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CSU 21/2009: FROM THE FIRST CENTURY OF THE MILBANK QUARTERLY

Wednesday, 15th of April 2009

CSU 21/2009: FROM THE FIRST CENTURY OF THE MILBANK QUARTERLY
 
 
 The centennial edition of the Milbank Quarterly, viewed at   http://www.milbank.org/8304.html
  brought together articles from the first century of that journal's 
 publication. Here are two: 
  
 PERROTT AND HOLLAND, 'POPULATION TRENDS AND PROBLEMS OF PUBLIC HEALTH'
 
 
 Writing about the America  of 1940, Perrott and Holland observed the
 demographic and epidemiological transition which the US was undergoing in
 that year.  They concluded as follows.
 
 
 General Implications
 
 
 Solution of the health problems associated with aging of the population
 will require the intensive application of existing methods for the
 prevention of disease to a larger number of the population than is now
 receiving the benefits of preventive medicine. Health gains in infancy and
 childhood have been chiefly responsible for the increase in average life
 expectancy, yet this field offers opportunity for further substantial
 improvement. Deaths of infants from congenital malformations and debility,
 birth injuries, and the broad group of the diseases of early infancy
 average about 63,000 annually, these conditions taken together ranking
 among the leading causes of death in the total population of all ages.
 
 
 Adequate prenatal and infant care is of demonstrated value in reducing both
 puerperal and neonatal mortality. School children and workers in industry
 afford opportunity for effective group health supervision.
 
 
 The specific attack on tuberculosis and the venereal diseases provides an
 additional approach to the health problems of young adults.
 
 
 Yet at certain points, the provision of preventive health services alone
 leaves the greater part of the health problem unsolved. The maternity case
 requires competent attendance at delivery as well as supervision in the
 prenatal period. Control of the communicable diseases of childhood requires
 not only preventive measures, but treatment of the sick child. Tuberculosis
 and syphilis control involves both case-finding and adequate treatment of
 cases and their contacts when found. The characteristic chronic diseases of
 middle and old age are subject to control primarily through therapeutic
 measures. On the whole, organized health agencies assume relatively little
 responsibility for making these curative services available. Individual,
 rather than community, income is the chief determining factor in the
 receipt of medical care, and individual income is generally recognized to
 be inadequate for medical needs in a large proportion of the population,
 particularly among the aged.
 
 
 A possible solution of this impasse lies in the employment of public funds
 to provide both preventive and curative services for those groups of the
 population unable to support the costs of such care from individual
 income. . . .
 
 
 Disability insurance is a pressing need which will increase in importance
 as the population ages.
 
 
 . . .Finally, an important approach to the solution of this broad problem
 is offered through the extension of research in the cause and control of
 the chronic diseases characteristic of advanced life. Effective control of
 certain of these diseases, of which cancer is an outstanding example, is in
 part dependent on the demonstration of the etiologic agents involved.
 
 
 Opportunity should be provided for the appraisal of existing methods of
 diagnosis and treatment, and the exploration of new procedures designed to
 bring the chronic diseases under early control. But an equally fruitful
 field of research consists in the development of public health methods
 which will solve the unique problems involved in coordinating the control
 of the chronic diseases in the community health program.
 
 
 Is this purely of historical importance? Many middle income countries are
 undergoing, as I write, the same transition which characterized the
 industrialized countries of  70 years ago.
 
 
 
 
 
 In the same centennial issue, Abdel Omran writes on 'The Epidemiologic
 Transition: A Theory of the Epidemiology of Population Change.' Among his
 observations:
 
 
 'The tendency of improved infant and childhood survival to depress
 fertility in the middle and subsequent stages of the transition can be
 attributed largely to the following factors:
 
 
 '1. Biophysiologic factors: The increased chance that a live birth will
 survive infancy and early childhood and result in prolonged lactation tends
 to lengthen the mother’s postpartum period of natural protection against
 conception. . . . the interval between births increases progressively at
 all parities as life expectancy rises. Ridley, et al., concluded that the
 lengthening of birth intervals, particularly among young, highly fecund,
 low-parity women, has a deflationary effect on ultimate parity and is a
 major mechanism linking improved survival and lowered fertility.
 
 
 '2. Socioeconomic factors: The risk of childhood death is lowered by better
 nutrition and sanitation as socioeconomic conditions improve. As the
 probability of child survival increases, the desirability of having many
 children may diminish in response to changes in the social and economic
 system that cast the child as an economic liability rather than asset.
 Concomitantly, improvements in birth control technology facilitate the
 achievement of emerging small family size norms.
 
 
 '3. Psychologic or emotional factors: Improved infant and childhood
 survival tends to undermine the complex social, economic and emotional
 rationale for high parity for individuals and hence high fertility for
 society as a whole. As couples become aware of the near certainty that
 their offspring, particularly a son, will survive them, the likelihood of
 practicing family limitation is enhanced.
 
 
 'Not only are compensatory efforts to “make up” for lost children reduced,
 but the investment of parental energies and emotions may take on a new,
 qualitative dimension as each child in the small family is provided better
 protection, care and education.'
 
 
 Good reading.
 
 
 BD