FACT AND FANCY ABOUT DRINKING WATER The finding of minute quantities of carcinogenic substances in the raw drinking water supply of a major city is an important event which raises urgent questions requiring careful pursuit and resolution. One important set of epidemiological studies is that of those attempting to find a cause-and-effect relationship between the presence of these carcinogenic substances in the drinking water and mortality rates from cancer among the people exposed to the water. Not only is this research obvious in its importance and urgency, it is also readily apparent to those familiar with epidemiology that it is research fraught with imprecision in its methodology and misinterpretation in its findings. Unless there is substantiating scientific evidence from other studies or substantial scientific support from critical review of the evidence on hand, the result of any single study of this type is not enough, on its face value, to warrant significant public health action. The release of the results to the public before evaluation has occurred plays on the fears of the public and may lead to expensive measures which are later shown to have been unwarranted. As illustrated in an article in this issue, "The New Orleans Drinking Water Controversy: A Statistical Perspective,"' there is an inherent problem in the statistical manipulation of data from diverse sources to prove that a cause-and-effect relationship existed between the presence of minute quantities of carcinogenic substances in the lower Mississippi River and cancer mortality in the New Orleans area. To implicate nanograms of certain hydrocarbons in Mississippi River water as the cause of "50 Deaths in White Males Annually Due to Water" by a regression analysis of such factors as degree of urbanization, median income, fraction of the population using the river as drinking water, and so on, goes far beyond any conclusion that can be drawn from the analysis. One gets the impression that the conclusion of the research was preconceived and the data arranged to "prove" it. DeRouen and Diem show that interpretation of epidemiological data without regard to the common test of validity put forth by Yerushalmy can lead to conclusions which crumble when subjected to even cursory scientific criticism.
Moreover, the authors have provided a perfect example of the "Chicken Little" phenomenon in their review of the Environmental Defense Fund study of the drinking water controversy. The manner which the Environmental Defense Fund used in presenting the unvalidated scientific data to the public could only lead to public alarm. This phenomenon is well known to public health officials responsible for protecting the health of a populace. It puts the health officer in a difficult situation. In a sense it shifts the burden of proof from the investigator who produced the research results to the health officer, who must now prove that the heavens are not falling in or that the drinking water is safe. In many instances it gets down to his credibility against the credibility of the "scientist." Among other things, this is not the most rational way to develop and implement public policy in the health field. This defensive posture has become more commonplace for public health officials in the last few decades. It has been brought about because our ability to detect foreign substances in the environment in increasingly smaller amounts is increasing, while at the same time our ability to understand the biological consequences of exposure to these small quantities over long periods of time has advanced slowly and with great uncertainty. The "Chicken Little" phenomenon will undoubtedly plague public policy formulation in the environmental health field for many years to come. Public debate will rage over the location of nuclear power plants, the need to balance increased coal burning with air pollution standards, and the impact of offshore oil exploration on coastal zones. The separation of fact from fancy will be critical in these debates. The article by DeRouen and Diem is a good example of separating fact from fancv. One hopes scientific criticism will find its way more often into the public health literature of the future. William H. Stewart, MD Commissioner, Louisiana Health and Human Resources Administration REFERENCE 1. DeRouen, T. A.. and Diem. J. E. The New Orleans Drinking Water Controversy: A Statistical Perspective. Am. J. Public Health 65:1060-1062. 1975.
IMMUNIZATION AND HEALTH EDUCATION October has been designated Immunization Action Month by the Center for Disease Control-and action is needed, paradoxically enough. During the 1950s, poliomyelitis claimed manv lives
each year and left thousands of children permanently crippled. Until recently, measles killed hundreds of children each year and was an important cause of brain damage. In the early 1960s, a rubella epidemic killed 30,000 unborn EDITORIALS 1 1 1 1
children and caused serious birth defects in 20,000 more by infecting pregnant women. Then, within a relatively short span of time, vaccines were developed to protect children against these and other diseases. The vaccines were safe, effective, and successful, seemingly a happy ending to a tragic tale. But the happy ending never fully materialized. Each year after the initial surge of enthusiasm, immunization rates fell. Some authorities now fear the return of local outbreaks or larger epidemics. What has gone awry? Immunizable diseases are among the simpler prototypes for all the preventable death and disability we are pledged to eliminate. There is no "rational reason" why children should continue to suffer and die from them. Accompanying this issue of the Journal is a special supplement entitled "Making Health Education Work."' The Committee responsible for this supplement has a number of sensible things to say about the educational process. Among the lessons are: (1) promotion of health action must be in keeping with the services and resources available; (2) enduring behavioral change must be selfimposed and cannot be administratively ordered; (3) the "learner" must be involved in defining his goals and actions and must evolve his own way of achieving them. These lessons are not new. The need to continually relearn them reflects some pathology in our own social order. The fall-off in immunization rates in recent years
parallels the fall-off in the national commitment to, and thus the growth of, services and resources for high risk (disadvantaged) segments of the population. To apply the other two lessons to the prevention of preventable diseases requires an infrastructure and home base considerably more solid and permanent than the salesmanship and enthusiasm of a national or state "campaign." In developing countries where no administrative structure and no health resources at all are to be found for the majority of the population, a "campaign," repeated with jet injectors, fanfare, and trumpets, house to house, every few years, may be a sensible way to prevent the immunizable diseases. The gimmick also worked in this developed society when polio and measles vaccines were first introduced. But the lack of strong infrastructures (local health departments, if you will) and the absence of continuing comprehensive health services reaching out to the disadvantaged left only a void in the wake of the campaigns. Our society has proved unable to discharge its responsibility to protect the health of all its children. Can we look forward to a day when Immunization Action months will no longer be needed and the wisdom of the Health Education Project Committee can be applied more widely than now seems possible? Alfred Yankauer, MD REFERENCE 1. Making Health Education Work. Am. J. Public Health (Suppl.) Vol. 65. No. 10. 1975.
-F LETTERS Letters are welcomed and will be published, if found suitable, as space permits. The editors reserve the right to edit and abridge letters, to publish replies, and to solicit responses from authors and others. Letters should be submitted in duplicate, double-spaced (including references), and generally should not exceed 400 words.
BARNES QUERIED Dear Dr. Barnes: Your article "Denver Developmental Screening Test: A Normative Study" (AJPH 65:363-369, 1975) has been read with great interest. Your study raises several important questions which I would appreciate clarified. 1. What was the basis for the numerical scores listed in Figures 1 to 4 and Table 3 of your article? Your article included mean scores for each age category. Neither the DDST manuals nor articles give numerical scores 1112 AJPH OCTOBER. 1975, Vol. 65, No. 10
for any items. In the DDST directions, scoring is "pass" or "fail" for each item asked. Did you score one point for each item passed or was your scoring based on the complexity of the item? For example, how did you score "recognize three of four colors?" Was it scored one point for the total item or one point for each correct color for a maximum of four points? By the original DDST directions, a child is asked only items crossing his age line and a minimum of three items passed and three items failed in each sector. How did you score the earlier items not asked to children? For ages 46 to 78 months, your scores do not reach one standard deviation above the mean. Could this reflect the lack of sufficient items for screening normal children over age 3 years 10
months? 2. Why was your sample so heavily weighted to children below age 2? Only
67 children of 226 (30 per cent) in your sample were over age 27 months (2-3/12). "Preschool" age usually refers to ages 3 to 6 years. "Infants" are newborn to age 18 months and "toddlers" are ages 18 months to 3 years. 3. Are the child-rearing patterns for infants in the population that you studied more similar to the American than to the British-European pattern? American infants spend more awake and resting time on their abdomens, which encourages motor exploration-crawling, sitting, standing, etc. British infants spend more time lying on their backs, which encourages earlier eye-hand activities and earlier language. This difference was recently documented by Bryant (Dev. Med. Child Neurol. 16:474-484, 1974). His sample of children from Wales had significantly different norms than Denver children on the DDST. Welsh children had earlier language and fine motor-adaptive skills and later gross
Moreover, the authors have provided a perfect example of the "Chicken Little" phenomenon in their review of the Environmental Defense Fund study of the drinking water controversy. The manner which the Environmental Defense Fund used in presenting the unvalidated scientific data to the public could only lead to public alarm. This phenomenon is well known to public health officials responsible for protecting the health of a populace. It puts the health officer in a difficult situation. In a sense it shifts the burden of proof from the investigator who produced the research results to the health officer, who must now prove that the heavens are not falling in or that the drinking water is safe. In many instances it gets down to his credibility against the credibility of the "scientist." Among other things, this is not the most rational way to develop and implement public policy in the health field. This defensive posture has become more commonplace for public health officials in the last few decades. It has been brought about because our ability to detect foreign substances in the environment in increasingly smaller amounts is increasing, while at the same time our ability to understand the biological consequences of exposure to these small quantities over long periods of time has advanced slowly and with great uncertainty. The "Chicken Little" phenomenon will undoubtedly plague public policy formulation in the environmental health field for many years to come. Public debate will rage over the location of nuclear power plants, the need to balance increased coal burning with air pollution standards, and the impact of offshore oil exploration on coastal zones. The separation of fact from fancy will be critical in these debates. The article by DeRouen and Diem is a good example of separating fact from fancv. One hopes scientific criticism will find its way more often into the public health literature of the future. William H. Stewart, MD Commissioner, Louisiana Health and Human Resources Administration REFERENCE 1. DeRouen, T. A.. and Diem. J. E. The New Orleans Drinking Water Controversy: A Statistical Perspective. Am. J. Public Health 65:1060-1062. 1975.
IMMUNIZATION AND HEALTH EDUCATION October has been designated Immunization Action Month by the Center for Disease Control-and action is needed, paradoxically enough. During the 1950s, poliomyelitis claimed manv lives
each year and left thousands of children permanently crippled. Until recently, measles killed hundreds of children each year and was an important cause of brain damage. In the early 1960s, a rubella epidemic killed 30,000 unborn EDITORIALS 1 1 1 1
children and caused serious birth defects in 20,000 more by infecting pregnant women. Then, within a relatively short span of time, vaccines were developed to protect children against these and other diseases. The vaccines were safe, effective, and successful, seemingly a happy ending to a tragic tale. But the happy ending never fully materialized. Each year after the initial surge of enthusiasm, immunization rates fell. Some authorities now fear the return of local outbreaks or larger epidemics. What has gone awry? Immunizable diseases are among the simpler prototypes for all the preventable death and disability we are pledged to eliminate. There is no "rational reason" why children should continue to suffer and die from them. Accompanying this issue of the Journal is a special supplement entitled "Making Health Education Work."' The Committee responsible for this supplement has a number of sensible things to say about the educational process. Among the lessons are: (1) promotion of health action must be in keeping with the services and resources available; (2) enduring behavioral change must be selfimposed and cannot be administratively ordered; (3) the "learner" must be involved in defining his goals and actions and must evolve his own way of achieving them. These lessons are not new. The need to continually relearn them reflects some pathology in our own social order. The fall-off in immunization rates in recent years
parallels the fall-off in the national commitment to, and thus the growth of, services and resources for high risk (disadvantaged) segments of the population. To apply the other two lessons to the prevention of preventable diseases requires an infrastructure and home base considerably more solid and permanent than the salesmanship and enthusiasm of a national or state "campaign." In developing countries where no administrative structure and no health resources at all are to be found for the majority of the population, a "campaign," repeated with jet injectors, fanfare, and trumpets, house to house, every few years, may be a sensible way to prevent the immunizable diseases. The gimmick also worked in this developed society when polio and measles vaccines were first introduced. But the lack of strong infrastructures (local health departments, if you will) and the absence of continuing comprehensive health services reaching out to the disadvantaged left only a void in the wake of the campaigns. Our society has proved unable to discharge its responsibility to protect the health of all its children. Can we look forward to a day when Immunization Action months will no longer be needed and the wisdom of the Health Education Project Committee can be applied more widely than now seems possible? Alfred Yankauer, MD REFERENCE 1. Making Health Education Work. Am. J. Public Health (Suppl.) Vol. 65. No. 10. 1975.
-F LETTERS Letters are welcomed and will be published, if found suitable, as space permits. The editors reserve the right to edit and abridge letters, to publish replies, and to solicit responses from authors and others. Letters should be submitted in duplicate, double-spaced (including references), and generally should not exceed 400 words.
BARNES QUERIED Dear Dr. Barnes: Your article "Denver Developmental Screening Test: A Normative Study" (AJPH 65:363-369, 1975) has been read with great interest. Your study raises several important questions which I would appreciate clarified. 1. What was the basis for the numerical scores listed in Figures 1 to 4 and Table 3 of your article? Your article included mean scores for each age category. Neither the DDST manuals nor articles give numerical scores 1112 AJPH OCTOBER. 1975, Vol. 65, No. 10
for any items. In the DDST directions, scoring is "pass" or "fail" for each item asked. Did you score one point for each item passed or was your scoring based on the complexity of the item? For example, how did you score "recognize three of four colors?" Was it scored one point for the total item or one point for each correct color for a maximum of four points? By the original DDST directions, a child is asked only items crossing his age line and a minimum of three items passed and three items failed in each sector. How did you score the earlier items not asked to children? For ages 46 to 78 months, your scores do not reach one standard deviation above the mean. Could this reflect the lack of sufficient items for screening normal children over age 3 years 10
months? 2. Why was your sample so heavily weighted to children below age 2? Only
67 children of 226 (30 per cent) in your sample were over age 27 months (2-3/12). "Preschool" age usually refers to ages 3 to 6 years. "Infants" are newborn to age 18 months and "toddlers" are ages 18 months to 3 years. 3. Are the child-rearing patterns for infants in the population that you studied more similar to the American than to the British-European pattern? American infants spend more awake and resting time on their abdomens, which encourages motor exploration-crawling, sitting, standing, etc. British infants spend more time lying on their backs, which encourages earlier eye-hand activities and earlier language. This difference was recently documented by Bryant (Dev. Med. Child Neurol. 16:474-484, 1974). His sample of children from Wales had significantly different norms than Denver children on the DDST. Welsh children had earlier language and fine motor-adaptive skills and later gross
