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 A Textbook of
Public Health Dentistry
 A Textbook of
Public Health Dentistry

CM Marya BDS MDS

Professor and Head
Department of Public Health Dentistry
Sudha Rustagi College of Dental Sciences and Research
Faridabad, Haryana, India

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

New Delhi • St Louis • Panama City • London
Published by
Jaypee Brothers Medical Publishers (P) Ltd

Corporate Office
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A Textbook of Public Health Dentistry

© 2011, Jaypee Brothers Medical Publishers

All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by
any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editor and the
publisher.

This book has been published in good faith that the material provided by the contributors is original. Every effort is made to
ensure accuracy of material, but the publisher, printer and editor will not be held responsible for any inadvertent error(s). In
case of any dispute, all legal matters to be settled under Delhi jurisdiction only.

First Edition: 2011

ISBN 978-93-5025-216-1

Typeset at JPBMP typesetting unit

Printed at
 To
My mother Veena Marya for making me what I am today,
My father Prof Dr RK Marya, a continuous motivational force in my life.
My wife Vandana for her constant encouragement and support.
My children for making life worthwhile.
—CM Marya
 Contributors

Abdul Rashid Khan MBBS MHSc Manik Razdan BDS MS

Associate Professor and Head PhD Student in Health Services Research and Policy
Public Health Medicine Department of Health Policy and Management
Penang Medical College University of Pittsburgh Graduate School of Public Health
Penang, Malaysia Pittsburgh, Pennsylvania
United States of America (USA)
Anil Ankola MDS
Professor and Head
Department of Public Health Dentistry Rakesh Dhankar MD
KLE Institute of Dental Sciences Associate Professor
Belgaum, Karnataka, India Department of Radiotherapy
Pt BD Sharma University of Health Sciences
Anil Gupta MDS Rohtak, Haryana, India
Professor and Head
Department of Pedodontics
RK Marya MD PhD
Desh Bhagat Dental College and Hospital
Professor and Head
Muktsar, Punjab, India
Department of Physiology
Avinash Jnaneswar MDS Faculty of Medicine
Professor AIMST University, Malaysia
Department of Public Health Dentistry
Sudha Rustagi College Dental Sciences and Research Sadanand Kulkarni MDS
Faridabad, Haryana, India Professor and Head
Bhavana Gupta MDS Department of Pedodontics
Reader Pravara Instistute of Medical Sciences
Department of Pedodontics Rural Dental College
Sudha Rustagi College of Dental Sciences and Research Loni, Maharashtra, India
Faridabad, Haryana, India
Swaroop Savanur MDS PG Diploma in Medicolegal Systems
Gurkeerat Singh MDS
Professor
Professor and Head
Department of Orthodontics
Department of Orthodontics
Sinhgad Dental College
Sudha Rustagi College of Dental Sciences and Research
Pune, Maharashtra, India
Faridabad, Haryana, India

KA Narayan MD Vandana Dahiya BDS

Professor and Head Postgraduate Student
Community Medicine and Medical Education Department of Conservative and Endodontics
Faculty of Medicine Sudha Rustagi College of Dental Sciences and Research
AIMST University, Malaysia Faridabad, Haryana, India
 Preface

This textbook is designed for undergraduate and postgraduate students in dentistry as well as health professionals with an
interest in understanding and promoting oral health within communities. Although Public Health Dentistry is concerned with
oral health of the population rather than dental needs of an individual patient, the ultimate beneficiary of public health programs
is an individual.
As expected in a book of Public Health Dentistry, epidemiology, etiology, and preventive measures in context of dental
caries, periodontal diseases and oral cancer have been discussed in detail. Extensive coverage has been given to the role of
fluoride in the prevention of dental caries. The principal diseases of the mouth such as caries, periodontal disease and oral
cancer are lifestyle dependent. A sound public health program can provide effective measures.
Some of the topics have been contributed by highly experienced colleagues from other dental colleges, bringing greater
depth to the subject. The contribution of some chapters such as epidemiology, statistics, and nutrition, by senior teachers in
Faculties of Medicine, Malaysia is gratefully acknowledged.
Forensic dentistry, Occupational hazards, Ergonomics in dentistry and Financial aspects of dental health practice are attracting
greater attention these days. These topics have been included in this book.
The book incorporates the latest syllabus. The study of Public Health Dentistry also involves an appreciation of aspects of
several disciplines including sociology, psychology and health-related behavior, health economics, health promotion and health
service organizational methods in preventive dentistry. All these topics have been given adequate attention.
This textbook deliberately takes a broader international perspective of the dental preventive measures. Optimal solutions of
health service provision are often hard one and one can often benefit from experiences in other countries.
An important aspect of this book is the large number of illustrations, mostly in color, as well as tables. Must-know information
has been highlighted in a large number of boxes.

CM Marya
 Acknowledgments

My teacher and guide Dr BR Ashok Kumar is the base of my academic career in Public Health Dentistry, who has always
inspired me in becoming a good academician.
I would like to express my sincere thanks to all the contributors Dr RK Marya, Dr KA Narayan and Dr Abdul Rashid Khan,
Dr Anil Ankola, Dr Avinash J, Dr Swaroop Savanur, Dr Sadanand Kulkarni, Dr Anil Gupta, Dr Bhavna Gupta,
Dr Manik Razdan, Dr Gurkeerat Singh, Dr Rakesh Dhankar, Dr Vandana Dahiya.
I thank all my colleagues and postgraduate students of Department of Public Health Dentistry at Sudha Rustagi College of
Dental Sciences and Research, Faridabad for their invaluable help in compiling this book. A special thanks to Dr Vartika Kathuria,
Dr Nidhi Pruthi, Dr Sonal Dhingra and Dr Shekhar Grover for helping me in checking and rechecking the manuscript of this
book. I would also like to thank World Health Organization for allowing me to use their world map on dental caries prevalence.
I greatly appreciate Dr Sanjay Tewari, Dean and Principal, Dental College, Pt BD Sharma University of Health Sciences,
Rohtak and Dr KR Indushekar, Director, PG Studies, Sudha Rustagi Dental College, Faridabad for their encouraging words and
support in this work.
I would like to thank my friends and colleagues Dr Vishal Juneja, Dr Hind P Bhatia, Dr Ashwani Pruthi,
Dr Ashish Gupta, Dr Baiju, Dr Navin A Ingle, Dr Suhas Kulkarni and Dr Pradeep Tangade for their support.
I would like to thank my Chairman Mr Dharamvir Gupta and Mr Deepak Gupta, Secretary, Wing Cdr Dr Niraj Rampal VSM,
Principal, Sudha Rustagi College of Dental Sciences and Research, Faridabad for providing me with a congenial environment to
compile this book.
My sincere thanks to Shri Jitendar P Vij (Chairman and Managing Director), Mr Tarun Duneja (Director Publishing),
Mr KK Raman (Production Manager), Mr Rajesh, and Mr Radhey Shyam of M/s Jaypee Brothers Medical Publishers (P) Ltd,
New Delhi and their team for their cooperation in the publication of this book.
 Contents

SECTION 1: PUBLIC HEALTH

1. Changing Concepts of Health and Prevention of Disease ......................................................... 3

CM Marya
Determinants of Health 3
Theories of Disease Causation 4
Levels or Categories of Prevention 6
Levels of Prevention 6
Approaches of Prevention 8

2. Basic Epidemiology ....................................................................................................................... 9

Abdul Rashid Khan, KA Narayan
Introduction to Epidemiology 9
Measuring Health 11
Epidemiological Studies 13
Screening 20
Association and Causation 21

3. Biostatistics .................................................................................................................................. 23
KA Narayan, Abdul Rashid Khan
Why Learn Statistics? 23
How Data is Collected? 24
Data Display and Summary 24
Data Summary 26
Statistical Distributions 28
Chi Square Distribution 29
Tests of Significance 29
Statistical Significance 30
Sampling 31

4. Environment and Health .............................................................................................................. 34

CM Marya
Water Quality—Criteria and Standards 39
Hardness of Water 42
Special Treatment of Water 43
Air 43
Noise 44
xii A Textbook of Public Health Dentistry
Radiation 45
Housing 46
Waste Management 47

5. Organization of the Health System in India ............................................................................... 49

CM Marya
Voluntary Health Agencies in India 50
Indian Council for Child Welfare (ICCW) 50
Family Planning Association of India 51
Nutrition Foundation of India 51
Voluntary Health Association of India (VHAI) 51
The Kasturba Gandhi Trust 51
Action for Autism 52
Ajit Foundation 52
Chethana 52
All India Women’s Conference (AIWC) 52
Pragati 52
The Hind Kusht Nivaran Sangh 52

6. Primary Health Care ..................................................................................................................... 55

CM Marya
Concept of Primary Health Care 55
Origin of Primary Health Care 55
Alma-Ata 56
Components of Primary Health Care 56
Declaration of Alma-Ata 58

7. Health Agencies of the World...................................................................................................... 61

CM Marya
International Red Cross and Red Crescent Movement 62
CARE USA 62
Refugee and Disaster Relief Organizations 63
WHO (World Health Organization) 63
PAHO (The Pan, American Health Organization) 66
FAO (The Food and Agriculture Organization) 67
UNDP (The United Nations Development Program) 68
PAHEF (The Pan-American Health and Education Foundation) 68
ICRC (International Committee of the Red Cross) 69
The World Bank 70
UNFPA (United Nations Population Fund) 70
CARE (Cooperative for American Relief Everywhere) 72
The Rockefeller Foundation [RF] 72
The Ford Foundation 73
World Health Days 73
Important Dates – World Health 74

8. Nutrition and Health ..................................................................................................................... 75

RK Marya
The Basal Energy Requirement 75
Physical Work 75
Total Caloric Requirements 75
Minerals 79
Fat Soluble Vitamins 79
Water Soluble Vitamins 81
 Contents xiii
Disorders of Malnutrition (Undernutrition) 82
Disorders of Overnutrition 84

SECTION 2: DENTAL PUBLIC HEALTH

9. Introduction to Public Health Dentistry ...................................................................................... 87
CM Marya
Definitions of Public Health 87
Essential Public Health Services 88
Concepts of Public Health 88
Public Health Problem 88
Impact of Oral Disease 88
Milestones in Dental Public Health 90
Historical Overview 90
Aims of Dental Public Health 92
Tools of Dental Public Health 93
Procedural Steps in Dental Public Health 93
Functions of Public Health Dentistry 95
Public Health Milestones in Independent India 95

10. Epidemiology of Dental Caries ................................................................................................... 98

CM Marya
Definition 98
Epidemiology 98
Trends in Dental Caries 100
Reasons for Caries Decline and Rise 100
Dental Caries Pandemic 100
Caries Incidence in Europe 100
Caries Incidence in the United States 100
Indian Scenario 100
Dental Caries in Underdeveloped Countries 101
Probable Reasons for the Marked Decline in Dental Caries in Most Western Industrialized
Countries 101
The Caries Process (Pathogenesis) 102
Theories of Dental Caries 103
Areas Prone to Dental Caries 104
Importance of Diagnosis of Dental Caries 104
Classification of Dental Caries 104
Enamel Changes During Early Caries Lesion Development 105
Changes Recorded in Enamel Covered by Dental Plaque 105
Histopathology of Dental Caries 105
Caries of the Enamel 105
Caries of the Dentine 106
Various Zones of Caries of Dentine 107
Caries in Dentine 108
Root Caries 108
Susceptibility of Different Teeth 108
Factors Affecting the Epidemiology of Dental Caries 108
Factors Affecting Development of Dental Caries 109
Host and Teeth Factors 109
Agent Factors 110
Environmental Factors 111
Early Childhood Caries 111
Root Caries 111
xiv A Textbook of Public Health Dentistry
11. Epidemiology of Periodontal Disease ....................................................................................... 114
CM Marya
Disease Process and Changing Concept 114
Epidemiology 114
Prevalence of Gingivitis 114
Prevalence of Periodontitis 115
Causes of Periodontal Disease 116
Risk Factors in Periodontal Disease 117
Structure of the Periodontal Tissues 117
Gingivae 117
Periodontal Ligament 118
The Natural History of Periodontal Disease 118
Periodontitis 119
Classification of Periodontal Disease 119
Determinants of Periodontitis 119

12. Epidemiology, Etiology and Prevention of Oral Cancer ......................................................... 126

CM Marya, Rakesh Dhankar
Incidence 126
In India and Sri Lanka 126
Western Countries 126
Trends 126
Smoked Tobacco 127
Types 127
Constituents of Tobacco Smoke 129
Smokeless Tobacco 130
Alcohol 131
Mouthwash Use 131
Vitamins and Essential Minerals 131
Occupation 131
Sunlight 131
Chemical Agents 131
Potentially Malignant Lesions 131
Viral Infection 132
Trauma 132
Pathogenesis 132
Pathological Types 133
Diagnostic Evaluation 135
Staging 135
The Exam Review 136
The Importance of Early Detection 140
Levels of Prevention of Oral Cancer 140
Public Health Approaches to Prevention of Oral Cancer 142
Tobacco/Smoking Cessation 142

13. Epidemiology and Etiology of Malocclusion ........................................................................... 144

Gurkeerat Singh
An Epidemiological View of Malocclusion 144
Classification of Malocclusion 144
Angle’s Classification of Malocclusion 144
Dewey’s Modification of Angle’s Classification of Malocclusion 147
Bennette’s Classification of Malocclusion 147
 Contents xv
Skeletal Classification 148
Ackerman-Profitt System of Classification 148
Incisor Classification 148
Prevalence of Malocclusion 150
Etiology of Malocclusion 153
Untreated Malocclusions 155

14. Dental Health Education ............................................................................................................ 156

CM Marya
Definition 156
Contents of Health Education 156
Principles of Health Education 157
Models of Health Education 158
Communication 159
Key Elements in Communication 159
Barriers or Road Block of Communication 160
Aids in Health Education 160
Methods in Health Education 161
Steps in Health Education Planning 162
Steps of Learning 163
Various Health Education Methods and Media 163

15. Oral Health Survey Procedures ................................................................................................ 165

CM Marya
Scientific Method in Conducting a Dental Survey 165
Oral Health Surveys (WHO-1997) 167
Pathfinder Surveys 168
Organizing the Survey 170
Reliability and Validity of Data 170
Implementing the Survey 171
Assessment Form 173
Obtaining Assistance from WHO 181
Post Survey Action and Preparation of Survey Reports 181

16. Dental Indices ............................................................................................................................. 185

CM Marya
Definition 185
Properties of an Ideal Index 185
Types of Indices 186
Purpose and Uses of an Index 186
Indices Commonly Used in Dentistry 187
Periodontal Indices 187
Plaque Control Record 188
Navy Plaque Index 188
Oral Hygiene Index (OHI) 189
Patient Hygiene Performance Index (PHP Index) 192
Gingival Index (GI) 193
Calculus Surface Index 193
Periodontal Index (PI) 193
Periodontal Disease Index (PDI) 194
Gingival Bleeding Index (GBI) 195
Papillary-Marginal-Attached Gingival Index 196
Gingival Bone Count Index 197
xvi A Textbook of Public Health Dentistry
Community Periodontal Index of Treatmant Needs (CPITN) 197
Community Periodontal Index (CPI) 201
Turesky-Gilmore-Glickman Modification of the Quigley-Hein Plaque Index 202
The Navy Periodontal Disease Index (NPDI) 202
Indices for Dental Caries 204
Decayed, Missing and Filled Teeth (DMFT) Index 204
WHO Modification of DMF Index 205
Dental Caries Index for Deciduous Teeth (dmft and dmfs) 205
Mixed Dentition 206
WHO Index for Dental Caries 206
Significant Caries Index 207
Fluorosis Index 207
Thylstrup-Fejerskov Index of Fluorosis (TF) 208
Tooth Surface Index of Fluorosis (TSIF) 208
Indices for Malocclusion 210
The Index of Orthodontic Treatment Need (IOTN) 210

17. Dental Auxiliaries ....................................................................................................................... 212

CM Marya
Dental Team 212
Comprehensive Dental Care 212
Definition 212
Classification 213
Types of Supervision 213
Nonoperating Auxiliaries 214
Operating Auxiliaries 215
Auxiliaries Personnel in India 216
Four-Handed Dentistry 216

18. Finance in Dentistry ................................................................................................................... 218

CM Marya
Preventive and Diagnostic Dental Care 218
Basic Dental Care and Dental Procedures 218
Major Dental Care 218
Common Terms 218
Mechanism of Payment for Dental Care 219
Postpayment Plan 219
Private Third Party Prepayment Plans 219
Reimbursement of Dentists in Prepayment Plans 220
Private Third Party Prepayment Plans 220
Health Maintenance Organization (HMO) 222
Staff Model 222
Group Model 222
Independent Practice Association (IPA) 222
Capitated Network or Direct Contract Model 222
Capitation Plan 222
Public Programs 223
Medicare 223
Medicaid 223

19. Oral Health Promotion ............................................................................................................... 224

CM Marya
Concept of Health 224
 Contents xvii
Definition of Health Promotion 224
Principles of Health Promotion 224
Oral Health Promotion 225
Strategies of Oral Health Promotion 225
Approaches in Oral Health Promotion 226
Concepts in Health Promotion 226
Elements of Health Promotion 226
Methods of Oral Health Promotion 227
Stages of Behavior Change 227
Goals of Oral Health 228
Global Oral Health Goals 228
National Oral Health Program in India 230
The Magnitude of the Problem 231
Status of Oral Health Care System in India 231
Economic Burden of Oral Diseases 232
Strategies for Implementation 232
Additional Measures Suggested 233
Involvement and Reorientation of the Dentists Working in Urban Areas 234
Implementation of Primary Preventive Package through the School Health Schemes in the Different Urban
Areas 234
Reorientation of Dental Education in India 235
Involvement of Other Allied Departments 235
National Institute of Dental Research (NIDR) 235
National Training Center 235

20. Planning and Evaluation ............................................................................................................ 236

CM Marya
Definition 236
Purpose of Planning 236
Uses of Planning 236
Planning Cycle 236
Evaluation 238
Reasons for Evaluation 239

21. School Dental Health Programs ................................................................................................ 240

CM Marya
Models 240
The Three-Component Model 240
The Eight-Component Model 240
Definition 241
Health Promoting Schools 242
Objectives of School Based Dental Health Program 243
Partners in School Oral Health Programs 243
Self-Applied Fluorides 243
School Based Sealant Program 243
School Water Fluoridation 244
Topical Fluoride Application Program 244
Oral Health Education 244
Guidelines for an Ideal School Dental Program 244
School Dental Health Programs 246
Learning about your Oral Health 246
Tattle Tooth I Program 246
Tattle Tooth II Program 247
Theta Program 247
xviii A Textbook of Public Health Dentistry
Yukon Children’s Dental Health Program 247
Askov Dental Health Education 248
The Maine School Oral Health Program 248
Elements of School Oral Health Program 248
Some School Based Oral Health Programs in Various Countries 249
Smiling Schools Project in Namibia 250
Dental Public Health Programs in Seychelles 250
School-Based Oral Health Education Program in China 250
School Oral Health Program in Kuwait 251
School Oral Health Program in India 251
Incremental Dental Care 251

22. Dental Council of India .............................................................................................................. 253

CM Marya
Introduction 253
Objectives/Duties 253
Constitution and Composition of Council 254
Incorporation of Council 254
Mode of Election 254
Term of Office and Casual Vacancies 254
President and Vice-President of Council 254
The Executive Committee 255
Recognition of Dental Qualifications 255
Nonrecognition of Dental Qualifications 256
Qualifications of Dental Hygienists 256
Qualifications of Dental Mechanics 256
Effect of Recognition 256
Withdrawal of Recognition 256
Withdrawal of Recognition of Recognized Dental Qualification 256
Professional Conduct 257
The Indian Register 257

23. The Dentist Act of India and Indian Dental Association ......................................................... 258
CM Marya
The Dentists Act (29th March, 1948) 258
Introduction 258
The Dentists (Amendment) Act, 1993 (2nd April, 1993) 259
Indian Dental Association (IDA) 261
Objectives of IDA 261
Types of Membership 262
Head Office 262
State Branch 264

24. Ethics in Dentistry ...................................................................................................................... 265

CM Marya
Definition 265
Principles of Ethics 265
Code of Ethics for Dentists by Dental Council of India 267
Duties and Obligation of Dentists towards Patients and Public 267
Duties of One Dentist towards Another 267
Unethical Practices 268
General Principles for a Dental Professional Ethical Code in the Countries of the EU
(European Union) 268
 Contents xix

SECTION 3: PREVENTIVE DENTISTRY

25. Dental Plaque .............................................................................................................................. 273
CM Marya
Formation of Dental Plaque Biofilms 273
Supra and Subgingival Plaque 276
Significance of Dental Plaque 276

26. Plaque Control ............................................................................................................................ 277

CM Marya
Definition 277
Guidelines for Acceptance of Chemotherapeutic Products 277
Approaches in Plaque Control 277
Manual Toothbrushes 278
Powered Toothbrushes 279
Sonic and Ultrasonic Toothbrushes 281
Ionic Toothbrushes 281
Bionic Toothbrush—Soladey 281
Toothbrushing Techniques 282
The Bass Method: Sulcular Brushing 282
Modified Bass Technique 283
Stillman’s Method 283
Modified Stillman’s Technique 284
The Rolling Stroke 284
Charter’s Method 284
Circular: The Fones Method 285
Vertical: Leonard Method 285
Physiologic: Smith’s Method 285
Interdental Oral Hygiene Aids 285
Dental Floss 286
Floss Holder 288
Toothpicks 288
Interproximal Brushes 289
Single Tuft Brushes 289
Knitting Yarn 290
Gauze Strip 290
Pipe Cleaner 290
Wedge Stimulator 290
Adjunctive Aids 291
Ingredients 292
Abrasives 292
Humectant 293
Water 293
Binding Agent 293
Detergents 293
Flavoring Agent 293
Preservative 293
Therapeutic Agent 293
Sweetening Agents 293
Therapeutic Dentifrices 294
Anticaries 294
Anti-plaque Agents 294
xx A Textbook of Public Health Dentistry
Anticalculus 294
Antihypersensitivity 295
Whitening Agents 295
Disclosing Agents 297
Chemical Plaque Control 298
Vehicles for Delivery of Chemical Agents 298
Antibiotics 299
Enzymes 299
Phenols and Essential Oils 300
Quaternary Ammonium Compounds 301
Bisbiguanide Antiseptics 301
Natural Products 302
Metal Salts 302
Amine Alcohols 302
Fluorides 302
Oral Hygiene Promotion 303
Oral Prophylaxis 304
Steps in Oral Prophylaxis 304

27. Diet and Dental Caries ............................................................................................................... 306

CM Marya
Role of Diet 306
Role of Saliva 307
Caries Mechanism 307
Human Observational Studies 307
Human Interventional Studies 308
Animal Experiment 309
Enamel Slab Experiments 309
Plaque pH Studies 309
Incubation Experiments 309
Evidence 309
The Basic Stephan Curve 310
Stephan Curve: Clinical Relevance 312
Dietary Factor and Dental Caries 312
Cariogenicity of Sugars 313
Carbohydrates and Dental Caries 313
Starches and Dental Caries 314
Fruits and Dental Caries 315
Protective Factors and Caries 315
Effect of Fluoride on Sugar-Caries Relationship 315
Non-sugar Sweeteners and Dental Caries 316
Limitations of Intense Sweeteners 316
Uses of Intense Sweeteners 316
Bulk Sweeteners 316

28. Caries Risk Assessment ............................................................................................................ 317

CM Marya
Goals of Caries Risk Assesment 317
Caries Disease Indicators 317
Caries Risk Factors 318
Caries Protective Factors 318
Factors Relevant to Assessment of Dental Caries 319
Xerostomia 320
Xerostomia and Dental Caries 320
 Contents xxi
Classification 321
Caries Risk Assessment 321
Factors in Low, Moderate and High Caries Risk Assessment 321
Cariogram 322

29. Caries Activity Tests .................................................................................................................. 324

CM Marya, Vandana Dahiya
Objectives of Caries Activity Tests 324
Advantages of Caries Activity Tests 324
Criteria of an Ideal Caries Activity Tests 324
Caries Activity and Caries Susceptibility 324
Various Caries Activity Tests 325
Streptococcus Mutans Screening Test 328

30. Fluorides in Dentistry ................................................................................................................ 330

CM Marya
History of Water Fluoridation 330
Fluoride in Environment 331
Fluoride in Water and Atmosphere 331
Fluoride in Biosphere 332
Fluoride Metabolism 332
Pharmacokinetics of Fluoride 333
Artificial Fluoridation (Controlled Studies) 334
Effectiveness of Water Fluoridation 335
World Status of Fluoridation 335
Appropriate Levels of Fluoride in Drinking Water 335
Fluoride Compound Used in Water Fluoridation 336
Methods of Water Fluoridation 336
Feasibility of Water Fluoridation in India 337
Mechanism of Action of Fluorides 337
Increased Enamel Resistance 339
Inhibition of Bacterial Enzyme System 340
Increased Rate of Post Eruptive Maturation 340
Enhancing Remineralization 340
Improves Tooth Morphology 341
Fluoride Administration 341
Systemic Fluorides 342
Water Fluoridation 342
Requirements for Water Fluoridation 342
Economics of Fluoridation 342
Medical Aspect of Water Fluoridation 343
Fluoridation and the Law 343
Reasons for Cessation of Fluoridation 344
Ethics of Water Fluoridation 344
Pre-eruptive Effect of Water Fluoridation 344
Water Fluoridation and Root Surface Caries 344
Dietary Supplements 345
Topical Fluorides 348
Advantages and Disadvantages of Topical Fluorides 348
Mechanism of Action 348
Classification 349
Professionally Applied Fluorides [PATF] 349
Clinical Application 351
xxii A Textbook of Public Health Dentistry
Fluoride Application Techniques 356
Self Applied Fluorides 358
Fluoride Dentifrices 358
Fluoride Mouthrinses 360
Methods of Preparation 360
Recommendations 360
Advantages 360
Fluoride Exposure from Multiple Sources 360
Evidence in Caries Reduction 361

31. Dental Fluorosis and its Prevention ......................................................................................... 363

CM Marya
Sources of Fluoride 363
Fluoride Intake 364
Fluoride Toxicity 366
Management of Acute Fluoride Toxicity 367
Lethal and Safe Doses of Fluoride 368
Dental Fluorosis and Enamel Opacities 368
Various Forms of Fluorosis 368
Prevention of Fluorosis 369
Defluoridation of Water 369
Various Methods of Defluoridation of Water 371
Defluoridation of Water Using Nalgonda Technique 373

32. Dental Caries Vaccine ................................................................................................................ 375

Avinash J, CM Marya
History of Vaccination 375
Molecular Pathogenesis of Dental Caries 375
Basic Concepts 376
Different Types of Immunity 376
Vaccines 376
Specific Vaccine Targets 378
Routes of Immunization 378
Common Mucosal Immune System 379
Passive Immunization 380
Active Immunization in Humans 380
Passive Immune Approaches 380
Adjuvants and Delivery Systems for Dental Caries Vaccines 381
Timing and Target Population for Caries Vaccination 382
Recent Advances 382
Risks of Using Caries Vaccine 382
Prospects and Concerns 383
Public Health Aspects 383

33. Pit and Fissure Sealants ............................................................................................................ 384

CM Marya
Classification of Pits and Fissures 384
Purpose of Sealant 384
Criteria for the Ideal Sealant 384
Rationale for Using Pit and Fissure Sealants 387
Procedure of Pit and Fissure Sealant Application 387
Indications for Use 388
Contraindications 388
Sealant Retention 388
 Contents xxiii
Incipient Fissure Caries and Sealants 389
Preventive Resin Restorations 389
Fluoride Containing Sealants 390
Public Health Sealant Programs 390
Cost Effectiveness 390
Sealant Failure 391
Newer Sealants 391

34. Atraumatic Restorative Treatment ............................................................................................ 395

CM Marya
Principles 395
Reasons of Using Hand Instruments for ART 395
Material Used 395
Contraindications for ART 395
Instruments 395
Materials 396
Restoring One-surface Cavities Using ART 396
Treatment Material (Glass Ionomer as a Restorative Material) 397
Restoring Multiple-surface Cavities Using ART 398
Monitoring ART Restorations 399
Protocol for Failed or Defective Restoration 399
Advantages and Limitation of ART 399
Failure Prevention and Management 400

35. Prevention of Dental Caries ...................................................................................................... 401

CM Marya
Caries Formation 401
Methods of Prevention of Dental Caries 402
Increase the Resistance of the Teeth 403
Combat Caries-inducing Microorganisms 403
Modify the Diet 403
Increase the Resistance of the Host/Teeth 404
Systemic Use of Fluoride 404
Topical Fluorides 405
Combat Caries-inducing Microorganisms/Plaque Removal and Control 406
Modify the Diet /Diet Control 407
Strategies for Prevention of Dental Caries 408
The Caries Balance 409
Modifying the Carious Process 410
Risk Groups for Dental Caries 410
Anticipatory Guidance: Parent and Patient Education 410
Levels of Prevention of Dental Caries 411
Behavior Modification in High Caries Risk Children 412
Preventive Therapy Based on Risk Factors 412
Behavior Modification in Geriatrics 412

36. Prevention of Periodontal Disease ........................................................................................... 415

CM Marya
Oral Hygiene Assessment 415
Stages of Periodontal Disease 415
Prevention of Periodontal Disease 416
Methods of Prevention of Periodontal Disease 417
Patients’ Role in Preventive Periodontal Therapy 420
Supportive Periodontal Therapy (SPT) 420
xxiv A Textbook of Public Health Dentistry
37. Prevention of Malocclusion ....................................................................................................... 422
CM Marya, Gurkeerat Singh
Introduction 422
Preventive Measures Undertaken (Preventive Orthodontics) 422
Parent Counseling 422
Caries Control 423
Space Maintenance 424
Exfoliation of Deciduous Teeth 424
Abnormal Frenal Attachments 424
Locked Permanent First Molars 424
Abnormal Oral Musculature 425
Space Maintenance (in the Deciduous and the Mixed Dentition) 425
Factors to be Considered for Space Maintenance 426
Ideal Requirements of Space Maintainers 427
Classification of Space Maintainers 427
Interceptive Orthodontics 427
Resolution of Crowding 431

38. Wasting Diseases of Teeth ........................................................................................................ 434

CM Marya
Introduction 434
Tooth Wear 434
Attrition 434
Abrasion 434
Erosion 435
Abfraction 437
Epidemiology of Tooth Wear 437
Prevention of Tooth Wear 439

39. Prevention of Dental Trauma ..................................................................................................... 441

CM Marya
Causes 441
Mechanism for the Action of the Mouthguards 442
Selection of a Mouthguard 442
Types of Mouthguard 443
Steps in Mouthguard Formation 444
Preventing Dental Injury in Childcare 445
Prevention of Dental Trauma 445
Primary Prevention 445
Playground Surfaces 446
Outdoor Home Playground Safety Checklist (CPSC) 446
Early Treatment of Large Overjets (Mixed Dentition) 447
Secondary Prevention 447
First Aid for an Avulsed Tooth 448
Dental Office Treatment for an Avulsed Tooth 448

40. Occupational Hazards in Dentistry ........................................................................................... 450

CM Marya
Prevalence 450
Definition 450

41. Infection Control in Dentistry .................................................................................................... 455

CM Marya
Infection Control 455
 Contents xxv
Transmission of Infection 456
Standard Precautions 456
Components of Infection Control 457
Treatment Room Features 465
Single-use Disposable Instruments 469
Handling of Biopsy Specimens 469
Use of Extracted Teeth in Dental Educational Settings 469
Biomedical Waste Management 469

SECTION 4: BEHAVIORAL SCIENCES

42. Sociology as Applied to Dental Public Health ......................................................................... 473
Manik Razdan, CM Marya
Definition 473
Historical Role of Medicine 473
Evolution of Human Society 473
Variation in Disease Patterns with Changing Society 474
Changing Society and Patterns of Dental Diseases 474
The Socio-environmental Approach (Social Model) 475
Health and Social Factors 475
Social Classes and the Reaction of Each to Dental Care 476
Age Inequalities in Health 478
Gender Inequalities in Health 479
Ethnic Inequalities in Health 479
Cultural Pattern and Concepts Taboos as Related to Health 479
Taboos Related to Dentistry 480
Medical Anthropology 481
History of Medical Anthropology 481
Traditional Medical Systems 481
The Relation of Sociology to Anthropology 481

43. Child Psychology ....................................................................................................................... 483

Bhavna Gupta, Anil Gupta
Definitions 483
Importance of Learning Child Psychology 483
Theories of Child Psychology 483
Other Theory 487

44. Behavior Management in Community Dentistry ..................................................................... 488

Sadanand K, Anil Gupta
Documentation/Categorizing Behavior 488
Variables Influencing Child Behavior 489
Clinic Setup 489
Behavior Management 490

SECTION 5: DENTAL PRACTICE

45. Dental Practice Management .................................................................................................... 497
CM Marya
Definition 497
Establishment of Dental Office 497
xxvi A Textbook of Public Health Dentistry
Selection of Place 497
Selection of Location 497
Selection of Building 498
Financial Assistance 498
Designing of Dental Office 498
Management of Dental Office 498
Personnel Management 498
Patient Management 499
Record Management 499
Accounting and Other Financial Aspects of Dental Practice 500
Factors Influencing Dental Practice 500
The Ways of Initiating a Dental Practice 500
Starting an Own Practice 500
Buying an Old Practice and/or Working with an Associate Dentist 500

46. Forensic Dentistry ...................................................................................................................... 501

CM Marya
Definition 501
Constituents of Forensic Odontology 501
History 501
Role of Teeth in Determination of Human Identity 502
Bite Marks 503
Mass Disaster 505
Age Estimation 505
Sex Identification 506
Internal and External Documentation and Communication Problems 506
Forensic Radiology 506
Child Abuse 507
Cheiloscopy 507
Forensic Anthropology 507
Computer Odontology 508

47. Computers in Dentistry .............................................................................................................. 509

CM Marya
Parts of Computer 509
Applications of Computers in Dentistry 511

48. Ergonomics in Dentistry ............................................................................................................ 517

CM Marya
Neck and Shoulder 517
Wrist and Hand 518
Lower Back Pain 518
Psychosocial Factors and Work-related MSDs in Dentistry 518
Prevention Strategies Work Place Intervention 518
Provide Sufficient Space 519
Accommodate Individual Preferences 519
Reduce Physical Effort 519
Instrument Design 519
Hand Instruments 519
Dental Handpieces 519
Lighting 520
Magnification 520
Operator Chair 520
 Contents xxvii
Patient Chair 520
Posture/Positioning 520
Scheduling 521
Personal Protective Equipment 521

49. Consumer Protection Act .......................................................................................................... 522

Avinash J, Swaroop Savanur
Introduction 522
Nature of the Legal System 522
Definitions 522
Consumer Disputes Redressal Agencies 523
Preventive Steps Against Litigation 525
Consent 526
Protection against Outcome of Litigation 528

50. Comprehensive Dental Care ..................................................................................................... 529

Anil Ankola
Initial Care versus Maintenance Care 529
Prevention versus Treatment 529
Manpower Involved in Comprehensive Dental Care 529
Prerequisites for a Good Comprehensive Dental Care Program 530
Record Maintenance 530
Challenges and Limitations 530
Role of Public Health Dentists 530

Definitions ............................................................................................................................................ 531

Index .................................................................................................................................................... 541
 Changing Concepts of Health
1 and Prevention of Disease
CM Marya

Health is defined in the World Health Organization’s Constitu- 2. Employment: Unemployment, underemployment and
tion as “a state of complete physical, social and mental well- stressful work are associated with poorer health. People
being, and not merely the absence of disease or infirmity. who have more control over their work circumstances and
Thus health “is a positive concept emphasizing social and fewer stress related demands of the job are healthier and
personal resources as well as physical capabilities”. often live longer than those in more stressful or riskier
To be healthy is to be in a state of homeostasis (balance) work and activities
with one’s surroundings. A healthy person, therefore, needs to 3. Education: Health status improves with level of educa-
maintain healthy habits such as taking regular exercise and tion. Education increases opportunities for income and
adequate rest, adopting a high level of personal hygiene, eat- job security, and equips people with a sense of control
ing a nutritionally balanced diet, abstaining from the abuse of over life circumstances-key factors that influence health.
drugs and alcohol, taking care of one’s mental well-being and Low education levels are linked with poor health, more
developing social skills to interact in a positive manner within stress and lower self-confidence.
society. 4. Social environments: The array of values and norms of a
society, in varying ways, influence the health and well-
DETERMINANTS OF HEALTH being of individuals and populations. In addition, social
stability, recognition of diversity, safety, good working re-
Many factors combine together to affect the health of individu-
lationships, and cohesive communities provide a support-
als and communities. Whether people are healthy or not, is
ive society that reduces or avoids many potential risks to
determined by their circumstances and environment. The fac-
good health. Studies have shown that low availability of
tors which have been found to have the most significant influ-
emotional support and low social participation has a nega-
ence – for better or worse – are widely known as the determi-
tive impact on health and well-being.
nants of health. While health and social services make a contri-
5. Physical environments: Physical factors in the natural
bution to health, most of the key determinants of health lie
outside the direct influence of health and social care; for ex- environment (e.g., air, water quality) are key influences
ample, education, employment, housing, and environment. on health. Factors in the human-built environment such
To a large extent, factors such as genetics, where we live, the as housing, workplace safety and road design are also
state of our environment, our income and education level, and important influences.
our relationships with friends and family all have considerable 6. Healthy child development: The effect of prenatal and
impacts on health, whereas the more commonly considered early childhood experiences on subsequent health, well-
factors such as access and use of health care services often being, coping skills and competence is very powerful.
have less of an impact. Children born in low-income families are more likely than
Public Health Agency of Canada and the World Health those born to high-income families to have low birth
Organization has identified 12 determinants of health: weights, to eat less nutritious food, and to have more
1. Income and social status: Health status improves at each difficulty in school.
step up the income and social hierarchy. High income 7. Personal health practices and coping skills: Balanced eat-
determines living conditions such as safe housing and ing, keeping active, smoking, drinking, and how we deal
ability to buy sufficient good food. The healthiest popu- with life’s stresses and challenges, all affect health.
lations are those in societies which are prosperous and 8. Health services: Access and use of services that prevent
have an equitable distribution of wealth. and treat disease influencing health.
4 Section 1 N Public Health
9. Social support networks: Support from families, friends A physically fit person can carry out usual daily activities
and communities is associated with better health. The without undue fatigue and has enough energy to enjoy leisure
importance of effective responses to stress and having time and to meet common emergencies.
the support of family and friends provides a caring and
supportive relationship that seems to act as a buffer against (ii) Social
health problems. It is the ability to interact with other individuals. Social depri-
10. Biology and genetic endowment: Inheritance plays a part vation - intellectual, emotional, ethical, and spiritual - and pro-
in determining lifespan, healthiness and the likelihood of longed exposure to social pathology and poverty may seri-
developing certain illnesses. ously impede the actualization of the individual’s constructive
11. Gender: Men and women suffer from different types of potentialities.
diseases at different ages.
(iii) Mental
12. Culture: Culture can be defined as all the ways of life
including arts, beliefs and institutions of a population that Ability to process information and act properly.
are passed down from generation to generation. Culture (iv) Emotional
includes codes of manners, dress, language, religion, ritu-
Ability to cope, adjust, and adapt.
als, norms of behavior such as law and morality, and sys-
tems of belief as well as the art. Customs and traditions, (v) Spiritual
and the beliefs of the family and community, all affect
It is the belief in some force or dynamic other than humans.
health.
Human health involves a struggle to achieve a meaningful re-
DETERMINANTS OF HEALTH lationship with the universe and life. To ignore humankind’s
psychospiritual nature in developing models of health, would
Public Health Agency of Canada and the World Health Organiza- be to deal with a dehumanized caricature.
tion have identified 12 determinants of health:
• Income and social status (vi) Environmental
• Employment
It comprises of (i) External: one’s surroundings, (e.g., habitat,
• Education
occupation) and (ii) Internal: an individual’s internal structure
• Social environments
• Physical environments (e.g., genetics)
• Healthy child development
• Personal health practices and coping skills THEORIES OF DISEASE CAUSATION
• Health services
• Social support networks i. Germ theory of disease (monocausal): Work of Koch and
• Biology and genetic endowment Pasteur revealed that the prevailing health problems of
• Gender the time were the products of living organisms. Isolation
• Culture of bacillus causing tuberculosis and identification of the
organism responsible for 22 infectious diseases between
1880 to 1900, gave rise to the idea that each disease had
Dimensions of Health a single and a specific cause. A set of rules was formu-
Health is complex and involves the interaction of various fac- lated by Koch (Koch postulates) for establishing causal
tors. In 1948, the World Health Organization identified pa- relationship between a microorganism and a disease
rameters to measure the functionality of an individual. The states. In brief, it was essential that to be ascribed a causal
first three identified barometers include the physical, the so- role, the agent must always be found with the disease in
question and not with any other disease.
cial, and the mental constructs. Later, the emotional, spiritual,
and environmental dimensions were added to the list. ii. Epidemiological triad: The germ theory could not explain
why not all those exposed to pathogen become ill: an
(i) Physical organism or other noxious agent is a necessary, but not a
sufficient cause of disease. The epidemiological triangle
It is an ability of human body structure to function properly.
approach sees disease as the product of an interaction
Levels of physical fitness are determined by interacting genetic,
between an agent, a host, and the environment. The epi-
environmental and individual factors. It is also affected by many demiological triangle is useful in understanding infectious
interacting variables such as age, sex, diet, disease, stress, sleep, disorders, but is less useful with respect to chronic and
physical activity, medical and dental services, and by one’s life degenerative disorders such as stroke arthritis and heart
cycle and lifestyle. disease.
 Chapter 1 N Changing Concepts of Health and Prevention of Disease 5
iii. Web of causation: The web of causation considers all the Prevention of Disease
predisposing factors of any type and their complex inter-
Definition
relationship with each other. This model is ideally suited
for study of chronic diseases, where the disease agent is Prevention can be defined as ‘the action of keeping from hap-
often not known. The disease is the outcome of the inter- pening, or of rendering impossible, an anticipated event or
action of the multiple factors. It does not mean that to act.’
control a disease all or most of the factors need to be This definition assumes that the thing being prevented is
removed or controlled. The removal or elimination of even anticipated, but it does not mean that the extent, severity, or
one factor may sometime be sufficient to control a dis- extent of the thing is always known. Prevention in health care
ease provided that factor is sufficiently important. means action to stop ill health before it begins.
iv. The theory of general susceptibility: This theory has
emerged over the past 25 years and is different in impor- Criteria for Disease Prevention
tant ways from monocausal and multicausal cause of dis- 1. The disease and conditions are significant.
ease. It is not concerned with identifying single or mul- 2. There is prevention that works.
tiple risk factors associated with specific disorders. It seeks 3. Prevention is better than cure, repair, or doing nothing.
to understand why some social groups are more suscep- 4. Sufficient resources are available to implement the pre-
tible to disease and death in general. ventive measures.
v. The socio-environmental approach: During the 1980s, the 5. The economics can be calculated.
theory of general susceptibility became more explicitly 6. The process is ethical.
formulated as the socio-environm ental approach. This 1. Disease is significant:
approach seeks to identify the factors which make and Significance of disease can be assessed in terms of three
keep people healthy and is not much concerned with the factors;
cause of the disease. It focuses on the population rather • Incidence and prevalence (how much disease is there
than the individuals. It forms the basis for the health pro- and how many people are affected).
motion strategies. • Mortality and morbidity (what are the effects of dis-
ease – mild discomfort, disablement or death).
THEORIES OF DISEASE CAUSATION • Economics (what is the cost of the disease to the indi-
vidual or the nation).
Germ theory: 2. There is prevention that works:
Disease is caused by transmissible agents. For an effective preventive strategy
A specific agent is responsible for one disease only (one-to-one
• The natural history of disease must be understood (
relationship).
Epidemiological triad: etiology; determinants; predisposing, initiating, excit-
• Exposure to an agent does not necessarily lead to disease. ing, environmental factors; stages of disease progres-
• Disease is the result of an interaction between agent, host and sion etc.).
environment. • There should be an effective intervention available.
• Disease can be prevented by modifying the factors that influ- 3. Prevention is better than cure, repair, or doing nothing:
ence the exposure and susceptibility. Even if a preventive method is available, certain factors
Web of causation:
need to be considered:
• Disease is a result of complex interaction of many risk factors.
• Any risk factor can be concerned in more than one disease. • Acceptability
• Disease can be prevented by modifying these risk factors. • Economics
General susceptibility: • Balance against process and outcome of disease.
• Some social groups have higher mortality and morbidity rates • Acceptable associated risk
from all causes. 4. Availability of resources to implement the preventive
• It is an imperfectly understood general susceptibility to health measures:
problems.
This includes all necessary and sufficient resources such
• This is probably because of complex interaction of the environ-
ment, behavior and life-styles.
as
Socio-environmental approach: a. Manpower numbers.
• Health is strongly influenced by social and physical environment b. Manpower skills and ability
• Risk conditions produced by such an environment affect health c. Materials.
directly and through the physiological, behavioral and psycho- d. Time.
social risk factor that they create. e. Political will.
• Improving health requires modification of these environments.
Often sufficient resources are available but priority for their
utilization is not there.
6 Section 1 N Public Health
5. Economics: • An organization for applying these measures to appropri-
Economics can be calculated by: ate persons or groups, and
a. Cost efficiency • Continuous evaluation of development of procedures
b. Cost benefit applied
c. Cost utility
To overcome the difficulty of comparing different health LEVELS OR CATEGORIES OF PREVENTION
care approaches such as cost effective analysis (CEA) and
cost benefit analysis (CBA) an approach termed cost util- These can be studied under two main frameworks:
ity analysis ( CUA) has been developed where a univer-
sal currency, a single quantitative unit is constructed. A. Levels of Prevention
The terms could be understood in terms of dentistry, i. Primordial prevention
as follows: ii. Primary prevention
- Cost Efficiency Cost of implementation iii. Secondary prevention
(Effectiveness) No. of tooth surfaces saved iv. Tertiary prevention.

- Cost Effectiveness Cost of implementation B. Approaches of Prevention

(Efficiency) Savings in cost of treatment
• High risk (target) strategy
- Cost Benefit Cost of implementation
• Mass (whole population) strategy.
(Utility) Benefits to quality of life
6. Ethics
LEVELS OF PREVENTION
Ethics is concerned with what is right or what is wrong.
Ethics in health care including prevention is as valid in i. Primordial prevention: It is the prevention of emergence
preventing strategies as in any other element of health or development of risk factors in countries or population
care provision. group in which they have not yet appeared. Individual
and mass education is main intervention method in pri-
An Ideal Public Health Measure Should Be mordial prevention.
ii. Primary prevention: It is defined as ‘action taken prior to
1. Of proven efficacy in the reduction of the targeted dis- the onset of the disease, which removes the possibility
eases. that a disease will even occur’. It is carried out on healthy
2. Easily and efficiently implemented, using minimum quan- populations. Information and / or public health measure
tity of materials and equipments. to the whole population may be sufficient to maintain a
3. Medically safe. disease free environment. It may be accomplished by
4. Readily administered by non-medical person. measures designed to promote general health and well
5. Attainable by the beneficiaries regardless of their socio- being or by specific protective measures.
economic, income, educational and occupational status. iii. Secondary prevention: It can be defined as ‘actions which
6. Readily available and easily accessible to large number halts the progress of a disease at its incipient stage and
of individuals. prevents complications’. It is carried out on targeted popu-
7. Inexpensive and hence affordable to majority of popula- lation identified by their being exposed to, or indulgence,
tion. in factors that place them ‘at risk’. The individual or the
8. Uncomplicated and easily learned by people. population is required to change, either to take some new
9. Administered with maximum acceptance on the part of action, or to cease an established action, or both, in or-
the patients. der to lower the levels of risk.
10. Administered with minimum compliance on the part of iv. Tertiary prevention: It provides a cure at an early stage in
the people. disease process, containing the disease or its effects on a
long term basis and seeks to prevent a recurrence of the
Successful prevention depends upon:
disease. It can be defined as ‘all measures available to
• A knowledge of causation, reduce or limit impairments and disabilities, minimizing
• Dynamics of transmission, suffering caused by existing departures from good health
• Identification of risk factors and risk groups, and to promote the patients adjustment to irremediable
• Availability of prophylactic or early detection and treat- conditions’. The individual or population is aware of the
ment measures, disease, can see its effects and requires rehabilitation.
 Chapter 1 N Changing Concepts of Health and Prevention of Disease 7
Modes of Intervention b. Prompt treatment: Secondary prevention attempts to ar-
rest the disease process, restore health by seeking out
Primary Prevention (Prepathogenesis)
unrecognized disease and treating it before irreversible
Primary preventive services are those that prevent the initia- pathological changes take place, and reverse communi-
tion of disease. cability of infectious diseases.
a. Health promotion: It is process of enabling people to in-
crease control over and to improve health. This can be Tertiary Prevention
achieved by (Pathogenesis: Late Stage of Pathogenesis)
i. Health education; instruction on proper plaque re-
moval, daily tooth brushing and flossing Actions taken when the disease process has advanced beyond
ii. Environment modification such as safe water, control its early stages i.e. intervention in late pathogenesis phase.
of insects and rodents. It is defined as “all the measures available to reduce or
iii. Nutritional interventions: improvement of nutrition in limit impairments and disabilities, and to promote the patients’
vulnerable group. adjustment to irremediable conditions.”
iv. Lifestyle and behavioural changes; which favor health Intervention that should be accomplished in the stage of
b. Specific protection: These are activities designed to pro- tertiary prevention is disability limitation, and rehabilitation.
tect against disease agents by decreasing the susceptibil- The aim of tertiary prevention is to limit disability and pre-
ity of the host or by establishing barrier against agents in vent further complications or death.
the environment. Methods include immunization, use of a. Disability limitation
specific nutrition, avoidance of allergens, protection from The objective of this intervention is to prevent or stop the
carcinogens, ingestion of optimally fluoridated water and transition of the disease process from impairment to handi-
application of pit and fissure sealants. cap (Fig. 1.1). The sequence is as follows:
• Disease • Impairment
Secondary Prevention • Disability • Handicap
i. Impairment: It is “any loss or abnormality of psychologi-
(Pathogenesis: Initial Stage of Pathogenesis) cal, physiological or anatomical structure or function.”
It is defined as “action which halts the progress of a disease at ii. Disability: It is “any restriction or lack of ability to per-
its incipient stage and prevents complications.” form an activity in the manner or within the range con-
These services intervene or prevent the progression and recur- sidered normal for the human being.”
rence of disease.
a. Early diagnosis: WHO Expert Committee in 1973 defined
early detection of health disorders as “the detection of
disturbances of homeostatic and compensatory mecha-
nism while biochemical, morphological and functional
changes are still reversible.”
The earlier the disease is diagnosed and treated the
better is its prognosis and helps to prevent the occurrence
of more cases.
Actions that detect and treat disease at an early stage
thus hinder the progress of a disease and prevent compli-
cations. i.e. intervention in early pathogenesis phase.
The methods (tools) employed for early diagnosis are:
1. Screening for sub-clinical disease, either in screening
surveys or in periodic medical examinations.
2. Case finding (individual and community). Fig. 1.1: Transition of disease process

Levels of prevention Primary Secondary Tertiary

Concept of prevention Prevention of disease Prevention of disease Prevention of

initiation progression and recurrence loss of function
Modes of intervention Health promotion Early diagnosis and Disability limitation
specific protection prompt treatment rehabilitation
8 Section 1 N Public Health
iii. Handicap: It is termed as “a disadvantage for a given indi- Mass Strategy
vidual, resulting from an impairment or disability that lim-
“Population strategy” is directed at the whole population irre-
its or prevents the fulfillment of a role in the community
spective of individual risk levels.
that is normal (depending on age, sex, and social and cul-
This approach does not differentiate between individuals
tural factors) for that individual.”
in any defined population and is directed towards the whole
Tools for tertiary prevention include rehabilitation population. It treats all individuals as at equal risk. Underlying
b. Rehabilitation: It is defined as “the combined and coordi- factors which contribute to the etiology of the disease, or them-
nated use of medical, social, educational, and vocational selves are causative factors, are targeted for alteration. The
measures for training and retraining the individual to the population approach is directed towards socio-economic, be-
highest possible level of functional ability.” havioral and lifestyle changes.
It is a measure to train the disable individuals to reach
the highest level of functional ability by using combined Advantages
coordinated medical, social, vocational, psychological and
educational measures. a. Easier.
b. Behaviorally appropriate for whole population.
Rehabilitation comprises:
c. Gets to the cause of the disease.
1. Medical rehabilitation: restoration of function or physi-
d. Reaches all who may become high risk / sufferers.
cal loss.
2. Educational rehabilitation: change of educational
methods. Disadvantages
3. Vocational (occupational) rehabilitation: restoration a. Requires a lot of motivation.
of the capacity to earn a livelihood. b. Dilution of efforts.
4. Social rehabilitation: restoration of family and social c. Dilution of effects.
relationships. d. Less specific.
5. Psychological rehabilitation: restoration of personal e. Higher rate of failure.
confidence f. Lessened benefit to individuals.
Examples of rehabilitation:
1. Special schools for blind pupils. Barriers (Challenges) to Preventive Strategies
2. Provision of aids for crippled.
1. Diversity of population
3. Reconstructive surgery for leprotics.
A homogeneous message may not be appropriate for a
4. Modification of life for tuberculous or cardiac patients. heterogeneous population. Population varies in social sta-
tus, age, ethnicity, differing attitudes, beliefs, expectations,
APPROACHES OF PREVENTION knowledge, understanding and disease level etc.
2. Inherent beliefs/mores
High-risk Strategy These include – fear of health/medical profession, confu-
sion from previous message, erroneous message etc.
Here the population is classified in relation to the degree of
3. Advertising
risk which individuals or groups of individuals exhibit, or are
Propaganda produces pressure selling on children and
exposed to. It aims to bring preventive care to individuals or a
blackmail on parents.
group at special risk, which will reduce their risk factors.
4. Pressure groups
Many pressure groups base their opposition to health pro-
Advantages
moting moves on the basis of loss of autonomy and choice
a. Doctor-patient relationship. ( seat belts, smoking in public places), and others on medi-
b. Better motivation. cal and epidemiological evidence ( water fluoridation etc.).
c. Cost benefits. 5. Access
d. Individual appropriateness. Access to people to improve health is usually poorest to
those who are in most need of intervention, e.g. Social
Disadvantages class III, IV, V, kids, risk group.
6. Resources
a. Criteria for ‘at risk’ not clear.
Although governments stress the importance of preven-
b. Cost of screening. tion, the major drain on health resources is the acute health
c. Does not tackle cause of disease. care sector. Directing resources into prevention is still not
d. Misses transitional populations. completely addressed.
 2 Basic Epidemiology
Abdul Rashid Khan, KA Narayan

INTRODUCTION TO EPIDEMIOLOGY sub clinical and carrier states and precursor states of
chronic diseases
Health and disease can be studied in 3 basic ways, (i) observa- • Epidemiology is used to monitor the health of popula-
tion of effects on individuals (ii) laboratory experiments (iii) tions (surveillance) to chart changes over time, place and
measuring their distribution in population (epidemiology). person and to determine which diseases are of most pub-
The origin of the word epidemiology is from the Greek lic health importance. By analyzing trends it is able to
word ‘epi’ meaning upon, ‘demos’ meaning people and logos predict and devise methods of control
meaning ‘doctrine’; the literal translation would be ‘the doc- • The design, conduct and interpretation of field trials, vac-
trine of what is upon the people’. cinations and control programs, therapeutic measures
The international epidemiological association defines epi- such as environmental modifications and dietary changes,
demiology as “the study of the distribution and determinants concerned with populations not individuals
of health related states and events in the populations and the • It supplies information necessary for health planning and
application of this study to control of health problems”. The development and management of programs for disease
primary unit of concern is groups of person not individuals. prevention and control
• It supplies tools for evaluating health programs
Scope of Epidemiology • It provides a foundation for public policy and for making
regulatory decisions relating to environmental problems.
Epidemiology covers all major health problems in the commu-
nity including: Epidemiological Perspective
• Communicable diseases
• Chronic degenerative, metabolic, neoplastic diseases Epidemiology is about information, the information needed
• Nutritional deficiencies for health planning, supervision and evaluation of the health
• Occupational health and injuries promotion and disease control activities. The key components
• Mental and behavioral disorders of the data needed can be approached through a series of
• Population issues and demographic trends. questions.
• Who? – Who is affected? - referring to age, sex, social
Uses of Epidemiology class, ethnic group, occupation, heredity and personal
habits. (These are person factors)
• The most important use of epidemiology is to increase • Where? – Where did it happen? - in relation to place of
the understanding of disease, shared with the other medi- residence, geographical distribution and place of expo-
cal sciences, but looking at communities or populations sure. (Place factors)
• Determine the cause of disease so that previously un- • When? – When did it happen? - in terms of months, sea-
available preventive or control measures may be success- son or year. (Time factors)
fully applied • What? – What is the disease or condition? - its clinical
• Epidemiology clarifies causative agents, the factors in web manifestation and diagnosis.
of causation, the populations at highest risk and environ- • How? – How did the disease occur? - in relation to the
mental and other determinants interplay of the specific agent, vector, source of infection,
• Epidemiology is concerned with describing the natural susceptible groups and other contributing factors.
history of disease, including not only the clinical stages • Why? – Why did it occur? - in terms of the reasons for the
seen in hospitals and medical practice but unapparent, disease outbreak.
10 Section 1 N Public Health
• What now? – The most important question - What action • Nutritional factors – both excess and deficiencies such as
is now to be taken as a result of the information gained? calories, proteins, vitamins
• Chemical agents – e.g. lead, solvents
Epidemiological Concept • Physical agents – humidity, vibration, heat, light, cold,
radiation, etc
The concept which is sometimes called the ecological concept • Mechanical agents – explosives, bullets, knives, etc
of disease or the concept of multiple causations is based on • Social and psychological stressors – poverty, smoking,
the three premises: drug abuse, work stress, etc.
1. Disease results from an imbalance between the disease
agent and the host.
Human Host
2. The nature and the extent of the imbalance depends upon
the nature and characteristics of the agent and the host. The factors which influence the exposure of response include:
3. The characteristics of the agent and the host and their • Age
interactions are directly related to and largely dependent • Sex
on the nature of the physical, biological and social envi- • Family size
ronment. • Marital status
The epidemiological concept of disease holds that • Religion
health and disease in an individual or community are out- • Occupation
comes of the dynamic relationship between the agent, • Intercurrent disease
the host and the environment (Fig. 2.1). A state of equi- • Ethnic or racial factors
librium between these factors indicates no disease; any • Habits and customs
disturbances of this equilibrium brought about by changes • Inherent immunity or non specific immunity
in the inherent characteristics of the agent the host and • Immunity – passive immunity, active immunity.
the environment results in disease.
Environment
Agents
The environment is the sum total of all external conditions and
The agent has been defined as an element, a substance or a influences that affect the life and development of an organism.
force either animate or inanimate, the presence or the absence It thus influences both the agent and the host.
of which may, following effective contact with the susceptible • Biological environment – infectious agents of disease,
human host and under proper environmental conditions, serve reservoirs of infection, vectors that transmit disease, plants
as a stimulus to initiate or perpetuate a disease process. The and animals.
classifications of agents are: • Social environment – the overall economic and political
• Biological agents – due to living agents. Viruses, bacteria, organization of a society and of the institutions by which
fungi, protozoa individuals are integrated into the society at various stages
in their lives.
• Physical environment – heat, light, air, water, radiation,
gravity, chemical agents.

Risk Factors: The “Beings” Model

Epidemiological research has focused on life threatening dis-
eases such as cancer. Majority of cancers were potentially pre-
ventable and were due to “extrinsic factors”. However extrin-
sic or environmental factors have often been misinterpreted to
mean “man made chemical” Hence the BEINGS is a helpful
acronym to remember the major categories of risk factors.
Biological factors and behavioral factors: Gender, age,
weight, smoking behavior, etc.
Environmental factors: Rainfall, season, housing, air-con-
ditioning, etc.
Immunological factors: Immunity and Immunodeficiency.
Nutritional factors: Cholesterol in heart diseases
Genetic factors: Thalassemia, Hemophilia, etc.
Fig. 2.1: Epidemiological triad and their interaction Services, social factors and spiritual factors.
 Chapter 2 N Basic Epidemiology 11

MEASURING HEALTH ii. Specific rates: rates that are used when a population is
divided into more homogenous subgroups based on a
There is a need for accurate information on illness (morbidity) particular characteristic of interest e.g., age.
and death (mortality) because of the high economic loss, so- iii. Standard rates: rates that are standardized to compare
cial disturbances as well as the cost of medical care associated between two or more different populations.
with them and to enable comparison within and between soci-
eties at a given point in time or over different time periods.
Measures of Disease Frequency
Health is measured by morbidity and mortality statistics.

Numerator and Denominator

Epidemiology is concerned with either the presence of health
problems in a population or the occurrence of new health events
in a population. In both the cases an epidemiological measure
(or expression) has at least two components: a numerator and
a denominator.
The numerator in a disease ratio or rate for example is
either existing (prevalent) cases as with measures of prevalence
or new (incidence) cases as with incidence.
The denominator is the population at risk or the popula-
tion in which cases exist or have occurred. Fig. 2.2: Relationship between incidence and prevalence

Prevalence
Ratio, Proportion and Rate
Prevalence is an estimate of the proportion of individuals in
There are three basic classes of mathematical quantity used to the population with a given disease, disability or health state
measure health status and the occurrence of health events on at a particular point in time. Prevalence is the measure of the
populations. existence of a particular condition i.e. prevalence measures
• Ratio – is the general term that includes a number of more the probability of people having a disease at a given point in
specific measures, such as proportion, percentage and time.
rate. A ratio is obtained by dividing one quantity by an- Prevalence is not strictly a rate although it is sometimes
other without implying any specific relationship between referred to as one. Prevalence is a proportion and should usu-
the numerator and the denominator. The value of a ratio ally be reported as one. The major difference between inci-
can range from minus to plus infinity dence and prevalence is that knowledge of time of onset is not
• Proportion – is a type of ratio in which those who are required in a prevalence study. Denominators in prevalence
included in the numerator must also be included in the always include the entire population since the numerator con-
denominator i.e. the numerator is a subset of the denomi- tains old as well as new cases.
nator. The magnitude of proportions is usually expressed Prevalence depends on two factors (Fig. 2.2): the number
as a percentage of people who have been ill in the past (previous incidence)
• Rate – is a ratio in which there is a distinct relationship and the duration of their illness. P~ I × D, if incidence and
between the numerator and the denominator. A speci- duration have been stable over a long period of time then this
fied time period is an essential component of the denomi- formula becomes P = I × D (Table 2.1).
nator
Rates are used as a comparison of an observed rate with a Table 2.1: Prevalence of disease over a period of time
target rate, a comparison of two different populations at the
same time (the two population should be similar and are mea- Increased by Decreased by
sured in exactly the same way), a comparison of the same popu- Longer duration of the disease Shorter duration of the
lation at two different time periods (used for studying time disease
trends). Prolongation of life of patients High case fatality rate from
without cure disease
Categories of Rates Increase in incidence Decrease in incidence
In migration of susceptible Out migration of cases
i. Crude rates: rates that apply to entire populations, with- people
out a reference to any characteristics of the individuals in Better reporting Improved cure rate of cases
it. They are valid rates but often misleading.
12 Section 1 N Public Health
There are two types of prevalence rates point prevalence be observed for different lengths of time. For differing periods
and period prevalence. of observation, person time denominator must be used.
IR is a true rate and is considered to be an instantaneous
Point Prevalence:
rate of development of disease in a population. The numerator
Attempts to measure disease at one point in time,
is the number of new cases or incident cases in the population.
Prevalence =
Number of existing cases of a Number of new cases
Incidence rate = × 1000
disease at a point of time Person time of observa
ation
× 1000
Tota
al population at that point of time
Point prevalence is preferred over period prevalence since Mortality Statistics
it is more precise. Although mortality is far from being an ideal measure of the
Period Prevalence: health of a population, thanks to vital registration systems, it is
It describes the prevalence of disease over a period of time. often the most easily available and accessible indicator that
Period prevalence = can be used by health agencies in the planning, implementa-
Number of existing casess of a tion and evaluation of health services. Morbidity is of course a
disease during a period or interval better indicator of health since it covers the whole spectrum of
× 1000 disease but there are numerous problems and errors associ-
Average population during a period
or interval (usuallly at mid point) ated with it. As most countries have a “vital events” registra-
tion system calculating mortality rates is easy. However, if deaths
Incidence are not reported the rates will be artificially low.
Incidence measures the number of new cases or new events of The commonly used rates are crude death rate, standard-
disease which develop on a given population during a speci- ized death rate, cause – specific death rate, age-specific death
fied time period. Incidence rates measure the probability that rate, case fatality rate, proportionate mortality rate, infant
healthy people will develop a disease during a specified pe- mortality rate (IMR), Neonatal mortality rate (NMR), postneo-
riod of time. To determine incidence, it is necessary to follow natal mortality rate (PNMR), prenatal mortality rate and ma-
prospectively a defined group of people and determine the ternal mortality rate (MMR).
rate at which new cases of disease appear.
Calculations for Common Mortality Rates
Incidence may Change with the Following Factors
Crude death rate =
• Introduction of a new risk factor
• Changing habits Number of deaths among residents
• Changing virulence of causative organism in an area in a calendar year
× 100
• Changing potency of treatment of intervention programs Average population in the area
• Selective migration of susceptible persons to an endemic area, n that year
in
which increases the incidence of the disease.
Cause-specific death rate =
Cumulative Incidence Number of deaths from a stated cause in a year
× 1000
CI is the proportion of people in a total population at risk and Average (mid-year) po opulation
free of disease at the start of a particular time period who be-
come diseased or develop the incident condition during the Age-specific death rate =
specified time period. CI provides an estimate of the probabil- Number of deaths among perrsons of a given
ity (or risk) that an individual will become diseased in the speci- age group in a year
fied time period × 1000
Average (mid-year) population in the
Number of new cases of a diseasse specified age group
in a given period of time
CI = × 1000 Case fatality rate =
Total population at risk
(Free from disease at beginningg of period) Number of deaths from a disease
× 100
hat disease
Number of clinical cases of th
Incidence Rate (Incidence Density)
Neonatal mortality rate (NMR) =
Often every individual in the denominator is not followed for
the specified period of time. For a variety of reasons including Deaths in a year of children <28 days of age
× 1000
loss to follow-up, death or migration different individuals will Number of five births in same year
 Chapter 2 N Basic Epidemiology 13

Postneonatal mortality rate (PNMR) =

Deaths in a year of children =
28 days of age upto 1 year
× 1000
Number of live births in the same year
Prenatal MR =
Births (28 wks or more of gestation) + deaths in the
first week of life
⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯ × 1000
Stillbirths + Number of live births in same year
Toddler MR =
Deaths of children agedd 1 to 4 years
in a given year
× 1000 Fig. 2.3: Classification of epidemiological studies
ar population of children aged
Mid yea
1 to 4 years for the same year
IMR = Non-experimental (Observational)
Number of deaths in a year of children In non-experimental studies, the assignment of subjects to ex-
less than 1 year of age posure groups is not determined by the researcher, but rather
× 1000 by the study subjects themselves or by other factors. The pos-
Number of live births in same year
sibility of bias in non-experimental studies is of constant con-
Number of deaths from pregnancy cern.
related causes in a year There are two types of non-experimental designs.
MMR = × 100,000 • Analytical studies
Numb
ber of live births in same year
• Descriptive studies.

EPIDEMIOLOGICAL STUDIES Descriptive Studies (Who? What? Where? When?)

Epidemiological studies are required to measure the rates of
These studies involve the systematic collection, analysis and
disease occurrence and the associated factors in a population,
interpretation of data to give a clear picture of a particular situ-
to make an unbiased comparison of those with or without a
ation. The wealth of data obtained in most descriptive studies
disease or risk factor and to make interventions. This is achieved
allows the generation of hypothesis, which can then be tested
by a good research design. Some research questions can be
by analytical experimental design. Both qualitative and quan-
answered by more than one type of research design. The choice
titative techniques may be used.
of design will depend on factors such as cost, speed and avail-
In descriptive epidemiology we organize and summarize
ability of data. Each design has advantages and disadvantages.
data according to time, place and person. These three charac-
teristics are sometimes called the epidemiologic variables. This
Design of Epidemiological Studies information provides important clues to the causes of the dis-
The design of an epidemiological study serves the function of ease, and these clues can be turned into testable hypotheses.
a measuring instrument. Though the design information is
obtained from the population being studied, the researcher Characteristics of Persons
designs the study in such a way that valid estimates are ob- • Age – overall the most important epidemiologic variable
tained. A number of design options exist, each with their own relating to exposure, susceptibility and pathogenesis. Age
purposes strengths and weaknesses. specific rates to make comparisons between populations
The selection of the type of study is the core of a research must be determined. The population pyramid of the group
design and is probably the single most important decision the studied must be considered
investigator has to make. The strategy must include definition • Sex – anatomical, physiologic, psychological and behav-
of variables, their levels and their relationships to one another. ioral characteristics account for many sex specific disease
The type of study design chosen depends on: associations
• The type of problem • Ethnicity – genetic, physiologic, behavioral, environmental
• The knowledge already available about the problem and and socioeconomic characteristics of importance as de-
• The resources available for the study. terminants of disease
Epidemiological studies are broadly classified as follows (Fig. • Place of origin – genetic pool, environmental, cultural and
2.3): behavioral and dietary factors
14 Section 1 N Public Health
• Marital status – a selective process, and associated with section of the population, which may comprise the whole
differences in physical state, behavioral and socioeco- population or a proportion (a sample). They provide a
nomic determinants of health prevalence rate at a point in time (point prevalence) or
• Occupation – reflects physical, mental, psychological, over a period of time (period prevalence). The study popu-
environmental and socioeconomic characteristics related lation at risk is the denominator of these prevalence rates.
to disease patterns Included in these studies are surveys in which the distri-
• Socioeconomic – determines many of the above charac- bution of a disease, disability, pathological condition,
teristics. immunological condition, nutritional status are studied.
This design may also be used in health systems re-
Characteristics of Place (Geographic, Landscape search to describe prevalence by certain characteristics –
Epidemiology) the pattern of health service utilization and compliance –
or in opinion polls.
• Biologic environment – climatic and ecologic character-
6. Longitudinal studies – use ongoing surveillance or fre-
istics that determine flora and fauna, including human
quent cross sectional studies to measure trends of disease
factors
over a period of time in a given population. By compar-
• Chemical and physical environment – quality of air, wa-
ing these trends in disease rates with other changes in the
ter and food
society the impact of these changes on disease occur-
• Social environment – cultural, behavioral patterns that
rence can be assessed. E.g: effect of introduction of vac-
determine risks, perceptions and responses.
cines, natural and manmade disasters economic change.
All the above studies can be the source of hypothesis genera-
Characteristics of Time
tion. Both cross sectional and ecological studies can be used in
• Endemics – diseases which are regularly and continuously hypothesis testing (i.e. are analytical.)
present
• Epidemic – a significant excess over that expected on basis Analytical Studies (How? Why?)
of past experience; an unusual clustering over time
• Short time variation – point epidemics Analytical strategies are observational means used in epidemio-
• Periodic variations – seasonal changes, cyclical variations, logical investigations to test specific hypotheses. The term ‘ana-
secular variations lytical’ implies that the study is designed to establish the cause
• Dynamics of disease – refers to distribution in time, is of a disease by looking for association between exposure to a
concerned with trends, cyclic and secular changes, inter- risk factor and disease occurrence.
vals between exposures, degrees of exposure, incubation The basic approach in analytical studies is to develop a
periods, communicability periods. specific testable hypothesis and to design the study to control
for extraneous variables that could potentially confound the
Types of Descriptive Studies observed relationship between the studied factors and the dis-
ease. The approach varies according the specific strategy used
1. Case studies – this kind of study is based on reports of a (Fig. 2.4).
series of cases of a specific condition or a series of treated
cases, with no specifically allocated control group. They
represent the numerator of disease occurrence and should
not be used to estimate risks.
2. Community diagnosis or needs assessment – entails col-
lection of data on existing health problems, programs,
achievements, constraints etc. Their purpose is to identify
existing needs and to provide base line data for the design Fig. 2.4: Classification of analytical studies
of further studies or action.
3. Epidemiological description of disease occurrence – en- Experimental (Interventional)
tails the collection of data on the occurrence and distri-
bution of disease in population according to specific char- An experiment or an interventional trial is designed to evalu-
acteristics of individuals, place, and time. ate the effect of an intervention in which the assignment of
4. Ecological descriptive studies – when the unit of observa- subjects to exposed and non exposed groups is designed by
tion is an aggregate (e.g. a family, clan or school) or an the researcher.
ecological unit (a village, town or district), the study be- The researcher manipulates objects or situations and mea-
comes a descriptive ecological study. sures the outcome of his manipulations. Usually (but not al-
5. Descriptive cross sectional studies or community (popu- ways) two groups are compared, one in which the interven-
lation) surveys – entails the collection of data on a cross tion takes place and another group that remains untouched.
 Chapter 2 N Basic Epidemiology 15
There are two categories of interventional studies: ii. Analytical Cross Sectional Studies
• Experimental studies In analytical cross sectional study the investigator mea-
• Quasi-experimental studies. sures exposure and disease simultaneously in a represen-
tative sample of the population. By taking a representa-
Experimental Studies tive sample it is possible to generalize the results obtained
in the sample to the population as a whole.
An experimental design is the only type of study design that Both exposure and disease outcome are determined
can actually prove causation. The classical study design has simultaneously for each subject. In this type of approach
three characteristics. the cases we identify are prevalent cases of the disease in
• Manipulations – the researcher does something to one question because we know that they existed at the time
group of subjects in the study of the study but we do not know their duration. For this
• Control – the researcher introduces one or more control reason this study is called prevalence study.
groups to compare with the experimental group
• Randomization – the researcher takes care to randomly
assign the subjects to the control and experimental groups.
(Each subject is given an equal chance of being assigned
to either group.)
The strength of experimental studies is that by randomiza-
tion the researcher eliminates the effects of confounding vari-
ables.

Quasi-experimental Studies
In this study at least one characteristic of a true experiment is
missing, either randomization or the use of a separate control
group. These studies, however, always include manipulation
of an independent variable that serves as the intervention.
Fig. 2.5: Design of an analytical cross-sectional study
Common Study Designs in Epidemiology
Cross-sectional Survey The data collected is examined by the prevalence of
disease in different sub group and the presence of variables
A cross-sectional survey is a survey of a population at a single (or absence) in disease vs. non disease (Fig. 2.5). The data is
point in time. Many methods like interview or mass screening tabulated in Table 2.2 thus
can be used in these surveys. They are quick and relatively
easy to perform and give a fair idea of the health status of the Table 2.2: Examined data by the prevalence of disease
community. They can also estimate risk of developing diseases.
Disease No disease Total
Survey could be descriptive (hypothesis generating) or ana-
lytical (hypothesis testing). Exposed a b a+b
i. Descriptive Cross-sectional Studies or Community (Popu- Not exposed c d c+d
lation) Surveys Total a+c b+d a+b+c+d
Many cross-sectional studies do not aim at testing a
hypothesis about an association and are thus descriptive. The rates calculated are:
They provide prevalence rate at a point in time (point i. prevalence of disease:
prevalence) or over a period of time (period prevalence). In exposed compared to non exposed
Cross sectional survey provide a “snapshot” of the popu- = a / (a + b) vs. c / (c + d)
lation at a certain point of time. Both exposure and dis- ii. prevalence of exposure:
ease outcomes are determined simultaneously. They are In disease and non disease
also called prevalence studies as prevalent cases are iden- = a /( a + c) vs. b /( b + d)
tified.
Included in this type of descriptive study are surveys Advantages of Cross Sectional Studies
in which the distribution of a disease, disability, nutritional
status, pathologic condition, fitness, intelligence, etc. This 1. Can be done in a short time.
design may also be used in health systems research to 2. Are less costly.
describe prevalence by certain characteristics, the pattern 3. Are a starting point in prospective cohort study for screen-
of health service utilization and compliance or opinions. ing out already existing conditions.
16 Section 1 N Public Health
4. Provide a wealth of data that can be used in health sys- are frequently used. Such controls may be of same or different
tems research. type.
5. Can be used for evaluating health safety services. The controls can be either matched or unmatched and ide-
6. May be used in examining and identifying risk factors for ally selected from the same population. Matching is defined as
acute diseases where the time between exposure and the process of selecting the controls so that they are similar to the
outcome is very short. cases in certain characteristics such as sex, age, race, socioeco-
7. Useful for monitoring control programs for chronic con- nomic status and occupation. Matching removes the influence of
ditions such as mental illness. that variable on the causation of the disease. Once we have
8. Periodic surveys useful in tracking changes in disease matched controls to cases according to a given characteristics we
patterns over time (imp: repeated cross sectional surveys cannot study that characteristics. We only match on variables that
over time do not constitute a longitudinal study). we are convinced are risk factors for the disease characteristics
that we are not interested in investigating in this study. Matching
Disadvantages on variables other than these is called overmatching.
1. They provide no direct estimate of risk (show association
only).
2. They are prone to bias from selective survival.
3. It is not possible to establish temporality.
4. Even if an association of exposure and disease is observed
the association may be due to survival.
5. Prone to selection bias, information bias, confounding
bias.
6. Not suitable for rare diseases and remission.

Case Control Studies (Retrospective Study)

Case control study is useful as a first step when searching for a Fig. 2.6: Design of a case control study
cause of an adverse health outcome. This hallmark of this type
of study is it compares a case group (with disease) with a con- Risk Measure in Case Control Study
trol group (not diseased) with reference to past exposure to Case control study yields odds ratio. It is the odds of exposure
possible risk factors. The cases and controls are selected from in diseased subjects and the odds of exposure in non diseased
a dynamic population and then compared. It has become much subjects.
more common in recent years (Fig. 2.6).

Selection of Cases and Controls Advantages of Case Control Studies

Cases can be selected from a variety of sources (hospitals, phy- a. Suitable for rare as well as common diseases.
sician clinics, community registries and more), and assessed b. Usually less expensive.
by interviews, questionnaires and direct measurement. The c. Performed relatively quickly.
criteria for eligibility are carefully specified. Ideally incident (new) d. Many different exposures may be studied.
cases should be used but the problem with using the incident e. Fewer subjects required.
cases is that we must wait for new cases to develop and be
diagnosed whereas a large number of prevalent (existing) cases Disadvantages
are often available for study. Despite this practical advantage a. Incomplete information.
of using prevalent cases it is generally preferable to use inci- b. Bias – selection bias, recall bias, information bias, non
dent cases as any risk factors identified by using prevalent cases response bias, analysis bias, misclassification bias, con-
may be related to the survival with the disease rather than to founding.
the development of the disease (incidence). Even if we use c. Problem in identifying control group and matching vari-
incident cases we will still be excluding patients who may have ables.
died before the diagnosis is made. d. Yields only odds ratio.
The controls should ideally be from the same population e. Temporal relationship not clear.
which gave rise to the cases, e.g. Non hospitalized persons
living in the community (hospital patients differ to people in
Cohort Study (Longitudinal Study)
the community). However, most often, hospitalized patients
admitted for diseases other than that for which the cases were A cohort is a group of persons who share a common experi-
admitted are chosen as controls. Multiple controls for each case ence within a defined time period. In a cohort study the inves-
 Chapter 2 N Basic Epidemiology 17
tigator defines a cohort of a naturally occurring non diseased, ability to facilitate the collection of relevant information. Choice
exposed individuals and another cohort of non diseased, non of a particular group to serve as the study population for any
exposed individuals (the comparison population) and follows given study is related to both the hypothesis under investiga-
them over time to determine disease incidence. A definitive tion and specific features of the design. The groups being com-
characteristic of a cohort (both retrospective and prospective) pared should be as similar as possible with respect to all other
study is that the subjects at the beginning of the study are free factors that may be related to the disease, except the determi-
of the disease outcome. nant under investigation. An internal comparison group can
be utilized, i.e. the experience of those cohort members classi-
Types of Cohort Studies fied as having a particular exposure is compared with that of
members of the same cohort who are either non-exposed or
There are two general types of cohort studies. exposed to a different degree.
a. Prospective Cohort Studies (concurrent cohort/prospec- It is important to obtain complete, comparable and unbi-
tive study) ased information of the subsequent health experience of every
A cohort of individuals free from the disease are se- study subject. Combination of various sources of the outcome
lected and grouped as per their exposure or non – expo- data may be necessary to obtain complete follow-up informa-
sure to a suspect causative factor and then monitored tion.
over a period of time for the development of disease (Fig. Collecting follow-up data on every person enrolled repre-
2.7). sents the major challenge of a cohort study as well as the ma-
jor cost in terms of time, fiscal resources and ingenuity.
The basic analysis is the calculation of rate of the incidence
of a specified outcome among the cohorts under investiga-
tion. Both relative and absolute measures of association can
be calculated. Relative risk is the estimate of the association
between exposure and disease and indicates the likelihood of
developing disease among the exposed individuals relative to
those not exposed i.e. how much more likely one group is to
develop a disease than the other. Attributable risk is a method
of attributing the occurrence of a disease to a specific exposure
which may be contributing to the development of the disease.
Its utility is that it represents the expected reduction in disease
if the exposure could be removed or never existed. It is the
difference between the frequency measures for the two popu-
lations.
Fig. 2.7: Design of a prospective cohort study

b. Retrospective Cohort Studies (historical cohort / non con-

Advantages
current prospective study) 1. Suitable for rare as well as common exposure.
In this type of study the investigator goes back in time 2. Exposure data are often more accurate.
to define the exposure and risk group and follows the 3. Less information bias.
members to the present to see the outcomes. A good 4. Examines multiple effects of a single exposure.
health recording system is beneficial for this type of study 5. Provides absolute and relative effect measures.
as an estimate of exposure to relevant variables in the 6. Can elucidate temporal relationship between exposure
past must be made based upon these records. It can usu- and disease.
ally be conducted more quickly and cheaply. It is efficient 7. Allows direct measurement of incidence of disease in the
for a cohort, whose investigation for a disease with a long exposed and non-exposed groups.
latency period, will require many years of follow up to
accrue sufficient end points. They depend on availability Disadvantages
of relevant exposure data in adequate details from pre-
existing records (data may be incomplete especially on 1. Inefficient for the evaluation of rare diseases unless at-
confounding factors). tributable risk present is high.
2. Expensive and time consuming (prospective).
Selection of Exposed and Comparison Population 3. Requires availability of adequate records (retrospective).
4. Validity can be seriously affected by losses to follow up
Cohort study is often conducted among groups specifically (attrition).
chosen, not only for their exposure status, but also for their 5. Large number of subjects required.
Other documents randomly have
different content
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THE PLAY PLAYED OUT. costume, and perfumed like a

milliner, descended from the carriage, and entered the office of
William Heath & Co. It was James Fisk, Jr., "the oiled and curled
Assyrian Bull" of Wall Street. He came prepared to play a part, but in
no mimic drama. The curtain rose with gold at 143 £. Fifty men, the
agents of the conspirators, put their shoulders under it, and held it
like a rock, while a hundred bear-hammers rained blows upon it as if
it were an anvil. The price rose swiftly, 145, 146, 147, 148, 149, and
at eleven, gold stood at 150. The duo, James Fisk, Jr. and Jay Gould,
sat in their head-quarters. The business of the former was to hold
up the price on his broad back. The latter sat cool and silent,
watching the battle, preparing new moves, and whispering low his
orders to his lieutenant, the irrepressible Fisk. Meanwhile the other
agents were busily at work frightening the bears into settlements.
The boars hurled defiance in their teeth. "Up she goes, then," cried
Fisk, and in five minutes gold was selling for 160. Albert Speyers
bought during the morning, $26,000,000. William Heath, on the
order of^the duo. his way through the throng and bid 160 for
$1,000,000. The bid was followed by an appalling silence. The crowd
saw Heath, the cautious, steady broker, rarely seen personally in the
gold-room, now standing in tinthickest of the throng, and heard him
bidding for a million. No one was bold enough to meet the bid. He
stood only for an instant, with his lin-er po high in the air, and then,
as if with some presentiment of the coming panic, he wheeled and
tied from the room.
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520 INSIDE LIFE IN WALL STREET. Many of the bears,

terrified at last, were now pouring into the office of Smith, Gould,
Martin & Co., of which firm Jay Gould was partner, and were settling
up their contracts to the amount of millions. But the heavy foreign
bankers still stood firm under the standard of Brown Bros., Duncan,
Sherman & Co., Seligman, and others. "Settle up!" shrieked the
cornerers. "Never! do your worst," was the retort. Up it went, then,
to 162 £, while Speyers bid for any number of millions. The bear
leaders wiped their brows, and prayed that Boutwell or night would
come. High noon was "clashed and clamored from a hundred
towers." While Speyers was bidding furiously for gold at 160, Gould
was selling all the gold he could through a dozen different brokers,
at 135 to 140, and still Speyers, his black eye flaming, and his
wrinkled face purple with excitement, kept up his bids, " 160 for a
million, 160 for any part of a million." He bought seven millions in
two lots, when a shiver ran through the crowd as some one cried
out, "the Government is selling." How^much? " Thirteen millions !"
rang out the voice of some bold bear. Down, down fell the price,
twenty-five per cent, in two minutes, and then up again to 160, like
a gigantic shuttlecock, as some one cried out, " the Government will
only sell four millions." Speyers brandished his arms and shrieked
only seven words, "160 for a million." Winged missiles, bids and
offers hurtled through the dense air for an instant, and then the
bear-hammers seemed to have been all welded into one great
sledge, which fell upon the price like a forty-ton boulder, and
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RUIN INCARNATE. 521 smashed it down to 135, while

Speyers fell back into the crowd, quivering like an aspen. Lights
seemed to dance before the eyes of the multitude, and then go out
in darkness, as they rushed tumultuously into Broad Street. From
Wall Street to Exchange Place there was a sea of bewildered, pallid
faces. The wildest rumors were afloat, but none worse than the
ruinous facts which stared all in the face. Frenzied operators hurled
curses at the clique leaders, and battered at the offices of Smith,
Gould, Martin & Co., which were closed and barred, while hard-
featured men, deputysheriffs and shoulder-hitters, guarded the
avenues which led to the head-quarters of the conspirators. A.
Speyers, looking like a goblin rather than a man, with dim eyes and
face as pale as ashes, was vibrating between the offices of Smith,
Gould, Martin & Co. and William Heath & Co. His limbs moved
automatically. His fortune of one million dollars had been swept
away in five minutes. In the Gold Bank, on Thursday, the 23d,
$239,000,000 of clearances had dizzied the arithmetic of a hundred
pallid accountants. On Friday, the 24th, $500,000,000 more
paralyzed them. The Gold Bank tottered; its assets had been loaned
to shaky firms; and this mighty foster-mother of speculation passed
into the hands of a receiver. The daring authors of all these
calamities had slunk away on the first intelligence of the
catastrophe, and were now buried in the recesses of Erie Castle in
Twenty-third Street. But ten days before, and Wall Street had been
waving with banners of pride and fortune; on Satur 
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522 INSIDE LIFE IN WALL STREET. day, the 25th, it was a

Golgotha — a place of skulls. The celebrated firm of William Heath &
Co., it was claimed, were responsible for millions of gold which Fisk,
without any authority from them, had ordered to be delivered to
them. In this supreme hour, they had nearly one million dollars
locked up in the gold bank until clearances could be made. But the
margins on the gold they were carrying, had been wiped out in an
instant, and the clique owed them an immense sum. Thus, although
they had no interest in the conspiracy, they were made to suffer by
it. The situation of a firm standing so well, added to the general
distrust. Fortunately the gold bank soon released the funds so locked
up, and enabled the firm to resume payment. Ten of the other
principal gold dealers were known to have failed. Some of the great
banking houses were reported as shaky. No one knew in whom to
confide. Many whose assets were in the possession of the gold bank,
suspended temporarily. Scarcely one was a gainer by the collapse.
The street was full of the rueful faces of those who had settled their
short contracts with the clique. They who had sold gold to Speyers
for account of Belden, were little better off; their profits were in the
form of lawsuits. One bold operator had gone short of gold at 160,
to the amount of $7,000,000. When gold fell, he covered his
contracts at from 135 to 140, but the parties to whom he had sold
failed, and he found instead of making a profit of $2,000,000, that
he was saddled with $7,000,000 of gold, which was selling five per
cent, below the price at which he had bought. His losses were more
than $300,000.
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GAZING AT THE RUINS. 523 The liabilities of the clique

were rated at $20,000,000, all incurred in the space of an hour.
What their profits might be, was the cloudiest of problems. Saturday
dawned upon a market in ruins. The fires of yesterday, smouldering,
showed the full extent of the disaster, to the crowd which once more
packed the sidewalks of Broad Street. Half of the firms which did
business in the gold-room were reported as having failed, and the
rest were suspected. The street was full of lawyers. The gates of the
ring in Broad Street and at Erie Castle were still guarded, while a
host of creditors pressed forward, and asserted claims for millions
against the chief conspirators. Two aged men could have been seen
slowly making their way through the throng. They were Cornelius
Vanderbilt, who came to lend courage to -their stock cliques, by his
presence, and Daniel Drew, who surveyed, with strange, puzzled
look, the ruin just wrought by some of his youngest pupils. But the
worst was not yet. The darkness which had fallen upon the market
about noon on Friday. that day of financial wrath and doom, still
brooded over it — thunderings lightnings and thick darki Monday
brought no relief. Firms failing by the score. The engine of the law
was set at work. Equity ! Heaven save the mark! — put on the mask
of injunctions, and came into court with unclean hand.-. Tli. Gold
Bank, the Gold Room, the Stock K\vlianir«', and a dozen prominent
firms were tied up with i»nl«-rs l»y the court. And now money
tightened, first to 100, then to 300 per cent, per annum; and four
per cent, a
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1 \SIDK LIFE IN WALL STREET. A new disaster was soon to

take place. The house of Lockwood & Co. had a capital of
$5,000,000, and an unspotted credit of twenty-five years' standing.
Who, on the first of September would have dared to predict the
failure of this house ? Their name was a tower of strength on
'Change. The senior member of the firm had expended nearly
$1,000,000 on a private residence in his native village in
Connecticut. Everything promised a lengthened career of wonderful
prosperity. 13 ut their time was come. They were loaded down with
untold amounts of Pacific Mail, Lake Shore, and Chicago and North-
western railroad stocks, on which the loss was millions, and with
money at from 300 to 1200 per cent, per annum. Wednesday, the
market rallied, and everything looked bright, when a dreadful
whisper was breathed, — "Lockwood & Co. have failed." It was true.
Then stocks came on the market like a landslide from the mountain
tops. Down! down! New York Central fell to 145 — seventy-three per
cent, from the highest point. Sweeping away a hundred great
fortunes as it fell, a hundred more rested on the ability of one man
to withstand the pressure. The whole market trembled when a
report ran through the street that the ring was now depressing
stocks, and that Jim Fisk had sworn that he would break Vanderbilt.
Vain boast ! Suddenly Lake Shore sprang up like magic. The
Commodore raised millions and carried his point. He held the key to
the gates of the West. He had Lake Shore in his grip. Then he
snatched at Central. If that should break lower, no one could picture
the ruin that would follow. He held it and then hoisted it.
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ERA. ;,•_>:> From Black Friday dates a new era in

speculation lasting four years, till the panic of 1 873. Fisk and Gould
were now a paramount influence in the market. By dint of bullying,
coaxing, and by a variety of ingenious legal devices, they extricated
themselves from their liabilities. They gathered around themselves
an army of agents and retainers by liberal wages. Their brokers
waxed rich on the commissions received from the millions of shares
bought and sold by F. and G. Charles J. Osborn, a shrewd, jovial
operator, had made himself useful to the gold conspirators, and
became one of their chief managers in the street. He is now a
millionaire. Samuel M. Mills, a famous manipulator, became wealthy
from his operations for the Erie ring, and for Gould individually, but
afterwards turned on his chief and attempted to corner him in
Western Union. The issue was what might have been expected: Mills
was caught in his own trap, and driven at last into insolvency. He is
now, however, back in the Board and growing rich again. Wm.
Belden, the scapegoat of the Gold Rinu', Washington Connor, Wm.
Heath, and a do/m other brokers employed by Gould since the
assassination of James Fisk, have earned large sums in brokerage
from their principals. Fisk and Gould had full control of Erie, and fr
July, 1868, till the death of Fisk in January, ' conducted a series of
startling operations mainly through the house of Smith, Gould,
Martin & Co. O ' ' The failure of Lockwood & Co. was a di-aone,
involving the Lake Shore R. R. Co. and the
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520 INSIDE LIFE IN WALL STREET. estate of Henry Keep to

the extent of a million or more. The house made an assignment and
afterwards resumed, but never recovered its financial standing.
LeGrand Lockwood, the senior partner, not long after died, and the
palace he built in South Norwalk, at an expense of $800,000, passed
into the hands of M rangers. The losses incurred by many Wall and
Broad Street firms on Black Friday and during the stock-panic that
followed were enormous on paper, but the apparent ease with which
so many millions of liabilities were paid or compromised was due
largely to the shrewdness of the chief plotters of the Gold
conspiracy, whose interest it was to silence the complaints of their
victims. William Belden, who, as before stated, was one of the main
tools of the gold ring, was a man of little ability and less conscience.
He went through bankruptcy in 1870, but being possessed of
dangerous power as the custodian of certain secrets of his principals
he was afterwards, in 1877, made partner in a firm in which Gould
had a special interest. In the following year Gould withdrew from
this firm, and in 1879 Belden was arrested on a serious charge, and
so he passes out of the ken of speculation.
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CHAPTEE XXXIV. My Flyer in Gold — A Narrow Escape —

What a Looker-on Saw — Pools and Pools — Henry N. Smith —
Gould's Partner, and How He Made $4,000,000— Daring Exploits—
Sketch of Jay Gould— The Magician of Values — Milking Erie —
James Fisk, Jr.'s Exit — Collapse of the Erie Ring — Rise of Alden B.
Stockwell — Another Red-Haired Operator — The Pacific Mail Ring—
Going for Smith Vigorously. 'V' ra£r y $£N the rush and din of past
events we have just described, the story of a modest " flyer " in gold
is like the hum of a musquito to the roar of a park of artillery —
unheard except in the intervals between the broadsides. Our stoiy is
soon told. When, ten years ago last month (September, 1869) gold
suddenly fell, I sold $50,000 at 135, and left with my broker a "stop
order" to cover if it rose to 135J-. Down went the price to 133; up
again to 135£ in a tiice; my gold was bought in, thanks to a little
say, at 1 •"•.">: loss only $62.50, that being the amount of the
brokerage.
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528 INSIDE LIFE IN WALL STREET. Then, in spite of

enormous sales, the price stood like a rock at 135. Rumors of large
purchases by Fisk, and Gould, and Woodward were rife. At this
junction I met Fisk. It was at the Grand Opera House ; time twelve
P.M., sharp ; he was in full dress, and his diamond brooch blazed like
an electric light. He had just handed a lady into a carnage, and as
he turned away I spoke to him. " Gold ! " he cried echoing my
words. " Gold ! sell it short, and invite me to your funeral." On that
hint the next morning I bought a jag of $50,000 at 135£. In an hour
it was up to 138£, and I took my profits $1,500, less brokerage, and
did not rest until my margin of $5,000 and my profit was turned into
a certified cheek. In four days after the broker through whom I
made this last purchase, and tha broker to wiiom I sold the gold,
vanished into the smoke of Black Friday, leaving behind a residuum
of worthless claims, and never thereafter reappearing as financial
entities. The effort of such catastrophies as that of the gold
conspiracy of September, 1869, upon the physical system of
operators is akin to that of a sharp fever or a slight stroke of palsy.
That wondrous battery plate, the brain, loses its sensitiveness under
the shock. of thousands of startling impressions received through
the nerves. The only remedy then is rest. My physician remarking
my languid air, felt my pulse, which he pronounced feverish, and
thereupon issued his fiat: " Stop right here ! Be a spectator of but
not an
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WHAT A LOOKER-ON SAW. T, L".< actor in this dangerous

game ! Amuse yourself in any way except taking flyers, or I won't
answer for the consequences." This advice tallied with my own
inclinations; I was tired, and more than ever before conscious of the
utter uncertainty of Wall street speculation. I invested my little pile in
Rock Island, and played the role of walking gentleman and " looker-
on in Venice." And this is what I saw. A long lethargy in the stock
market, during which the fluctuations seemed to be caused by the
fluid of Galvani rather than by human energy. An abortive attempt
on the part of Woodward and S. V. White to corner Reading. A sharp
but temporary rise in gold in the summer and fall of 1870, known as
the Franco-Prussian gold flurry. Woodward " kiting" Rock Island in
the summer of 1871 up to 130, and then falling from the giddy
height, ruined beyond repair, and after that wandering through the
market, a swarthy, bearded, but to the financial eye a very
unsubstantial ghost. Then the Chicago Fire Panic, which brought to
the front another famous speculator — Henry N. Smith. He was long
the senior partner of the firm of Smith, Gould, Martin & Co., and
intimately concerned in the great operations conducted by Fisk and
Gould during his connection with that well-known firm. A sh<>rt,
dapper man with a blue eye, sandy complexion, and what Prof.
Huxley would call xanthus (i. e. red ) hair, a bustling gait, and an
inexpressive face, there is little to distinguish him from the crowd of
daring gamblers which daily fills the hall of the Stock Exchange. He .
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530 INSIDE LIFE IN WALL 8TLEET. made good use of his

opportunities as a member of the Fisk-Gould ring, passed through
the trying ordeal of Black Friday though not unscathed, absorbed a
larujc line of profits from the manipulations of Erie stock, and in
1870 and '71 was rich enough to engage in vast speculations on lu's
own account, which issued successfully with" enormous profits to
himself. His heaviest stroke was in the fall of 1871. Stocks had been
engineered into the tall figures, and in spite of the usual autumnal
outflow of currency and the tendency towards a more stringent
money market, they yielded but little to the hammering to which
they were daily subjected by the more ardent of the bears. Smith
had a considerable line of shorts which he had for some weeks
hoped to cover at a handsome profit; this he had failed to do prior to
the 9th of October, when something happened which enabled him to
effect his object. It was early Monday morning, the 9th of October,
1871, that telegrams were received in New York that Chicago was in
flames throughout its length and breadth, and that unless rain
should fall nothing could save the Lake city from utter destruction.
All the morning fresh telegrams came streaming in confirming the
first news of the day and giving it a blacker coloring. Then one of
those inspirations that possess men at times happened to the
speculator of whom we are speaking. At the first moment that
morning when stocks could be dealt in, Smith commenced selling
every active stock on the list. The full extent of the disaster in its
effects upon stocks was quickly seen ; prices did not fall, they
plunged downward ; the soundest stocks on the list were hurled
downward as if shot out of a rifled
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OPERATIONS OF HENRY N. SMITH. 531 cannon; New York

Central struck 80; the fancies, like North West common, seemed as
if they were to be swallowed up in the limbo of nothingness ; the
feeling that if Chicago was destroyed the whole transcontinental
system of railways would suffer damages almost irretrievable, wras
uncontrollable for a few < upon the Stock Exchange. When prices
struck their lowest point, Smith covered his contracts and bought
enormously for a rise. Within a week the community were amazed at
the swiftness with which the burned city was springing from its
ashes; prices began to rally; the market had been oversold, and
recovered itself with corresponding rapidity. Within four months
Smith succeeded in disposing of the major part of his holdings ; his
profits were estimated at between two and three million. His success
in speculation tempted him into operations on the turf; he bought
Goldsmith's Maid, the trotting mare which rivalled Dexter ; his stud
contain ing several other trotters almost equally famous; he built a i
nificent steam yacht at an expense of a quarter <>! a million. Jay
Gould and Henry N. Smith, partners in business and friends of each
other, now were co-nil ers of Wall street. It is rare that a man
readies and holds long a high position as a stock speculator without
being soon reminded that riches have wings; Smith Wftfl tined to
receive at this point in his career a number of serious checks, which
damaged his pre.-iige M an operator and made heavy inroads upon
his huge bank account. The first of these disasters was in the
Hannibal and St. Joseph movement. This railroad company had
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532 INSIDE LIFE IN WALL STIiEi-IT. been pooled up above

par by a clique which comprised among its members the notorious
Win. M. Tweed, P. B. Sweeny, and other members of the Tammany
ring, besides Gould, Fisk, and other desperate speculators. H. N.
Smith was elected President of the Hannibal and St. Joseph road,
and all would have gone well, but a rival line (the Burlington and
Quincy railroad,) by building an extension postponed indefinitely the
promised dividends of the Hannibal and St. Joseph company. The
price fell 40 per cent. It was nevertheless still one of the favorite
fancies, and was freely bought at from 60 to 70. The pool, headed
by Smith, now sold short a large amount and then prepared to make
its deliveries with 50,000 shares of new stock issued to order ; these
deliveries were refused by the Stock Exchange, and the pool would
have been cornered but for an accidental decline in the price, which
enabled Smith and his associates to fill then: contracts without
material loss. Again in April 12, Smith having gone short of the
market, he attempted to create an artificial tightness in money to
depress the market ; in order to carry out tli is scheme he sold a
large amount of gold, and depositing $4,000,000 of greenbacks in
the Tenth National Bank, drew them out and locked them up. . A
stroke so bold and undisguised at once filled the souls of those who
held stocks with indignation. An investigation of the matter was set
on foot simultaneously in the courts, in Congress, and in the
associated banks. Although nothing came out of these
investigations, they seemed to deter any one from repeating such an
operation in the future, and the attempt to create a stringency in
money to any marked degree was a failure.
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CHARACTERISTICS OF JAY GOULD. In the years 1868-9,

'70, '71, and '72, perhaps the most compact and powerful railway
ring was that of which James Fisk, Jr., and Jay Gould were the chiefs
: the former of these noted stock operators we have described in
chapter thirty-first: the latter, win* was the abler man of the two,
and whose network of railroads to-day nearly span the continent,
deserves a more extended notice than we have yet given him. Born
in Roxbury, a small village in Delaware county, New York, he early
manifested those qualities of intellect which have since made him
the controller of great railway lines and the acknowledged king of
the stock market. Bold and yet not reckless, quick to acquire
knowledge, resolute in purpose, patient of toil, acute in his judgment
of men and things, rapid in his decisions, following a plan
tenaciously as long as it promised well, but abandoning it whenever
it seemed likely to fail and adopting something better — to these
qualities he added a bodily organization remarkably enduring, wiry,
and compact. Thus endowed and without the taste for pleasure
which sometimes besets and drags down noted financiers, he was
well fitted by nature to play a prominent part in the great theatre of
speculation. He seems from the start to have been attracted to the
profession of a railway man, a profession now distinct, and requiring
to some extent a distinct eduration. We cannot, from want of space,
describe his earliest essays in that field, which proved that iln-ujh a
boy in years, he even then possessed the niind of a •man. He made
his appearance in Wall street, soon » the greenback speculation
commenced, and as earlv as 1867 he had identified himself with it.
22
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534 INSIDE LIFE IN WALL STREET. He is a theorist and at

the same time a man of practice and affairs. As a manipulator of
market values on a gigantic scale, Wall street lias never seen his
equal. lie reminds one of Rubinstein in the delicacy of his touch on
the grand piano of finance. Values rise and fall under his cunning
fingers. Nearly every active stock has felt the power of his strong
and subtle intellect. Of course he is unscrupulous. He believes that
as in love, war, or politics, so in the stock market everything is fair.
At the same time he is a man of generous impulses, as is shown by
his recent munificent gift to the yellow fever sufferers of Memphis.
His fortune was assured when, in 1868, he with Fisk stepped into
the control of the Erie Railroad Company. This was an elephantine
milch cow, and copiously did it give down the lacteal fluid under the
grip of Jay and James. They "coralled the critter" by aid of legislative
acts which they bought and judicial orders which they procured from
a venal bench. From July, 1868, it seemed as though Erie was
assured to them en permanence. Fisk had his harem, his opera
troupes, his diamonds, his four in hands, and his crew of retainers ;
Gould was on a still hunt, and quickly accumulated in a hundred
ways, from contracts, from new issues to break the market, from a
game of loaded dice — in fact, until he could draw his check for
$10,000,000. The Erie ring seemed to be entrenched so strongly
now that nothing could dislodge them. But in the fall of 1871 the
Tweed clique was broken to atoms,and the sudden taking off of Fisk
paved the way for the grand collapse of March, 1872.
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JIM FISK'S EXIT. 535 The assassination of James Fisk, Jr., in

Jannarv. 1872, was like a thunder clap to the Erie Ring. The
Tammany explosion of the preceding fall was the first step towards
their downfall, and now the removal of Fisk enabled them to see the
handwriting on the wall. The murdered man always claimed that
James Fisk. Jr., was an essential spoke in the Erie wheel, and \va<
wont to slap Gould on the back after some successful stroke and say
in his jocose way, "Jay, my boy, you fellows can't get on without J. F.,
Jr. ; " no doubt there was more truth in this than perhaps Gould
would even admit; at all events it is certain that Fisk's fate struck
consternation into the hearts of his associates of the Erie ring. By
means of what is known as the classification law, Fisk and Gould
were assured of their continuance in the Erie Board for some years
to come ; the fall of Tammany and the impeachment of certain
subservient judges, followed by the death of Fisk. showed them how
insecure was their tenure of power. For more than a year
movements had been on foot among the English stockholders of Erie
to disj><>Fisk and Gould of their hold on that railway company.
These movements culminated in what is called the Erie coup d'
etat,in March 1S7± when after a sharp fight, Gould was ousted and
the road jKi-ed into the hands of what was called the McHenry-
Bischoffsheim party, whose headquarters are in London.
Notwithstanding this breaking up of the Erie Ring and the loss of the
steady profits they had BO long drawn from their milch cow Erie,
both Gould and Smith are said to have profited enormously by it
through the thirty per cent, rise which followed tinsuccess of the
London party. Gould has sine,
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536 INSIDE LIFE IN WALL STREET. under oath that at the

time of the coup d' efat 240,000 shares of Erie stood in the name of
Smith, Gould, Martin & Co. The rise of thirty per cent, on a qua it
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CKETCII OF ALDEN B. STOCKW1 LL. 537 President of both

companies; he made an alliance with the Union Pacific Railroad
Company which accrued to the ad vantage of his own line; he
succeeded in securing a large subsidy from Congress ; he procured
the passage of a law by the legislature of New York which enabled
the Pacific Mail Company to speculate in their own stock; he had the
treasury of the Panama Railroad Company to resort to for loans on
an emergency; the wealth of the Howe Sewing comp.any, an
immense concern, was at his back. The effect of these various
movements upon Panama showed itself by the rise in the stock of
that company from 50 to 146. The price of Pacific Mail stock rose
more slowly. Some hidden obstacle seemed to block its upward path.
It appears that one of .the directors was a prominent member of the
Jay Gould and Henry N. Smith clique ; the same individual was also
one of Stockwell's brokers. Whenever an order was given by Stock
well with a view to the manipulation of the price in either direction,
its execution failed to accomplish the object intended, because Gould
and Smith nullified it by » contrary movement for their own
purposes. Stockwell, as soon as he discovered the cause of failui
these moves, dismissed the broker and ultimately defeated him hi
the next annual election of directors. From the moment when this
discovery was made, the Stockwell interest and the Gould-Smith
interest were arrayed against each other. Each party tried to outwit
the other. The Stockwell faction wen- hulls and the rival faction
bears, and as Stockwell had the inside track he worsted his
antapmiMs. While Smith was heavily short of the stock his rival
jumped it
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538 INSIDE LIFE IN WALL STREET. swiftly up from 65 to 87

; Smith took a loss of nearly $500,000 on the short side, and then
buying at high prices for a rise, the stock broke 18 per cent. Once
more Smith took his loss and went short of it again for a steady pull
downwards. Both Smith and Gould believed at this time that the true
policy was to sell stocks for a decline ; to this end they had invested
largely in gold, by means of which they expected to control currency
sufficiently to create a stringency in the market and help stocks
downward. But the strong movement in Pacific Mail gave a general
upward tendency to the market. The heats of of the summer were
come, and Smith's magnificent steam yacht was fired up for a cruise,
but Captain Smith was detained ashore by his embarrassing position
on the market. Both he and his partner had sold more Erie than they
could deliver. Drew, who knew that the bulk of the stock was held
abroad, had, assisted by certain German bankers, bought up the
floating stock in the street, and when it became scarce for delivery,
Smith and Gould had to go to their "Uncle," to borrow the stock, for
which they had to pay an exorbitant commission. Daniel was of
course reluctant to extort these commissions from his old associates,
but he felt it to be a duty to himself and his family, — a duty from
which he should not shrink. "I've known Jay and Henry," said the old
man, to his broker, in a deprecatory tone, "goin' on seven year. They
is good boys ! Don't charge 'em three per cent, a day — charge 'em
one and a half, and they'll give down freer, and more'n that, they'll
feel better." It was soon after this time that Gould made that
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UXCLE DANIEL SQUEEZING THE BOYS. 539 famous sudden

change of front. Cutting loose from Smith, who still kept his position
on the short side, he covered his contracts and bought enormously
on the long side. It was, from henceforth, war to the knife between
Smith and Gould. The former was reported to be short of Pacific Mail
to the extent of fifty thousand shares, one fourth part of the whole
capital stock of the company. He clung to his position with a tenacity
that seemed under the circumstances like an infatuation. Gould and
Stock well joined hands in bulling Pacific Mail, and one fine day in
August, under the skilful manipulation of William Heath & Co., the
pool brokers, the stock was seen to pass 103 in its upward course.
Smith again was forced to come to terms. His net losses on this
transaction were half a million, ami Stockwell's star was in the
ascendant ; two years before he had been addressed as plain Mister
Stockwell ; he was now given a title, he was called Commodore
Stockwell.
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CHAPTER XXXV. THE PANIC OF 1873 AND AFTER. The

Northwest Corner. — Arrest of Jay Gould. — One hundred per cent,
in an hour. — Tight money and dull days. — The Bull Rings. — The
shadow of the panic. — The storm breaks. — Gould and Vanderbilt
in a tight place. — Darker and darker. — Shrinkage in values. —
Organizers of panic. — Sunshine and an eclipse. — The last grand
collapse. — When bottom was touched. ?HE rise of Pacific Mail was
the most brilliant pool movement since the year 1869, when New
York Central was lifted by the strong * hands of Vanderbilt and his
followers from 135 to 218. It was soon overshadowed, however, by
another gigantic operation, which was unparalleled by any similar
movement since the Prairie du Chien corner in 1865. We allude to
the corner in Chicago and Northwestern. The secret history of this
wonderful rise will, perhaps, never be written, for it is known only to
the leaders who engineered it. The three men who achieved the
startling result were Horace F. Clark, Augustus Schell, and Jay Gould.
Clark, whom we have before alluded to,
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THE NORTHWESTERN CORNER. 541 was a lawyer and

prominent railroad man. August us Scliell had also in former years
been a leading lawyer and politician, and was for many years
chairman of the National Democratic Committee. Both were a
hitmen, experienced financiers, and possessed of gj wealth, chiefly
acquired in the Vanderhilt movements. Several months were
consumed in 1872 in buying the common stock, which had been
slowly rising, under this absorption. One great danger threatened
the success of the movement, and that was the possibility that the
directors of the company would issue a batch of convertible bonds,
and, exchanging them for stock, load down the ring with this new
stock at high prices. In fact some of the directors were heavily short
of the stock, believing that it was much higher than it was worth.
This circumstance became known in the street, and several of the
largest operators had followed their example, believing that the
directors knew what they were about. Henry N. Smith was said to
have sold short 40,000 shares. Daniel Drew nearly as much more.
John L. Tracy, the President of the Company, was also on the short
side, and a host of smaller operators followed the examp'these
leaders. The pool had by the first of October bought the whole
capital stock, $11,000,000, either for cash or in the form of "calls"
and contracts. The din suspecting the danger they were in. met and
aul ized the issue of $11,000,001) pf
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542 INSIDE LIFE IN WALL STREET. November, while the

eyes of the "street" were daity watching the long vibrations of Pacific
Mail, suddenly Northwest bounded up to par, dropped back to '.Ml,
and then rushed to 105. Smith and Drew both knew that they were
trapped ; the latter had already relieved himself by borrowing 10,000
shares of Mrs. Keep, widow of the lute Henry Keep, and filling his
contracts to that extent; Smith, unable to make IMS deliveries,
bought largely of the preferred stock of the same company, and
tendered it in lieu of the common stock, but the tender was refused.
He had one last card to play — a desperate measure, but one that
he hoped would bring Gould to terms ; he was cognizant of certain
old transactions in Erie which would enable the Erie Company to
demand of Gould an immense sum, — about $6,000,000. He
disclosed these matters to the President of the Erie Railway
Company ; a warrant was issued for Gould's arrest, and this operator
was taken by the sheriff soon after the price had risen above par, as
already mentioned. Clarke and Schell promptly gave bail, and Gould
was soon back in the street, burning for revenge. Meanwhile, and
during his temporary absence, the stock rose like lightning to 200,
and all who were responsible to deliver saw themselves in the abyss
of ruin. The next day it rose to 230. The smaller tribe of bears were
let off at from 150 to 160. Drew and Smith alone were denied any
compromise. But at last they were allowed to settle at a considerable
discount from the summit price ; still the losses of both were
enormous— millions would not have covered them. The price then
sank back to 75, and the pool were still holders of most of the
capital stock, their situation
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TIGHT MONEY AND DULL DAYS. 543 under the burden

being somewhat relieved by the large sums paid them by the bears
in order to IK- let off from their contracts. The sequel to the arrest of
Jay Gould was an extraordinary one. It was believed that a hard
fight would be made by Jay Gould over the Erie claim, on account of
which, at the instance of H. N. Smith, he had been subjected to
arrest. But very much to the astonishment of everybody he promptly
made restitution to the Erie Railway — nominally — $6,000,000,
excusing himself from personal liability in the matter by the plea that
he was merely holding the property of the company in trust, and had
always been ready to surrender it upon demand. To this plea some
color of reason was given by the fact that a considerable number of
the legal instruments under which he held the property expressed
upon their face that he held it in trust. Before making this
restitution, he bought 200,000 shares of Erie in the neighborhood of
50: the price soon rose to G9; a dividend of one per cent, was
declared, and Gould, under the firmness f Iii> -li(l- (l(l(| shares, and
selling short 100,000 shares more for a turn on the other side.
These vast operations which we have just docrihed gave a ncwr
activity to the market, and the public were drawn into the vortex of
speculation by tinthousand. An interval of some weeks passed away,
and everything was quiet on the American IMMIIM-. The pools were
inactive; the outside battalion* I lying on their arms; after the feve*
<>f the pa>t three
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