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In 1903, the Specialized Mortality Investigation, a study commissioned by the insurance industry, identified risks factors such as “build, occupation, medical history, and residence” as related to premature mortality. The risk factors provided the companies with easily ascertainable criteria which could be used to identify “substandard risks” or “impaired lives.” (p. 63.) Based on these risks, insurance companies could raise or lower premiums accordingly. One of the key factors identified as having a strong relationship to mortality was an individual’s build. Contrary to the prevailing medical opinion of the time, the study found that overweight people were much more likely to meet an early demise. Other studies quickly determined that blood pressure was also useful in predicting mortality. Blood pressure had never been considered especially important to the medical community before its identification as a risk factor.
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Not only did the insurance industry identify risk factors, it educated a generation of physicians “about new developments of diagnosis,” created education programs for the general public and provided nurses to their clients. (p. 74.) Throughout the early twentieth century, insurance companies conducted innovative research designed to improve the accuracy of medical diagnosis. Scores of young doctors were hired by insurance companies to examine potential clients and indoctrinated regarding the importance of risk factors in general health. These early experiences shaped their attitudes regarding the utility of statistics and probability in medical research. On the other hand, the Metropolitan’s health education and visiting nursing programs promoted preventive health care among the general population. The primary motivation behind the Metropolitan’s health programs was financial and not philanthropic. Despite the companies mercenary motivations the programs were overwhelming beneficial and widely praised.
As mortality rates from infectious diseases declined in the twentieth century, the medical profession increasingly focused on preventing chronic diseases (such as coronary heart disease). Unlike the insurance industry, medicine was more skeptical of the utility of statistics and probability in identifying the underlying causes of disease. Additionally, physicians were not adept at interpreting their results. Chronic diseases (such as heart disease) have been especially difficult for the medical profession, because it has been challenging to determine the biological mechanism that causes chronic heart disease. Medicine has not been able to identify the root biological causes of heart disease in the laboratory. Instead, physicians have been forced to diagnose heart disease primarly through large statistical studies.
Rothstein argues that a careful analysis of these studies do not necessarily support the conclusions of their authors. The data from the Framingham Heart Study has been used for years, but it focused on only three specific risk factors (smoking, blood cholesterol, and blood pressure). Rothstein posits that results of that study were flawed because its authors narrowed the concept of risk factors and ignored social characteristics (such as “education, income, occupation, living conditions, health care, marital status, place of birth and family structure”) even though they appeared to play an important role in who developed heart disease. (p. 285.)
The most problematic risk factor for Rothstein is the correlation between blood cholesterol and heart disease. Blood cholesterol’s role in the development heart disease is uncertain and Rothstein directly questions the findings of that a reduction in cholesterol levels prevents heart disease. The side effects of the drugs and the high cost outweigh any speculative benefits. Additionally, the focus on cholesterol has diverted attention from the most likely causes of heart disease, obesity and insufficient physical exercise. Rothstein’s conclusions fit neatly with the historical evidence provided earlier in the book that heart disease was uncommon before the twentieth century. According to Rothstein, obesity and exercise are the single greatest determining factors for heart disease. Unfortunately, physicians are not well-positioned to alter an individual’s weight or mandate exercise. Instead of focusing on these issues, the medical profession has been sidetracked by prescribing blood pressure and cholesterol medicines.
Rothstein does not appear rely on any specific social theory. If anything, Rothstein’s work is more informed by a sophisticated understanding of statistics, probability, and mathematics. Whether or not that constitutes a type of social theory may be worth debating. Additionally, it is arguable whether his work would benefit from the inclusion of any specific social theory. Unlike Warwick Anderson in his work Colonial Pathologies, Rothstein is not particularly interested in the motivations, morality or ethics of scientists involved in the Framingham Heart Study. Instead, he is focused on analyzing whether their conclusions were supported by the accompanying statistical evidence. Rothstein seeks to undermine the contemporary understanding and treatment of coronary heart disease by questioning the validity of the interpretations of these statistical studies. Because the biological cause of heart disease has not been determined in the laboratory setting, it
is possible for statistician or sociologist to ascertain risk factors as well as any physician.
[[Category:Book Review]] [[Category:Historiography]] [[Category:Medical History]] [[Category:United States History]]