No. 2, April 2004
FROM THE EDITOR IN CHIEF
Health Monitoring and Life
on the Mississippi
Lynne S. Wilcox, MD, MPH
Suggested citation for this article: Wilcox LS.
Health monitoring and Life on the Mississippi. Prev Chronic
Dis [serial online] 2004 Apr [date cited]. Available from: URL: http://www.cdc.gov/pcd/issues/2004/
Designing health monitoring systems is a complex task. This issue of
Preventing Chronic Disease includes a report and commentary on measuring the burden of diabetes at the individual level in
minority populations (1,2) and a report on measuring heart disease and stroke
indicators at the policy level (3).
To inspire stalwart professionals to design such systems, I turn to an
individual recognized for his insightful commentary — Mark Twain, also known
as Samuel Clemens. Twain had a keen eye for the idiosyncrasies of human
behavior, and his nonfiction works suggest he was adept at amateur
qualitative research. Though he was a man of letters rather than a
scientist, he clearly appreciated the issues involved in gathering quality
There is something fascinating about science. One gets such wholesome
returns of conjecture out of such a trifling investment of fact (4).
The balance of conjecture and fact is a source of ongoing tension in public
health: collecting data is time-consuming and costly, but operating health
programs based on conjecture is risky.
Although Healthy People 2010 (5) emphasizes the elimination of health
disparities, the nation lacks an accurate way of measuring the burden of
diabetes in minority populations. Surveillance
systems, for example, may treat Spanish-speaking populations as a homogeneous
Hispanic group while individuals within the group may have originated from
different Spanish-speaking countries (1). Without an understanding of the diversity
of these cultures,
health programs may lack the context to serve these populations effectively.
A report in this issue of Preventing Chronic Disease, prepared by an
expert panel at the Centers for Disease Control and Prevention (CDC), recommends extending
the capacity of existing surveys to obtain better measurements of minority
populations instead of developing new surveys, in light of the high costs of
taking the latter route (1).
Community-level policy and environmental indicators related to stroke and
heart disease prevention present a different problem. Researchers in 2
states, Alabama and South Carolina, examined data sources for 31 pilot
indicators and found that, while data sources for most indicators are
available in the school setting and are available for indicators of tobacco
policies across all settings examined, data sources are least available in
the health care and work site settings (3). This report calls for combining current data sources
with new surveillance efforts. These efforts are also likely to be costly,
but will focus on the policies of states, work sites, and health care
than on data from individual respondents.
There are three kinds of lies: lies, damned lies and statistics (6).
The game of "lying with statistics" creates confusion for both
public health professionals and the people who use their data. Even when
diligent public health professionals strive to explain the nuances of
surveillance findings, numbers are often misconstrued by well-meaning
The CDC expert panel on using survey data for diabetes surveillance among
minority populations points out that most diabetes
surveys lack sufficient sample size to provide statistics for the burden of diabetes
smaller minority populations, especially at state or local levels. These populations
thus remain hidden and the causes of health disparities
remain obscure. The panel recommends enhancing
community-level health surveys to gain more details on populations within each community.
The study on policy indicators for heart disease and stroke identifies
another challenge in surveillance statistics: indicators may lack the sensitivity
or specificity needed to assess a policy's
effects on health (3). The study's investigators define an insensitive indicator
as one that states the simple presence or absence of a policy without
indicating the extent to which the policy addresses an issue. Indicators
with poor specificity are ambiguous or lack definition of key terms. The report found that both
characteristics were frequent problems among the indicators examined. The
authors state that improving sensitivity and specificity of indicators
is critical to measuring
improvements in population health.
I was gratified to be able to answer promptly, and I did. I said I didn't
There are times when humility is the best response. The expert panel and
policy indicator research group labored long and hard to establish
recommendations. Nevertheless, the
recommendations are still only conjecture, and until they are implemented and
validated, we must fall back on Twain's prompt response as a young riverboat pilot.
When we have no answers, we can contemplate quotes
from a master. Indeed, these quotes may carry you through any number of
trying circumstances in public health. Twain was a pragmatic man. He would
understand if you quote him frequently, and occasionally without proper
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- Burrows NR, Lojo
J, Engelgau MM, Geiss LS. Using survey data for diabetes surveillance among
minority populations: a report of the Centers for Disease Control and
Prevention's expert panel meeting. Prev Chronic Dis [serial
online] 2004 Apr [2004 Mar 15]. Available from: URL: http://www.cdc.gov/pcd/issues/2004/
- Desai J.
State-based diabetes surveillance among minority populations.
Prev Chronic Dis [serial online] 2004 Apr [2004 Mar 15].
Available from: URL: http://www.cdc.gov/pcd/issues/2004/
- Pluto DM,
Phillips MM, Matson-Koffman D, Shepard DM, Raczynski JM, Brownstein JN. Policy and
environmental indicators for heart disease and stroke prevention: data
sources in two states. Prev Chronic Dis [serial online] 2004 Apr [2004
Mar 15]. Available from: URL: http://www.cdc.gov/pcd/issues/2004/
- Twain M. Life on the Mississippi. New York (NY): Signet Publishing;
2001 Nov 7. p. 106.
- Healthy People 2010: understanding and improving health. 2nd ed. U.S.
Department of Health and Human Services; 2000. 76 p. Available from:
- Twain M. The autobiography of Mark Twain. Neider C, editor. New York
(NY): HarperCollins, Publishers, Inc.; 1959. p. 195.
- Twain, 2001, p.36.
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