIRY COUNCIL CHICAGO 6
(19) 1958

This will be music to your ears

2
 Introduction
TO SLENDERNESS

Not skinniness! It’s no light matter, Hortense, this question of

figures. You can figure on that. Even the new styles won’t hide the
awful fact that you bulge where you shouldn’t, OR that you own no
curves where you should.

Yes, it’s a tough racket melting the too, too solid flesh. Figure how
much you have crept up on the scale, let your doctor figure how fast
you dare go down without landing—flop—farther than you ever
intended. This little book? It’s encouragement, blandishment, a little
judicious enragement—but it isn’t medicament.

How about reducing tricks? Well, Dumpling, let’s take a look. Glands?
A slick trick for a few, probably not you. Bath salts? They 3
dissolve the budget, nothing more. Laxatives? Money in the
promoter’s pocket. Thyroid and other drugs? No, no, NO!

Suppose you want to go up the scale? Put some curves in place of

angles? Improve the pep and disposition? Reverse what the fat gal
does. Where she envies, you eat. Where she hustles, you rest. When
she refuses a snack, you snatch it.

Either way you go on the scale—up or down—it comes back largely

to how much you eat, when, and most important, what. Either way
you go, don’t neglect—milk, cheese, eggs, meat, and fish—fruits,
vegetables, and whole-grain cereals. Emphasize salt and water to
gain, cut down on both to lose.

Cheerio, whichever way you’re bound. The diet does it. You can
figure on that, lady!

W. W. BAUER, M.D.
Director, Bureau of Health Education
American Medical Association

DESIRABLE WEIGHTS FOR WOMEN

Ages 25 and Over

After thirty it is better to be weighed in the balance and found

wanting.

HEIGHT WEIGHT IN POUNDS

(with shoes) (as ordinarily dressed)
Small Build Medium Build Large Build
4 ft. 11 in. 104-111 110-118 117-127
5 ft. 0 in. 105-113 112-120 119-129
5 ft. 2 in. 110-118 117-125 124-135
5 ft. 4 in. 116-125 124-132 131-142
5 ft. 6 in. 123-132 130-140 138-150
5 ft. 8 in. 129-139 137-147 145-158
5 ft. 10 in. 136-147 145-155 152-166
5
 COMES THE DAY!

There comes a day in many a woman’s life when she has a

THOUGHT. Namely: “I MUST start on a diet.”

A mere trifle may bring on this thought. Such as:

a) a saleswoman murmurs, “Well, dear, perhaps a size 38 would be

just a wee bit more comfy.”

b) a taxi driver asks, “Where to, Madam?” (they’ve always called you
“Miss”).

c) a husbandly voice commands, “Sit in front with me, Sonnie, and

give mother the back seat where she can spread.” 6

d) walking down Main Street you catch a quick, dreadfully candid

glimpse of yourself in a plate glass window. “Heavens!”

If the THOUGHT has come to you, it is likely, alas, to be followed

swiftly by second, third, fourth, and fifth thoughts. Thus:

2) “Oh well, I’m not so very fat.”

3) “As it is, I don’t eat enough to keep a bird alive.”

4) “Anyhow, I come by it naturally—look at my own mother!”

5) “Besides, diets are dreadful.”

We won’t argue with you about thoughts 2, 3 or 4, assuming that

you know more about your weight, your intake, and your mother
than we do. But when you get to thought 5, we rise up, thus:

DIETS NEED NOT BE DREADFUL

(If this booklet doesn’t prove it, then you go right on eating food
and we’ll have to eat the booklet.)

DON’T FALL FOR FALLACIES!

You can easily talk yourself out of dieting by falling for one of those
old fallacies that women hug to their (ample) bosoms, namely:

“What I really need is a new girdle.”

“To be slim and svelte, all you need to do is to ooze yourself into our
Streamliner Stretch.” Sez the ad. “Pooh!” sez we. Common courtesy
should tell you that you have to meet a two-way stretch half-way. No
sixteen-ounce trifle of satin and elastic is going to cope with 8
160 pounds of womanhood, and stay svelte. Science is
wonderful, my dear, but it’s not that good!

“I really need my extra weight for reserve.”

We freely admit that camels are said to store up extra fat for reserve
in their humps. Camels lead hard lives. But when were you last in
the Sahara Desert?

“I haven’t the will power to go on a reducing diet.”

It isn’t will power so much as choice power that’s needed. We

complimented a girl recently for sticking so faithfully to a diet.
“Honestly, it isn’t a bit hard now,” she said. “I simply looked myself
in the eye one day and asked, ‘Well, which do you choose—to step
into a nifty 36 without alterations? Or fudge cake?’ After I really set
my mind on the 36, the fudge cake just bored me.” (There must 9
be a moral here somewhere.)

“Oh, well, I’ll start on a diet ... next week.”

All we can say to this is that statistics (and human nature) prove
that you won’t.

THE CASE OF MRS. PLENTEOUS

So far we’ve been appealing to your good looks. Here goes for a try
at your good sense. (You must have some, or you wouldn’t still be
reading.) We refer to good sense about health.

Some women are beautiful, some are healthy, some are both, and
some are neither. And into the last class fall (or roll) the definitely
overweight.

Now you’re going to cry, “Nonsense! Look at Mrs. Plenteous; 10

she’s enormous, and as healthy as a horse.”

Well, we don’t know Mrs. Plenteous personally, but we’ll take your
word that she’s a human being, and as such she was never intended
to be enormous. She was made according to a careful pattern that
hasn’t varied in thousands of years, by an expert designer who put
strength and usefulness and beauty into his designs. Mrs. Plenteous
has the regulation number of bones, muscles, and vital organs
(barring operations). None of them is enormous. Each was built to
carry around a certain weight without undue strain. If Mrs. Plenteous
is enormous, her organs are carrying around an enormous strain.
They can take it—for a while—and they will—for a while. But Mrs.
Plenteous is not really healthy, she’s just lucky—so far.

11

DON’T TAKE OUR WORD FOR IT

Ask your doctor. Ask your insurance agent (if you can edge in a
word). They will tell you, we think, that excessive waistlines tend to
go along with shorter lifelines. Medical records warn us that the
overweight (or underweight, see page 21) person is much more
susceptible to illness than the person whose weight is normal. And
how surgeons loathe operating through layers of fat! And by the
way, look around you at a roomful of elderly people. Aren’t most of
them rather willowy? The “enormous” ones left early.

SAFETY FIRST!

There are so many tricky health questions involved in reducing that

we are not going to take the responsibility of advising you
specifically how to do it. We do suggest, however, that you:

1) See your doctor. If you haven’t a doctor of your own, see 12

somebody else’s. He’ll be glad to become yours for the asking.
He knows much more about you than you do, having spent a great
deal of time and money to learn it, which you never did. Perhaps an
ordinary reducing diet is not for you. Perhaps you have funny glands
or a messy metabolism, which he will discover by careful tests and
experiments. Perhaps you are not as overweight as you think you
are.

2) Do what your doctor tells you. This will surprise him very
much, but will also please and flatter him, and will cause him to
work like mad on your case.

3) Don’t take any advice from your friends. You know 13

very well that you don’t agree with their politics, approve of
their hats, or care much for their children. Why should you trust
them on a matter much more intimate and vital?
4) Don’t try short cuts. It took time to put on those extra pounds,
and it will take time to get them off. Don’t be beguiled by success
stories of fad diets or slimming salts. You want to reduce your
weight only—not your chances of life, liberty and the pursuit of
happiness. These magic potions may be harmless in nine cases out
of ten, but it’s maybe just your luck to draw number ten!

14

WHERE DO WE GO FROM HERE, GIRLS?

... into the pantry! To hear us talk about diets you might be thinking
that we disapprove of food in general. Not so; we love it! Both kinds,
the Protective Foods and the Energy Foods.

LIVE—AND ENJOY LIFE

The Protective Foods keep you alive. The Energy Foods keep you
enjoying life. Energy foods are like the gas in your car; they give you
the quick start, the power to go places, the speed to get there fast.
If you’ve ever run out of gas on a country road, you know how
important energy is.

Energy foods are delicious. And fattening. Let’s boldly mention a

few:
 Chocolate eclairs, pies, French pastries, griddle cakes, shortcake,
rich salad dressings—yummy!

If you would reduce yourself, reduce them first! Of course, 15

there are other Energy Foods without so much glamor but
with more honest goodness (and less fat). We refer to such friends
of humanity as bread and potatoes. Don’t see too much of them, but
don’t snub them entirely. And whenever you reduce any of the
Energy Foods, be sure to put in their places more of the Protective
Foods.

For the Protective Foods are like the brakes on your car. They keep
you out of trouble. They build up your blood by bringing it minerals
and vitamins. They help you repel colds and other worse things (if
there are any worse things).

We can conceal from you no longer the fact that these good,
reliable, tasty and health building foods include:

16

MILK—VEGETABLES—FRUITS—EGGS—MEAT—CHEESE

Whatever you weigh, you need both kinds of food. So don’t go

cutting out all energy foods and then, when you get to feeling
droopy, say we told you to do it. WE NEVER DID.

DID SOMEBODY SAY “MILK”?

At this point some pupil is sure to raise her hand and ask, “Oh, but
isn’t milk terribly fattening?”
No, Gwendolyn, it isn’t. Milk gets its chief fame from calcium.
Calcium may sound like a pretty dull mineral, but believe us, it’s
worth its weight in gold. In fact, if you have plenty of calcium in your
teeth, you won’t need so much gold. As for bones, they are 17
full of calcium, or should be. Milk also contains several
vitamins and a dozen or so other minerals. In fact, milk is a mineral
mine (and yours, too, since there’s plenty for both of us).

Moreover, milk is rich in proteins. And proteins are the material from
which your muscles are made. If you have no muscles to speak of,
please consider that we are speaking of your husband’s muscles. (If
he has none, we have just been wasting our time.)

BABY TALK

Some people seem to think that milk is for babies only. You might
just as well say that baths are for babies only. Or love, or petting. No
one ever outgrows the need for milk (or baths or love or petting). No
other food will do as much to maintain health throughout life.

18
 Why, THIS Isn’t Bad!
To prove that you can diet and like it, here is a sample of a delicious
—but discreet—menu. Be guided in quantities by your calorie needs.
See page 20. (For the not-very-active, reducing diets average 1,400
to 1,500 calories a day.)

Breakfast
Sliced Orange
Poached Egg
Buttered Toast
Milk
Coffee or Tea
Luncheon
Open-face Grilled Cheese Sandwich
Tomato
Cabbage Slaw
Fruit Cup
Milk
Dinner
Broiled Fish or Steak
Green Beans
Combination Salad, Lemon Juice
Bread and Butter
Ice Cream
Average servings. See pages 30 to 35.
Calories for the day—1,450 to 1,500.

19
CONCERNING CALORIES
You probably know about calories. There’s been a lot of talk about
them. In case, however, you still confuse them with vitamins, we
point out that a calorie is simply a rather nice word for a
measurement of energy. If you weigh too much, you aren’t using up
calories as fast as you are taking them in.

In case you have vowed to carry this booklet around with you until
you have lost such and such a number of pounds—and it might be a
good idea—we have gone to considerable pains to make lists of
foods with the number of calories in each. We have not counted
these calories personally, but somebody with better eyes than ours
has, and you may rely on his count. (See pages 30 to 35.)

20

WORDS TO LADIES OF WILL POWER

If you need to reduce, take your excess weight off gradually (no
more than 1 to 2 pounds weekly) by cutting your calories every day.
Try eating 500 to 1,000 calories less daily until you discover what it
takes to lose the desired amount. Pick your calories to reduce your
weight, not your disposition.

When you reach the weight at which you feel best and look best,
don’t get wobbly in will power or careless in eating.

This may take some figuring, but remember, this booklet is all about
figures anyhow.

THANK YOU for going all this way with us. We hope that you’ll find it
was well worth the time. If we ever meet you face to face we’ll
probably exclaim, “Darling, how WELL you look! Haven’t you lost
some weight?”

21
UP THE SCALE
The next few pages are written on an ascending scale for those who
want to go up, up, UP to Par:

Par in vitality
Par in energy
Par in good looks

We spoke pretty sternly to a certain Mrs. Plenteous. Now let us give

thought to Mrs. Plenteous’ sister-under-the-skin-and-bones, Miss
Gaunt.

For months Miss Gaunt’s overstuffed friends may have fawned on

her figure:

“You’re so slender, my dear!” Now “slender” is indeed a 22

flattering word. But any good dictionary will list some sinister
synonyms: spare, lank, skinny, scrawny, scraggly, and spindly, to
name a few. Some day the remark will be: “You’re so skin—er—
slender, my dear!”—and Miss Gaunt will feel flattened—not flattered.

And perhaps she’ll take a good long look at herself, noting certain
hollows in the cheek, certain knobs in the elbows, a certain chronic
weariness, (not to mention crossness) and she’ll think: “Maybe I
should try to build up a little.” When that time comes, we do hope
that Mrs. Plenteous lends her this booklet.
 FIGURE IT OUT

Many over or underweight people love to blame their figures on their

ancestors. (If they’re perfect 36’s, of course, they take all the credit
themselves.) “My dear grandmother weighed 200 pounds, so 23
there’s not a thing I can do about it,” beams Mrs. Plenteous,
splashing the third lump of sugar in her coffee. “My family tree was
a beanpole,” sighs Miss Gaunt. “No thanks—no sugar or cream.”

The truth is that, according to anthropologists, there are in general

three types of body build: the stout, the medium, and the lean. You
may possibly have inherited your grandmother’s type of figure, just
as you may also have inherited her house. But there’s no law against
remodeling the house—or the figure. Surely the smart thing is to
make the house the best possible house of its type, one which you’ll
enjoy living in; and the figure the best possible figure of its type—
one you’ll enjoy living with.

24

IT SHOULD BE DONE

Perhaps we’ve dwelt overmuch on the good looks angle. But surely
the right angle on good looks is good health. To be under par is to
be caught short on the reserves which, if you have them, do so
much to cushion the bumps of hectic modern living, and ward off
the illnesses that pounce so gleefully on the tired, the rundown, the
undernourished human frame.
 IT CAN BE DONE

A wise nutritionist has said, “There are two ways of building up, just
as there are two ways of getting rich. One is to cut down on your
expenses, the other is to increase your income.”

The “expenses” are energy, and you can decrease them by taking
more rest, less violent exercise, more sleep, and by keeping 25
calm. The “income” is food. And the thing to do with it is to
eat more of it—and more choosily of it! For though music may be
the food of love, the food of growth is groceries!

Too often have we heard languid creatures wail, “But I’m not hungry
—I can’t swallow a thing!” To them from us goes a simple but hearty
“Nonsense!”

Swallowing is an ordinary mechanical act which almost anybody can

perform, providing there is no foreign body in the throat (in which
case hang by your heels or call your doctor). The hitch is that most
people who claim that they can’t eat are waiting for appetite to say
when. Now your appetite is a fickle counselor and often does not
have your best interest at heart. Just look what it does to Mrs. 26
Plenteous! Our advice is this: Ignore it and eat anyhow.
Chances are that appetite, surprised and stimulated by regular
shipments of body-building food, will come to life and get back on
the job.
Other non-eaters insist that their stomachs are too small. Well,
stomachs are timid creatures. If they don’t get much they quit
expecting much. And they shrink. But they are flexible organs and
adapt well to inflation. Start feeding them more, and they’ll take it—
and like it. Start gradually, though, and give them time to adjust. Eat
oftener and less at a time. And at regular times! Increase your
calories by 500 to 1,000 a day (see pages 30 to 35). But don’t just
pile them on. Team them up with their right partners—the
PROTEINS, VITAMINS, MINERALS. And of course don’t take our
word for anything without checking with your doctor!

27

MRS. PLENTEOUS SHOULDN’T PEEK

The next few pages may be a little hard on Mrs. Plenteous, so we

hope she left us on page 20. For from here on in we get just
voracious about food. “Help yourself,” Miss Gaunt—

NOT to a cup of bouillon—BUT to a brimming bowl of cream soup

NOT to lettuce leaves and lemon juice—BUT to a salad bowl, tangy

with cheese and dressing

NOT to a dry rye crisp—BUT to those warm rolls and butter

NOT to just wafers of lean meat—BUT to a thick pork chop

sometimes—with gravy

NOT to a modest glass of milk twice a day—BUT to an extra glass or

a double chocolate malted maybe.
 28

WHO SAID MILK

Milk? Ah, now there’s a beverage both Mrs. P. and Miss G. can sip
with sociability. For milk is the menu’s best builder-upper and is
essential whether you’re headed UP or DOWN. But while Mrs.
Plenteous should stick to plain, whole milk, (with such companions
as cottage cheese, American cheese, plain ice cream, and some
butter) Miss Gaunt may let herself go on parts of milk that will stick
to her—cream, butter, and cream cheeses.

Milk has many virtues: It adds to the food income without cramming
bulk into those small stomachs previously noted. And it is the world’s
best mixer, combining graciously with hundreds of other foods,
enhancing and enriching them.

Consider a few of the forms milk can assume. Every one is a boost
for Miss Gaunt as she goes up, up, UP that scale:

cereals cooked with milk 29

eggs poached in milk
vegetables anointed with butter
cheese souffles
potatoes, scalloped, mashed, or creamed
custards and custard sauces
oyster stew—half and half
cakes, cookies, tarts—with ice cream
strawberries, peaches and cream
cantaloupe à la mode, pie à la mode—

Indeed, anything à la mode is the right mode for Miss Gaunt!

Whee! Merely setting down such a list makes us feel as though we’d
put on ten pounds. Pardon us while we unhook our stays!
And may you, Miss Gaunt, soon be doing the same! BUT—don’t
overdo it! Mrs. Plenteous knows it is hard to melt. Set your goals to
look and feel your best.

30
 TABLE OF CALORIES
Take your calories in good, reliable, tasty, and health-building foods
first. Expand cautiously.

DAIRY PRODUCTS
Average Serving Calories
Whole Milk 1 glass (8 oz.) 170
Skimmed Milk 1 glass 85
Buttermilk 1 glass 85
Cheese (American) 1 ounce 110
Cottage Cheese, creamed ½ cup 120
Cream Cheese 2 tablespoons 110
Cream (coffee) 2 tablespoons 60
Cream (heavy) 2 tablespoons 100
Cream (whipped) 2 tablespoons 50
Half-and-half ¼ cup 80
Butter 1 tablespoon 100
Ice Cream ⅙ quart 205
VEGETABLES (raw)
Lettuce ¼ head 10
Cabbage 1 cup 25
Celery 2 stalks 5
Carrots 1 medium 20
GREEN VEGETABLES (cooked)
Cabbage ½ cup 20
Greens ½ cup 25
Asparagus ½ cup 20
Green Beans ½ cup 15
Broccoli ½ cup 20
ROOT VEGETABLES (cooked)
Carrots ½ cup 20
Beets ½ cup 35
Potato (plain) 1 medium 100
Potatoes (scalloped) ½ cup 120
Potatoes (mashed) ½ cup 120
Sweet Potato 1 medium 180
OTHER VEGETABLES (cooked)
Tomato (fresh) 1 medium 25
Tomato Juice ½ cup 25
Peas ½ cup 65
Corn ½ cup 70
Onions ½ cup 40
Hubbard Squash ½ cup 50
SALADS
Cabbage (vinegar dressing) ½ cup 50
Cabbage (cream dressing) ½ cup 85
Banana-Nut (mayonnaise) ½ cup 260
Mixed Green (Fr. dressing) ½ cup 70
Combination (lemon juice) 1 medium 40
Perfection (no dressing) ½ cup 85
Potato (mayonnaise) ½ cup 185
Waldorf (mayonnaise) 3 hp. tbsp. 140
Dressing, French 1 tablespoon 60
Dressing, fruit 1 tablespoon 50
Dressing, mayonnaise 1 tablespoon 90
Dressing, boiled 1 tablespoon 30
FRUITS (fresh)
Apple 1 medium 75
Apple (baked, sweetened) 1 large 200
Apricots 5 medium 80
Banana 1 medium 90
Avocado ⅓ pear 165
Grapefruit ½ medium 75
Lemon Juice 1 tablespoon 5
Orange 1 medium 70
Orange Juice 1 cup 110
Peach 1 medium 50
Pear 1 medium 65
Pineapple ¾″ slice 45
Raspberries ½ cup 35
Prunes (dried) 4 large 100
Cantaloupe ½ of 5″ melon 50
FRUIT (canned)
Apricots 3 large halves 100
Cherries (Royal Ann) ½ cup 100
Fruit Cup ½ cup 90
Peaches 2 large halves 100
Pineapple 3½″ × ½″ 50
CREAMED DISHES
Creamed Eggs 1, ¼ cup sauce 175
Creamed Carrots ½ cup 70
Macaroni and Cheese ¾ cup 350
Cheese Souffle ¾ cup 150
MEAT, FISH, POULTRY, EGGS
Steak (broiled, gravy) 2″ × 3″ × ½″ 100
Lamb Chop 1 medium 130
Pork Chop (broiled, lean) 1 medium 200
Roast Beef 3¾″ × 3½″ × ¼″ 150
Meat Loaf (beef) 4″ × 2½″ × ½″ 150
Hamburger 1 medium 200
Beef Hash ¾ cup 200
Ham (boiled, lean) 5″ × 5″ × ⅛″ 115
Liver 4″ × 3″ × ½″ 100
Bacon 2-3 Slices 100
Lamb Stew 1 cup 390
Fish (steamed, broiled) 1 medium serv. 100
Salmon ⅓ cup 100
Chicken ¼ cup 100
Egg (soft-cooked, poached) 1 75
Egg (pan scrambled) 1 120
BREAD STUFFS AND CEREALS
Griddle Cakes 2 med. cakes 120
Waffle 1 medium 215
Biscuits 2 small 130
Bread l-ounce slice 75
Cooked Cereal ½ cup 70
Muffin 2¾″ diam. 135
Zwieback 3¼″ × 1¼″ × ½″ 35
Corn Bread 2″ × 2″ × 2″ 140
French Toast 4″ × 3¾″ × ½″ 150
Rye Wafer 1 small 20
Cracker (saltine) 2″ square 15
LENTILS AND NUTS
Limas (dried, cooked) ½ cup 140
Limas (fresh, cooked) ½ cup 75
Navy Beans (stewed) ½ cup 100
Baked Pork and Beans ½ cup 160
Peanut Butter 1 tablespoon 90
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