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November 5, 2003

Risk Factors: Public Health and the Risk Factor: A History of an Uneven Medical Revolution

Author Affiliations
  • 1Seattle, Wash

by Rothstein  William G. (Rochester Studies in Medical History), 466 pp, $95, ISBN 1-58046-127-1, Rochester, NY, Rochester University Press, 2003.

JAMA. 2003;290(17):2336. doi:10.1001/jama.290.17.2336

Public Health and the Risk Factor is a terrific book. It describes the evolution of a concept that has become central to public health and medical thought: the risk factor. The author uses nontechnical language to guide readers through a wide array of 18th-, 19th-, and 20th-century technical developments that are the basis of our current understanding of the risk factor concept.

How did we come to rely on statistical correlations as one basis for taking action steps with individual patients and with populations? Chapters 2 through 5 describe the development of methods (probability, statistics, censuses), measurements (blood pressure, sugar in urine), and systems (vital statistics, life insurance) that laid the foundation for what the author calls "The Invention of the Risk Factor." The role played by commercial life insurance companies was essential. In the United States these companies were established in the early to mid-19th century but, for a variety of reasons, including mismanagement and fraud, covered a relatively small number of lives. In the late 19th century, a new type of policy, industrial life insurance, was sold to millions of workers. Thousands of physicians across the country were paid by life insurance companies to examine potential policy holders. The results of millions of examinations allowed insurance company actuaries to identify or confirm certain risks for death and to share those prognostic findings with the medical community. During the first half of the 20th century,