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A proposed social indicator system for alcohol-related problems
PREVENTIVE
MEDICINE
2,438-444
(1973)
A Proposed
Social
Indicator
for Alcohol-Related
System
Problems
JOSEPH WESTERMEYER Department
of Psychiatry
AND JACOB BEARMAN Department University
of Minnesota,
of Biometry, Minneapolis, Minnesota
55455
The proposed social indicator system for alcoholism would be based on data recorded by various social agencies for problematic alcohol-related behavior, including: child abuse; alcohol-related arrest; death from accidents, homicide, suicide, cirrhosis, pneumonia, and ulcer; and admission to specified treatment facilities for alcoholism. The system offers an epidemiologic tool for assessing, not only alcohol-related events, but also institutional activity. Comparisons can be made between various subpopulations or in a given population over a limited time period. Preventive and treatment programs can be evaluated with this method, and it lends itself to cost accounting of such programs. Sample statistics are presented for Minnesota where the method will be tested in pilot study.
Two methods have been commonly used in psychiatric epidemiology. In the first, hospital and clinic statistics are employed to count all persons entering treatment over a certain period of time (7). In the second, all cases in a sample population are counted (4). At times, both methods have been combined in a single study (19). Both of these methods have also been employed in studying the epidemiology of alcoholism (2,14). However, hospital and clinic data cannot be expected to indicate the magnitude of alcohol-related problems, since a small percentage of such problems surface to societal recognizance in medical settings. Likewise, population surveys will not elicit information from people unable or unwilling to identify a problem as alcohol related. For reasons such as these, Jellinek developed a prevalence rate for alcoholism based on death rates from cirrhosis of the liver (10). This formula has been criticized on several counts (17), and Jellinek acknowledges the formula’s difficulties (9). A large-base population is required to obtain replicable statistics by this method; furthermore, what comprises a case of “alcoholism” is not specifically explained. While a modified Jellinek method has been used for population comparisons over the time in one geographic area, the method has been largely abandoned as an instrument for estimating alcoholism prevalence in a population. Recently, a variety of methods have come into existence for measuring alcohol-related events-especially accidental injuries and deaths. Analyses of 438 Copyright @ 1973 by Academic Press, Inc. All rights of reproduction in any form reserved.
SOCIAL
INDICATOR
SYSTEM
FOR ALCOHOLISM
439
blood, exhaled breath, and autopsy tissues have been done in emergency rooms and postmortem studies (6,16,21). Intensive case studies of fatal accidents have also been carried out (18). While these studies have not indicated the total prevalence of alcohol-related problems abroad in society, they have shown (1) that alcohol-related problems are more commonplace than was thought previously, and (2) there is a need to specify the problem which is alcohol related, rather than loosely use an arbitrary term such as “alcoholism.” Bahn has suggested an epidemiologic model for psychiatric and parapsychiatric events (1). Her method involved collecting a wide variety of data from various societal institutions. These might include, for example, psychiatric facilities, police, courts, and social agencies. Kiessler has undertaken just such a register of psychiatric and parapsychiatric events in a rural area of northern Minnesota (11). The method requires that (1) a social event occur, (2) a social institution perceive the event, and (3) the institution record the event. We believe that the Bahn-Kiessler method could be used with certain modifications elaborated below, to produce an indicator system for the prevalence of alcohol-related problems in a given population. While such a system would still miss some of the problematic behavior related to alcohol, nonetheless the number and diversity of events would more accurately reflect the actual state of affairs. As such, it could provide an improvement over past epidemiologic methods. For social-problem solving, this method may have an inherent practical advantage over earlier methods. Emphasis falls on an event and on social response, rather than on a “case.” Instead of attending only to “pathological” behavior or “disadvantaged’ people, the mores and responses of societal institutions also become matters for concern. Dynamic psychosocial relationships may become apparent, and social remedies (which intimately involve social institutions) may be suggested.
CRITERIA FOR A SOCIAL INDICATOR SYSTEM FOR ALCOHOLISM
1. The Statistics
Should
Be Readily
Available
in Social Znstitutions
Many alcohol-related behaviors are scanned by various social institutions, but are never used to quantify alcohol-related problems. Since these behaviors are scanned and recorded at considerable cost to society, a Social Indicator System for Alcoholism might employ these records to both qualify and quantify these problematic behaviors. 2. The Data Should Allow Collection of Pertinent Demographic Data, (e.g., Age, Sex, Race, etc.) While Respecting Personal Anonymity Epidemiologic studies require that subpopulations at high risk be identified by demographic variables. Without these variables, treatment programs cannot be efficiently planned or effectively evaluated. However, the reports coming from such a system must be available to social planners, legislators,
440
WESTERMEYER
AND
BEARMAN
bureaucrats, newsmen, and others if it is to contribute to planning tion. Therefore, individual anonymity must be assured. 3. The Method Must Give Reliable Statistics for Relatively Populations Over Relatively Short Periods of Time
and evalua-
Small
Most alcoholism treatment programs reach a small population (i.e., from several thousand to several tens of thousands). Moreover, in view of cost factors and the many confounding variables introduced by time, the time period in which the system can give reliable data should be brief. Thus, the man-years of exposure to alcohol-related events must be much less than the approximately 300,000 man-years of exposure to cirrhosis death needed for Jellinek’s method. 4. The System Should Be Sufficiently Sensitive to Discern (but Significant) Changes Zndicating Either Improvement
Small or Exacerbation
Programs are most liable to be flexible in their early phases. Institutions and programs can be expected to respond most effectively to social need if they can perceive the success or failure of their activities. Reporting of small but significant changes can have important impact on the directions which a program might take. A SOCIAL
INDICATOR
SYSTEM
FOR ALCOHOLISM
In order to meet the criteria above, the system must scan several alcoholrelated behaviors. These behaviors should have a known relationship to alcohol usage. The institution or agency scanning and recording these behaviors in Minnesota will be presented as a sample case, since it is anticipated that the system will be tried and evaluated in that state. 1. Child
Abuse
Alcohol intoxication has been highly correlated with child abuse in this and other societies (5,12,13). It has become a reportable disorder in many states. The Department of Public Welfare in Minnesota records extensive demographic data on each case. Reported cases are still infrequent (125-150 per year) and originate mostly from a few counties; but awareness of the problem is gradually increasing. 2. Alcohol-Related
Arrest
This can be measured directly by tabulating cases of illegal possession by a minor, driving while intoxicated, open bottle in the car, provision of alcohol to a minor, and disorderly conduct while drunk. These data are recorded in the county sheriffs’ offices and in municipal police departments which have a jail. Extrapolating from arrest data which we have collected in one urban and one rural county, an excess of 10,000 such arrests occur in Minnesota each year. Reasonably complete demographic information is available for these arrests (age, sex, race, home town), though urban counties presently record more complete data than do rural counties (i.e., marital status, employment).
SOCIAL
INDICATOR
SYSTEM
FOR ALCOHOLISM
441
A sizable minority of these arrests are actually rearrests within the same year, as the same person becomes involved repeatedly in alcohol-related problems. All arrests, whether for the first time or not, would be counted equally, for this reflects the amount of problematic behavior in a community.
3. Accidental and Violent Death Accident mortality is frequently associated with acute or chronic alcohol usage (6,8,16,18). Both homicide and suicide show a similar correlation (22). -4lmost 2000 such deaths occur in Minnesota each year. These statistics (like other mortality rates) are maintained at the Minnesota State Department of Health.
4. Pneumonia Death Mortality from pneumonia has long been known to bear a statistical relationship to alcoholism (8). The original study, done in 1940, has gained support from work done in the antibiotic era (3,15). About a thousand such deaths occur in Minnesota each year.
5. Cirrhosis and Ulcer Death Liver cirrhosis mortality comprised one of the earliest measures of alcoholism (9). The same investigator also demonstrated that peptic ulcer mortality also occurs significantly more often among alcoholics (8). These two causes, when combined, contribute about 1000 deaths in Minnesota mortality each year.
6. Treatment Facilities for Alcoholism Each year thousands of Minnesotans are admitted to the hospital with delirium tremens, acute alcoholic intoxication, and other alcohol-related brain syndromes. Unfortunately, the total number of such admissions is not recorded in any one place. However, some such data are collected by the State Division of Mental Health Services; these represent a number of people admitted to state psychiatric facilities from throughout the state. About 5000 “inebriate” admissions were made to State institutions during the last 2 fiscal years. It would be a considerable task to collate information on alcoholism admissions from all general hospitals throughout the state. The several hospitals with alcoholism units could be surveyed, however. Approximately 2000 such admissions occur each year. Data might also be obtained from the several detoxification centers about the state. The several half-way houses and several residential treatment facilities for alcoholics scattered about Minnesota could also be surveyed. Roughly 5000 admissions are made each year to these facilities. STATISTICAL
HANDLING
OF THE DATA
The numerator, All of the recorded behaviors noted above would be used to obtain incidence
rates. That is, each unit of child
abuse or arrest, or death, or
442
WESTEBMEYER
AND BEARMAN
hospital admission related to alcohol would appear as an “event” (even though some “events” would be recurring in the same individual, or the same individual would be involved in more than one kind of event). Approximately 27,000-30,000 “events” would be obtained for Minnesota (with population of 3,850,OOO in 1970). A majority of these “events” (22,000-25,000 of them) would be arrests and admissions for treatment directly related to alcoholism. Most, but not all of the remaining “events” would be alcohol related; (e.g., deaths from pneumonia, ulcer, cirrhosis) a “correction factor” could be obtained from the literature in order to determine eswhat proportion of these “events” are alcohol related. By conservative timate, the method would yield about one alcohol-related “event” per 150 population each year in Minnesota. The denominator. Rates would be obtained using the census data to determine. the denominators. While the national census provides fairly accurate statistics each 10 years, up-dated annual estimates can be obtained for each county. Need for specific rates. Crude rates would not be particularly helpful for program planning and might prove misleading for program evaluation. Fairly specific rates would be necessary for the following parameters: county of residence, age, sex, and race. By specifying such rates (e.g., white men in St. Paul aged 30-39 years, Indian rural men aged 20-29 years), large rates would be obtained for sizeable populations. Specific rates as high as one “event” per 10 or 20 persons are anticipated under these conditions for some subpopulations identified as to age, sex, and race. Multiplier effect. As mentioned earlier, the same person might repeat the same event (e.g., two arrests) in the same year and/or might be recorded for more than one event per year (e.g., drunken driving and ulcer death). If treatment programs can appreciably reduce all of the problematic alcohol-related behavior of such individuals, the beneficial effect on this one person as measured by this system would be multiplied. That is, the two or three or five “events” produced .by this one person would all drop from the statistics. Conversely, a program might be quite satisfied by its therapeutic effect on a given person. (Perhaps he attends treatment sessions regularly in a sober state or spends less money on alcohol.) However, if the individual continues to surface to societal recognizance with repeated problematic behavior, the statistics would objectively refute his “improvement.” DISCUSSION
The social indicator method enables us to assess the alcohol-related problems of a population both quantitatively and qualitatively. Since each parameter is quantified, we could compare two subpopulations in the same geographical area with uniform laws and customs (e.g., within Minnesota); or we could follow the same subpopulation over time. The latter strategy would allow a treatment program or a preventive program to be evaluated within a metropolitan or multicounty area. Of course, the differences in data collection of these “social indicators” precludes the use of this method in comparing
SOCIAL
INDICATOR
SYSTEM
FOR
ALCOHOLISM
443
data from areas that far apart or in the same area for a long time, since temperospatial gaps would make the data less comparable. In short, while the method is reasonably objective compared to other methods, various social factors prevent its widespread use for any and all comparisons. generated by people with problematic Besides counting the “events” behavior, this method also permits us critically to examine institutional behavior. Large sums of money can be expended for alcoholism treatment programs; but if alcohol-related morbidity and mortality are not reduced, the programs should be seriously questioned. The method may also help us to learn more about alcoholism. It could be used to compare social and ethnic groups, as well as to contrast adjacent geopolitical areas. Ways in which such profiles are either similar or different might suggest both social etiologies and social remedies. The social indicator profile, while somewhat akin to the old Jellinek formula, might prove to be more practical as well as more accurate. Jellinek’s method relies on mortality from Laennec’s cirrhosis, an event so infrequent that populations of 300,000 are needed to produce reliable data. REFERENCES 1. BAHN, A.An outline for community mental health research, in“The Sociology of Mental Disorders” (S. K. Weinberg, Ed.), pp. 310-314. Aldine, Chicago, 1967. 2. BAILXY, M., HABERMAN, P., AND ALKSNE, H. The epidemiology of alcoholism in an urban residential area. Quart. I. Stud. Ale. 26, 19-40 (1965). 3. CHOMET, B., AND GACH, B. Lobar pneumonia and alcoholism: an analysis of thirty-seven cases. Amer. 1. Med. Sci. 253, 300-304 (1967). 4. EATON, J., AND WEIL, R. “Culture and Mental Disorder. Free Press, Glencoe, Ill,, 1955. 5. GFUSLAIN, J., MAINARD, R., AND BARRANGER, P. Child abuse, social and legal problems. Ann.
Pediatr. 14,440-448 (1968). 6. HADDON, W., AND BRADESS, G. Alcohol in the single vehicle accident experience of Westchester County, New York. J. Amer. Med. Ass. 169, 1587-1593 (1959). 7. HOL~LINGSHEAD, A. B., AND REDLICK, F. C. “Social Class and Mental Illness” Wiley, New York, 1958. 8. JELI.INEK, E. M. Death from alcoholism’ in the United States in 1940. Qua7t.J. Stud. Ale. 3, 465-494 (1943). 9. JELI,INEK, E. M. Estimating the prevalence of alcoholism: modified values in the Jellinek formula and an alternative approach. Quart. J. Stud. Ah. 25, 261-269 (1959). 10. JOLLIFFE, M., AND JELLINEK, E. M. Cirrhosis of the liver. Quart. J. Stud. Ale. 2, 544-582 (1941). 11. KIESLER, F. Northland Mental Health Center: Grand Rapids, Minnesota (Personal communication). 12. NAN, E. Kindersmisshandlung (Child abuse). Monatsschr. Kinderheilk. 115,192-194 (1967). 13. NEIMAN, N. Child abuse. Sem. Hop. 44, 1523-1525 (1968). 14. ROBERTS, B., AND MEYERS, J. Religion, national origin, immigration, and mental illness. Amer. J. Psychiat. 110, 759-764 (1954). 15. SCHMIDT, W., AND DELINT, J. Mortality experiences of male and female alcoholic patients. Quart. J. Stud. Ale. 30, 112-118 (1969). 16. SCOTT, G. R. Drink and driving. N. 2. Med. J. 68, 360-364 (1968). 17. SEELEY, J. R. Estimating the prevalence of alcoholism: a critical analysis of the Jellinek formula. Quart. /. Stud. Ale. 25, 245-253 (1959). 18. SEZLER, M. L. Alcoholism, mental illness, and stress in 96 drivers causing fatal accidents. Behau. Sci. 14, 1-18 (1969).
444
WESTERMEYER
AND
BEARMAN
19. SROLE, L., LANGER, T. S., MICHAEL, S. T., OPLER, M. K., AND RENNIE, F. A. C. “Mental Health in the Metropolis” McGraw-Hill, New York, 1962. 20. TERRIS, M. Epidemiology of cirrhosis of the liver: national mortality data. Amer. J. Pub. Health 57,2076-2088 (1967). 21. WECHSLER, H., KASEY, E. H., THUM, D., AND DEMONE, H. W. Alcohol levels and home accidents. Pub. Health Rep. 84, 1043-1050 (1969). 22. WESTERMEYER,J.Violent death and alcohol use among Chippewa in Minnesota. Minn. Med. 55,749-752 (1972).
MEDICINE
2,438-444
(1973)
A Proposed
Social
Indicator
for Alcohol-Related
System
Problems
JOSEPH WESTERMEYER Department
of Psychiatry
AND JACOB BEARMAN Department University
of Minnesota,
of Biometry, Minneapolis, Minnesota
55455
The proposed social indicator system for alcoholism would be based on data recorded by various social agencies for problematic alcohol-related behavior, including: child abuse; alcohol-related arrest; death from accidents, homicide, suicide, cirrhosis, pneumonia, and ulcer; and admission to specified treatment facilities for alcoholism. The system offers an epidemiologic tool for assessing, not only alcohol-related events, but also institutional activity. Comparisons can be made between various subpopulations or in a given population over a limited time period. Preventive and treatment programs can be evaluated with this method, and it lends itself to cost accounting of such programs. Sample statistics are presented for Minnesota where the method will be tested in pilot study.
Two methods have been commonly used in psychiatric epidemiology. In the first, hospital and clinic statistics are employed to count all persons entering treatment over a certain period of time (7). In the second, all cases in a sample population are counted (4). At times, both methods have been combined in a single study (19). Both of these methods have also been employed in studying the epidemiology of alcoholism (2,14). However, hospital and clinic data cannot be expected to indicate the magnitude of alcohol-related problems, since a small percentage of such problems surface to societal recognizance in medical settings. Likewise, population surveys will not elicit information from people unable or unwilling to identify a problem as alcohol related. For reasons such as these, Jellinek developed a prevalence rate for alcoholism based on death rates from cirrhosis of the liver (10). This formula has been criticized on several counts (17), and Jellinek acknowledges the formula’s difficulties (9). A large-base population is required to obtain replicable statistics by this method; furthermore, what comprises a case of “alcoholism” is not specifically explained. While a modified Jellinek method has been used for population comparisons over the time in one geographic area, the method has been largely abandoned as an instrument for estimating alcoholism prevalence in a population. Recently, a variety of methods have come into existence for measuring alcohol-related events-especially accidental injuries and deaths. Analyses of 438 Copyright @ 1973 by Academic Press, Inc. All rights of reproduction in any form reserved.
SOCIAL
INDICATOR
SYSTEM
FOR ALCOHOLISM
439
blood, exhaled breath, and autopsy tissues have been done in emergency rooms and postmortem studies (6,16,21). Intensive case studies of fatal accidents have also been carried out (18). While these studies have not indicated the total prevalence of alcohol-related problems abroad in society, they have shown (1) that alcohol-related problems are more commonplace than was thought previously, and (2) there is a need to specify the problem which is alcohol related, rather than loosely use an arbitrary term such as “alcoholism.” Bahn has suggested an epidemiologic model for psychiatric and parapsychiatric events (1). Her method involved collecting a wide variety of data from various societal institutions. These might include, for example, psychiatric facilities, police, courts, and social agencies. Kiessler has undertaken just such a register of psychiatric and parapsychiatric events in a rural area of northern Minnesota (11). The method requires that (1) a social event occur, (2) a social institution perceive the event, and (3) the institution record the event. We believe that the Bahn-Kiessler method could be used with certain modifications elaborated below, to produce an indicator system for the prevalence of alcohol-related problems in a given population. While such a system would still miss some of the problematic behavior related to alcohol, nonetheless the number and diversity of events would more accurately reflect the actual state of affairs. As such, it could provide an improvement over past epidemiologic methods. For social-problem solving, this method may have an inherent practical advantage over earlier methods. Emphasis falls on an event and on social response, rather than on a “case.” Instead of attending only to “pathological” behavior or “disadvantaged’ people, the mores and responses of societal institutions also become matters for concern. Dynamic psychosocial relationships may become apparent, and social remedies (which intimately involve social institutions) may be suggested.
CRITERIA FOR A SOCIAL INDICATOR SYSTEM FOR ALCOHOLISM
1. The Statistics
Should
Be Readily
Available
in Social Znstitutions
Many alcohol-related behaviors are scanned by various social institutions, but are never used to quantify alcohol-related problems. Since these behaviors are scanned and recorded at considerable cost to society, a Social Indicator System for Alcoholism might employ these records to both qualify and quantify these problematic behaviors. 2. The Data Should Allow Collection of Pertinent Demographic Data, (e.g., Age, Sex, Race, etc.) While Respecting Personal Anonymity Epidemiologic studies require that subpopulations at high risk be identified by demographic variables. Without these variables, treatment programs cannot be efficiently planned or effectively evaluated. However, the reports coming from such a system must be available to social planners, legislators,
440
WESTERMEYER
AND
BEARMAN
bureaucrats, newsmen, and others if it is to contribute to planning tion. Therefore, individual anonymity must be assured. 3. The Method Must Give Reliable Statistics for Relatively Populations Over Relatively Short Periods of Time
and evalua-
Small
Most alcoholism treatment programs reach a small population (i.e., from several thousand to several tens of thousands). Moreover, in view of cost factors and the many confounding variables introduced by time, the time period in which the system can give reliable data should be brief. Thus, the man-years of exposure to alcohol-related events must be much less than the approximately 300,000 man-years of exposure to cirrhosis death needed for Jellinek’s method. 4. The System Should Be Sufficiently Sensitive to Discern (but Significant) Changes Zndicating Either Improvement
Small or Exacerbation
Programs are most liable to be flexible in their early phases. Institutions and programs can be expected to respond most effectively to social need if they can perceive the success or failure of their activities. Reporting of small but significant changes can have important impact on the directions which a program might take. A SOCIAL
INDICATOR
SYSTEM
FOR ALCOHOLISM
In order to meet the criteria above, the system must scan several alcoholrelated behaviors. These behaviors should have a known relationship to alcohol usage. The institution or agency scanning and recording these behaviors in Minnesota will be presented as a sample case, since it is anticipated that the system will be tried and evaluated in that state. 1. Child
Abuse
Alcohol intoxication has been highly correlated with child abuse in this and other societies (5,12,13). It has become a reportable disorder in many states. The Department of Public Welfare in Minnesota records extensive demographic data on each case. Reported cases are still infrequent (125-150 per year) and originate mostly from a few counties; but awareness of the problem is gradually increasing. 2. Alcohol-Related
Arrest
This can be measured directly by tabulating cases of illegal possession by a minor, driving while intoxicated, open bottle in the car, provision of alcohol to a minor, and disorderly conduct while drunk. These data are recorded in the county sheriffs’ offices and in municipal police departments which have a jail. Extrapolating from arrest data which we have collected in one urban and one rural county, an excess of 10,000 such arrests occur in Minnesota each year. Reasonably complete demographic information is available for these arrests (age, sex, race, home town), though urban counties presently record more complete data than do rural counties (i.e., marital status, employment).
SOCIAL
INDICATOR
SYSTEM
FOR ALCOHOLISM
441
A sizable minority of these arrests are actually rearrests within the same year, as the same person becomes involved repeatedly in alcohol-related problems. All arrests, whether for the first time or not, would be counted equally, for this reflects the amount of problematic behavior in a community.
3. Accidental and Violent Death Accident mortality is frequently associated with acute or chronic alcohol usage (6,8,16,18). Both homicide and suicide show a similar correlation (22). -4lmost 2000 such deaths occur in Minnesota each year. These statistics (like other mortality rates) are maintained at the Minnesota State Department of Health.
4. Pneumonia Death Mortality from pneumonia has long been known to bear a statistical relationship to alcoholism (8). The original study, done in 1940, has gained support from work done in the antibiotic era (3,15). About a thousand such deaths occur in Minnesota each year.
5. Cirrhosis and Ulcer Death Liver cirrhosis mortality comprised one of the earliest measures of alcoholism (9). The same investigator also demonstrated that peptic ulcer mortality also occurs significantly more often among alcoholics (8). These two causes, when combined, contribute about 1000 deaths in Minnesota mortality each year.
6. Treatment Facilities for Alcoholism Each year thousands of Minnesotans are admitted to the hospital with delirium tremens, acute alcoholic intoxication, and other alcohol-related brain syndromes. Unfortunately, the total number of such admissions is not recorded in any one place. However, some such data are collected by the State Division of Mental Health Services; these represent a number of people admitted to state psychiatric facilities from throughout the state. About 5000 “inebriate” admissions were made to State institutions during the last 2 fiscal years. It would be a considerable task to collate information on alcoholism admissions from all general hospitals throughout the state. The several hospitals with alcoholism units could be surveyed, however. Approximately 2000 such admissions occur each year. Data might also be obtained from the several detoxification centers about the state. The several half-way houses and several residential treatment facilities for alcoholics scattered about Minnesota could also be surveyed. Roughly 5000 admissions are made each year to these facilities. STATISTICAL
HANDLING
OF THE DATA
The numerator, All of the recorded behaviors noted above would be used to obtain incidence
rates. That is, each unit of child
abuse or arrest, or death, or
442
WESTEBMEYER
AND BEARMAN
hospital admission related to alcohol would appear as an “event” (even though some “events” would be recurring in the same individual, or the same individual would be involved in more than one kind of event). Approximately 27,000-30,000 “events” would be obtained for Minnesota (with population of 3,850,OOO in 1970). A majority of these “events” (22,000-25,000 of them) would be arrests and admissions for treatment directly related to alcoholism. Most, but not all of the remaining “events” would be alcohol related; (e.g., deaths from pneumonia, ulcer, cirrhosis) a “correction factor” could be obtained from the literature in order to determine eswhat proportion of these “events” are alcohol related. By conservative timate, the method would yield about one alcohol-related “event” per 150 population each year in Minnesota. The denominator. Rates would be obtained using the census data to determine. the denominators. While the national census provides fairly accurate statistics each 10 years, up-dated annual estimates can be obtained for each county. Need for specific rates. Crude rates would not be particularly helpful for program planning and might prove misleading for program evaluation. Fairly specific rates would be necessary for the following parameters: county of residence, age, sex, and race. By specifying such rates (e.g., white men in St. Paul aged 30-39 years, Indian rural men aged 20-29 years), large rates would be obtained for sizeable populations. Specific rates as high as one “event” per 10 or 20 persons are anticipated under these conditions for some subpopulations identified as to age, sex, and race. Multiplier effect. As mentioned earlier, the same person might repeat the same event (e.g., two arrests) in the same year and/or might be recorded for more than one event per year (e.g., drunken driving and ulcer death). If treatment programs can appreciably reduce all of the problematic alcohol-related behavior of such individuals, the beneficial effect on this one person as measured by this system would be multiplied. That is, the two or three or five “events” produced .by this one person would all drop from the statistics. Conversely, a program might be quite satisfied by its therapeutic effect on a given person. (Perhaps he attends treatment sessions regularly in a sober state or spends less money on alcohol.) However, if the individual continues to surface to societal recognizance with repeated problematic behavior, the statistics would objectively refute his “improvement.” DISCUSSION
The social indicator method enables us to assess the alcohol-related problems of a population both quantitatively and qualitatively. Since each parameter is quantified, we could compare two subpopulations in the same geographical area with uniform laws and customs (e.g., within Minnesota); or we could follow the same subpopulation over time. The latter strategy would allow a treatment program or a preventive program to be evaluated within a metropolitan or multicounty area. Of course, the differences in data collection of these “social indicators” precludes the use of this method in comparing
SOCIAL
INDICATOR
SYSTEM
FOR
ALCOHOLISM
443
data from areas that far apart or in the same area for a long time, since temperospatial gaps would make the data less comparable. In short, while the method is reasonably objective compared to other methods, various social factors prevent its widespread use for any and all comparisons. generated by people with problematic Besides counting the “events” behavior, this method also permits us critically to examine institutional behavior. Large sums of money can be expended for alcoholism treatment programs; but if alcohol-related morbidity and mortality are not reduced, the programs should be seriously questioned. The method may also help us to learn more about alcoholism. It could be used to compare social and ethnic groups, as well as to contrast adjacent geopolitical areas. Ways in which such profiles are either similar or different might suggest both social etiologies and social remedies. The social indicator profile, while somewhat akin to the old Jellinek formula, might prove to be more practical as well as more accurate. Jellinek’s method relies on mortality from Laennec’s cirrhosis, an event so infrequent that populations of 300,000 are needed to produce reliable data. REFERENCES 1. BAHN, A.An outline for community mental health research, in“The Sociology of Mental Disorders” (S. K. Weinberg, Ed.), pp. 310-314. Aldine, Chicago, 1967. 2. BAILXY, M., HABERMAN, P., AND ALKSNE, H. The epidemiology of alcoholism in an urban residential area. Quart. I. Stud. Ale. 26, 19-40 (1965). 3. CHOMET, B., AND GACH, B. Lobar pneumonia and alcoholism: an analysis of thirty-seven cases. Amer. 1. Med. Sci. 253, 300-304 (1967). 4. EATON, J., AND WEIL, R. “Culture and Mental Disorder. Free Press, Glencoe, Ill,, 1955. 5. GFUSLAIN, J., MAINARD, R., AND BARRANGER, P. Child abuse, social and legal problems. Ann.
Pediatr. 14,440-448 (1968). 6. HADDON, W., AND BRADESS, G. Alcohol in the single vehicle accident experience of Westchester County, New York. J. Amer. Med. Ass. 169, 1587-1593 (1959). 7. HOL~LINGSHEAD, A. B., AND REDLICK, F. C. “Social Class and Mental Illness” Wiley, New York, 1958. 8. JELI.INEK, E. M. Death from alcoholism’ in the United States in 1940. Qua7t.J. Stud. Ale. 3, 465-494 (1943). 9. JELI,INEK, E. M. Estimating the prevalence of alcoholism: modified values in the Jellinek formula and an alternative approach. Quart. J. Stud. Ah. 25, 261-269 (1959). 10. JOLLIFFE, M., AND JELLINEK, E. M. Cirrhosis of the liver. Quart. J. Stud. Ale. 2, 544-582 (1941). 11. KIESLER, F. Northland Mental Health Center: Grand Rapids, Minnesota (Personal communication). 12. NAN, E. Kindersmisshandlung (Child abuse). Monatsschr. Kinderheilk. 115,192-194 (1967). 13. NEIMAN, N. Child abuse. Sem. Hop. 44, 1523-1525 (1968). 14. ROBERTS, B., AND MEYERS, J. Religion, national origin, immigration, and mental illness. Amer. J. Psychiat. 110, 759-764 (1954). 15. SCHMIDT, W., AND DELINT, J. Mortality experiences of male and female alcoholic patients. Quart. J. Stud. Ale. 30, 112-118 (1969). 16. SCOTT, G. R. Drink and driving. N. 2. Med. J. 68, 360-364 (1968). 17. SEELEY, J. R. Estimating the prevalence of alcoholism: a critical analysis of the Jellinek formula. Quart. /. Stud. Ale. 25, 245-253 (1959). 18. SEZLER, M. L. Alcoholism, mental illness, and stress in 96 drivers causing fatal accidents. Behau. Sci. 14, 1-18 (1969).
444
WESTERMEYER
AND
BEARMAN
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