Gerald M. Oppenheimer

Becoming the Framingham Study 1947–1950

In the epidemiological imagination, the Framingham Heart Study has attained iconic status, both as the prototype of the cohort study and as a result of its scientific success. When the Public Health Service launched the study in 1947, epidemiological knowledge of coronary heart disease was poor, and epidemiology primarily involved the study of infectious disease. In constructing their investigation, Framinghams initiators had to invent new approaches to epidemiological research. These scientific goals were heavily influenced by the contending institutional and personal interests buffeting the study. The study passed through vicissitudes and stages during its earliest years as its organizers grappled to define its relationship to medicine, epidemiology, and the local community.

Routine HIV Testing, Public Health, and the USPSTF — An End to the Debate

On the basis of a systematic examination of new evidence on clinical and public health benefits of early identification of HIV infection, the U.S. Preventive Services Task Force will soon release recommendations endorsing routine HIV testing in adults and adolescents.

Health and human rights: old wine in new bottles?

t is one of the remarkable and significant consequences of the AIDS epidemic that out of the context of enorI mous suffering and death there emerged a forceful set of ideas linking the domains of health and human rights. At first, the effort centered on the observation that protecting individuals from discrimination and unwarranted intrusions on liberty were, contrary to previous epidemics, crucial to protecting the public health and interrupting the spread of HIV But in fairly short order, the scope of the health and human rights perspective expanded dramatically to focus on the ways in which the most fundamental social arrangements rendered individuals and communities vulnerable to H N Racial and ethnic minorities, those who were marginalized, and women were at risk because of their subordinate status. In the face of such an understanding, nothing short of social change could be adequate to the challenge posed by the AIDS epidemic. While many long-time workers in the fields of public health and human rights contributed to the forging of a new ideological perspective, there is little question that Jonathan Mann played a singular role in challenging not only those who rejected the new-found centrality of human rights for public health, but those with whom he worked most closely as well. No greater respect can be paid to visionary work than to engage it critically. Of elemental importance at this juncture is to understand the nature of the innovations forged by Mann and others committed to linking health and human rights. It is also vital to assess the extent to which such innovations represented a fundamental departure. These are the tasks of this paper. As the AIDS epidemic took shape in the early 1980s in economically advanced nations bounded by the liberal-demo-

Routine HIV Screening — What Counts in Evidence-Based Policy?

Should U.S. adolescents and adults be screened routinely for HIV? The same evidence has led the top U.S. public health agency and the body charged with providing scientifically grounded recommendations on preventive interventions to dramatically different conclusions.

Framingham Heart Study: The First 20 Years

The Framingham Heart Study remains the most famous and influential investigation in cardiovascular disease epidemiology. To generations of epidemiologists, it is a model for the cohort design. Here we revisit the origins of the Framingham Study before it became an accomplished and famous investigation whose existence and success are taken for granted. When in 1947 the Public Health Service initiated the study, knowledge of the distribution and determinants of coronary heart disease was sparse. Epidemiology was primarily focused on infectious disorders. Framinghams pioneers struggled to invent an appropriate epidemiological approach to this chronic disease and to establish support for a new kind of research within a community. Thereafter they had to convince skeptical medical professionals that the results of epidemiological investigations of heart disease were applicable to their clinical practices.

McGovern's Senate Select Committee on Nutrition and Human Needs Versus the: Meat Industry on the Diet-Heart Question (1976–1977)

For decades, public health advocates have confronted industry over dietary policy, their debates focusing on how to address evidentiary uncertainty. In 1977, enough consensus existed among epidemiologists that the Senate Select Committee on Nutrition and Human Need used the diet-heart association to perform an extraordinary act: advocate dietary goals for a healthier diet. During its hearings, the meat industry tested that consensus. In one year, the committee produced two editions of its Dietary Goals for the United States, the second containing a conciliatory statement about coronary heart disease and meat consumption. Critics have characterized the revision as a surrender to special interests. But the senators faced issues for which they were professionally unprepared: conflicts within science over the interpretation of data and notions of proof. Ultimately, it was lack of scientific consensus on these factors, not simply political acquiescence, that allowed special interests to secure changes in the guidelines.

Social disorder and diagnostic order: the US Mental Hygiene Movement, the Midtown Manhattan study and the development of psychiatric epidemiology in the 20th century

Recent scholarship regarding psychiatric epidemiology has focused on shifting notions of mental disorders. In psychiatric epidemiology in the last decades of the 20th century and the first decade of the 21st century, mental disorders have been perceived and treated largely as discrete categories denoting an individuals mental functioning as either pathological or normal. In the USA, this grew partly out of evolving modern epidemiological work responding to the States commitment to measure the national social and economic burdens of psychiatric disorders and subsequently to determine the need for mental health services and to survey these needs over time. Notably absent in these decades have been environmentally oriented approaches to cultivating normal, healthy mental states, approaches initially present after World War II. We focus here on a set of community studies conducted in the 1950s, particularly the Midtown Manhattan study, which grew out of a holistic conception of mental health that depended on social context and had a strong historical affiliation with: the Mental Hygiene Movement and the philosophy of its founder, Adolf Meyer; the epidemiological formation of field studies and population surveys beginning early in the 20th century, often with a health policy agenda; the recognition of increasing chronic disease in the USA; and the radical change in orientation within psychiatry around World War II. We place the Midtown Manhattan study in historical context--a complex narrative of social institutions, professional formation and scientific norms in psychiatry and epidemiology, and social welfare theory that begins during the Progressive era (1890-1920) in the USA.

Scale-ups, scarcity, and selections: the experience of doctors in South Africa

Objectives:To present the ethical and clinical experience of public sector physicians during the post-Apartheid period in South Africa, who were faced with poverty, medical scarcity and unexpected government resistance in treating individuals with HIV infection. Methods:Oral history interviews with 73 physicians from major cities, mine company clinics, and rural hospitals selected because of their long-standing commitment to treating people with AIDS. Conclusion:The onset of the governments ‘rollout’ of antiretroviral therapy (ART) in 2003, providing drugs to public sector patients, has not put an end to the rationing of care that characterised the pre-ART period. Subsequently, rules were established to guide such rationing in an equitable fashion. But there are occasions when doctors override their own rules, demonstrating the complex interplay between principles of equity and the claims of moral duty to patients, especially in instances of life and death.

To Build a Bridge: The Use of Foreign Models by Domestic Critics of U.S. Drug Policy

Domestic critics of American policy concerning illicit drugs have frequently looked abroad for evidence to bolster their agenda. Policies developed elsewhere, specifically heroin maintenance in Britain and harm reduction in Holland, have profoundly affected debate over the American approach to addiction. In each instance, the interest in foreign models was whetted by a perceived social emergency: the heroin epidemic following World War II and the HIV epidemic of the last decade.

Was there ever really a “sugar conspiracy”?

Twists and turns in science and policy are not necessarily products of malevolence Over the past quarter-century, historical research has revealed how major industries from tobacco to lead to petroleum have meddled in science to conceal the hazards of their products. Drawing on secret industry documents, these studies have shown how special interests have used financial incentives to influence scientists, fabricate doubt, and delay regulation (1). Recently, similar allegations have been made against the sugar industry, with claims that prominent industry-backed researchers in the 1960s downplayed or suppressed evidence linking sugar and heart disease. Building on a newly popular narrative holding that the low-fat campaign of the 1980s was not based on solid science, these allegations have suggested that if not for the machinations of the sugar industry and its cadre of sponsored researchers, the history of U.S. dietary policy might have unfolded very differently. In this article, we argue that the historical evidence does not support these claims. Although we do not defend the sugar industry and cannot address every aspect of this history, we believe recent high-profile claims come from researchers who have overextended the analogy of the tobacco industry playbook and failed to assess historical actors by the norms and standards of their time. Our analysis illustrates how conspiratorial narratives in science can distort the past in the service of contemporary causes and obscure genuine uncertainty that surrounds aspects of research, impairing efforts to formulate good evidence-informed policies. In the absence of very strong evidence, there is a serious danger in interpreting the inevitable twists and turns of research and policy as the product of malevolent playbooks and historical derailments. Like scientists, historians must focus on the evidence and follow the data where they lead.