Aaron Antonovsky

Epidemiological study of multiple sclerosis in Israel. II. Multiple sclerosis and level of sanitation.

The frequency of multiple sclerosis has been found to increase with increasing latitude. This peculiar geographical distribution has given rise to various hypotheses implicating an environmental factor in the aetiology of the disease (Dean, 1949; Westlund and Kurland, 1953; Kurland and Westlund, 1954; Kurland, Mulder, and Westlund, 1955; Acheson, Bachrach, and Wright, 1960; Mutlu, 1960; Alter, Halpern, Kurland, Bornstein, Leibowitz, and Silberstein, 1962; Kurland and Reed, 1964). Recently, Poskanzer, Schapira, and Miller (1963) have discussed the possibility of an infectious aetiology and have suggested that multiple sclerosis may be an occasional manifestation of a widespread subclinical infection. They think that an enteric infection should be considered because of many similarities in the epidemiological pattern of poliomyelitis and multiple sclerosis. They postulate further that the prevalence of clinically apparent multiple sclerosis might be correlated with the level of sanitation, a situation analogous to that observed in poliomyelitis. Thus, in areas where the sanitary level is high, infection may be acquired later in life, when the individual is more susceptible to the process which produces multiple sclerosis. Conversely, where sanitation is poor, infection may be acquired early when the individual is less susceptible. Although supporting evidence is meagre, these postulates are attractive because they are compatible with the known geographical distribution of the disease. In temperate areas where sanitation is generally on a high level, multiple sclerosis is common; in tropical regions the sanitary level is generally poorer and multiple sclerosis is rare. There are some clinical observations suggesting that the central nervous system of older individuals may be less resistant to the pathological process of

Social class and the major cardiovascular diseases.

Abstract An attempt will be made, wherever the original data allow, to make explicit the scope of the diseases covered by the data in a given study. (All code category numbers in the text refer to the above lists.) The reader should be aware that not only is this not always possible; changes in diagnostic criteria as well as in classification over time mean that often the same label does not refer to the same phenomenon.

Epidemiological study of multiple sclerosis in Israel Part III Multiple sclerosis and socio-economic status

The frequency of multiple sclerosis increases with latitude both in the northern and southern hemisphere (Dean, 1949; Kurland, Mulder, and Westlund, 1955; Acheson, Bachrach, and Wright, 1960; Sutherland, Tyrer, and Eadie, 1962). This peculiar distribution suggests that an environmental factor (or factors) whose distribution is also correlated with latitude plays a role in the aetiology of the disease. The nature of the environmental factor remains obscure, although a wide variety of factors, including climatic variables, e.g., sunlight, temperature, and cultural factors, e.g., diet, have been considered over the years. In view of the apparent difficulty in determining the nature of the aetiological agent in multiple sclerosis, attempts to narrow the range of possibilities have merit. In this regard, the observations of Miller, Ridley, and Schapira (1960) that multiple sclerosis is more common among individuals in the higher socio-economic classes deserves attention. It is generally true that the socio-economic level of populations in temperate zones where multiple sclerosis is common tends to be higher than in tropical regions where the disease is rare. Therefore, a relation between socio-economic level and the distribution of multiple sclerosis seems feasible and the aetiological agent could conceivably be some condition related to socio-economic status. Data collected in Israel afforded an opportunity to evaluate the suggestion of Miller et al. (1960) that there was a relation between socio-economic status and risk of multiple sclerosis, and Israel offers a number of advantages for studies of socio-economic factors in relation to chronic illnesses like multiple sclerosis. The country is small and its population is ofa size permitting collection of data from the nation as a whole. Bias introduced by studying one region or another may thus be avoided in Israel. Moreover,

The model dental patient: An empirical study of preventive health behavior

Abstract The paper seeks to present an integrated model of the determinants of preventive health behavior. Data from a study of 384 employees of a hospital and 200 of their dependents are presented which test hypotheses derived from this model.

The life crisis history as a tool in epidemiological research.

In a controlled epidemiologic study of multiple sclerosis in Israel, many items referring to crisis events were included. The concept of a life crisis history was developed as being of possible importance within the framework of a multifactor theory of etiology. A relatively simple technique for measurement of the life crisis history is described. The results pointed to significant differences between patients and controls. It is proposed that this technique may be useful in many epidemiologic investigations.

A Model to Explain Visits to the Doctor: With Specific Reference to the Case of Israel*

W HEN do people see a doctor? At one extreme, blatant pathology and extreme pain will, with few exceptions, bring one to a doctor in those societies where doctors are available (with the possible exception of mental illness). At the other extreme, a small portion of the visits are accounted for by a preventive health orientation, where no symptoms have been perceived. But, as Zola points out (1966, 1968), we find that the vast bulk [of a physicians load] is concerned with quite minor disorders. There is, on the other hand, he notes, a great body of data which show that there is much illness, defined as such both clinically and subjectively, which is not brought to the attention of the physician. What Zola is saying, then, is that the potential for entry into patienthood is extraordinarily widespread and continuous. One can be ill, clinically speaking, without going to the doctor; or one can go to the doctor, either without any particular change in ones clinical condition or even without any particular justification from the point of view of the physician. If variations among individuals, social subgroups, or societies in visiting rates cannot be explained, within limits, by variations in clinically-determinable morbidity, what are the factors that can predict such variations? It is the purpose of this paper to present a model which. though derived from the case of Israel, should be applicable to other societies as well.

The image of four diseases held by the urban Jewish population of Israel

Abstract This study has applied the Semantic Differential for Health technique, developed by Jenkins, in a study of the images of cancer, heart disease, mental illness and cholera held by a random sample ( N = 1770) of the Israeli Jewish adult urban population in 1971. Six scales were used to represent the dimensions of seriousness, control, personal susceptibility, and salience. The data show that the images of these four diseases vary considerably from each other, with cancer being the most anxiety-providing, while mental illness is most mysterious and distant. The image of heart disease is not radically different from that of cancer, yet nonetheless is significantly less pessimistic. The possible fatal consequences of cholera are recognized, but in overall terms the image held is one of confidence. Analysis of the disease images held by age-sex and ethnicity education subgroups leads to the unanticipated conclusion that, despite a number of specific differences, in overall terms the disease images are not distributed differentially along these demographic lines. Some of the possible implications of the findings for action by health authorities are discussed.

Does pregnancy increase the risk of multiple sclerosis

The association of pregnancy and onset or relapse of multiple sclerosis is well known to every clinician and raises practical problems in clinical work. The problem of the relationship between multiple sclerosis and pregnancy and childbirth had been the subject of several investigations. Early investigators (Beck, 1913) considered pregnancy so detrimental to patients with multiple sclerosis that therapeutic abortion was recommended. However, termination of pregnancy did not guarantee remission (von Hoesslin, 1934). Millar, Allison, Cheeseman, and Merrett (1959), in a careful analysis of the subject, concluded that the exacerbation rate of multiple sclerosis among women who had been pregnant was increased as compared with women who had not been pregnant, and Schapira, Poskanzer, Newell, and Miller (1966) also found that the frequency of relapse among women with multiple sclerosis who had been pregnant was somewhat higher than in non-pregnant patients. In contrast to the above studies, there are others which purport to have found no detrimental effect of pregnancy upon the course of the disease (Muller, 1949; Tillman, 1950; McAlpine and Compston, 1952). Kurland (1952) pointed out that the childbearing period corresponds to the ages during which multiple sclerosis is active, namely, 15 to 45. If a woman were pregnant only three times then she would spend about 36 months in a pregnant or post-partum state and chance association with the onset or exacerbation of multiple sclerosis of about the extent reported would be possible. If pregnancy and delivery had an aetiological role in the pathogenesis of multiple sclerosis, then a comparison of the obstetrical histories of patients with multiple sclerosis and controls before the onset of illness might be of interest. The present study uses this approach, comparing the obstetrical history of

Illness: A mechanism for coping with failure☆

Abstract Illness represents one way of coping with failure and the physician plays a unique role as the sole authority granting legitimation for the sick role. For people of limited means or incomplete knowledge of and access to other medical alternatives, the neighborhood clinic, when it is free and accessible, may serve as the major locus for obtaining legitimation of illness. Such a situation places a special burden on the physician particularly in a social context in which feelings of failure could be widespread in the population. Helping people cope with failure is a stable function of medical institutions and is likely to persist in the face of possible changes in the structure of the professional role. It probably has a good deal of generality to many societies.

The doctor-patient relationship in an ethnically heterogeneous society☆

Abstract This paper concerns aspects of the physicians role performance which are associated with two latent functions of the medical institution for its client: provision of status and provision for catharsis. The institutional context of the study is Kupat Holim, the Workers Health Insurance Institution of Israel which provides preventive, diagnostic and curative treatment for approximately three-quarters of the Jewish population of Israel. Clinics are usually located in local communities or neighborhoods and access to the physician is free to members during clinic hours. 342 Kupat Holim physicians with experience treating Rumanian and Moroccan patients in rural and urban settings completed a systematic questionnaire and the present material is drawn from the analysis of these data. The findings suggest that these two latent functions of the Kupat Holim clinic are differentially ‘activated’ by physicians for different types of clients. Physicians tend to ‘give’ more status to Rumanian than to Moroccan clients possibly because of the latters tendency to conform less to the prescribed role of Western patients or because of physicians own internalization of prejudice norms which are prevalent in the larger social system. At the same time it is of interest to note that physicians do not differentiate between ethnic groups of clients in their readiness to ‘provide’ for catharsis. There is therefore no evidence to support the contention that cultural closeness increases the physicians willingness to ‘provide’ for catharsis. There is no evidence for more particularistic doctor-patient relationships in rural as compared to urban clinics. The findings suggest a revision of our originally proposed hypothesis to the effect that physicians in urban practices will be under greater professional, colleagual scrutiny and will therefore be more likely than their rural counterparts to conform to norms of the profession.