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Intermittently, the concept of herd immunity has been a potent, if sometimes ambiguous and controversial, means of framing the global response to the COVID-19 pandemic and envisaging its end. Realizing the full meaning of human herd immunity requires further attention to its connections after World War I with British social theory. Distracted by “obvious” yet unsubstantiated correspondences with veterinary research, historians of the concept have not engaged with the more proximate influence of discussions of social psychology and group dynamics on postwar epidemiology. Understanding the openness of early 20th century epidemiology to social thought deepens our appreciation of the significance of herd or population immunity, as well as suggests new avenues for exchange between public health and contemporary social sciences. (Am J Public Health. 2022;112(10):1465–1470. https://doi.org/10.2105/AJPH.2022.306931 )

In response to rapidly changing societal conditions stemming from the COVID-19 pandemic, we summarize data sources with potential to produce timely and spatially granular measures of physical, economic, and social conditions relevant to public health surveillance, and we briefly describe emerging analytic methods to improve small-area estimation. To inform this article, we reviewed published systematic review articles set in the United States from 2015 to 2020 and conducted unstructured interviews with senior content experts in public heath practice, academia, and industry. We identified a modest number of data sources with high potential for generating timely and spatially granular measures of physical, economic, and social determinants of health. We also summarized modeling and machine-learning techniques useful to support development of time-sensitive surveillance measures that may be critical for responding to future major events such as the COVID-19 pandemic. (Am J Public Health. 2022;112(10):1436–1445. https://doi.org/10.2105/AJPH.2022.306917 )

I reexamine the notion of public health after reviewing critiques of the prevalent individualistic conception of health. I argue that public health should mean not only the health of the public but also health in the public and by the public, and I expound on the social contingency of health and highlight the importance of the interpersonal dimensions of health conditions and health promotion efforts. Promoting public health requires activating health-enhancing communicative behaviors (such as interpersonal advocacy and mutual responsibility taking) in addition to individual behavioral change. To facilitate such communicative behaviors, it is imperative to first construct a new discursive environment in which to think and talk about health in a language of interdependence and collective efforts.

Growing consensus indicates that progress in tuberculosis control in the low- and middle-income world will require not only investment in strengthening tuberculosis control programs, diagnostics, and treatment but also action on the social determinants of tuberculosis. However, practical ideas for action are scarcer than is notional support for this idea. We developed a framework based on the recent World Health Organization Commission on Social Determinants of Health and on current understanding of the social determinants of tuberculosis. Interventions from outside the health sector—specifically, in social protection and urban planning—have the potential to strengthen tuberculosis control.

A community-based cluster randomized control trial in a medium-sized municipality in Tanzania was designed to increase local competence to control HIV/AIDS through actions initiated by children and adolescents aged 10 to 14 years. Representative groups from the 15 treatment communities reached mutual understanding about their objectives as health agents, prioritized their actions, and skillfully applied community drama (“skits”) to impart knowledge about the social realities and the microbiology of HIV/AIDS. In independently conducted surveys of neighborhood residents, differences were found between adults who did and did not witness the skits in their beliefs about the efficacy of children as HIV/AIDS primary change agents.

Using the concept of vulnerable populations, we examine how disparities in health may be exacerbated by population-approach interventions. We show, from an etiologic perspective, how life-course epidemiology, the concentration of risk factors, and the concept of fundamental causes of diseases may explain the differential capacity, throughout the risk-exposure distribution, to transform resources provided through population-approach interventions into health. From an intervention perspective, we argue that population-approach interventions may be compromised by inconsistencies between the social and cultural assumptions of public health practitioners and targeted groups. We propose some intervention principles to mitigate the health disparities associated with population-approach interventions.

Causal thinking in public health, and especially in the growing literature on social determinants of health, routinely employs the terminology of proximal (or downstream) and distal (or upstream). I argue that the use of these terms is problematic and adversely affects public health research, practice, and causal accountability. At issue are distortions created by conflating measures of space, time, level, and causal strength. To make this case, I draw on an ecosocial perspective to show how public health got caught in the middle of the problematic proximal–distal divide—surprisingly embraced by both biomedical and social determinist frameworks—and propose replacing the terms proximal and distal with explicit language about levels, pathways, and power.

THE ENTRANCE OF THE psychiatrist into the social field has been a very natural and logical one, growing out of what was originally an interest, even more, a responsibility that was distinctly his in the prevention of mental and nervous disease. When he started upon this quest, he had no preconceived notions in regard to social problems. He was more likely than not, not to be well informed about them and he had little or no suspicion that they concerned him in any way, except as a citizen. He assumed, as do most good citizens, that the jurist, the educator, the social worker, the parent, knew what they were doing and were doing it as well as could be expected of fallible human nature. He desired only to do his job as well as others were doing theirs. Innocent, therefore, of any design upon the professional prerogative of others, almost naive as it would seem now, he undertook to investigate the possibilities of preventing nervous and mental disease. His interest was primarily medical, social merely in so far as mental and nervous disease itself constituted a major social problem. That nervous and mental disease is a major social problem he was convinced. There are in the United States some 200 public hospitals for those ill of mental disease (insane). . . . There are admitted to these hospitals each year 70 000 new patients. . . . The question the psychiatrist had to ask himself was: Where are the 70 000 people who by this time next year will have found each his bed in some hospital for mental diseases? . . . [S]ome-where within the United States were 700 000 persons going daily about their work, in the homes, in the schools, in the universities, in the offices and factories, all of whom were definitely ticketed for the state hospital for mental disease by the time ten years had passed. Where are these individuals now and how are they to be found, were the questions the psychiatrist put to himself. Knowing that, contrary to popular conception, mental disease seldom appears suddenly, but develops over a considerable period of time, he knew that many of these individuals must already be exhibiting signs and symptoms of their condition, and, their condition not being understood, must be meeting with serious difficulties in their social adjustments. Thus stimulated, the psychiatrist began to look about a bit outside his hospital, first, on the search for individuals who might be on their way to him, and second, curious as to how many who might in a sense be said to belong to him as “patients” were now in the hands of others as “clients” or “prisoners.” . . . The data certainly indicate that the problem of delinquency is not to be solved by such simple-minded, naive methods as “hard-boiled,” thundering justice, with its severe penalties, on the one hand, or by confidence, love, and good will, on the other; that there may be a place for “punishment” in the solution of the problem and will always be a place for good will, but that both must be intelligent and know what they are about; that is not sufficient for a judge to be convinced merely of the guilt of an individual, but equally important for him to know—if through the treatment he is about to prescribe by his sentence, any benefit is to come—what kind of individual it is with whom he has to deal. . . . To be convinced that a man is a thief is not enough to warrant, even to the most learned judge, to prescribe what shall be done with the man in order that he may cease being a thief. The entrance of the psychiatrist into the field of social investigation came at an opportune time. There was already stirring, in the field of education, social work, criminal jurisprudence, domestic relations, industry, the church, dissatisfaction with results and methods. The psychiatrist has since considerably augmented this dissatisfaction, but it existed before; and from the beginning, and increasingly so, the contribution that the psychiatrist might possibly make has been seen, and he has been urged to carry on his studies in these various fields and to give such assistance to other professional groups as he could. . . . As the psychiatrist left the institution, whether it was a hospital for mental disease, a school for the feebleminded, or a prison, the further he processed into the community, the more he began to see new material, to be challenged by problems he had never been called upon to face before, to be confronted by questions to which there were no ready-made answers. . . . He was no longer dealing with purely psychiatric problems, but with psychiatric problems inextricably mixed up with other problems. The study of a cross section of the life of an individual at any given time does not reveal the reasons for his conduct or indicate how this conduct may be changed. . . . Only by a study of this entire history, of the various factors and forces that have entered in to make it up—a longitudinal study of the life of the individual, if you will—will give us the facts and clues that will aid us in understanding the conduct of the individual at the present moment and indicate the forces that may be brought into play to alter that conduct. . . . Aid at this point came from Austria. . . . As psychoanalysis, it made little headway but what did immeasurably affect psychiatry in the United States was the psychoanalytic point of view. . . . Tracing back the history of our cases as they came to the hospitals for mental disease, in the process of gathering data that might help us in the prevention of mental disease, we found, of course, that these illnesses rarely developed suddenly, but that they had been developing over a long period of time, and reached into childhood, where in many instances the unhealthy development was sufficiently marked to have attracted the attention of a trained person had one been about. . . . What actually we had to deal with, whether it was in the field of functional nervous and mental disease, delinquency, dependency, industrial unrest, was social maladjustment, due to faulty emotional development, which had its roots in childhood. We are substituting in the field of human behavior inductive for deductive methods. The bitterest battles in all history have been fought here and there will have been none more bitter than the one that eventually will be fought out in the field of human behavior. . . . One may observe bacteria, one may even dissect the once sacred human body, but one may not so irreverently question, study, dissect such things as character, personality, “mother love,” “hate of wickedness,” “desire to save others,” honesty, sense of duty, charity, “loving-kindedness,” the will to do right, or the perverse will to do wrong. . . . These elements are already being scrutinized and will be as objectively studied as any bacterium or fossil bone. Only as one sits in one’s comfortable armchair and “thinks,” can one be sure that one “understands” the problem of delinquency and can formulate a simple plan for its control. As one stops “thinking,” so to speak, and turns to examining with greater and greater care the delinquent material itself, the more one sees how inextricably mixed the problem is with life itself and all its forces, and, particularly, with the artificialities that man has built into life and into his social structure. . . . Delinquency . . . is but a single aspect of a larger problem having many aspects and we are concerned here with methods of meeting in so far as possible the total situation. A program can be stated that is simple in words, but that offers difficulties in its administration—psychiatric facilities, or facilities for the understanding and guidance of the emotional development of the child at all strategic points in life as the child and as an adolescent. These strategic points are the home and the school. In America the home can best be reached, in the largest number of cases, through the school. The school, therefore, becomes the natural center for such work, and by school one does not mean schools for children of any particular age, but all schools, beginning with the kindergarten . . . through the so-called grade schools, . . . the high school, . . . and work in the colleges and universities. Children, of course, reach the limits of their adjustability and begin to show signs of their distress and incipient failure at different ages. Our desire is to be prepared to meet these early situations as soon as they arise, in their yet simple form, and not to have to wait until serious disorganization or much badly directed organization has taken place, thus complicating the situation, before we are able to interfere. All of this is good. But there is yet something else. Teaching this mother how better to manage her children, or this group of mothers, teaching this father how better to gain the confidence of his son, or this group of fathers, giving lectures and courses of instruction now to this and now to that group of teachers—all of these things that we have to do in our everyday work and all useful—will no more change the fundamental situation than will the remodeling of this law or the amending of that in the case of the law. Into all social relations and the forces that hold them together—ethics, morals, religion—must come the same process mentioned above and eventually the same recasting that will give them the reality they do not now have. Figure 1 Frankwood E. Williams, MD, PhD(Hon), AB

The diabetes and obesity epidemics are closely intertwined. International randomized controlled trials demonstrate that, in high-risk individuals, type 2 diabetes can be prevented or at least delayed through lifestyle modification and, to a lesser degree, medication. We explored the relative roles of science, surgery, service delivery, and social policy in preventing diabetes. Although it is clear that there is a role for all, diabetes is a complex problem that demands commitment across a range of government and nongovernment agencies to be effectively controlled. Accordingly, we argue that social policy is the key to achieving and sustaining social and physical environments required to achieve widespread reductions in both the incidence and prevalence of diabetes.

South Africa was the third largest exporter of asbestos in the world for more than a century. As a consequence of particularly exploitative social conditions, former workers and residents of mining regions suffered—and continue to suffer—from a serious yet still largely undocumented burden of asbestos-related disease. This epidemic has been invisible both internationally and inside South Africa. We examined the work environment, labor policies, and occupational-health framework of the asbestos industry in South Africa during the 20th century. In a changing local context where the majority of workers were increasingly disenfranchised, unorganized, excluded from skilled work, and predominantly rural, mining operations of the asbestos industry not only exposed workers to high levels of asbestos but also contaminated the environment extensively.

Poor housing conditions are associated with a wide range of health conditions, including respiratory infections, asthma, lead poisoning, injuries, and mental health. Addressing housing issues offers public health practitioners an opportunity to address an important social determinant of health. Public health has long been involved in housing issues. In the 19th century, health officials targeted poor sanitation, crowding, and inadequate ventilation to reduce infectious diseases as well as fire hazards to decrease injuries. Today, public health departments can employ multiple strategies to improve housing, such as developing and enforcing housing guidelines and codes, implementing “Healthy Homes” programs to improve indoor environmental quality, assessing housing conditions, and advocating for healthy, affordable housing. Now is the time for public health to create healthier homes by confronting substandard housing.

The human right to adequate housing is enshrined in international law. The right to adequate housing can be traced to the Universal Declaration of Human Rights, which was unanimously adopted by the world community in 1948. Since that time, the right to adequate housing has been reaffirmed on numerous occasions and further defined and elaborated. A key component of this right is habitability of housing, which should comply with health and safety standards. Therefore, the right to adequate housing provides an additional tool for advocates and others interested in promoting healthful housing and living conditions and thereby protecting individual and community health.

Overcrowding and poor-quality housing have a direct relationship to poor mental health, developmental delay, heart disease, and even short stature.

The wide spectrum of damage to the health of children from environmental lead (Pb) is a matter of global concern. The neurotoxicity of long-term low-level exposure to lead has a special relevance in children.1,2 Although the consumption of paint chips or proximity to a lead-emitting smelter has been associated with PbB (blood lead) levels > 40 μg/dL, these 2 factors are not considered contributors to moderately elevated levels (> 10 μg/dL). Therefore, activities that contribute to lower levels of Pb exposure should be identified. The aim of this pilot study was to establish the social variables predictive of higher lead levels in young Egyptian children.

The article profiles physician and pathology professor Alice Hamilton, referred to as the mother of U.S. occupational medicine. Hamilton participated in the settlement movement of Jane Addams. Her article summarizing evidence for lead poisoning in 1914 acted as a call to action for occupational health.

Objectives. We examined the influence of neighborhood environment on the weight status of adults 55 years and older. Methods. We conducted a 2-level logistic regression analysis of data from the 2002 wave of the Health and Retirement Study. We included 8 neighborhood scales: economic advantage, economic disadvantage, air pollution, crime and segregation, street connectivity, density, immigrant concentration, and residential stability. Results. When we controlled for individual- and family-level confounders, living in a neighborhood with a high level of economic advantage was associated with a lower likelihood of being obese for both men (odds ratio [OR] = 0.86; 95% confidence interval [CI] = 0.80, 0.94) and women (OR = 0.83; 95% CI = 0.77, 0.89). Men living in areas with a high concentration of immigrants and women living in areas of high residential stability were more likely to be obese. Women living in areas of high street connectivity were less likely to be overweight or obese. Conclusions. The mechanisms by which neighborhood environment and weight status are linked in later life differ by gender, with economic and social environment aspects being important for men and built environment aspects being salient for women.

ALTHOUGH FRANKFORD HAS identified important problems in prevention and positive youth development, there are at least 2 concerns about the type of positive youth development framework proposed. First, a broad analysis of youth development provides only a starting point for understanding the etiology and course of adolescent problem behaviors and the development of effective interventions. Second, a focus on positive youth development may not provide the basis for a truly public health approach because it may be tied to strategies that “fix” or “inoculate” individuals through participation in inter-and intrapersonal prevention programs, rather than promote strategies to strengthen the broader social environment. The positive youth development model proposed by Frankford is grounded in 2 sets of ideas that have influenced much of the contemporary research and practice in health education, namely risk and protective factor theory and the tripartite classification of intervention programs (i.e., universal, selective, and indicated). As Frankford notes, the basic premise of risk and protective factor theory is that the greater the number of risk factors experienced by a young person, the greater the probability that he or she will experience 1 or more of an array of behavioral, emotional, and mental health problems such as drug use, violence, and school failure. It is further argued that this risk can be off-set or mitigated by the presence of protective factors such as attachment to prosocial others and personal competency. At a very general level, the basic premise of the youth development model is almost certainly true—the backgrounds of children and adolescents who develop behavioral, emotional, and mental health problems are probably more similar to one another than they are to those who reach adulthood unscathed. They are also individuals with more negative experiences that threaten social and emotional competence, self-efficacy, and other personal traits. Thus, from one perspective, child and adolescent problem behaviors can be considered the result of some broad common developmental pathway. However, when one focuses attention on the experiences that place youth at risk, the picture becomes more complex. For example, research suggests that adolescent problem behaviors cluster into more than a single factor, that the associations between problems and behaviors are unstable over time, and that the predictors of problem behaviors differ according to socio-demographic characteristics, such as gender, and from one point in time to another.1–3 Indeed, even if one focuses on a single health or behavioral problem (e.g., substance use and abuse or delinquency), the evidence shows that there are different risk factors associated with different types of the problem.4–6 Such research suggests the existence of a number of at-risk subtypes within any one of the adolescent health and behavioral problems of concern to public health, based on factors such as etiology, duration, and co-occurrence with other types of problems. This has important implications for the development of preventive interventions. Specifically, if there are distinct subtypes within the broad category of adolescent problem behaviors with distinct developmental paths, one would expect generic interventions such as those delivered through school-based curricula to work with some individuals but not others and with some problem behaviors but not others. Indeed, one might expect some interventions to have a detrimental effect with some subgroups of individuals, as indeed seems to be the case with high-risk youth in poorly structured group settings.7,8 Beyond the issue of adolescent subgroups is the idea that there exists a number of empirically supported positive youth development programs grounded in risk and protective factor models. This big picture of effectiveness is presented in the recent review of positive youth development programs by Catalano et al.9 cited by Frankford. This work describes 15 broad objectives considered relevant to the issue of positive youth development, such as promoting bonding and social competence and fostering self-efficacy and resilience. It then goes on to identify programs that target 1 or more of these objectives and purport to have had a positive effect in the form of reduction or prevention of some type of problem behavior. For example, evaluations of Catalano and colleagues’ Seattle Social Development Project revealed some positive outcomes (e.g., increased attachment to school) attributed to the objectives of positive youth development (e.g., bonding). These limited positive outcomes are used to affirm the benefits of a positive youth development approach. The difficulty with using scattered positive effects from a wide range of prevention program evaluations to support a general theory of positive youth development is that it gives the appearance that these interventions have a potentially broad reach. However, when one focuses on the specific evidence presented in the evaluations of these programs one finds that they often do not show effects on the behaviors that they were designed to influence. This weakens the argument for some generalized effect of these programs upon a successful transition to adulthood.10–12 Although the use of isolated statistically significant results to designate programs as “best practice” in relation to a specific outcome (e.g., drug use) is in itself a problem,11 it is even more questionable to use such evidence to argue that they provide some form of generalized developmental panacea. Finally, although Frankford notes the importance of changing the broader social environment, the model she presents is grounded in the delivery of services and intervention programs through schools and primary health care settings. The major reviews of positive youth development interventions cited9,13 also focused on inter- and intrapersonal intervention programs typically delivered in schools. Thus, there is little focus at the population level, and one might question the extent to which positive youth development models provide a basis for a genuine public health approach. Indeed, with a focus on individual-level risk and protective factors and interpersonal interventions, it is not clear how this model moves beyond much previous public health practice that has ultimately yielded disappointing results.14 As a recent description of the tobacco industry’s promotion of a well-known school-based positive youth development program illustrates, such a focus may actually draw attention and resources away from environmental and community-based strategies.15

OBJECTIVES. This study examined long-term trends and differences in infant mortality in the United States from 1950 through 1991 according to race and ethnicity, education, family income, and cause of death. Forecasts are made through the year 2010. METHODS. Log-linear regression models were applied to data from the National Vital Statistics System, National Linked Birth and Infant Death files, the National Maternal and Infant Health Survey, the National Natality Survey, and the National Infant Mortality Survey to model and forecast infant mortality. RESULTS. Dramatic declines in the US infant mortality rate have occurred in the past 4 decades, largely as a result of declines in mortality from pneumonia and influenza, respiratory distress syndrome, prematurity and low birthweight, congenital anomalies, and accidents. Despite the overall reductions, however, substantial racial/ethnic, educational, and income differences in infant mortality still exist. CONCLUSIONS. The long-term downward trend in US infant mortality has not benefited Blacks and Whites equally. The Black/White disparity in infant mortality has not only persisted but increased over time and is not expected to diminish in the near future. Educational inequalities have also widened, and racial disparities have generally increased across all educational levels.

Friedrich Engels was born on November 28, 1820, in Barmen, Germany, into a wealthy family with deep roots in the yarn and cloth industry. His father owned a textile factory in Barmen and was a partner in a cottonspinning factory in Manchester, England. At the age of 17, under pressure from his father, Friedrich began to acquire business experience. But as a spirited and precocious young man, he also published poetry, learned languages fluently, engaged in contemporary philosophical debates, and displayed a marked talent for journalism. He was soon leading a double life as a businessman by day, and increasingly, a radical at night.1 Affiliating with left-wing intellectuals, he began a career as a political journalist under the pseudonym Friedrich Oswald. Among his more impressive early writings were his Letters From Wuppertal (1839), an eyewitness account of the evils of early industrialization and an attack on provincial bourgeois hypocrisy in the Rhineland district where he had grown up. In October 1842, Engels moved to Manchester to work in the family business and to continue his career as a radical journalist. He contributed articles to various European publications, including Outlines of a Critique of Political Economy (1844) to an annual publication coedited in Paris by Karl Marx. Marx was deeply impressed by Engels’ work, terming it a “brilliant sketch on the criticism of the economic categories”; the 2 men began a long-term friendship and intellectual partnership that has been called “the most famous intellectual collaboration of all time.”2(p1) In 1845, Engels published, in German, The Condition of the Working Class in England. Based on his own observations and a mass of contemporary reports, the book described in trenchant prose the multitude of horrors daily suffered by English workers—the unsanitary streets of densely crowded urban slums, the decaying and degrading living quarters, the disrupted and disintegrating families, and, in the passage reproduced here, the unsavory, unsafe, and physically debilitating factories themselves. Engels’ book had an enormous impact and has been called “the best invective ever written . . . against industrial society and its conditions.”3(p66) Engels now joined Marx on the Continent, initially in Brussels, and worked closely with him over the next several years building the intellectual and political foundations of an international revolutionary movement. They coauthored The Holy Family (1845), The German Ideology (1846), and, most famously, The Communist Manifesto (1848). They joined forces in transforming various workers’ groups, secret socialist societies, and incipient radical political parties into, first, the League of the Just, and then into the International Communist League. When hopes for revolution faded on the Continent in the late 1840s, Engels and Marx moved to England. Engels returned to the family business in Manchester while Marx lived and wrote in London. Engels supported Marx with money he earned in the textile industry; he also continued his own radical activities. He became Marx’s most effective popularizer and propagandist. Indeed, when Marx published volume 1 of Das Kapital (1859), few could understand it; it was Engels’ reviews of the volume in a variety of journals that presented the “materialist conception of history” and the “dialectical method” of economic and social analysis with the greatest clarity and persuasiveness. Engels consolidated Marx’s influence among competing revolutionary programs in a variety of works, most notably in Anti-Duhring: Herr Eugen Duhring’s Revolution in Science (1878) and Socialism: Utopian and Scientific (1880), which vigorously defended Marx’s commanding position among radical political theorists. After Marx’s death in 1883, Engels served as the premier international authority on Marx and Marxism. In addition to his own intellectual and political work and other promotional activities on behalf of Marxism, he completed volumes 2 and 3 of Das Kapital (1885 and 1894), working from Marx’s notes and incomplete manuscripts. Late in life, and despite the advance of European parliamentary democracy and, with it, of social reform, Engels still defended the need for continuing the class struggle and revolutionary political tactics. He died in London of cancer in 1895.

Objectives. We studied the association between the local food environment and residents’ report of recommended dietary intake. Methods. Recommended intakes of foods and nutrients for 10 623 Atherosclerosis Risk in Communities participants were estimated from food frequency questionnaires. Supermarkets, grocery stores, and full-service and fast-food restaurants were geocoded to census tracts. Results. Black Americans’ fruit and vegetable intake increased by 32% for each additional supermarket in the census tract (relative risk [RR] = 1.32; 95% confidence interval [CI] = 1.08, 1.60). White Americans’ fruit and vegetable intake increased by 11% with the presence of 1 or more supermarket (RR = 1.11; 95% CI = 0.93, 1.32). Conclusions. These findings suggest the local food environment is associated with residents’ recommended diets.

Objectives. We describe the prevalence of asthma risk factors within racial/ethnic and language groups of infants participating in an intervention study for reducing chronic asthma. Methods. Low-income children aged 9 to 24 months with 3 or more episodes of wheezing illness were enrolled. Baseline information included family and medical histories, allergic status, environmental exposures, emotional environment, and caregiver psychosocial resources. Results. Racial/ethnic and language groups—European Americans, African Americans, high-acculturated Hispanics, and low-acculturated Hispanics—showed different patterns of risk factors for childhood asthma, with low-acculturated Hispanics showing the most distinctive pattern. Conclusions. Patterns of covariation of biological and psychosocial risk factors for childhood asthma were associated with racial/ethnic and language status among urban, low-income children.

OBJECTIVES: This study evaluated the contributions of lower socioeconomic status (SES) and neighborhood socioeconomic characteristics to neural tube defect etiology. The influence of additional factors, including periconceptional multivitamin use and race/ethnicity, was also explored. METHODS: Data derived from a case-control study of California pregnancies from 1989 to 1991. Mothers of 538 (87.8% of eligible) case infants/fetuses with neural tube defects and mothers of 539 (88.2%) nonmalformed infants were interviewed about their SES. Reported addresses were linked to 1990 US census information to characterize neighborhoods. RESULTS: Twofold elevated risks were observed for several SES indicators. Risks were somewhat confounded by vitamin use, race/ethnicity, age, body mass index, and fever but remained elevated after adjustment. A risk gradient was seen with increasing number of lower SES indicators. Women with 1 to 3 and 4 to 6 lower SES indicators had adjusted odds ratios of 1.6 (1.1-2.2) and 3.2 (1.9-5.4), respectively, compared with women with no lower SES indicators. CONCLUSIONS: Both lower SES and residence in a SES-lower neighborhood increased the risk of an neural tube defect-affected pregnancy, with risks increasing across a gradient of SES indicators.

BACKGROUND. Events in Chile provided an opportunity to evaluate health effects associated with exposure to high levels of social and political violence. METHODS. Neighborhoods in Santiago, Chile, were mapped for occurrences of sociopolitical violence during 1985-86, such as bomb threats, military presence, undercover surveillance, and political demonstrations. Six health centers providing prenatal care were then chosen at random: three from "high-violence" and three from "low-violence" neighborhoods. The 161 healthy, pregnant women due to deliver between August 1 and September 7, 1986, who attended these health centers were interviewed twice about their living conditions. Pregnancy complications and labor/delivery information were subsequently obtained from clinic and hospital records. RESULTS. Women living in the high-violence neighborhoods were significantly more likely to experience pregnancy complications than women living in lower violence neighborhoods (OR = 5.0; 95% CI = 1.9-12.6; p less than 0.01). Residence in a high-violence neighborhood was the strongest risk factor observed; results persisted after controlling for several sets of potential confounders. CONCLUSION. Living in areas of high social and political violence increased the risk of pregnancy complications among otherwise healthy women.

An introduction to the journal is presented in which the editor discusses the interaction of social conditions and health, which she describes as the theme of the articles published within the issue.

Rational program planning and evaluation has been suggested as a necessary skill. First, a conceptual framework for planning and evaluation was presented and discussed, using the example of preventing alcoholism and providing services and rehabilitation for alcoholics. Second, a case study was presented, which is similar to that used by many professionals in their efforts to plan programs. Finally, some of the marked limitations of the case study were pointed out, when it was projected upon the conceptual framework.

relationships clearly do exist. Andhowcoulditbeotherwise? Everyone knows frompersonal experience thatupsetting life events often result insomekindofsomatic disturbance, forexample, in changed gastrointestinal mobility orintachycardia, to mention onlytwoexamples. Galen, Hippocrates, andother classic founders ofmedicine, aswellasthephilosophers Spinoza, Descartes, Leibniz, andtheir contemporary offshoots, havepointed totheintricate interaction between psychological andsomatic phenomena intheir statements. Themind-body problem isnotnewbuthasbeenwithus foralong, longtime. Onlyitseemsthat eachgeneration has toreexplore therelationship andreformulate itintermsof its ownframework andvocabulary.

DUBLIC health problems in the Mexican American barrio (community) can be appreciated if one considers the incidence of reportable diseases in health districts in which Mexican Americans comprise the ethnic majority. The morbidity and mortality rates among them generally run two or three times higher than for the dominant Anglo culture group.1'2 In Los Angeles County, it has been found that the incidence rates for most reportable diseases are higher in the two Mexican American districts than in the county as a whole.2 The greatest differences were found in rates of diseases associated with poor sanitary conditions. The tuberculosis case rate was more than double the county rate.2 The syphilis case rate had more than doubled in the East and Northeast Health Districts.2 A low rate of hospital admissions and medical attention occurred despite high rates of bacterial and parasitic infections, circulatory disease, and accidents. Immunizations were two-thirds under what is considered adequate. Untreated medical conditions commonly observed included skin infections, diarrhea, tonsillitis, iron deficiency anemia, and pregnancy without prenatal care. Pregnancy without prenatal care was of particular interest since a perinatal mortality 10 per cent higher than in the rest of the state has been reported from predominantly Mexican American health districts.' The Mexican Americans constitute a cultural entity-in various phases of adaptation to a changing society. They have been described as dumb, dirty, lazy; as fatalistic voodoo practicers of a criminal mentality.3 The Mexican American represents a larger ethnic minority group than the Negro population in the state of California. This is 10 to 15 per cent of the population depending on the region and source of reference. Metropolitan Los Angeles acquired so many Spanish-speaking residents that it qualified for a time as one of the largest Latin American metropolitan areas in the Western Hemisphere.4 Fanon's5 observations on the oral traditions that perpetuated the North African Syndrome led this investigator to look for similar causes which might contribute to the Mexican American Syndrome. It has been pointed out that