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Objectives. To investigate the rate of manuscript submission to a major peer-reviewed journal (American Journal of Public Health) by gender, comparing periods before and during the pandemic. Methods. We used data from January 1 to May 12, 2020, and defined the start of the pandemic period by country as the first date of 50 or more confirmed cases. We used an algorithm to classify gender based on first name and nation of origin. We included authors whose gender could be estimated with a certainty of at least 95%. Results. Submission rates were higher overall during the pandemic compared with before. Increases were higher for submissions from men compared with women (41.9% vs 10.9% for corresponding author). For the United States, submissions increased 23.8% for men but only 7.9% for women. Women authored 29.4% of COVID-19–related articles. Conclusions. Our findings suggest that the pandemic exacerbated gender imbalances in scientific research.

OBJECTIVES. Cloth diapers with front closure and all-in-one design were compared with paper diapers containing absorbent gel material for their influence on fecal contamination of the environment in licensed child day care centers. METHODS. One infant room and two toddler rooms in each of four day care centers were monitored for the presence of fecal bacteria. Microbial samples were taken from the play/sleep area, the diaper-changing area, and the hands of the caregivers and the children. Sampling was done twice weekly for two 4-week periods. Each center used either cloth or paper diapers during the first period, changing to the other diaper type during the second period. RESULTS. A total of 1722 samples were cultured, 881 during the first 4 weeks and 841 during the second 4 weeks. The frequency of isolation of fecal organisms ranged from a low of 12% of the total bacteria isolates at a center using cloth diapers, to highs of 46% and 45%, respectively, at a center using first paper and then cloth diapers. Sink faucets and the hands of the caregivers and the children were often contaminated. CONCLUSIONS. Analysis of the results of comparisons between cloth and paper diapers showed no significant difference in the frequency (F = .380, P < .535) or the intensity of fecal contamination in child day care centers.

The article discusses the publication's editorial team's benchmark of processing 10,000 submissions as of September 2018 since it began its activity in June 2015 and offers a description of how the editorial process works for full-length papers.

We reviewed the authorship characteristics, editorial processing, and final fate of 126 papers dealing with data from countries other than the United States and Canada and submitted to the American Journal of Public Health in 1989. The acceptance rate of these international health papers was 22%, similar to that of all papers (25%). Authors from developed countries had higher acceptance rates than authors from developing countries, but the highest acceptance rate (36%) was for international health papers with joint authorship from both developed and developing countries. Of 83 rejected papers, 72% were published in other journals. Of these, 45% were published in journals covered by Index Medicus, a figure similar to that for all papers rejected by the Journal.

The importance of reviewers to the American Journal of Public Health publication process cannot be underestimated. Without our reviewers, the Journal would not only be worse off but would actually fail to exist as the quality vehicle for dissemination of public health information that it strives to be. As editors, we are proud to read submissions and screen them for validity and contribution, but we rely heavily on the expertise of reviewers for their precise comments and critical responses that maintain the Journal’s quality and significance. The past year has brought many exciting changes for the Journal, including the hiring of new editorial and production staff and, most notably, the unveiling of a new Web-based electronic submission system. These changes have inspired considerable conversation among the editorial staff about the value of our review process and, of course, the value of our reviewers. Because we have the utmost appreciation for our reviewers, we have made it a priority to provide as much support and guidance as they would like. As part of our commitment to the process, we have developed reviewer recommendations to make the job of the reviewer easier and more efficient. Because one person’s ease and efficiency is another’s headache, these guidelines and recommendations come with an invitation to read the following once, 10 times, or not at all—indeed, these are simply guidelines for those who want them, not rules carved into stone. Of course, no list is complete without the requisite caveats, and the reviewer recommendations are no exception. The following recommendations represent 2 sets of thoughts about the reviewer’s role: the rules we depend on and the exceptions we make to these rules. Our reviewers should know that no guidelines are inflexible, and the ultimate goal of disseminating quality work that furthers the field of public health is never sacrificed for rigidity or bureaucracy. We aim to keep this overall goal in sight every time we read a submission. We hope that these reviewer recommendations will empower reviewers to be part of the Journal’s contribution to the larger public health community and discourse.

In laboratory- and village-based evaluations researchers compared chlorine decay and disinfection rates in turbid surface water that had been treated and stored in locally available clay vessels and plastic jerry cans. Three vessel types were evaluated: 1) wide-mouthed 20-liter clay vessels; 2) narrow-mouthed 20-liter clay vessels with lids and spigots; and 3) narrow-mouthed 20-liter plastic jerry cans with lids. Water was treated with 1% sodium hypochlorite while free chlorine levels were measured. The researchers assessed the microbiological quality of treated and untreated water. Overall results indicate that jerry cans and clay vessels can achieve adequate chlorine levels to disinfect turbid contaminated source water in laboratory and household settings. Moreover village evaluation findings suggest that disinfected water that is stored in traditional clay vessels may be at risk for contamination which may result from contact with hands during water retrieval. The study also revealed that wide-mouthed storage vessels have been implicated in the transmission of cholera.

We evaluated the acute health effects of a strong emission of malodorous sulfur compounds released from a pulp mill in South Karelia, Finland. The 24-hour ambient air concentrations of hydrogen sulfide for the two emission days were 35 and 43 micrograms/m3 (maximum 4-hour 135 micrograms/m3). A questionnaire was distributed after the high exposure and later after a low exposure period to 29 households with 75 subjects living in the nearby community. During the high exposure, 63% of the respondents reported experience of at least one symptom compared to 26% during the reference period. Every third participant reported difficulties in breathing. In the 45 subjects responding to both questionnaires more eye, respiratory and neuropsychological symptoms occurred during the exposure compared to the reference period. The strong malodorous emission from a pulp mill caused an alarming amount of adverse effects in the exposed population.

IT is with considerable hesitation that the writer undertakes to attack so broad a problem within the compass of a short paper. It should go without saying that only the barest essentials can be touched upon. For our purposes, we shall confine ourselves to child hygiene, that is to .say, the application of the laws of health to the needs of the child. The term, child welfare, which is frequently employed more or less synonymously with child hygiene, covers a broader field and brings in factors which, though indirectly, are not directly, connected with child hygiene. The subject of child hygiene more properly includes prenatal hygiene, obstetrics (in part), infant hygiene, the hygiene of the child of pre-school age, school hygiene, and lastly, the hygiene of the child in industry. Furthermore, we may perhaps safely say that the greater portion of mental hygiene lies within the field of child hygiene. A distinction has been drawn in the title of the paper between state and municipal administration of the child hygiene problem. This distinction is in part real and in part artificial. From the standpoint of law, the municipality derives its powers and responsibilities from the state. In practice, however, there must often be a fairly sharp line of demarcation between the kind of administration which is proper to a municipality and that of which it is most fitting for the state to assume control. It must never be forgotten that the activities involved in child hygiene from the point of view of municipality and state, primarily represent an attempt to do something for the health of the child which cannot readily be done by the

Sidestream smoke yields for 15 brands of cigarettes were determined under conditions where mainstream yields were approximately equal to those used for determining the values which appear on packages of Canadian cigarettes. Sidestream yields of tar, nicotine, and carbon monoxide were much higher than mainstream yields for all brands tested. The average sidestream-to-mainstream ratios for the 15 brands were 3.5, 6.6, and 6.8 for tar, nicotine, and carbon monoxide, respectively. The highest yields of sidestream were obtained from the brands with the lowest mainstream yields.

Chemical analysis has long played an important part in the determination of the degree of pollution of natural waters, and in the measurement of the results of sewage purification. The methods employed for this purpose have been inherited from the older methods of water analysis almost without change. The latter were designed primarily to determine the purity of drinking waters but they have been adhered to in sewage work despite the fact that sanitarians have long since abandoned the idea of maintaining streams at a drinking water standard and in disregard of the present day aspects of sewage disposal. Sewage purification is essentially oxidation of organic matter. In the wellnigh perfect work of the slow sand filter the oxidation was so complete that it was conveniently measured in terms of nitrification. This is not a true quantitative measure of the whole work of the filter, but appears to be an end-point reaction indicating the completion of the process. With the introduction of rapid methods of purification designed for partial oxidation only, the test of nitrification and the whole scheme of chemical analysis fail utterly to meet the requirements of the situation. Hence the recent development and general use of putrescibility determinations. From a stream pollution aspect the older analytical procedure not only fails to define the quality of an effluent, but is actually misleading. Lederer' has shown that the removal by sedimentation of 63 per cent. of suspended solids results in an improvetnent iIl stability of only 31 per cent. In dealing with oxidation processes and employing as criteria of improvement the decrease of albuminoid ammonia and of oxygen consumed, the opposite effect is noted. A complete removal of the putrescibility of the sewage may be accompanied by an improvement in these analytical values of not over 50 per cent. In stream pollution studies the condition is, if possible, a more serious one. Here there is no " per cent. removal " with which to cover the uncertainty of the result. We are given a definite statement that the stream in question contains so many parts per million of free and albuminoid ammonia or of organic nitrogen or oxygen consumed. We are expected from his information to draw a conclusion as to the present condition of the stream in question and the possible effect upon it of the discharge of additional sewage either untreated or partially purified. If these analvtical determinations do not enable one to distingulish betweein organic matter in

The anaërobic spore test for manurial pollution of milk has certain definite advantages. Total bacterial count is at best an indefinite warning, visible dirt gives no clue to manure in solution, while B. coli depends on temperature and may give false indications. The anaërobic spore test is simple and meets requirements.

Sulphate of alumina as a coagulant and decolorizer is in use on many waters in the United States, and is recognized as one of the most effectual means of reducing an objectionable color in the water prior to filtration. The river water as applied to the West Parish filters of the Springfield water supply is naturally a water of few objectionable features. No large population is resident upon the water-shed and the sanitary conditions are excellent so that there is not a large danger of serious contamination of the supply at any time. By filtration a water free from practically all objections is produced, except that at times, the remaining color is noticeable, and the present systeni of coagulation is the result of a study of the means of correcting this one objection to the water. This water was first used as a supply in December, 1909, and sulphate of alumina was used for the reduction of color in the manner in which it is usually applied. The accompanying cut showing the use of coagulant during 1910 illustrates the amount of sulphate of alumina which was necessary for this reduction. Its application during this year was in accordance with the usual practice, that is, in amounts sufficient to secure a clear-cut reaction and the coagulant was applied continuously. The present method is illustrated by the chart showing the amounts and the color of the raw and filtered water during 1912 and 1913. As at present practised, excellent color reduction is secured by the use of 0.2 grain of sulphate of alumina per gallon of water during a larger portion of the time.

In connection with the examination of a series of samples of ice cream by the Health Department Laboratory of Chicago, in the course of which the presence of foreign fats was demonstrated in a few instances, the contention was raised by scientific counsel representing one of the ice cream manufacturers that reprocessed butter often yields a low Reichert Meissl number and saponification value; that, judging from the data furnished by these tests, it is often impossible to distinguish renovated butter from mixtures of butter and foreign fat. As a basis for this contention it was stated that the alleged lowering of the findings of these two tests was due to a loss of volatile acids occurring during the process of renovation, as a result of the heating and washing. The assertion was confidently made that the aforementioned loss of volatile fatty acids may represent as much as one third of the volatile fatty acid content, as determined by the Reichert Meissl method. It was the opinion of the city's experts that the loss of volatile acids occasioned by the process of renovation would be slight, and would not in any case be sufficient to invalidate the test as a means of distinguishing genuine butter from other fats. The firm in question admitted that renovated butter had been purchased for the preparation of homogenized cream, used in the manufacture of ice cream, but disclaimed any knowledge of the use of oleomargarin or other foreign fats for this purpose. The purchase of supplies, however, had not been controlled by laboratory tests. As very little definite data could be found upon the point in question, however, it was decided to undertake the series of tests here reported. The procedure adopted was as follows: Samples of butter purchased in the open market were subjected to tests for the determination of the Reichert Meissl number and saponification value. They were then placed in an incubator, at 37°C., for from three to five weeks, until an extreme degree of rancidity developed. The samples were then reprocessed by blowing steam through them for two

[...]despite the large influx of papers, our peer reviewers managed to keep pace and render 2105 decision recommendations to our editors, most within 12 days of accepting the invitation to review. "9 Articles in the journal also echoed the uproar against racism and assertions of White supremacy articulated in the massive demonstrations that followed the murder of George Floyd.10,11 From the beginning of the pandemic, our editorial strategy has been to focus on post-COVID-19 reconstruction. Because it takes three to four months from submission to publication of a research paper or analytic essay in AJPH, we could not publish time-sensitive results about the evolution of the pandemic. Alpren et al. described the control of an outbreak of HIV infection among people who inject drugs during 2015 to 2018 in two cities in northeastern Massachusetts, which resulted in a significant decline in new HIV diagnoses, but also observed that opioid use was fueling HIV transmission in Massachusetts and likely in other urban settings.17 Cicero et al. also reported that polysubstance use needed to be taken into consideration to effectively meet the treatment, prevention, and policymaking challenges ofthe opioid epidemic.18 Another significant area of public health in which the pandemic exacerbated problems is workplace health and safety. A meta-analysis by Wang et al., showing that e-cigarettes used as consumer products are not associated with increased smoking cessation but that free e-cigarettes provided as a clinical intervention are, contributes support to the FDA strategy.23 Finally, Norris et al. described the evolution of abortion access in Ohio between 2010 and 2018,24 an issue that has been exacerbated by the imperviousness ofthe previous administration to the anxiety of pregnant women infected by COVID-19.

Objectives. To study the effects of several survey features on response rates in a general population health survey. Methods. In 2012 and 2013, 8000 households in British Columbia, Canada, were randomly allocated to 1 of 7 survey variants, each containing a different combination of survey features. Features compared included administration modes (paper vs online), prepaid incentive ($2 coin vs none), lottery incentive (instant vs end-of-study), questionnaire length (10 minutes vs 30 minutes), and sampling frame (InfoCanada vs Canada Post). Results. The overall response rate across the 7 groups was 27.9% (range = 17.1–43.4). All survey features except the sampling frame were associated with statistically significant differences in response rates. The survey mode elicited the largest effect on the odds of response (odds ratio [OR] = 2.04; 95% confidence interval [CI] = 1.61, 2.59), whereas the sampling frame showed the least effect (OR = 1.14; 95% CI = 0.98, 1.34). The highest response was achieved by mailing a short paper survey with a prepaid incentive. Conclusions. In a mailed general population health survey in Canada, a 40% to 50% response rate can be expected. Questionnaire administration mode, survey length, and type of incentive affect response rates.

Objectives. We conducted 2 studies to determine the impact of text message immunization reminder–recalls in an urban, low-income population. Methods. In 1 study, text message immunization reminders were sent to a random sample of parents (n = 195) whose children aged 11 to 18 years needed either or both meningococcal (MCV4) and tetanus–diphtheria–acellular pertussis (Tdap) immunizations. We compared receipt of MCV4 or Tdap at 4, 12, and 24 weeks with age- and gender-matched controls. In the other study, we compared attendance at a postshortage Haemophilus influenzae B (Hib) immunization recall session between parents who received text message and paper-mailed reminders (n = 87) and those who only received paper-mailed reminders (n = 87). Results. Significantly more adolescents with intervention parents received either or both MCV4 and Tdap at weeks 4 (15.4% vs 4.2%; P < .001), 12 (26.7% vs 13.9%; P < .005), and 24 (36.4% vs 18.1%; P < .001). Significantly more parents who received both Hib reminders attended a recall session compared with parents who only received a mailed reminder (21.8% vs 9.2%; P < .05). After controlling for age, gender, race/ethnicity, insurance status, and language, text messaging was still significantly associated with both studies’ outcomes. Conclusions. Text messaging for reminder–recalls improved immunization coverage in a low-income, urban population.

Objectives. Despite national support for electronic laboratory reporting (ELR), the transition from paper to electronic reporting has been slow both nationally and locally. We assessed the ELR experience of New York City’s surveillance programs to identify barriers to ELR implementation and generalizable lessons about automated electronic notifiable disease surveillance. Methods. We conducted interviews with key staff of the New York City Department of Health and Mental Hygiene to evaluate ELR implementation. A review of paper and ELR disease reports enabled a comparison of the reporting systems. Results. The completeness and timeliness of ELR were similar to, and sometimes better than, paper reporting for certain diseases. Incorporating electronic data into surveillance databases created new problems with data quality, shifted work demands, and required additional skills for data monitoring. ELR improved the handling of high-volume and time-sensitive diseases but did not completely automate reporting for diseases that required complicated assessments by staff. Conclusions. Although ELR streamlines data processing, electronic reporting has its own limitations. A more successful use of ELR can be achieved by understanding its strengths and limitations for different disease types.

Objectives. To determine the association between e-cigarette use and smoking cessation. Methods. We searched PubMed, Web of Science Core Collection, and EMBASE and computed the association of e-cigarette use with quitting cigarettes using random effects meta-analyses. Results. We identified 64 papers (55 observational studies and 9 randomized clinical trials [RCTs]). In observational studies of all adult smokers (odds ratio [OR] = 0.947; 95% confidence interval [CI] = 0.772, 1.160) and smokers motivated to quit smoking (OR = 0.851; 95% CI = 0.684, 1.057), e-cigarette consumer product use was not associated with quitting. Daily e-cigarette use was associated with more quitting (OR = 1.529; 95% CI = 1.158, 2.019) and less-than-daily use was associated with less quitting (OR = 0.514; 95% CI = 0.402, 0.665). The RCTs that compared quitting among smokers who were provided e-cigarettes to smokers with conventional therapy found e-cigarette use was associated with more quitting (relative risk = 1.555; 95% CI = 1.173, 2.061). Conclusions. As consumer products, in observational studies, e-cigarettes were not associated with increased smoking cessation in the adult population. In RCTs, provision of free e-cigarettes as a therapeutic intervention was associated with increased smoking cessation. Public Health Implications. E-cigarettes should not be approved as consumer products but may warrant consideration as a prescription therapy.

WALT WHITMAN (1819–1892), the great American poet, was also a public health activist. We have presented excerpts from several of his notable early articles on water. Whitman began his career as a journalist, writing frequently on public health issues ranging from cholera to bathing to clean air.1 From 1846 to early 1848, he served as editor of the Brooklyn Daily Eagle and used his columns in that paper and others to argue for public health reforms, especially the provision of clean water for Brooklyn, New York, which was by 1850—at a population of nearly 140000 people—one of the largest urban areas in the United States. Whitman, or “Walt,” had long been interested in problems of municipal water supply, but when his younger brother, Thomas Jefferson Whitman, or “Jeff,” became a sanitary engineer, his advocacy became all the more informed.2 At the age of 23 years, Jeff worked under the celebrated engineer James P. Kirkwood on the location and construction of the Brooklyn waterworks.1 The water works were planned by William Jarvis McAlpine, the civil engineer who also designed and built the Albany, New York, waterworks in 1850 and 1851, and the Chicago, Illinois, waterworks from 1851 to 1854. Toward the end of his life, Walt related his enthusiastic support of the Brooklyn waterworks as “a feather in my wings”—an accomplishment of which he was especially proud.2 As he wrote to fellow journalist Charles M. Skinner, “I bent the whole weight of the paper steadily in favor of the McAlpine plan [for the new waterworks], as against a flimsy, cheap and temporary series of works that would have long since broken down, and disgraced the city.”3 The Brooklyn waterworks were completed in 1858. The following years saw the paths and experiences of the Whitman brothers diverge considerably, even while they remained close as brothers. In 1860, Jeff became an assistant engineer in the sewer departments of Brooklyn and New York City. In 1863, while Jeff became chief assistant engineer under Moses Lane of the Consolidated Sewer and Water Departments of Brooklyn, Walt traveled to Washington, DC, in search of their other brother, George, whose name the Whitman family saw listed on a newspaper casualty roster from the battlefield at Fredericksburg, Virginia. After searching for George in nearly 40 Washington hospitals, Walt traveled to Fredericksburg to find George's unit. There, he found George alive and having suffered a superficial facial wound. However, Walt's personal relief quickly turned to horror as he witnessed the human costs of battle. “I notice a heap of amputated feet, legs, arms, hands, &c.,” he wrote in his wartime journal, “a full load for a one-horse cart.”4 Here, Walt believed, the future of US democracy was being amputated and killed. The experience of this tragedy loomed large in his mind as he devoted himself not only to visiting Washington's hospitals and nursing wounded soldiers, but also concerning himself through his writing with the health and well-being of the American public divided by war.

This paper, based on an analysis of cancer articles published in popular periodical literature since the early part of the century, argues that gender has played a key role in medical and popular understandings of cancer. Cancer education, the author finds, has taught women and men different things. Public health materials created with the intention of improving health through education actually send a multiplicity of messages, not all of them helpful. This essay suggests that public health messages targeted by sex are problematic, although perhaps necessary. The paper also contributes to scholarship concerned with the question of how people develop their ideas about risk of disease.

IN THE EARLY TO MIDnineteenth century in Europe and America, thousands of young women died from childbed fever, also known as puerperal fever, a disease rampant in the charity maternity clinics of the time.1 Women were generally affected within the first three days after childbirth. The disease progressed rapidly and caused acute symptoms of severe abdominal pain, fever, and debility. Therapy usually involved bloodletting, but with or without this treatment the disease was often fatal. Perhaps Jane Seymour, the third wife of England's King Henry VIII, was the most famous victim of puerperal fever. She died two weeks after giving birth to Henry's only surviving son, the future Edward VI of England. Two heroes in the fight against puerperal fever were Oliver Wendell Holmes and Ignaz Philipp Semmelweis. If Holmes now stands in Semmelweis's shadow, it is because Holmes's own medical reputation was largely eclipsed by the brilliant success he achieved in the fields of literature, poetry, and popular lectures.2 In the late nineteenth and early twentieth centuries, Holmes's literary and poetic works were reprinted in hundreds of editions by American and British publishers. Even his own profession came to value him more as a professor and poet than as a fearless and outspoken defender of the life and health of childbearing women. In the late nineteenth century, Oliver Wendell Holmes was so popular that his image and lines from his poetry and prose appeared on items such as this calendar, as well as games, postcards, and gift books. Courtesy of Marilyn Barth and the National Library of Medicine, National Institutes of Health, Bethesda, MD. Semmelwei s Defender of Motherhood. Courtesy of the National Library of Medicine, National Institutes of Health, Bethesda, MD. Born into a family whose ancestors had distinguished themselves in both literature and medicine, Holmes attended Harvard University and also studied at the prestigious medical schools of Paris. After two and a half years, he returned to the United States and received his medical degree from Harvard in 1836. He maintained a small medical practice for 12 years but found that his main interests lay in teaching and research. Hearing of the death of a physician one week after performing a postmortem exam on a woman who had died of puerperal fever, Holmes began a thorough investigation and read a paper on “The Contagiousness of Puerperal Fever” before the Boston Society for Medical Improvement in 1843. Because the paper was published in the New England Quarterly Journal of Medicine and Surgery,3 a journal with a very small circulation which ceased publication after only one year, it went largely unnoticed until it was republished in 1855 as a booklet entitled Puerperal Fever, as a Private Pestilence.4 Holmes argued the controversial view that physicians with unwashed hands were responsible for transmitting puerperal fever from patient to patient. Holmes was promptly attacked by the leading Philadelphia obstetrician, Charles D. Meigs, who derided his arguments as the “jejeune and fizzenless dreamings” of a sophomoric writer, and declared that any practitioner who met with epidemic cases of puerperal fever was simply “unlucky.”5 A few years later, Semmelweis took up the struggle in Europe to persuade other physicians of the contagiousness of puerperal fever. Semmelweis completed his MD degree at the University of Vienna in 1844. In 1846, he was appointed assistant to Johannes Klein in the maternity clinic of the Vienna General Hospital. Semmelweis was puzzled to discover that the First Clinic of the Hospital had a much higher maternal mortality rate (10%) than the Second Clinic (less than 4%). The only difference he could find between the two clinics was that the first was used to train medical students whereas the second trained midwives. When his friend and colleague, Professor Jakob Kolletschka, died from septicemia from a finger injury acquired from a postmortem examination on a woman who had died of puerperal fever, Semmelweis concluded that he and his fellow physicians were carrying “cadaverous particles” from the autopsy rooms to the patients they examined in the First Clinic. The midwives, who were not involved in autopsies, had no such contact with corpses or “cadaverous particles.” Semmelweis began to insist that anyone attending autopsies scrub their hands in chloride of lime before entering the maternity wards. The maternal mortality rate immediately fell to that of the Second Clinic.6 Semmelweis soon became the focus of a fierce power struggle within the Vienna medical faculty as his work became the subject of a bitter dispute among European obstetricians. His arguments ran contrary to the disease theories of the time, that infections were due to “miasmas” or “bad air,” or to the balance of humors within a patient's body. In 1861, Semmelweis published Die Atiologie, der Begriff und die Prophylaxis des Kindbettfiebers [The Etiology, Concept, and Prophylaxis of Childbed Fever].7 When his book was either ignored or ridiculed, Semmelweis began to denounce prominent European obstetricians as irresponsible murderers. He became depressed and started drinking; his public behavior became irritating and embarrassing to his professional colleagues and to his family. In 1865 he was deceived into entering an insane asylum and when he tried to escape, he was severely beaten by guards. A gangrenous wound to his hand, probably caused by the beating, led to his untimely death two weeks later. Thanks to the work of Holmes and Semmelweis, the gradual acceptance of sterile procedures, and to a variety of other factors such as improved environmental conditions, better overall obstetrical care, and the availability of antibiotics, puerperal fever has become rare in developed countries. In time, with sufficient organization, political will, and dedication, maternal mortality will be very rare in all parts of the world.

OBJECTIVES. Every year about 38,000 elderly people with diabetes have a lower extremity amputation. Therapeutic shoes are prescribed by clinicians specializing in foot care to prevent foot ulcerations and amputations among at-risk patients with diabetes. Medicare ran a 3-year demonstration of a therapeutic-shoe benefit for beneficiaries with diabetes. Medicare added the benefit nationwide in May 1993. METHODS. This paper describes the benefit and its implementation in the demonstration based on demonstration records, a patient survey, and discussions with clinicians and shoe suppliers before and during the demonstration. RESULTS. During the demonstration, far fewer beneficiaries applied for the therapeutic shoes than were eligible for them. The paper discusses reasons for the low beneficiary application rate and the associated low participation rate among physicians treating patients with diabetes. CONCLUSIONS. The benefit is unlikely to be used any more in the national program than in the demonstration unless physicians are educated in the role therapeutic shoes can play in diabetic foot disease, they prescribe the shoes for their patients, and they increase their patients' awareness of the shoes' value.

Part I of this paper traced the evolution of modern epidemiology in terms of three eras, each with its dominant paradigm, culminating in the present era of chronic disease epidemiology with its paradigm, the black box. This paper sees the close of the present era and foresees a new era of eco-epidemiology in which the deployment of a different paradigm will be crucial. Here a paradigm is advocated for the emergent era. Encompassing many levels of organization--molecular and societal as well as individual--this paradigm, termed Chinese boxes, aims to integrate more than a single level in design, analysis, and interpretation. Such a paradigm could sustain and refine a public health-oriented epidemiology. But preventing a decline of creative epidemiology in this new era will require more than a cogent scientific paradigm. Attention will have to be paid to the social processes that foster a cohesive and humane discipline.

The article discusses the history of the publication "American Journal of Public Health." The American Public Health Association (APHA) was founded in 1872 and began publishing meeting transactions in its annual publication "Public Health Reports and Papers," which later was titled "Public Health Papers and Reports." In 1907 the "American Journal of Public Hygiene," originally published as the "Journal of the Massachusetts Association of Boards of Health," became the laboratory section of the APHA. The article also discusses Burt Ransom Rickards', managing editor of the "American Journal of Public Hygiene," role in the founding of the "American Journal of Public Health."

I NOW WISH TO TURN TO . . . workers in whom certain morbid affections gradually arise from . . . some particular posture of the limbs or unnatural movements of the body called for while they work. Such are the workers who all day long stand or sit, stoop or are bent double; who run or ride or exercise their bodies in all sorts of ways. First to come upon the stage shall be those who stand at their work, such as carpenters when they hew and saw wood, carvers, blacksmiths, masons, and others. . . . Standing, even for a short time, proves so exhausting compared with walking and running, though it be for a long time. It is generally supposed that this is because of the tonic movement of all the antagonist muscles, both extensors and flexors, which have to be continually in action to enable a man to keep standing erect. . . . It follows that whenever occasion offers, we must advise men employed in the standing trades to interrupt when they can that too prolonged posture by sitting or walking about or exercising the body in some way. . . . The maladies that afflict the clerks . . . arise from three causes: First, constant sitting, secondly the incessant movement of the hand and always in the same direction, thirdly the strain on the mind from the effort not to disfigure the books by errors or cause loss to their employers when they add, subtract, or do other sums in arithmetic. . . . Incessant driving of the pen over paper causes intense fatigue of the hand and the whole arm because of the continuous and almost tonic strain on the muscles and tendons, which in course of time results in failure of power in the right hand. . . . Those who sit at their work and are therefore called “chair-workers,” such as cobblers and tailors . . . become bent, hump-backed, and hold their heads down like people looking for something on the ground; this is the effect of their sedentary life and the bent posture of the body as they sit and apply themselves all day to their tasks in the shops where they sew. . . . Since to do their work they are forced to stoop, the outermost vertebral ligaments are kept pulled apart and contract a callosity, so that it becomes impossible for them to return to the natural position. . . . These workers, then, suffer from general ill-health . . . caused by their sedentary life. . . . But it is not so true of many other sedentary workers, potters and weav-ers, for example, who exercise the arms and feet and in fact the whole body; this keeps them in better health because the impurities in the blood are more easily dispersed by such movements. All sedentary workers suffer from lumbago. . . . They should be advised to take physical exercise, at any rate on holidays. Let them make the best use they can of some one day, and so to some extent counteract the harm done by many days of sedentary life. . . . Now there are two kinds of printers; some are almost constantly seated while they select the metal types from their boxes and set up the copy or sort and replace in the boxes types that are no longer needed. . . . Then there are the others whose work is at the press, and they stand all the time; using both hands they smear with ink the type that has been set up, for which they use a kind of tool made of soft leather and stuffed with hairs; one of them with the right hand moves the upper part of the press and presses hard on it, and thus on the instant there appears clearly printed on the paper. . . . They repeat the process again and again till they have made the required number of copies of the whole work. This is certainly a very ingenious device; I wish that the result were only to supply learned men with books and not fishmongers with paper to wrap up their mackerel. The first class of men, the compositors, are sentenced to the sedentary life and hence are exposed to the diseases that ensue therefrom; the second class, the pressmen, have to stand incessantly at work that is very fatiguing, for almost the whole body must be exerted in such a task; hence these workmen inevitably suffer from lassitude and intense fatigue, and when stricken in years are compelled to say farewell to that sort of work. Those who remain seated and work with their hands are threatened with another misfortune from having to keep the eyes continually fixed on those black letters, for they gradually contract weakness of vision, and when their eyes are not strong to begin with they are afflicted with dimness of sight, suffusions (bloodshot eyes) and other diseases of the eyes. . . . Bakers . . . all become bow-legged. . . . Above a thick board or three-legged table they fasten a smooth block of wood of conical shape at the top of a three-legged frame in such a way that it can be rotated, then they place a great mass of dough underneath, drop down the wooden block from above and press with all the strength of their arms and with their knees as well, while someone keeps turning over the dough. Since the articulation of the knees is not very strong, their legs are bowed outwards. For this trouble there is no remedy, for even when they are young and strong they soon become bow-legged and in course of time, lame. . . . In crowded cities, especially sea-ports like Venice . . . one sees a vast number of porters whose work is indispensable for loading and unloading merchandise from the cargo-ships. . . . All porters become in time round-shouldered, because the dorsal vertebral are constantly bent forward and become set in that position. For though they know none of the laws of mechanics, nature has taught them that it is easier to carry weights on the shoulders with the chest hollowed, than with the body erect. . . . I have noticed that at Venice and Ferrara these heavily laden men carry sacks of wheat and other weights, not as ours do on one shoulder, but on the neck and dorsal vertebrae, so that the weight may lie all along the carrier's back; they say that the load tires them less and they feel less pressure than if they carried it on one shoulder. . . . Carpentering is a toilsome business and greatly fatigues the workers, but those who suffer most are the men who with a saw cut up trees into boards. This kind of work is very tiring. . . . Those too who work at the lathe, especially when the wood is box, olive, or turpentine tree or the like, find their task very fatiguing; for they are obliged to put an incessant strain on the hands and arms in order to control the chisel and with it by degrees shave off the right amount according to the design of the work; the right foot is always at work to keep the wood that is to be shaped turning round and round; moreover they must keep the eyes fixed on the work, and from that rotary motion of the wood the eyes contract some injury, since it stimulates the spirits and humors to a vertiginous sort of motion. . . . For carpenters I have no precautions to suggest except this: They should be moderate and not overwork. . . . Nowadays women sit to weave, but in such a posture that they somehow look as though they were standing. This kind of work is certainly very fatiguing, for the whole body is tasked, both hands, arms, feet, and back, so that every part of the body at once shares in the work. . . . Now an occupation so fatiguing naturally has its drawbacks, especially for women, for if pregnant they easily miscarry and expel the fetus prematurely and in consequence incur many ailments later on. It follows that women weavers, I mean those who are engaged wholly in this occupation, ought to be particularly healthy and robust, otherwise they break down from overwork and as they get on in years are compelled to abandon this trade. . . . Therefore in work so taxing moderation would be the best safeguard against these maladies, for men and women alike; for the common maxim “Nothing to excess” is one that I excessively approve. Editors' Note In March 2001, with the support of President George W. Bush, the US Congress voted to undo the nation's landmark ergonomics standard, passed just a few months earlier in November 2000. Congressional votes on repeal were split mainly along party lines, with the votes against the standard running 66 (Republican) to 44 (Democrat) in the Senate and 223 (R) to 206 (D) in the House of Representatives. The repealed Occupational Safety and Health Administration (OSHA) standard addressed one of the longest-ignored occupational threats to American workers. Each year, more than 1.8 million US workers report musculoskeletal disorders such as carpal tunnel syndrome and back injuries; in 600|000 cases, the disorders are serious enough that workers take time off from work, costing industry an estimated $9 billion a year in sick days and decreased productivity. The OSHA standard was supported by public health and labor advocates and was the result of more than 10 years of work and a year of hearings and public comment. It would have required employers to create programs to inform workers about musculoskeletal disorders and their symptoms; to encourage reporting; and, if a serious incident were reported, evaluate the workplace and take action to address the risks. The standard had consistently come under fire from business groups, who claimed it would be too costly to enact. This extract from the writings of Bernardino Ramazzini (1633–1714) reminds us that, however current the battles over OSHA's ergonomic standard may be, these types of occupational hazards were recognized by astute public health and medical observers long ago. Elizabeth Fee, PhD Theodore M. Brown, PhD Contributing Editors

OBJECTIVEs. An earlier paper estimated the per-case and national incidence costs of Alzheimer's disease for 1983. This paper updates the estimates of costs per case to 1991 and presents new national prevalence estimates of the economic and social costs of the disease. METHODS. All data for the cost estimates were taken from published sources or provided by other researchers. RESULTS. At midrange values of the estimated cost and epidemiological parameters, the discounted (at 4%) direct and total costs of Alzheimer's disease were $47,581 and $173,932 per case, respectively. The estimated 1991 national direct and total prevalence costs were $20.6 billion and $67.3 billion, respectively. Assuming conservatively that the prevalence of the disease remains constant, the estimated discounted present values of the direct and total costs of all current and future generations of Alzheimer's patients are $536 billion and $1.75 trillion, respectively. CONCLUSIONS. The $536 billion and $1.75 trillion figures are minimum estimates of the long-term dollar losses to the US economy in 1991 caused by Alzheimer's disease.

There is the expectation that outcomes research and the promulgation of medical practice guidelines will be able to identify and hopefully reduce the amount of unnecessary or inappropriate medical care through a variety of methods, including utilization review. However, past efforts by public and private insurers to deny claims on the basis of formal technology assessments or practice guidelines have frequently been overturned by the courts for multifarious reasons. This paper examines the court's reluctance to accept a variety of technology assessment methods in coverage policy decisions. The paper reviews the options that have been proposed to restrict judicial involvement in the formulation of coverage policy and then proposes a new option that employs a more precise taxonomy of medical practice assessment.

This collection of papers, published in the American Journal of Public Health (Vol. 95, p. S1-S150, 2005) is the product of a symposium on Scientific Evidence and Public Policy convened March 2003 by the Project on Scientific Knowledge and Public Policy (SKAPP) in Coronado, California. In June 1993, the US Supreme Court ordered federal trial judges to become gatekeepers of scientific testimony. Under Daubert and two related rulings, trial judges are now required to evaluate whether any expert testimony is both relevant and reliable. What began as a well-intentioned attempt to improve the quality of evidentiary science has had troubling consequences. The symposium provided a forum for scientists, philosophers and science studies scholars to have a dialog with legal scholars and federal judges about Daubert's philosophical underpinnings and impacts, and on the use (and misuse) of science in the legal and regulatory arenas. The Coronado Conference papers provide an important assessment of Daubert. Science is more subtle and less rigid than Daubert characterizes it. Whether applied in the courts or by regulatory bodies, Daubert's demand for scientific certainty runs counter to the workings of science, as well as to the basic principle that policy decisions should be made with the best evidence currently available.

lu c ea OSHA's Four Inconsistent Carcinogen Policies Background No issue has proven more conten- tious in occupational health policy than the control of chemical carcinogens. The Occupational Safety and Health Admin- istration (OSHA) has focused much of its efforts on cancer risks, both through sub- stance-specific regulations and through broader efforts to establish generic poli- cies and work practices. The 1980 Generic Carcinogen Policy was conceptualized as the centerpiece of OSHA's shift from sub- stance-specific to generic regulations cov- ering hundreds if not thousands of sub- stances. Despite adverse judicial rulings and a generally anti-regulatory political climate, OSHA continued to pursue a ge- neric approach to occupational health hazards during the 1980s, particularly through its 1983 Hazard Communication Standard and 1989 Air Contaminants Standard. The legal and political wran- gling have left deep scars on OSHA's strategy, however. While consistency and comprehensiveness were once the princi- ples underlying OSHA's efforts to control carcinogens, the current collection of pol- icies and regulations is remarkable for the inconsistent and incomplete way in which suspect chemicals are treated. In this paper, we analyze OSHA's four carcinogen strategies, as embodied in the Generic Carcinogen Policy, the sub- stance-specific carcinogen regulations, the Hazard Communication Standard, and the Air Contaminants Standard. Two issues are of particular interest. Given the inherent methodological limitations to epidemiological data on oc- cupational and environmental cancer, a June 1991, Vol. 81, No. 6 an e avv major scientific and policy debate has de- veloped over the appropriate use in hu- man risk assessment of laboratory evi- dence on chemical carcinogenesis in animals. The four OSHA policies exhibit quite different positions on this debate. 0 The choice between direct regula- tion and indirect labor market pressure, and the stringency of those exposure lim- its that are imposed, reflect different atti- tudes toward the appropriate balance of economic costs and health benefits for oc- cupational health regulations. OSHA's four policies reflect dramatically different balancing efforts. We begin with the Generic Carcino- gen Policy, which remains OSHA's for- mal policy on the issue but which has been blocked by administrative stays and never incorporated into risk management pro- grams. The substance-specific cancer standards are then analyzed in terms of their comprehensive treatment of a few public health hazards and neglect of many others. While partially an attempt to pre- empt stronger state and local regulations, the Hazard Communication Standard is in many ways both comprehensive and in- novative, covering a wide range of chem- icals and imposing duties on employers that could potentially lead to substitution of alternative products and processes. Given its current prominence as the cen- terpiece of OSHA's regulatory program, the Air Contaminants Standard receives the greatest emphasis. Containing its own internal inconsistencies, the Air Contam- inants Standard embodies the best and the worst of OSHA's new regulatory philos- ophy and its strategy for controlling chem- ical carcinogens in the workplace. T7e GenericCarcinogen Poly OSHA's Generic Carcinogen Policy1 was a response to two complementary concerns that emerged over the course of the 1970s and came to dominate the agen- cy's agenda. OSHA had devoted a sub- stantial portion of its resources to the reg- ulation of individual carcinogens but had achieved only meagre results. The agency leadership faced growing demand for an accelerated regulatory timetable from Congress, organized labor, and environ- mental groups. Of equal significance, per- haps, was the competition among several federal agencies for leadership in formu- lating governmental policies with respect to chemical carcinogens. Proposed in 1977 and promulgated in 1980, OSHA's Ge- neric Carcinogen Policy embodied a highly protective approach to chemical carcinogenesis. Based on the most con- servative set of assumptions concerning methods of cancer induction and the most stringent set of requirements for exposure controls, the 1980 policy represents the high water mark of governmental enthu- siasm for regulating occupational and en- vironmental carcinogens. OSHA devoted much of its energies during the 1970s to developing standards regulating exposure to occupational car- cinogens, including asbestos2 in 1972, vi- nyl chloride3 and a group of 14 chemicals4 in 1974, coke oven emissions5 in 1976, plus benzene,6 dibromochloropropane (DBCP),7 inorganic arsenic,8 and acry- From the Center for Occupational and Envi- ronmental Health, University of California, Berkeley. Address reprint requests to James C. Robinson, PhD, Center for Occupational and Environmental Health, School of Public Health, University of California, Berkeley, CA 94720. This paper, submitted to the Journal June 20, 1990, was revised and accepted for publication January 30, 1991. George J. Annas, JD, MPH, Chair, Health Law Department, Boston University, Schools of Public Health and Medicine, 80 East Concord Street, Boston, MA 02118, is editor of the Public Health and the Law column. American Journal of Public Health 775

THE LEAD AUTHOR OF THIS paper, Michael S. Gottlieb, was, in 1981, a 33 year-old assistant professor specializing in immunology at the University of California Los Angeles (UCLA) Medical Center. When he asked one of his immunology fellows to look for interesting “teaching cases,” he learned of a young gay man with unexplained fevers, dramatic weight loss, and a severely damaged immune system. His mouth was full of thrush, or candidiasis, which was usually seen in patients with a defect in one particular component of the immune system, the T-lymphocytes. Gottlieb later described a process of reasoning that led him to conclude that that this patient was suffering from some syndrome that had not previously been reported.1 He discussed the unusual case with his clinical immunology postdoctoral fellows and internal medicine residents. Additional blood tests confirmed a marked deficiency of T-lymphocyte numbers and functions. Then a postdoctoral fellow who was using a series of new monoclonal antibodies to identify subclasses of T-lymphocytes was asked to examine a sample of the patient’s blood and found that the T-cells bearing the surface marker CD4, the “helper” cells, were virtually absent. The patient was discharged from hospital without a definite diagnosis but 1 week later was readmitted, this time with fever and pneumonia. The resident physician was concerned about an opportunistic infection in this individual, who was known to have an immune deficiency, and he convinced a pulmonary specialist to perform a bronchoscopy and retrieve a sample of lung tissue for analysis. This procedure is commonly done in immunedeficient patients to identify particular microorganisms, thus allowing for rapid specific diagnosis and treatment. The diagnosis was Pneumocystis carinii, a rare but well-known cause of pneumonia found in some organ transplant patients and children with immune deficiency. The patient was treated and again discharged. Soon thereafter, Gottlieb heard about 2 patients of Joel Weisman. Weisman and his partner were gay physicians with a largely gay practice.2 Both patients had chronic fevers, swollen lymph nodes, diarrhea, and thrush. Gottlieb tested the T-cells of Weisman’s patients and found they had the same abnormality as his original patient. Over the next several months, both were diagnosed by bronchoscopy with Pneumocystis carinii. Both also had the DNA virus cytomegalovirus (CMV). The fourth case came to Gottlieb through a former student, Wayne Shandera, who had become the CDC’s Epidemic Control Officer in Los Angeles. Gottlieb told him that there was a new disease in gay men that seemed to have something to do with CMV and pneumocystis pneumonia and asked Shandera to see what he could find out. Shandera had a report sitting on his desk about a man in Santa Monica who had been diagnosed with pneumocystis pneumonia. Shandera went to see the patient and found that the man was deathly ill. The patient died soon after the visit; on autopsy, CMV was found in his lungs. A fifth case came from a Beverly Hills internist. This patient too had Pneumocystis carinii and CMV. Several of these patients went on to develop Kaposi’s sarcoma, a rare skin cancer sometimes found in older men or immunosuppressed kidney transplant recipients. Gottlieb, an ambitious young man, was excited to think he might have made a significant discovery. He telephoned Arnold Relman, the editor of the New England Journal of Medicine, and declared that he had a story that was “possibly a bigger story than Legionnaire’s disease.”3(p1788) When Gottlieb described his patients suffering from this complicated new malady, Relman advised that, because publication in the New England Journal would take a minimum of three months, Gottlieb should first submit a brief article to the CDC Morbidity and Mortality Weekly Report. This would serve the dual function of alerting public health officials and physicians to the new disease and also stake Gottlieb’s claim to be its “discoverer.” A longer and more detailed account could then be submitted to the New England Journal. Gottlieb followed this good advice and the result was the rather terse announcement reprinted here. It was generally overlooked; few physicians bothered to read the MMWR. A few weeks later, however, when Alvin Friedman-Kien published a description of twenty-six cases of Karposi’s sarcoma in gay men in New York and California, the media began to pay more attention.4 National Public Radio, the Cable News Network, the Associated Press, the New York Times, and the Washington Post all followed with stories. Gottlieb’s article in the New England Journal of Medicine was published a few months later and attracted enormous attention.5 As Gottlieb said later, the publication of this article changed his life. For several years, it was one of the most heavily quoted papers in the medical literature. The story would unfortunately prove to be a great deal more important than Legionnaire’s Disease. In the New England Journal article, Gottlieb and his co-authors described a “potentially transmissible immune deficiency”5(p1425) and suggested that a sexually transmissible agent contracted at different times by the patients was the common factor. Asymptomatic infection with CMV had recently been found to be common among the male homosexual population, and acute CMV infection had been associated with immunologic abnormalities, including reduction in CD4 cells. They therefore hypothesized that a new strain of CMV had emerged in the homosexual population and was causing immune deficiency. They also acknowledged the possibility that CMV was a result rather than a cause of the T-cell deficiency and that some other undetected microorganism, drug, or toxin might be making these patients susceptible to opportunistic organisms, including CMV. In an editorial accompanying the publication of the article, DT Durack asserted that CMV infection was more likely to be an opportunistic consequence of immune deficiency than its cause.6 In the early 1980s, Gottlieb treated a growing number of patients with AIDS and continued his clinical research at UCLA, publishing over 50 papers on various aspects of HIV infection and treatment. He obtained one of the earliest National Institutes of Health grants for AIDS research, served on many AIDS-related boards, and became physician to the stars: Rock Hudson, perhaps the most famous of all people with AIDS, was his patient. Gottlieb was also one of the few scientists who were willing to talk openly to reporters in the early years of the epidemic. His colleagues and superiors let it be known that his frequent appearances in the media were unbecoming to an academic.7 Part of the problem, said Gottlieb, was that the UCLA Medical Center aspired to develop cardiac and liver transplant programs, and the physicians feared that if the hospital became too well known for AIDS, transplant patients might stay away.2(p98) They also foresaw that there would ultimately be a lot of AIDS patients without good health care coverage. AIDS loomed as a threat to the well-being of the hospital and Gottlieb, so publicly and professionally identified with the disease, was becoming a nuisance. Despite or perhaps because of his fame, Gottlieb was denied tenure at UCLA and went into private practice in 1987. In 1985, Gottlieb and Mathilde Krim became the Founding Chairmen of the American Foundation for AIDS Research (amfAR), with Elizabeth Taylor as its Founding National Chairman. AmfAR would make a crucial contribution to AIDS research by supporting innovative projects; it would also help craft AIDS legislation, accelerate research on new treatments, and argue for rapid access to experimental HIV/AIDS drugs.

OBJECTIVES: This paper explores several critical assumptions and methodological issues arising in cost-effectiveness analyses of genetic screening strategies in the reproductive setting. METHODS: Seven issues that arose in the development of a decision analysis of alternative strategies for cystic fibrosis carrier screening are discussed. Each of these issues required a choice in technique. RESULTS: The presentations of these analyses frequently mask underlying assumptions and methodological choices. Often there is no best choice. In the case of genetic screening in the reproductive setting, these underlying issues often touch on deeply felt human values. CONCLUSIONS: Space limitations for published papers often preclude explaining such choices in detail; yet these decisions determine the way the results should be interpreted. Those who develop these analyses need to make sure that the implications of important assumptions are understood by the clinicians who will use them. At the same time, clinicians need to enhance their understanding of what these models truly mean and how they address underlying clinical, ethical, and economic issues.

It is well recognized that the tradition that now calls itself community-oriented primary care (COPC) traces its roots to the work of Sidney and Emily Kark and their colleagues, who set up an innovative socially oriented clinic and public health outreach program in a rural area of Natal, South Africa, in the early1940s.1 They first organized primary health care services and then, when this approach proved inadequate to address the multiple health and disease problems of the community, implemented a strategy of community assessment. In a community assessment or diagnosis, health practitioners viewed the entire community as the “patient,” and they often found that social, cultural, economic, and environmental determinants were more important than particular disease-causing agents.2 Sidney Kark, for example, traced the high prevalence of syphilis to the system of migrant labor. Because families were required to live in small reservations in the rural Native Territories, men were forced to travel into towns to seek work, returning to their homes only for visits. This pattern of segregated housing and labor broke up families, led to the proliferation of prostitution in the towns, and exposed both urban and rural dwellers to the transmission of venereal diseases. At Pholela, the Karks initially selected a defined community of some 130 families who were visited by health workers and intensively studied, surveyed, educated, counseled, and assisted. This defined community was gradually expanded and eventually grew to some 10 000 persons. Interdisciplinary teams of doctors, nurses, and health educators worked in and with the community to address health problems and improve sanitation and nutrition. As a response to widespread malnutrition, for example, community members were encouraged to grow vegetable gardens and thus to enrich their diets with a wide range of fresh fruit and vegetables. These highly successful experiments in social medicine and community development declined in the 1950s because of political opposition from provincial authorities, the resistance of large sections of the medical profession, and the rise to power of the National Party and its apartheid regime.3 The Karks and many of their colleagues left South Africa over a 10-year period, settling in the United States, Israel, and other countries. Given these historical roots, it is especially interesting that in the early 1990s, around the time of Sidney Kark’s 80th birthday, Derek Yach and Stephen Tollman traced Kark’s own roots farther back, indeed back another century, to the 1840s, Europe’s “decade of revolution,” and especially to 2 of the leading figures of that decade: South Africans in the 1940s were influenced not only by the results of their own empirical studies but also by earlier work from the 19th century, such as that of Friedrich Engels and Rudolf Virchow. Engels’ work, published in1845, showed that mortality in England was inversely related to social class, not only for entire cities, but also within geographic districts of cities. . . . Virchow developed a broad theory of multifactorial etiology. He emphasized that various material deprivations interacted to produce disease in the individual and transmit it throughout the community. . . . Virchow’s policy recommendations included a series of profound economic, political, and social changes such as increased employment, better wages, local autonomy in government, agricultural cooperatives, and a more progressive tax structure. His medical solutions, however, were rather limited.4 It is curious that in these paragraphs Yach and Tollman express a certain ambivalence about the heritage of social medicine ideas from the revolutionary context of the 1840s. They praise Engels for showing that mortality was related to class or socioeconomic status but omit mention of his broader political analysis and agenda; they likewise praise Virchow for his “multifactorial etiology” but seem to criticize him for having only limited medical solutions. It is probably not accidental that in the background lay several major presentations of the ideas of community-oriented primary care elaborated in the 1980s, which mediated in various ways between an earlier radical tradition and the economically and politically conservative tenor of the times. The Institute of Medicine created a Committee on Community Oriented Primary Care, chaired by Joyce Lashof, and sponsored a conference in 1982, organized by Fitzhugh Mullan, at which Sidney Kark and H. Jack Geiger presented the lead papers.5 A second Institute of Medicine Committee on Community Oriented Primary Care then attempted to produce an “operational definition” and “operational model” of COPC and to assemble a database describing the operation, costs, and impact of COPC initiatives. This second committee tried to define COPC to fit within the models of health services research, costeffectiveness analysis, and outcomes measurement. Its model of community-oriented primary care prescribed a 4-step process: (1) definition of a practice community, (2) identification of a health problem, (3) intervention to improve the health problem, and (4) evaluation of the intervention to modify and improve its effect on health.6 This reconstituted version of COPC removed “community development” from the list of “essential features” of COPC and emphasized rigorous, stepwise, and quantitative methods for measuring the efficacy of professional interventions. (Four members of the committee protested the omission of community participation as a key feature of the model.) If we go back to Kark’s early papers on Pholela, it is evident that in his formative years he was very aware of, and explicitly sympathetic to, the much broader perspective of Virchow and Engels. His papers begin with graphic descriptions of the social conditions of the people living in the Native Territories, the system of forced migrant labor, the denudation and devastation of the land, and the extensive and severe malnutrition that afflicted the population.7 He notes that medical services per se did not, and could not, prevent or modify the basic causes of ill health. While hundreds were being treated, thousands more were developing similar diseases. Clinical services had to be brought within a larger social framework before they could make their best contribution to national health, and health practitioners had to work with agricultural, housing, and sanitary personnel as well as with community members if they were to begin to address the real causes of morbidity and mortality. In a 1945 essay on “the practice of social medicine,”8 Sidney and Emily Kark generalized further. Scientific and technical advances during the 19th century succeeded in improving the health of populations only because “[t]he French Revolution of 1789–94 introduced an era of social change characterized by revolutions of one kind or another. This revolutionary era required a revolutionary philosophy, and the leading thinkers of the age were born into an environment which no longer accepted the order of things as being static and ever-lasting.”8 A passage the Karks seemed to have in mind was this famous formulation by Rudolf Virchow, in his epochal 1848 “Report on the Typhus Epidemic in Upper Silesia”: Medicine has imperceptibly led us into the social field and placed us in a position of confronting directly the great problems of our time. Let it be well understood, it is no longer a question of treating one typhus patient or another by drugs or by the regulation of food, housing and clothing. Our task now consists in the culture [socioeconomic condition] of 1½ millions of our fellow citizens who are at the lowest level of moral and physical degradation. With 1½ million people, palliatives will no longer do. If we wish to take remedial action, we must be radical. . . . If we wish to intervene in Upper Silesia, we must begin to promote the advancement of the entire population, and to stimulate a common general effort. . . . The people must acquire what they need by their own efforts.9 This political vision was very much part of the Karks’ original Pholela model, and H. Jack Geiger carried it forward when he translated that model to the United States during America’s “war on poverty” in the 1960s.10 It has also come back in recent years, especially nurtured by health activists who want to jettison a prescriptive stepwise COPC model in favor of a more fluid and dynamic understanding that emphasizes community engagement and embraces sociopolitical objectives.11–13 It may thus be helpful to remember the deep roots and ultimate inspiration of the Karks’ original model of COPC. Stepwise progress and evaluative rigor are fine things, but we should not focus only on technical issues. More precious are the moral engagement and dedication to social justice that started it all and that will be the sustaining energy of innovative programs in the future.

Field Epidemiology Training Programs (FETPs) and Public Health Schools Without Walls use the “learning while doing” approach to build public health's international capacity.1–9 Under the auspices of the World Health Organization (WHO) and the late Charles Merieux, these programs in 1997 established Training Programs in Epidemiology and Public Health Interventions Network (TEPHINET). The network's mission is to strengthen international public health capacity through initiating, supporting, and networking field-based training programs that enhance competencies in applied epidemiology and public health interventions. Since its inception, TEPHINET has linked professionals to WHO epidemic response and polio eradication teams and has organized “train-the-trainers” workshops and the first global TEPHINET conference, held in Ottawa in April 2000 and hosted by Canada's FETP. This conference, attended by 187 participants from 30 countries, featured 93 trainee papers. Five regional conferences were held in 2001. There are now 30 programs participating in TEPHINET, with 1317 graduates and 428 current fellows, excluding those of the oldest TEPHINET program, the Centers for Disease Control and Prevention's Epidemic Intelligence Service. TEPHINET programs target midcareer professionals working for public health agencies; 46.7% of participants are women, 64% are medical doctors, and 20.3% hold postgraduate degrees in public health. There is a growing interest among ministries of health in establishing new TEPHINET programs. These programs are becoming increasingly recognized as catalysts for strengthening the scientific basis of policy-making through the continuous examination of data available from surveillance systems; their systematic field investigations provide opportunities for training and enable ministries of health to better respond to public health problems. Table 1 ▶ shows the range of problems faced in countries served by TEPHINET programs and the methods used to address them. The vast majority of these problems involve communicable diseases (70.5%), and almost half of the projects use the method of outbreak investigation. By responding to pressing public health problems through field projects, the programs usually provide services to the poorest of the poor. TABLE 1 —Public Health Problem Topics and Methods Reported in Trainee Papers Submitted for Consideration at Scientific Conferences: TEPHINET Programs, 1995–2000 The programs result in improvements in surveillance, disease prevention, and health promotion programs. Consider the following examples. The Mexican and Peruvian programs were central to the response to cholera in the 1990s, which resulted in a 93% decrease in incidence and a remarkably low case-fatality rate (0.7.%) through improved surveillance case management, health education, and sanitation. Systematic studies of nosocomial transmission of blood-borne pathogens (Plasmodium falciparum, Klebsiella pneumoniae) in Saudi Arabia in the 1990s resulted in better infection control practices for preventing catheter-related infections and extrinsic contamination of infusates and led to nationwide recognition of the usefulness of public health surveillance. The Thailand FETP contributed to the establishment of surveillance systems early in the HIV epidemic, which proved critical to characterizing the epidemic and to developing and evaluating interventions. These interventions, in turn, have resulted in a decreasing incidence of HIV since 1994 through increased condom use and through lower rates of sexual intercourse with commercial sex workers among young men. TEPHINET aims to increase its participation in international epidemic and disaster response teams and to collaborate with its partners to train field epidemiologists, which are currently available to only 30% of the world's population. The TEPHINET second global conference, scheduled for June 2–6, 2002 in Madrid, will be hosted by Spain's FETP.

There is the expectation that outcomes research and the promulgation of medical practice guidelines will be able to identify and hopefully reduce the amount of unnecessary or inappropriate medical care through a variety of methods, including utilization review. However, past efforts by public and private insurers to deny claims on the basis of formal technology assessments or practice guidelines have frequently been overturned by the courts for multifarious reasons. This paper examines the court's reluctance to accept a variety of technology assessment methods in coverage policy decisions. The paper reviews the options that have been proposed to restrict judicial involvement in the formulation of coverage policy and then proposes a new option that employs a more precise taxonomy of medical practice assessment.