Stephen J. Kunitz

Disease and social diversity : the European impact on the health of non-Europeans

1. Natural History and Local History 2. Death in the Fourth World 3. Historical and Contemporary Mortality Patterns in Polynesia 4. Settler Capitalism and the State in Australia 5. The Impact of Socio-Cultural Differences on Health 6. The Health Consequences of Modernization 7. Conclusions Appendix 2-1. The Size and Definition of Indigenous Populations Appendix 3-1. Estimates of Various Polynesian Populations: 1790s-1980s Appendix 6-1. Data and Methods for Regional Analyses

Alcohol Dependence and Domestic Violence as Sequelae of Abuse and Conduct Disorder in Childhood.

OBJECTIVESnTo examine in the Navajo population: (1) the importance of childhood abuse as a risk factor for conduct disorder; (2) the importance of each form of abuse and conduct disorder as risk factors for alcohol dependence; and (3) the relative importance of each form of abuse, conduct disorder, and alcohol dependence as risk factors for being a perpetrator and/or victim of domestic violence.nnnMETHODnThe study is based on a case-control design. Cases (204 men and 148 women) between the ages of 21 and 65 were interviewed in alcohol treatment program and matched to community controls. There were two groups of controls: alcohol dependent (374 men, 60 women) and nonalcohol dependent (157 men, 143 women). When adjusted for stratification by age, community of residence, and sex, the combined control groups comprise a representative sample of the Navajo male and female population 21-65 years of age.nnnRESULTSnThe prevalence of physical and sexual abuse before age 15 is within limits observed in other populations. Each form of abuse is a risk factor for conduct disorder. Along with conduct disorder, physical abuse is a risk factor for alcohol dependence. Physical abuse and alcohol dependence are independent risk factors for being involved in domestic violence as both perpetrator and victim. There appears to have been no secular trend in the incidence of childhood abuse over the past several generations, but there is suggestive evidence that domestic violence has become more common.nnnCONCLUSIONSnPhysical abuse is a significant risk factor for alcohol dependence as well as for domestic violence independent of the effects of alcohol abuse. The effects of sexual abuse with regard to both domestic violence and alcohol dependence do not appear to be significant.

Metropolitan governance, residential segregation, and mortality among african americans

OBJECTIVESnThis study tested the hypothesis that the degree to which local government is metropolitanized is associated with mortality rates for African Americans and with residential segregation, which has itself previously been shown to be positively associated with mortality among African Americans.nnnMETHODSnOne hundred fourteen US standard metropolitan statistical areas were examined. The primary dependent variable was the age-adjusted, race- and sex-specific all-cause mortality rate, averaged for 1990 and 1991. The 2 primary independent variables were residential segregation, as measured by the index of dissimilarity, and metropolitanization of government, as measured by the central citys elasticity score.nnnRESULTSnMortality rates for male and female African Americans were lower in metropolitan statistical areas with more metropolitanized local governments and lower levels of residential segregation. Mortality for male and female Whites was not associated in either direction with residential segregation. White male mortality showed no association with level of metropolitanization, but lower White female mortality rates were associated with less metropolitanization.nnnCONCLUSIONSnThis study suggests the need for further research into whether policy changes in areas not traditionally thought of as health policy areas can improve the health of urban minorities.

Indian Reservations, Anomie, and Social Pathologies

Several common notions are examined concerning the relationship between social pathology (homicide, suicide, and alcoholism) and social disorganization and anomie. The findings of studies conducted by the authors among the Navajo and Hopi Indians are presented. In the main, the studies suggest that both the prevalence and patterning of these behaviors are largely explainable in terms of persisting elements of aboriginal culture rather than as responses to acculturation and social disorganization. It is concluded that previous approaches to the subject have been more influenced by Western traditions of social thought than by any hard consideration of the data and theory appropriate to their analysis and interpretation.

NAVAJO CRIMINAL HOMICIDE

This paper examines several common notions concerning homicide among the Navajo and its relationship with alcohol and acculturation. Earlier references to the act are reviewed, and all reported homicides occurring between 1956 and 1965 are analyzed in a manner comparable to an extensive study done in Philadelphia between 1948 and 1952. It was found that homicide rates among the Navajo at the present time are stable and comparable with those of the nation. There are indications that they have been so for some time. Greatly increased use of alcohol was not found to increase homicide rates or to be significantly associated with violence in the homicide situation. Navajo patterns which differed from those found in Philadelphia are discussed. The Navajo offender is typically a married male between 35 and 39 years of age who kills his wife as a result of sexual jealousy or domestic quarrels. A high proportion of homicides are followed by suicide.

Ethics in Public Health Research: Changing Patterns of Mortality Among American Indians

Mortality rates for American Indians (including Alaska Natives) declined for much of the 20th century, but data published by the Indian Health Service indicate that since the mid-1980s, age-adjusted deaths for this population have increased both in absolute terms and compared with rates for the White American population. This increase appears to be primarily because of the direct and indirect effects of type 2 diabetes. Despite increasing appropriations for the Special Diabetes Program for Indians, per capita expenditures for Indian health, including third-party reimbursements, remain substantially lower than those for other Americans and, when adjusted for inflation, have been essentially unchanged since the early 1990s. I argue that inadequate funding for health services has contributed significantly to the increased death rate.

Explanations and ideologies of mortality patterns.

Over the past century two ideas of disease causation have coexisted and sometimes competed: causal necessity or the idea that specific diseases cannot occur in the absence of specific causes; and causal sufficiency the idea that multiple causes can result in the same disease. With reference to first the evolution of epidemiology and public health in the United States since the mid-nineteenth century and second the formulation of public health strategies for the developing countries from the 1940s to the 1980s the article explores ways in which these notions of causality have been used to explain changes in mortality to justify public policies and to advance the claims of various groups of public health professionals. While the relative importance given to causal sufficiency and necessity reflects the state of knowledge about the most prevalent diseases in specific settings and about the disease process it also reflects political ideologies and deeply held assumptions about the nature of society the individuals responsibility for his own well-being and moral responsibility. (SUMMARY IN FRE AND SPA) (EXCERPT)

Rearrest Rates After Incarceration for DWI: A Comparative Study in a Southwestern US County

OBJECTIVESnThis study was undertaken to assess a 28-day detention and treatment programs effect, in a multiethnic county with high rates of alcohol-related arrests and crashes, on first-time offenders sentenced for driving while impaired (DWI).nnnMETHODSnWe used comparison of baseline characteristics, survival curves of subsequent arrest, and Cox proportional hazards regression to examine probability of rearrest of those sentenced and those not sentenced to the program.nnnRESULTSnProbability of not being rearrested was significantly higher for the treatment group after adjustment for covariates. At 5 years, probability of not being rearrested for the treatment vs the nontreatment group was 76.6% vs 59.9%.nnnCONCLUSIONSnResults suggest that this countys program has significantly affected rearrest rates for Native Americans, Hispanics, and non-Hispanic Whites.

Professionalism and Social Control in the Progressive Era: The Case of the Flexner Report

It is proposed that the Progressive Era (about 1890-1914) saw the emergence of many occupational groups claiming professional status as experts in the control of a variety of social problems. The medical profession is only one of a number of such groups, albeit the most successful in advancing its claims. The Flexner Report (Flexner, 1910) is reviewed as one example of the role elite members of the occupational group played in achieving higher status for the occupation.

The Making and Breaking of Yugoslavia and Its Impact on Health

The creation of nation-states in Europe has generally been assumed to be intrinsic to modernization and to be irreversible. The disintegration of Czechoslovakia, the Soviet Union, and Yugoslavia demonstrates that the process is not irreversible. I argue that in the case of Yugoslavia, (1) disintegration was caused by the interaction between domestic policies with regard to nationalities and integration into the global economy and (2) the impact of the disintegration of the federation on health care and public health systems has been profound. Improving and converging measures of mortality before the collapse gave way to increasing disparities afterward. The lesson is that processes of individual and social modernization do not result in improvements in health and well-being that are necessarily irreversible or shared equally.