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EDUCATION INVETERINARY PUBLIC

HEALTHANI)

PREVENTIVE MEDICINE

PAN AMFRICAN HIIALT'H ORGANIZATIO()N

Pan Amierican Sanitary Bureau, Regional Office of the

\WORLD) HEALTHI ORGANIZATION

1969

SYMPOSIUM ON EDUCATION IN

VETERINARY PUBLIC HEALTH AND

PREVENTIVE MEDICINE

(St. Paul, Minnesota, 18-22 March 1968)

Scientific Publication No. 189

PAN AMERICAN HEALTH ORGANIZATIONPan American Sanitary Bureau, Regional Office of the

WORLD HEALTH ORGANIZATION525 Twenty-Third Street, N.W.

Washington, D. C. 20037

CONTENTS

PREFACE ................................................................ V

Organization of the Symposium ............................................ viiObjectives of the Symposium

Pedro N. Acha and Harold B. Hubbard .................................. ix

RECOMMENDATIONS OF THE SYMPOSIUM . .................................... 3

PART I. THE VETERINARY PUBLIC HEALTH CURRICULUM

Teaching Programs to Meet Present and Future Needs: The Public Service Veter-inarian-Ernest E. Saulmon .............................................. 17

Teaching Programs to Meet Present and Future Needs: A Veterinary MedicalScientist Training Program-James H. Steele ............................... 20

Teaching Programs to Meet Present and Future Needs: An Air Force View-Edward L. Menning ..................................................... 23

Teaching Programs to Meet Present and Future Needs: An EpidemiologicalApproach-Paul R. Schnurrenberger ....................................... 25

The Teaching of Epidemiology: Teaching the Basic Principles-Leonard M. Schuman .................................................... 27

The Teaching of Epidemiology: The Kentucky Program-Hugh S. Fulmer..... 33The Teaching of Biostatistics: Objectives and Principles-Paul Leaverton ..... 38The Teaching of Biostatistics: Minimum Goals for Veterinary Students-

Jacob Bearman .......................................................... 43The Teaching of Food Hygiene: Meat and Poultry Hygiene-James D. Lane.. 44The Teaching of Food Hygiene: Curriculum Objectives-Morris A. Shiffman.... 50The Teaching of Environmental Health: Over-All Objectives and Responsi-

bilities-William F. McCulloch ............................................ 55The Teaching of Environmental Health: Expanding the Curriculum-

J. Douglas McCluskie ................................................... 62The Teaching of Veterinary Community Medicine: Changes in Emphasis and

Methods-Henry M. Parrish and Donald C. Blenden ....................... 68The Teaching of Veterinary Community Medicine: Are Our Veterinary Schools

Equal to the Task?-Calvin W. Schwabe .................................. 75The Teaching of Veterinary Community Medicine: An Applied Program-

John H. Helwig ......................................................... 82Field Training Programs: The Ohio Preventive Medicine Program-

Jack H. Russell .......................................................... 84Field Training Programs: Veterinary Student Orientation in the U.S. Department

of Agriculture-Daniel F. Werring ........................................ 88Field Training Programs: The St. Paul Program-Paul J. Cox ............... 91Field Training Programs: The U.S. Department of Agriculture Meat Inspection

Program-V. L. Dahl .................................................... 92The Teaching of Disaster Preparedness-Donald C. Blenden .................. 94

PART II. BIOMEDICAL COMMUNICATIONS

Some Implications of Research for the Design of Instructional Material-William T. Stickley ..................................................... 101

Application of Learning Resources in the Veterinary Curriculum-Robert Getty.. 110

iii

iv Contents

The Computer Fact Bank: Multidisciplinary Laboratory Interrelationships-Fred W. Clayton ........................................................ 119

Audiovisual Communications: An Action Program-Norman L. Cole .......... 121

PART III. EVALUATION

Evaluating the Student's Learning-Edwin F. Rosinski ....................... 129

Appendix: List of Participants ............................................. 138

PREFACE

While this Symposium on Education in Veterinary Public Health and Pre-ventive Medicine was being planned, an expression on education in generalwas kept in mind: "If the learner hasn't learned, the teacher hasn't taught."

The instructor of public health and preventive medicine is first of all ateacher. The teacher speaks, but what he does speaks as strongly as what hesays. To the students of veterinary public health, the teacher of that disciplineis public health. The students respect the teacher who can see beyond his ownimage, who creates in each of them an awareness of their responsibility for thehealth of the people in their community. The teacher must provide knowledgeof the most acceptable and recently developed principles and procedures forresolving the health problems of man that have a veterinary medical aspect.

But knowledge and experience are not enough in this discipline; it is vitalthat the skills learned be applicable to the mores, superstitions, and sociopoli-tical differences of any community. In today's borderless world, every personis our neighbor and every country is within our community. The health prob-lems of the community today are poverty, disease, illiteracy, and ignorance.One of the paramount objectives of any future teaching program in veterinarypublic health and preventive medicine should be the development and imple-mentation of a contemporary educational philosophy. From this first Sympo-sium on Education in Veterinary Public Health and Preventive Medicinecome recommendations outlining methods for instilling in students a con-temporary educational philosophy aimed at achieving the optimum healthof man.

HAROLD B. HUBBARDEditor of the Proceedings

v

ORGANIZATION OF THE SYMPOSIUM

In October 1966 the University of Minnesota College of Veterinary Medi-cine extended an invitation to the Association of Teachers of Veterinary PublicHealth and Preventive Medicine to conduct a symposium on education inthese subjects at the University. The Pan American Health Organizationfurnished financial support for the organization and conduct of the Sympo-sium. Doctors Pedro N. Acha, Robert K. Anderson, and Harold B. Hubbardwere designated program co-chairmen.

In January 1968 invitations were extended to the deans and professors ofveterinary public health and preventive medicine of the colleges and schoolsof veterinary medicine in the United States of America and Canada to partici-pate in the Symposium, and the Pan American Health Organization invitededucators from medical schools, schools of public health, and schools of otherhealth-related disciplines to prepare working documents.

Registration and a social hour were held on Sunday evening, 17 March1968. Participants included representatives of twenty-one schools of veterinarymedicine (twenty in the United States and Canada, one in Latin America),six medical schools, and three schools of public health. Federal and stateagencies were represented by fourteen participants, and the United StatesArmed Forces by four.

The opening session was held in the Veterinary Science Building, at theUniversity of Minnesota College of Veterinary Medicine in St. Paul, Minne-sota. Dr. Donald K. Smith, Associate Vice-President, Academic Administra-tion, University of Minnesota, who welcomed the participants, pointed outquite explicitly in his remarks the significance to the academic arena of asymposium on veterinary medical education, particularly in the fields ofpublic health and preventive medicine.

Short presentations (twenty to forty-five minutes in duration), followed bylong discussion periods open to all participants, provided a new approach tothe conduct of symposia on veterinary medical education. Participants ex-pressed favorable comments concerning this method of presentation. It wasfelt that more self-evaluation of each teacher's instructional program wasaccomplished in this manner.

The subjects for the daily sessions were selected and programmed to focusstudy on the constituents needed in the public health curriculum. The maintopics of the public health curriculum were scheduled early in the program inorder to develop discussion on what to teach before the several excellent ses-sions on biomedical communications, which engendered discussion on howto teach. Evaluation of the teaching-learning process was reserved until lastto emphasize the fact that evaluation is equally as important as the subjectmatter and how it is to be presented.

The recommendations on subject content and methods for their implementa-tion were considered during the final session. Chairmen of the various com-

vii

viii Organization of the Symposium

mittees presented the recommendations as prepared by each committee. Sug-gestions for alterations, additions, and corrections were offered by the Sympo-sium participants, and it was voted to adopt the recommendations.

A general recommendation was proposed and adopted: to develop a referencelist of the recommendations formulated by the Symposium, which should becirculated to each college and school of veterinary medicine in the UnitedStates and Canada to verify implementation of the recommendations or tosolicit a schedule of implementation.

To provide continuity to the efforts of the Symposium, another generalrecommendation was proposed and approved; to establish and support anAdvisory Group of members of the Association of Teachers of Veterinary PublicHealth and Preventive Medicine to visit each college or school of veterinarymedicine in the United States and Canada for the purpose of presenting theconcepts, responsibilities, and requirements of veterinary public health andpreventive medicine as expressed by the Symposium.

Dr. Pedro N. Acha, Chief of the Veterinary Medieal Services of the PanAmerican Health Organization, expressed appreciation to the University ofMinnesota for its contribution to the Symposium and stated that it was apleasure for the Pan American Health Organization to cooperate with theAssociation of Teachers of Veterinary Public Health and Preventive Medicineby providing financial support for the Symposium.

Dr. Daniel Cohen, Chief of the Section of Epidemiology and Public Healthof the University of Pennsylvania School of Veterinary Medicine, expressedon behalf of the Association gratitude to the Pan American Health Organiza-tion for their leadership and financial support, and to the University ofMinnesota College of Veterinary Medicine for their hospitality in providingfacilities conducive to intellectual concentration and expression of opinion.

An evaluation of the Symposium by the participants revealed unanimouspraise for the agenda, the speakers, the method of presentation, and theconduct of the Symposium in general. It was suggested that the next suchconference be held as a cooperative effort with the teachers of veterinarypublic health and preventive medicine in Latin America in order to promotea unified educational philosophy in the Western Hemisphere in instructionin this discipline.

In conclusion, the participants suggested that the deans, other administrativeofficers, and curriculum revision committees of the veterinary medical collegesand schools give serious and favorable consideration to the implementationof the recommendations of this Symposium.

During the banquet held on the evening of 18 March, the Association ofTeachers of Veterinary Public Health and Preventive Medicine presented anAward of Recognition to Dr. Gaylord W. Anderson for his outstanding leader-ship and contribution to the education of veterinarians in public health. Dr.Anderson is Mayo Professor and Director of the School of Public Health,University of Minnesota.

OBJECTIVES OF THE SYMPOSIUM

PEDRO N. ACHA, D.V.M., M.P.H.,* AND HAROLD B. HUBBARD, D.V.M., M.P.H.t

In recent years, three Seminars on the Teaching of Preventive Medicineand Public Health in Schools of Veterinary Medicine in the Americas havebeen sponsored by the Pan American Health Organization: in August 1959at Kansas City, Missouri; in August 1963 at Mexico City, Mexico; and inMarch 1967 at Lima, Peru.

In a sense, the 1968 meeting in St. Paul complements the meeting heldin 1967 in Lima. During that meeting, at which representation was limitedto the teachers of public health in veterinary medical schools in Latin Amer-ica, a series of recommendations were adopted which should be of considerableinterest to participants in the present Symposium. We shall mention a few ofthe most important recommendations. Before doing so, however, we shouldmention the fact that some essential differences exist regarding the importanceof public health as a subject in the veterinary curriculum in Latin America.First and foremost, it must be borne in mind that the countries of the Americasare in a state of accelerated development. This is especially true of the live-stock industry, which is an industry basic to the economic development ofthese countries. This fact in itself underscores the growing need for moreveterinarians. From 1957 to 1967, a total of 25 new veterinary schools wereopened in Latin America, and the number continues to increase. Secondly, agreat deal more than simple attention to veterinary medical activities is beingexpected of, and demanded from, the graduating veterinarian. He is expectedto suddenly be prepared to deal with a whole host of disease problems whichin some instances have a specific relationship to the gravity of economicproblems. Many times he is the only qualified professional in the publichealth field who not only understands the major zoonoses and other diseasecomplexes but can interpret their significance and formulate, execute, andevaluate a program designed for their control.

In the United States the veterinary profession has had the benefit of yearsof experience, advanced thinking, resources, and assistance in the developmentof programs of veterinary public health significance. Federal and state veteri-nary medical services have been developing at a high level as part of a complexwatchdog structure, designed to afford a quick response to the appearance ofzoonoses which threaten the safety of the public or which constitute a hazardto the economic well-being of the livestock industry. Guidance has beensupplied for the enactment of Federal, state, and local legislation in such

* Chief, Veterinary Medical Services, Pan American Health Organization, Regional Officeof the World Health Organization, Washington, D.C.

t Associate Professor, Department of Medical Microbiology, School of Veterinary Medi-cine, University of Georgia, Athens, Georgia. At present, Deputy Chief, Veterinary MedicalServices, Pan American Health Organization, Washington, D.C.

ix

x Objectives of the Symposium

areas as inspection of food, meat hygiene, storage, and transportation. Withfew exceptions (and those are in very special situations) such trusteeshipover public health from the veterinary medical point of view is absent fromthe Latin American scene, though we must point out that this is changing.Today, as never before, the demand is for both quantity and quality, asregards the knowledge of veterinary public health expected of the veterinarymedical student.

The extent to which the recommendations which came from the 1967 meet-ing in Lima should be borne in mind by the participants of this meeting is amatter of degree. It will be found that, to a great extent, the recommendationsare entirely applicable to the North American scene. Therefore, we present forconsideration the following summary of viewpoints expressed by our LatinAmerican colleagues:

1. The teaching of biostatistics, epidemiology, and administration constitutesa basic prerequisite in the preparation of a fully trained veterinarian.

92 The health departments and livestock units of departmcents of agr,1cultreat various levels of government should establish departments of epidemiologyand biostatistics; furthermore, all officers of such departments who are carryingout work related to either of these fields should be adequately trained in theirspecialty.

3. Postgraduate courses in the subject of teaching of public health shouldbe held from time to time.

4. Courses in public health held in schools other than veterinary medicalschools should be so designed as to afford special usefulness to the participatingveterinary medical graduate; and the usefulness of having a suitably qualifiedveterinarian in the school of public health as part of the teaching staff shouldbe recognized.

5. The graduate veterinarian, with his adequate knowledge of public healthimplications of veterinary medical interest, should be utilized to the full inthe team approach to solutions of problems in environmental health, zoonosescontrol, food hygiene, etc.

For the participants in the present Symposium, perhaps, the subject is notwhat but how, as it is for our colleagues in Latin America. The papers pre-sented are intended to provoke discussion as to how best we can achieve ourgoals. As more and more demands are made by society and by our times, itbehooves us always to anticipate the needs of the future and to define theresponsibilities which fall to us. We should remember, too, that our responseto such provocation is necessarily a delayed reaction. Even if we begin at onceto implement recommendations, it is usually not until two to three years after(or even later) that the first results can be perceived, and it is much longerbefore the fledgling veterinarian can contribute significantly.

The Pan American Health Organization has continued to support effortsto meet this challenge. Now, as never before, we are conseious of the needto maintain close liaison with our colleagues in Latin America and with oursister profession of human medicine, if full use is to be made of resourcesfor the attainment of the economic and health goals of the countries of theHemisphere.

If a survey were to be conducted among recent graduates of schools ofveterinary medicine concerning their opinions regarding public health training,

Objectives oj the 5Symposium xi

there would be a considerable variation in responses. Some would suggest thatmore time be spent in teaching public health; others would want to eliminatethe teaching of the subject altogether. We would guess that some wouldagree that certain teaching programs are poorly organized and lack imagina-tion in presentation. Departmentalization of public health activities in variousschools presents almost the same state of disorganization. The public healthteaching program is incorporated into the teaching of microbiology, pathology,parasitology, or almost any other subject embraced by "public health." Incontrast, many schools have complete departments devoted to comprehensivepublic health instruction.

Hand in hand with diversity in instruction go differences in the quality ofthe student's background. Each of you knows the basic knowledge implantedinto the students of your region. You alone are aware of the metal or steelwith which you must work. Ofttimes, the tempering of this steel presents thegreatest difficulty. The purpose of this Symposium is to help find newer andbetter ways to perform this tempering process.

To provide a protocol of instruction for every school would be a pretentiousand obviously inadequate effort. Each format of instruction must be gearedto the local philosophy and facilities. However, certain fundamental con-cepts and commonly accepted practices can be utilized by all.

We need to strive for a realistic approach to veterinary public health instruc-tion applicable to today's needs and challenges. Concurrently, each teachermust be dedicated to a program of unified effort if we are to achieve our goals.

A unified group of dedicated teachers can present programs and resolutionscalling for action that will be listened to more attentively and judged farsooner than can a few teachers individually. The implication here is notnecessarily securing more curriculum time but seeking support in depth forthe philosophy of the public health teaching program. At the same timefar-reaching instructional resources should be provided. By attaching someslight human health significance to their research programs, some schools ofveterinary medicine are able to operate vast research programs with moniesobtained from the Federal health agencies. But the true purpose of some ofthese programs is to provide the means for research in the researchers' owndiscipline, some of which is quite removed from public health. While soakingup the benefits of these resources, some researchers and administrators payonly lip service to their teaching programs in veterinary public health. Whenobservant students begin to ask why this is so, the need for administratorsto correct this imbalance becomes all the more necessary.

The responsibility of public health instruction in schools of veterinarymedicine should not be delegated to teachers whose foremost interests are inmicrobiology, pathology, or some other discipline. Public health is a disciplinein itself like parasitology, medicine, or surgery. The true public health teacherwho conducts research in microbiology, pathology, or immunology is to beadmired, since the new knowledge he gains will be fed back into his teachingprogram in public health.

It is time we subjected our public health teaching to a re-evaluation. Is ita sideline activity or our primary endeavor? If it is not just a job to be accom-plished with token enthusiasm, then we should request the administration tosecure the services of a full-time instructor formally trained in public health.

xii Objectives oj the Symposium

This Symposium offers the opportunity not only for self-analysis by theindividual but for an external analysis of the entire teachers' group by highlyskilled teachers of medicine, public health, education, and other disciplines.Our present teaching programrs should' be re-evaluated in the light of thecurricula and methods presented here. Some sound, realistic recommendationswill be proposed by this Symposium, in line with today's needs. If we imple-ment these recommendations when we return to our classrooms, we will havetaken great strides in the direction of the optimum health of man.

RECOMMENDATIONS

OF THE SYMPOSIUM

RECOMMENDATIONS OF THE SYMPOSIUM

THE PROMOTION OF HEALTH

Although progress has been made since the 1963 Seminar on the Teachingof Preventive Medicine and Public Health in Schools of Veterinary Medicine,not all of the recommendations of that meeting have been implemented.

The critical shortage of personnel in the health professions has increasedthe demands on both veterinary medicine and public health. As a member ofthis "health team," the veterinarian has been asked to assume an ever-increasing number of responsibilities in the field of public health at local, state,national, and international levels. These increased demands have occurredbecause of both existing environmental and public health problems andincreased awareness on the part of the public as to the veterinarian's abilityto contribute to the solving of community health problems (e.g., serving onlocal boards of health).

Because of these trends and further improvements in the teaching of veteri-nary public health and preventive medicine, more graduating veterinarians areentering directly into full- or part-time positions with various health agencies.

If the schools of veterinary medicine are to provide the necessary leadershipin these areas, then it is imperative that basic material on veterinary publichealth and preventive medicine be taught by faculty trained specifically inpublic health. It is recognized that other areas of the curriculum incorporatepublic health philosophy. However, it is recommended that schools of veteri-nary medicine establish teaching and research departments, sections, or unitsfor the purpose of organizing and coordinating the teaching of this subjectand for developing the student's knowledge and understanding of the objectivesand principles of public health.

Subject matter in the veterinary medical curriculum must reflect trends insociety that affect the health of man, animals, and plants. Promotion of healthis as important as prevention of disease and disability.

The deans of the schools and colleges of veterinary medicine must acceptthe responsibility for seeing that all veterinary medical students are not onlytrained but educated to assess the importance and consequences of futuretechnological changes that affect the "wellness" and "illness" of the totalanimal kingdom of which man is a part.

EPIDEMIOLOGY

It is vital that all students of veterinary medicine be taught the principlesand practices of epidemiology, since this science is basic to all problems ofdisease and veterinary community medicine.

To begin with, there should be a separate course in the veterinary curriculum3

Recommendations of the Symposium

on the principles of epidemiology, comprising a minimum of 30 contact hours.Preferably, this basic epidemiology course should be presented early in thestudent's experience.

Opportunities for formal reinforcement of epidemiological principles shouldbe provided late in the curriculum, perhaps in connection with the teaching ofpreventive medicine, infectious diseases, and/or public health. This formalepidemiological training should include problem-solving experience. Oppor-tunities for this experience should be created both in the field and in thelaboratory.

Experimental epidemiological models should be developed for teachingpurposes. The general availability of closed laboratory animal and poultrypopulations on all veterinary medical campuses, and the practical importanceto veterinary medicine of studies on these populations, suggest their use forthis purpose.

These courses require for their instruction the participation of veterinarianswho have had postdoctoral-level training and experience in epidemiology.

Prompt, adequate attention should be given to effective correlation of epi-demiological and biostatistical instruction in the curriculum.

Teachers of veterinary public health and preventive medicine should activelyencourage the exchange of teaching materials, particularly those relevant toepidemiological problems. The Association of Teachers of Veterinary PublicHealth and Preventive Medicine should designate from its membership ateacher of epidemiology to assume the functions of collection, duplication, anddistribution of these materials.

Serious consideration should be given to the possible utilization of existingextramural programs, both at home and abroad, in the training of veterinarymedical students in epidemiology and related fields. The Association shouldmake an effort to expand such training opportunities for veterinary medicalstudents and to keep its membership adequately informed.

BIOSTATISTICS

The Second Seminar on the Teaching of Preventive Medicine and PublicHealth in Schools of Veterinary Medicine, held in Mexico City in August 1963,expressed in general terms the need for education in statistical methods. Be-cause of the delay in implementation of the Seminar's recommendations, it isappropriate at this time to provide more specific guidelines for effecting sucha program.

The impact of a resident statistical unit on the progressive development ofquantitative thinking makes it essential that all schools aim for the establish-ment of a fully trained statistical unit in residence at the veterinary medicalschool. Its functions should include (1) assistance to students and faculty inthe design and analysis of experiments and (2) the training of students andfaculty in statistical techniques. This unit should be located within the depart-ment or section of public health, epidemiology, or preventive medicine, sincethese areas are the prime users of biostatistical procedures.

4


There are three areas in which all students should be instructed:

I. Basic Biostatistics1. Population distributions

Binomial, Poisson, and normal distributionsCentral tendencies (means, medians, and modes)Dispersion (range, standard deviation, standard error)

2. Probability theory3. Methods of testing hypotheses-null and alternate

t tests for numberst tests for proportionschi-squareAnalysis of variance

4. Experimental designRandomized individuals or blocksGreco-Latin squaresIncomplete balanced blocksPrinciples of scientific methods

5. Regression analysisII. Vital Statistics (Population characteristics in health and disease)

1. Natality, growth, and mortality of normal and abnormal populations; age, sex,breed, etc.

2. Rates and ratiosIncidence and prevalence ratesCase fatality, attack rates-apparent and inapparent

3. Adjustment of rates and standardization of rates4. Comparison of rates5. Life tables and life table methods-life expectancy6. Sampling and sampling surveys and bias

Random samplingSystematicStratifiedClusteredTwo-stage samplingSequential analysisDouble blind studies

7. Validity and reliability of testingAgreementSpecificitySensitivity

8. Data processingPrinciples of collection of dataConstruction of tables and graphsReview of methods used in data processing

Hand methods (tally sheets, cards, etc.)Machine methods (IBM, etc.)

III. Statistical Applications in Other Disciplines (such as pharmacology, physiology,microbiology, and clinical medicine; e.g., Reed-Muench, geometric means, etc.)

The first area (basic biostatistics) should have a minimum of 30 contacthours to be presented in the preveterinary medical curriculum or within the firsttwo years of the veterinary medical curriculum.

The second area (vital statistics) should have a minimum of 16 contacthours plus an appropriate amount of time for work sessions or homework.It should be given as part of the course in epidemiology.

5


The third area (statistical applications) can best be left to the individualdepartments concerned. These departments could utilize the basic biostatisticsunit as a teaching resource.

Laboratory space and equipment (caiculaLing machines and data processingequipment) should be provided for the teaching of biostatistics. Furthermore,appropriate space, faculty positions, personnel, and equipment should be allo-cated for the purpose of establishing a statistical unit as soon as possiblewithin the veterinary medical school.

It has been said that statistics is the language of modern science. Throughstatistics, students and graduate veterinarians alike are able to communicatewith each other and with other scientists in their professional pursuits.Accordingly, statistics is an essential component of professional preparationand must receive its appropriate share of faculty positions, facilities, andcurriculum time.

FOOD HYGIENE

The current era is one of great change, both in legal aspects of inspectionand in food production, transportation, and processing technology. Thesechanges are necessary to meet the demands of the consumer and to protect hishealth and welfare. Rapid movement of livestock, people, and goods increaseshazards from exotic diseases of both man and animals.

The Wholesome Meat Act of 1967, the pending Wholesome Poultry ProductsAct, and the act pertaining to the inspection of fish and marine products placea greatly increased demand on inspection personnel (both veterinarians andsubprofessional food inspection technicians) and on the competency of theindividuals involved.

It has long been recognized that one of the major responsibilities of theveterinary profession is to assure the wholesomeness of human food products ofanimal origin. To meet the requirements of the increasingly complex situa-tion it is essential that the veterinary profession assume leadership in estab-lishing, expanding, and improving both the scope and the quality of generalfood hygiene and the hygiene of foods of animal origin in particular.

To fulfill the responsibilities of the profession and achieve our objectives,the following recommendations should be implemented: that the Associationof American State Boards of Examiners in Veterinary Medicine and the Na-tional Board of Veterinary Medical Examiners re-evaluate coverage of foodhygiene in their examinations; and that questions related to food hygieneemphasize scientific knowledge of principles or concepts rather than the abilityto perform techniques of food inspection. The Association of Teachers ofVeterinary Public Health and Preventive Medicine should be requested toprovide the examination questions. Currently, there is a great lack of uni-formity among states in the scope of coverage of food hygiene in the examina-tions. Further, in examinations both by the states and the National Boardemphasis is frequently placed on minutiae of techniques of inspection ratherthan on a knowledge of principles and concepts.

The curricula of the veterinary medical colleges and schools must includefish hygiene in the food hygiene program. The role of fish as a protein sourceis increasing tremendously, in part because fish farming is coming more into

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Recommendations of the Symposium 7

use. Fish raising, fish harvesting, and diseases of fish are subjects which arereceiving close scrutiny by marine biologists and wildlife scientists. Thewholesomeness of fish and marine products should be the concern of the veteri-nary food hygienists.

The veterinary medical profession has to assume its role of leadership inthe proper use of chemicals and other substances which may affect the whole-someness of foods of animal origin and also influence human and animalecological factors. Drugs, biologics, herbicides, insecticides, rodenticides, anti-microbials, and other chemicals and biological substances are being used inever-increasing frequency for diverse purposes, requiring a constant revisionof acceptable tolerances. Many new compounds are being developed and used.The full impact on man and animals, on the ecology of both human andanimal diseases, and on the environment has not been accurately and fullyassessed. Residues in foods of animal origin and the solution of problems asso-ciated with them are logically veterinary medical public health responsibilities.

Schools and colleges of veterinary medicine should begin to provide intensi-fied, in-depth training in principles and practices of food hygiene at theMaster's and Ph.D. degree levels for those veterinarians who will be requiredto assume positions of responsibility in teaching, administration, and super-vision of food hygiene activities. Schools and colleges of veterinary medicineare the logical educational institutions to assume leadership in providing suchgraduate training for developing the necessary expertise for veterinarians en-gaged in this area of veterinary medicine, so vital to the health and welfareof man and to the control, prevention, and eradication of diseases of animals.

Continuing education courses in food hygiene should be made available toveterinarians engaged in food hygiene. These courses are necessary to properlyinform interested persons of new developments concerning diseases, toxicology,emergencies, and disasters, and other topics. This training will provide expertiseto help safeguard the health of man and animals.

Course offerings in all aspects of veterinary food hygiene in the collegesof veterinary medicine should be formulated with more uniformity. Theyshould be strengthened, improved in quality, and modernized and their subjectcontent scientifically oriented with less emphasis on mechanical techniques.Current and pending legislation demands uniformity of competence of gradu-ates of all veterinary medicine schools and colleges throughout the UnitedStates and Canada. Since the shortage of veterinarians will require them toparticipate in an appropriately comprehensive professional capacity, thetraining must of necessity provide the veterinarian with a higher level ofprofessional competence in the area of food hygiene.

Microbiological examination should be properly applied in monitoring sani-tation procedures and food processing activities in food plants. Eventuallythis may lead to the establishment of ranges of microbial content as one of thecriteria for judging the wholesomeness of foods. Organoleptic examination isno longer sufficient owing to the complexity of food processing. Furthermore,the effectiveness of sanitizers in food processing plants can be evaluated onlyby microbiological examination.

Techniques of inspection must be subjected to a continuing evaluation andre-evaluation to ensure the most effective utilization of personnel and theapplication of new techniques and concepts in control systems. Techniques ofinspection as currently applied are essentially the same as when veterinary


medical inspection was first instituted. However, profound changes in diseasepatterns of man and animals and in food processing techniques have takenplace. Under certain conditions, meat and poultry inspection could be basedon a continuing survey of the, health conditions in the production unit as asupplemnent to ante-mortem and post-mortem inspection in the slaughteringplant. This would not only protect the consumer but would also contribute tothe prevention of diseases in food animals. It should also be pointed out thatprinciples of statistical quality control have not yet been generally applied inthe inspection of foods of animal origin and should be given serious considera-tion.

Job specifications for inspectors of red meat and poultry need to be changedin order to establish as a prerequisite certification of completion of an approvedtwo-year course in food inspection or its equivalent. The curriculum for atwo-year food hygiene course for the training of subprofessional techniciansshould be developed by a committee appointed by the Council on Education ofthe American Veterinary Medical Association. The curriculum for such atwo-year course should be under the supervisior of a veterinary food hygienist,and uniformity of curriculum content for these courses should be assured.

Certification of veterinary food hygienists by the American Board of Veteri-nary Public Health is essential to ensure the quality of training. The Boardshould study the matter of the certification of subprofessional food technolo-gists with a view to the development of this specialty. The more sophisticatedtechniques of inspection require a better-trained, more capable inspector. Ifveterinary food hygienists are to assume a totally professional role in thefood hygiene program, the inspector of meat products must have increasedcompetence and ability.

ENVIRONMENTAL HEALTH

The initial objective in teaching veterinary medical students the practiceof environmental health is to make them aware that the health of animals,plants, and man are significantly related to the quality of the environment.The ultimate objective is to improve the quality of the environment for thewell-being of mankind.

Environmental influences on health include physical, chemical, biological,and sociological agents. Technologists in agriculture and industry are causingshifts in host-agent relationships which in many instances are detrimental tohealth. The student should be trained to assess the consequences of newtechnologies as they affect society generally and the practice of veterinarymedicine specifically. Pollutants, as related to the population explosion, areincreasing in the environment at an alarming rate. Control of these agentshas become a responsibility of all informed persons, particularly members ofthe medical professions. The understanding of the concept of environmentalhazards should be established early in the veterinary curriculum, or even inthe preprofessional years. Training in environmental health practices shouldbe integrated in all of the veterinary medical curricula, but should be spe-cifically covered in a department of veterinary public health or communitymedicine.

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Recommendations of the Symposium 9

We recommend that the teaching of environmental health practices includeconsideration of the following: animal and human wastes; air and waterpollutants; ionizing radiation; environmental stresses from overcrowding, in-adequate housing, and high noise levels; occupational and institutional hazards;accidents; food and residues in foods; drugs; recreation-created hazards;disasters (natural and man-made); and vectors.

Plans for the study of these factors should encompass: research; legislation;inspection standards; enforcement; incentives; systems analysis and evalua-tion; demography and land usage; sociological and aesthetic considerations;and forensic medicine.

Teaching methods and techniques for presenting this material should in-clude: lectures; field and laboratory exercises; demonstrations; visual aids;externship programs; visits to environmental health agencies; performancetesting, and problem-solving situations.

A curriculum including the above considerations would not only make eachveterinarian aware of his increased responsibility as a citizen but would helphim to successfully carry out his role in society by providing him with anunderstanding of:

The fundamentals of ecology;The fact that good and bad changes of our ecologic equilibrium are often very subtle

and difficult to measure;The "natural" and "man-made" factors affecting health and disease;The effect of man's technological impact on man-animal relationships;The socioeconomic-political implications of controlling and preventing environmental

hazards to optimum health;The fact that multiple causes are involved in environmental health problems;The interdisciplinary approach to problem-solving;The use of the scientific method in assessing the effect of the environment on host-

agent relationships; andIatrogenic disease conditions.

VETERINARY COMMUNITY MEDICINE

In view of the rapid changes in society in the last 50 years-includingmodifications in scientific knowledge, migrations of the general populationfrom rural to urban areas, diversities in the aspirations of the people for betterhealth care, alterations in the functions of veterinary medical practitioners,and transpositions in educational aims-it is suggested that the administrativeofficers and executive faculties of colleges and schools of veterinary medicinerecognize these changes by giving serious consideration to the followingrecommendations.

The role of the veterinarian in society and the health care field shouldreceive more emphasis in the veterinary medical school curriculum.

Specific departments of veterinary public health and preventive medicineshould be created in colleges and schools of veterinary medicine. It is assumedthat such departments will be given administrative, faculty, secretarial, andbudgetary support.

"Joint academic appointments" should be given to qualified and interestedpublic health professionals in schools of medicine, schools of public health,


and schools of allied sciences, particularly engineering. Ordinarily, this jointappointment does not require an additional salary or partial salary commit-ment.

Trainled and initerested pul"ic htealth professlonals M local, state, andnational health agencies should be given "clinical faculty appointments" inthe department of veterinary public health and preventive medicine. Theseclinical appointments do not ordinarily require salary funds.

Such departments are to be responsible for presenting either alone or incooperation with other departments in the veterinary medicine school or col-lege, such course content as biostatistics, epidemiology, community and veteri-nary public health, food hygiene, regulatory or preventive animal medicine,and environmental health.

These departments, in addition to undergraduate instruction, should sponsora "total educational program" of graduate and resident study in veterinarypublic health and preventive medicine, with emphasis on continuing educationfor practitioners of veterinary medicine. This instructional program shouldcontribute to the preparation for certification by the American Board ofVeterinary Public Health.

A large part of the teaching of veterinary public health and preventivemedicine can best be done by using the community as a laboratory. There-fore, such departments should establish for undergraduate veterinary medicalstudents practical field training in health departments and in regulatoryagencies, and with the utilization of owned herds. These field training assign-ments may be on a local, national, or international level.

The department of veterinary public health and preventive medicine shouldemphasize the concept of disaster preparedness to the undergraduate student.It is important that the student recognize the responsibility of the veterinarymedical profession in the multidisciplinary effort of a post-disaster period.

FIELD TRAINING

The responsibility for teaching and research in the disciplines of preventivemedicine and public health should be delegated to a section in the depart-mental or curricular structure of a college or school of veterinary medicine.In these areas, programs of field training in which the student is activelyinvolved should be developed. Participation should be supervised and directedby a qualified instructor with faculty rank assigned to the preventive medicinecurriculum. The college administration should give consideration to facultyassignments in order that an adequate faculty-student ratio will allow develop-ment of such field training.

The following types of facilities are suggested as appropriate for utilizationin field training: available university facilities (food, health, and animal);cooperating local, state, Federal, and international health agencies and labora-tories (for example, public health and animal health diagnostic laboratoriesshould be utilized in the teaching processes to familiarize the student with theavailable services, diagnostic tests, specimen processing, and data gathering;also, laboratory personnel will help promote the philosophy of value gained bycooperation between them and the private and public veterinary medical

10

Recommendations oa the Symposium

practitioner in reporting both human and animal diseases); animal healthagencies and laboratories; all types of food establishments and food processingplants; animal holding and handling facilities (zoos, dog pounds, laboratoryanimal facilities); and animal production units (farms, feedlots, etc.).

An appropriate amount of time from the total college curriculum should bedevoted to the increasingly important area of preventive medicine and publichealth. Considering the utilization and application of the professional capa-bilities of a graduate veterinarian, whether in private or public practice, anadequate amount of time for this specific area of teaching would be one-thirdof the total curriculum time available in the third and fourth years. An appro-priate portion of this time should be devoted to field training.

BIOMEDICAL COMMUNICATIONS

The Symposium endorses the following report by Dr. Robert Getty, whichwas published in The Proceedings of the 104th Annual Meeting of the AmericanVeterinary Medical Association, 9-13 July 1967:

The 14th annual meeting of the Audiovisual Conference of Medical and Allied Scienceswas held on July 18-19, 1966, at the Washington Hilton Hotel, Washington, D.C. Thisconference meets annually under the auspices of the National Audiovisual Associationat its annual convention.

The Conference membership includes the Council, made up of representatives fromnonprofit medical and allied science organizations, and associate and individual organi-zational members. A total of 96 registrants, in addition to Council members, attendedthe 1966 meeting.

The first day of the meeting was devoted to reviews of the audiovisual programs ofthe respective professional associations represented. Each attending member of theCouncil gave an oral report and submitted a written report to the Secretary of theConference. The reports of the respective professions represented emphasized, as inpast years, the sophisticated programming and the tremendous amount of time, energy,and money being expended in the general area of audiovisual education by the health-related professions.

The remaining one and one-half days of the Conference were devoted to papers anddiscussions of the following topics, all presented by nationally recognized authorities intheir respective fields: the multimedia approach; designing educational facilities forbest use of audiovisuals; television, versatile servant of the health sciences; curriculumcourses on educational television; the 8-mm cartridge film for programmed instruction;the potential for research in biomedical A/V education; mental health film forums;communicating to world's medical scientists; medical tapes; remote dial selection ofvideo and audiotape.

Recommendations for the future. In view of the information explosion and thelimited time available to impart this information, the shortage of faculty and trainedpersonnel, the increased student enrollment, and the fact that the veterinary professionis playing a more and more important role in world health and agricultural and eco-nomic welfare, a more effective means of presenting information seems imperative. Theeffectiveness of audiovisual methods in biomedical communication has been well docu-mented and proved over the years by our sister health professions.

Some national central agency or council of the AVMA, or both, consisting of severalfull-time professional personnel, should be delegated responsibility in the general areaof biomedical communication. These individuals, committee, or council could ascertain

11


the status of audiovisual material, not only in the veterinary profession but in all alliedhealth-related professions as well, and advise the AVMA and its constituent state asso-ciations and educational institutions relative to the many facets of audiovisual education.The aetivities could be coordinated with those of the Council on Education, Council ofResearch, and the American Association of Veterinary Medical Colleges.

Their duties would encompass serving in a liaison capacity between medical communi-cators at the college and university levels in all matters pertaining to audiovisual educa-tion and research; ascertaining the ideal objectives of postgraduate veterinary medicalprograms at a national level, and coordinating such activities at a state and local levelthrough audiovisual methods; indexing, summarizing, and codifying all available audio-visual material as it pertains to the veterinary profession; circulating an annual reportand questionnaire to institutions throughout the United States; keeping all abreast ofnew films contemplated or in production, the availability of videotapes, kinescopes,5-minute concept films, programmed material, and other audiovisual aids and tools;working at a national and local level, using audiovisual methods and media in thecontinuing education of our profession; coordinating the audiovisual activities of theAVMA central office at local, state, and national levels as well as with the audiovisualactivities of our sister ..ea1..1.-rela.+ed sie-..

It should be noted that similar recommendations had been presented to thedeans of schools and colleges of veterinary medicine as early as 1956 (Getty,this volume, Ref. 3).

To help achieve these goals in biomedical communications in the schools andcolleges of veterinary medicine, the following recommendations should begiven serious consideration.

The dean of each school or college of veterinary medicine should include, aspart of the duties of an assistant or associate dean (or a director appointedfor the purpose), the development of biomedical communications for the col-lege. This person should be assisted by a committee of interested facultymembers. He should be provided with a budget and empowered to seekadditional funds to support this work.

This committee should include as a part of its responsibility the develop-ment of competency in areas such as educational technology (includingmethodology and objectives), photography, the graphic arts, information re-trieval (including retrieval of literature and demographic information) andmedical illustration. The committee should obtain full-time personnel assoon as possible to expedite the development of these special areas.

It is further recommended that this committee develop channels throughwhich members of the faculty and the profession (via continuing education orother methods) will be informed of the newer concepts of teaching and in-structed in the use and operation of equipment and procedures related to thebiomedical communications field.

The Symposium recommends the exchange of biomedical communicationsteaching materials among schools and colleges of veterinary medicine, andadvocates the concepts of EDUCOM, CIC, and WICHE as examples of thespirit of exchange of information with other institutions.

The Symposium recommends that each college make an immediate andserious effort to develop biomedical communications teaching materials andthat any future Symposium on Education in Veterinary Public Health andPreventive Medicine devote a portion of the program to the review of recentlydeveloped materials.

12


GENERAL RECOMMENDATIONS

Establishment of An Advisory Group

In consideration of the sincere efforts of the Symposium participants andthe complex problems faced by the individual schools and colleges of veterinarymedicine, a specific method of actively supplementing the publication andimplementation of the recommendations formulated at this Symposium shouldbe initiated. It is recommended that an Advisory Group of members of theAssociation of Teachers of Veterinary Public Health and Preventive Medicinebe established and supported financially so that this group may schedule visitsto each school and college of veterinary medicine for the purpose of present-ing, by the most direct method possible, the concepts, requirements, and obli-gations of veterinary public health and preventive medicine as expressedduring this Symposium.

Development of a Reference List of Recommendations

In order to focus emphasis on the efforts of the teachers of veterinary publichealth and preventive medicine in their endeavor to implement the recom-mendations formulated by the Symposium, a reference list shall be preparedthat incorporates every recommendation. Each school and college of veteri-nary medicine in the United States and Canada shall receive this referencelist so as to determine which of the recommendations have been adopted in thecurriculum and to what degree.

The replies from the various schools and colleges will be consolidated intoa master reference list, which will be reproduced and made available to editorsof journals in the field of veterinary medicine, to the Council on Education ofthe American Veterinary Medical Association, the Association of AmericanState Boards of Examiners in Veterinary Medicine, and the American Board ofVeterinary Public Health.

As an additional aid to the teachers of veterinary public health and pre-ventive medicine in implementing the recommendations and in improvingtheir teaching programs, instructional resource material will be compiledand registered. A registration or catalog list of all this material will be printedand circulated to each school or college of veterinary medicine in the UnitedStates and Canada.

13

Part I

THE VETERINARY PUBLIC HEALTH CURRICULUM

TEACHING PROGRAMS TO MEET PRESENT ANDFUTURE NEEDS

THE PUBLIC SERVICE VETERINARIAN

ERNEST E. SAULMON, D.V.M.*

Economists stress that the heart of theirproblems lies in trying to plan for the mosteffective use of resources that are never ade-quate to the demand. It seems to me thatthis is the type of situation confronting usin this Symposium.

We all know that the explosion of knowl-edge in recent years has affected veterinarymedicine as well as the other sciences. Fromthe standpoint of teaching programs, theproblem is one of deciding which is the mostimportant information to present, ratherthan how to cover all that a professionalstudent should really have.

Given the variety of specialties that aveterinarian may elect, the basic profes-sional curriculum obviously cannot fullyprepare a graduate for a lifetime career inall of these fields. It would appear, there-fore, that the preparation must lay a strongbasic foundation from which to advance,with the concurrent aim of giving the stu-dent an understanding of other fields withinthe profession so that he can relate hischosen activity to those of the specialistshe must work with, in our current era ofinterdependence.

My professional life has been spent in

* Director, Animal Health Division, AgriculturalResearch Service, U.S. Department of Agriculture,Hyattsville, Maryland.

17

the Animal Health Division of the U.S.Department of Agriculture, an organizationdevoted to large-scale public programs ofanimal disease prevention, control, anderadication. There are at present in theneighborhood of 800 veterinarians in ourorganization; a comparable number com-prise the state organizations with which wework cooperatively. Approximately 13,000veterinarians in the United States are ac-credited to perform professional services inconnection with our activities, so this fieldof effort is one that has a direct relationshipto most members of our profession in thiscountry.

One important factor in basic foundationtraining for this field is presenting the con-cept of disease prevention. This is impor-tant in many fields of veterinary medicine.In our field it is vital.

To be effective, the public service veteri-narian in the animal health field mustunderstand how his work relates to a totalpopulation. Though he may work in someprograms with the individual animal, hemust have the perspective to see beyond theanimal or the herd-or the county or eventhe state. We are increasingly convincedthat the real professional, in our work, mustbe able to visualize how his activities fitinto the very large and very complicated

The Veterinary Public Health Curriculum

network that makes up our modern live-stock industry.

The public service veterinarian needs togo further. He needs to recognize that he isin an action situation and that his technicalability, even in terms of this total popula-tion awareness, must be translated into aprogram that produces measurable andbeneficial results-and that he will bejudged on these results.

This is a stimulating and challengingdemand and one not easy to learn; there-fore, it is important that it be an early andsignificant part of professional preparation.

This does not mean that the basic medicaldisciplines have decreased in importance inour work. The need for these is even greaterthan before, and this need will grow. Ourveterinarians, as those in other fields repre-sented in this Symposium, use more of theirbasic veterinary education than ever before.To these we now must add as broad anappreciation of epidemiology as can bepacked into the already crowded curricula.

Given an understanding of the concept ofpreventive medicine, the tools of our tradeare closely allied with what we call epide-miology-although I suppose epizootiologywould be more precise terminology for mostof our work. For this reason, we applaudthe great progress made in adding an appre-ciation of epidemiology to undergraduateinstruction. We hope there can be more.Here again, we recognize that there arelimits to what can be covered in a four-yearperiod, but epidemiology is so closely relatedto preventive medicine, which is so much apart of either public or private veterinarypractice, that it is an area of great value tomost graduates.

The importance of epidemiology to ourwork is illustrated by the fact that in thelast six or seven years we have conductedbasic epidemiological orientation coursesfor more than 800 state and Federal veteri-narians. We have depended heavily, in

these cases, upon faculties from several uni-versities; our demands upon the Universityof Minnesota have been as great as, if notgreater than, for any other institution.

We know that basic orientation is notenough-which is why we have sent, andwill continue to send, selected veterinariansback to the university for graduate train-ing. But the stronger the emphasis placedon epidemiology at the undergraduate level,the better the foundation for professionallife.

There is another area of increasing im-portance, and that is an understanding ofdisease conditions exotic to our iivestockpopulation. In our work in the AnimalHealth Division we are of necessity becom-ing internationally minded. It is a clichéto say that the world is getting smaller, butin relation to foreign animal diseases it isnonetheless true. We no longer have alengthy built-in quarantine period aboardship for animals coming to this country,and we are no longer reasonably self-suffi-cient in terms of animals and animal prod-ucts. We imported in excess of 900,000live animals and over a billion pounds ofanimal prouuts iast year.

So these foreign animal diseases are notsomething to be mentioned in passing dur-ing a pathology course-as was the casewhen I was in school. They are knockingon our doors every day, and there is noway to put a guard on every door to ensureagainst their entry. While our system ofsafeguards at points of entry has been todate quite effective as a first line of defense,the pressure grows and will continue togrow.

Our livestock industry depends on theveterinary profession as a second line ofdefense to rapidly detect any exotic agentthat may enter. Our division maintainsabout 80 specially trained veterinary diag-nosticians at strategic points throughoutthe country with a primary mission of

18

The Public Service Veterinarian

immediate investigation of suspected exoticdisease conditions. In a normal year, weconduct several hundred such investiga-tions, but the heart of a successful effort inthis direction is not these few trained menbut the alertness of the thousands of veteri-narians on farms and their awareness ofevery case that looks "different."

So it is important that veterinary stu-dents learn the nature of foreign animaldiseases and develop an awareness of thedanger they pose here. It is important thatthey carry such knowledge away with themupon graduation.

One of the strong unifying factors in anyprofession is a common basic educationalbackground. This rules out excessive spe-

cialization in early academic training, andproperly so. In our field, as in others, wewant a man with a broad basic foundationin veterinary medicine. We are not inter-ested in technicians. Recognizing the ab-solute necessity of continuing educationthroughout a working lifetime, we wantmen who are capable of continued growth.

In recognizing the primary need fortraining in the basic sciences, I have men-tioned three areas that appear worthy ofconsideration: preventive medicine, epi-demiology, and, especially, exotic diseases.All three are important as preparation forthe public service veterinarian and also, Ibelieve, for the majority of graduates, nomatter what field they elect to enter.

19

TEACHING PROGRAMS 1 TO MEET PRESENT ANDFUTURE NEEDS

A VETERINARY MEDICAL SCIENTIST TRAINING PROGRAM *

JAMES H. STEELE, D.V.M., M.P.H.t

Veterinary medicine is capable of fulfill-ing a more significant role in the future.In order to attain this role, a cleariy iden-tifiable program should be developed whichis aimed (1) at the attraction of a fewexcellent scholars from each participatingveterinary school into the veterinary medi-cal sciences, and (2) at the establishment ofwell-demarcated but flexible pathways bywhich the developing young scientist canobtain appropriate combinations of scien-tifle, medical, and veterinary trainingneeded for a research and/or academiccareer. For the first five years the programshould be clearly experimental in naturesince, of necessity, this is an undertakingthat not all veterinary schools would be ina position to undertake at this stage intheir development.

An important aspect of the proposalwould be the development of a veterinaryassociate program through which the re-search training of the veterinary medicalscientist could be continued while he is inthe government service.

The veterinarian, like the physician, issubject to a rather rigid curriculum duringhis didactic training. The physician's train-

* Reprinted from Appendix C of "Career De-velopment for Veterinarians," Career ServiceBoard for Veterinarians (James H. Steele, Chair-man), Department of Health, Education, andWelfare, 21 June 1968.

t Chief, Veterinary Public Health, U.S. PublicHealth Service, Atlanta, Georgia.

ing has two directions: the first in thebasic science disciplines, and the second inthe clinical specialties. Veteri.aiy . medi-cine, on the other hand, has a third dimen-sion in the application of scientific andmedical knowledge to a variety of animalspecies. Because of this third dimension,the veterinary curriculum is perhaps evenmore crowded than the medical curriculumand more difficult to compress. However,as a result of this dimension, veterinariansare in a position to introduce a compara-tive approach into medical research whichis of definite value.

Veterinary medical scientists can con-tribute to meudical research in a number ofways:

1. In basic research, in which veterinarymedical scientists can utilize their scientifictraining for research in the area of com-parative medicine, utilizing a wide varietyof animal species with which they arefamiliar.

2. In veterinary pathology, because oftheir common interest with pathologists inanimal diseases as models for humandisease.

3. In clinical investigation in many areasof clinical medicine, in experimental sur-gery, and in other clinical subspecialties.

4. In medical research and public healthadministration, as the result of their broadknowledge of medicine and disease and

20

Veterinary Medical Scientist Training

their depth of training in a given scientificarea.

In considering the development of a vet-erinary medical scientist training program,one must be aware of the differing state ofthe evolution of veterinary medicine ascompared with human medicine. Whereashuman medicine has reached a high degreeof specialization during the past half-cen-tury, veterinary medical practice is still ina relatively unspecialized state, with fargreater involvement of most veterinarianswith general practice. Because of this dif-ference it may not be feasible at this timefor veterinary schools to attempt the sametypes of revisions in their curricula thatmedical schools are undertaking today.

trainee through his veterinary medicalyears, enabling him to initiate his scientifictraining and to begin to define his careergoals within the biomedical sciences. Train-ing initially should focus on the develop-ment of research competence in the basicsciences, with later training provided asneeded in appropriate clinical areas. Anadditional period of thorough and rigorousresearch training should be provided duringthe postdoctoral years. In any case, thetotal training period should be approxi-mately four to six years to assure adequatematuration of the trainee as a well-trainedscientist. Training grants should be re-viewed by a committee composed of veteri-nary medical scientists and scientists fromappropriate basic science and clinical dis-ciplines.

Program Plan

The goal of the veterinary medical scien-tist program would be the development ofa flexible program which provides thetrainee access to the appropriate basicscientific and clinical training that he willneed to develop his career along a clearlydefined path. The breadth of his veterinarytraining will provide considerable latitudein this effort and will enable him to crossdiscipline lines in ways that are not readilyachieved by basic scientists. His veterinaryexperience will provide a depth and rich-ness of experience to clinical investigationthat is different from that commonly avail-able on the medical scene.

Students should be able to enter the pro-gram at various stages in their career:after the first two basic science years ofthe veterinary curriculum; immediatelyafter D.V.M. training; after military ser-vice training; or during mideareer training.

The veterinary medical seientist programshould concentrate primarily on freeing asmuch time as possible for the individual

In-Service Training

With regard to in-service training, thefollowing points merit particular considera-tion:

1. A certain number of positions shouldbe specifically assigned to this program forin-service scientific and research training.

2. The in-service aspect of the programshould be operated under the guidance ofa committee or board composed of repre-sentatives from the Career Service Boardfor Veterinarians of the Department ofHealth, Education, and Welfare and anequal number of carefully selected repre-sentatives from veterinary and medicalschools who can assist in the definition anddevelopment of the program.

3. The period of obligated service inreturn for in-service training should becarefully considered and kept as short asreasonably possible so as to enhance theattraction of outstanding veterinarians tothe program.

4. An important in-service aspect of the

21


program would be the development of aveterinary associate program, which wouldenable veterinary officers to continue theirresearch training at the National Institutesof Health, the National CommunicableDisease Center, or at other appropriate lociwithin the Department of Health, Educa-tion, and Welfare. The identity of a specialprogram for veterinarians within the ser-vice would help attract outstanding young

veterinarians-if its quality is kept veryhigh.

5. The need for quality within the veteri-nary medical scientist program is para-mount, and the primary goal of the pro-gram should be to attract outstandingstudents into the program and to give themsuperb training for a scientific career withingovernment, within veterinary schools, orin other biomedical research settings.

22


AN AIR FORCE VIEW

EDWARD L. MENNING, LT. COL. USAF, VC *

There are several recommendations thatI should like to make concerning teachingprograms to meet the current and futureneeds of veterinary public health.

First, several basic tenets must beaccepted:

1. The raison d'étre of the veterinaryprofession is the over-all well-being of man-not animals.

2. Disease is a unit. In our borderlessworld, subject to foot-and-mouth diseasepollution as well as to air pollution, whenone species is affected, others will be also.

3. Veterinary education, by omission orcommission, is building "cash technicians"rather than professionals who are truly in-terested in animal disease as it relates inthe broadest sense to public health.

4. We are members of a team of healthprofessionals.

What educational programs or philoso-phies are required to meet the needs whichlogically flow from these tenets?

Aside from our reason for existing, let uslook at a few figures:

* One-third of our profession in theUnited States is engaged in other thanprivate practice; the majority of veteri-narians are in health specialties aimed di-

*Department of Veterinary Medicine, MedicalService School, US. Air Force, Sheppard Air ForceBase, Texas.

rectly at maintaining or promoting humanhealth.

* At any one time there are more than1,000 veterinarians in military service.

* Of the approximately 900 veterinarygraduates each year the military utilizesseveral hundred for at least a two-yearperiod.

What can veterinary colleges do to bet-ter prepare these individuals to meet theneeds of society whether in the Air Force,private practice, or other direct health sup-port endeavors? From my point of view(in the Air Force) a change of emphasisin various subject areas is needed.

Rather than instill a philosophy in stu-dents that the animal patient is an indi-vidual entity, we should stress that theanimal is protein nourishment for man(this fits in with our civic action programsin the Air Force). It should also be stressedthat foreign animal diseases could crippleparts of our society (the Air Force is con-cerned because of the many military air-craft that enter the United States fromother countries). Pet owners must be madeaware of the disease potential when azoonosis is encountered (Air Force clinicsare based solely on zoonoses). There is apsychological need for pet owners to havea better understanding of their pets' healthin general. Most laymen are aware of the

23


danger of rabies, but their knowledge ofanimal diseases stops there.

The reporting of morbidity and mortalityinformation should be encouraged. In-volvement in epizootiological investigationsshould also be encouraged, as should liaisonwith other members of health service teams.Veterinarians have been individualists andisolationists by tradition. We have dugour own professional rut. In the countieswhere I and two other members of our staffhave been stationed, the only monthly mor-bidity and mortality totals for the statehave been our totals. (Evidently none ofthe onfhr Iq on 19 nranftitioners in the coun-ties diagnosed any reportable conditions.)We should be very willing to advertise andeducate by speaking to any group in ourcommunity and by privately discussingmutual areas of concern with members ofother professions.

Additional enlightenment in the areas ofenvironmental health principles in foodhygiene and sanitation, sanitizers and dis-infectants, and water and air pollutionwould be invaluable for veterinarians inprivate practice, for part-time public healthveterinarians, and for members of boards ofhealth. I am constantly amazed that newstudents know little if anything about theprinciples of chemical or heat disinfection,yet this is basic to modern clinical practice,not to mention public health sanitation.

Laboratory animal medicine is vital toprogress in medicine, yet what is taughttoday?

Better teaching methods are needed.These can be effected if public healthteachers will:

* Deemphasize the tradition of spilling

out repetitious facts and encourage thoughtby discussing principles. Albert Schweitzeronce said, "Our age has discovered how todivorce knowiedge from thought." The stu-dent should be able to correlate facts sothey can effectively solve new and unfa-miliar problems. Memorization courses-such as anatomy, embryology, learningwhich lymph nodes to incise on post-mortem inspection-should be re-evaluatedas to time spent for value gained.

* Exemplify professionalism in publichealth. Our students feel that public healthis beneath them, yet the "giving of shots,"which consumes a good percentage of theirtime in practice, is a professional publichealth procedure.

* Discourage isolationism.

* Form dynamic teaching programs. Thetypical veterinarian fights with vigoragainst unqualified persons diagnosing,treating, or even "giving shots"; neverthe-less he usually considers himself qualified,without any preparation, to teach and teststudents. It should be obvious that thereis more to teaching and learning than lis-tening to a 50-minute lecture of facts de-livered in a monotone. We in public healthcannot change school policy but we canpersonally avail ourselves of all types ofcourses which could teach us to teach bet-ter. We must learn to:

MotivateProfitably use training aidsExude interest

All of which requires teaching plans thatare focused more on student learning andless on lecturing and grading. Collegesshould educate the student.

24_-


AN EPIDEMIOLOGICAL APPROACH

PAUL R. SCHNURRENBERGER, D.V.M., M.P.H.*

One method of analyzing the problem ofprograms in teaching to meet present andfuture needs entails the epidemiologicalapproach-visualizing the agent as the in-structor, the host as the student, and theenvironment as the school or curriculum.

The Agent

We have long been concerned with estab-lishing qualifications of the teacher as anexpert in the field of preventive medicineor public health. Unfortunately, this hason occasion resulted in neglecting the factthat he is primarily a teacher and onlysecondarily a preventive medicine expert.We must recognize that in today's societyit is vital for each person to be trulycompetent in his specialty. Further wemust realize that, with the present over-loading of curricula, there will be less andless time available to present more andmore material. It then becomes obviousthat the teacher must make maximum uti-lization of the teaching opportunities avail-able. It is vital that the time spent withthe students be a genuine learning processand not a mere exposure to facts.

It is further important that the agent,or teacher, realize the importance of, and

*Bureau of Epidemiology, Division of Preven-tive Medicine, Illinois Department of PublicHealth, Springfield, Illinois.

25

accept, his responsibility in motivating thestudent to learn. The teacher is the initialcontact which most students have with thefield of preventive medicine and publichealth. If this exposure leaves him with asense that the field is exciting and impor-tant, we will have progressed a great dis-tance toward changing the image of publichealth and preventive medicine from thatof a professional area which collects onlythe dregs of veterinary medicine to onewhich requires vision, foresight, and a de-gree of competence unsurpassed within theprofession. Then it will no longer be con-sidered merely as a last resort for thosewho have failed at all other phases of vet-erinary medicine.

Further, one of the most effective waysof recruiting individuals into a specialty isto provide them with an attractive image.The teachers must be such that they willencourage students to follow their example.An interested student automatically entersthe high-risk group for future enlistment.This in itself is the greatest opportunityfor recruiting available to us.

The Host

Every day there are more graduate vet-erinarians entering the field of preventivemedicine or public health as a full-timespecialty; however, it is important for us


to remember that the majority of theseindividuals enter and leave veterinary col-lege with the sole intent of entering privatepractice. Therefore, it is far better to instillin the student a sense of responsibility tosociety and an awareness of his role in thecommunity aspects of preventive medicinethan to try to convert him to a publichealth specialist. Regardless of his area ofspecialization after graduation, there willbe countless opportunities to practice pre-ventive medicine, since it is one of theimportant foundations of the total veteri-nary education process. It is much betterUlla we ihave an entire class of practutioneruI O

leaving the college with a full awarenessof their responsibilities in this area and acomplete understanding of the principles ofpreventive medicine than it is to have onespecialist in a class while the other mem-bers have only a small understanding of,or worse yet, an active distaste for the field.

The Environment

This approach requires that we avoid anenvironment, or curriculum, full of regula-tory details aimed at producing a specialistin public health. Rather, we must first pro-vide the student with broad principles ofpreventive medicine that he can use aftergraduation, regardless of whether he enterspreventive medicine, commercial medicine,or private practice, and becomes a zoo vet-erinarian, a laboratory animal specialist,or what have you. After this has beenaccomplished, specific, detailed informationcan be filled in as time permits.

Since these principles are to apply toevery phase of veterinary practice, privateor otherwise, they should be taughtthroughout the curriculum and not re-stricted to courses labeled "preventivemedicine." Preventive medicine and publichealth must be taught as principles rather

than courses. This necessitates close coor-dination with other faculty members anda total awareness of the contents of courses.

Again, we must keep in mind that eacharea cannot be covered in equal detail.There is little logic to teaching detailedlocal or state regulations which will varywith the students' location. With the pro-liferation of information which we are en-countering in this age, we must realize thatwhat is being taught today will be dis-carded as obsolete or, in many instances,untrue in the near future. We are fartherahead when we teach broad principlesrather than present specific detailed factswhich are subject to rapid obsolescence.

Therefore, we must know now what thesemen will be doing in the next five yearsand present them with that informationwhich will be most useful to the majorityof the class. This decision must be basedon projected roles to be filled by the profes-sion, not the specific interests of a teacher.Further, it must not be guided by the avail-ability of teaching aids but rather shouldbe based on the needs of the students inthe period immediately following gradua-tion.

In Summary

1. We must teach efficiently to teacheffectively.

2. In the eye of the student, the teacherof public health is "public health."

3. Preventive medicine is a set of con-cepts, not a dated collection of details.

4. Regardless of his specialty, every vet-erinarian utilizes preventive medicine prin-ciples daily in his work.

It is an established fact that veterinarymedicine has an important role to play inthe future of public health; how well wefulfill that role will be determined by whatwe ourselves do.

26

THE TEACHING OF EPIDEMIOLOGY

TEACHING THE BASIC PRINCIPLES

LEONARD M. SCHUMAN, M.D.*

For more than a decade now, I havemaintained the conviction that the scienceof epidemiology may readily be taught toveterinary medical students, for much oftheir curriculum is dedicated to the conceptof the herd, which in a real sense is oneof the types of population that epidemi-ology is concerned with. The experienceof the past 14 years in teaching both vet-erinary and medical students has led meto believe that the early teaching of thebasic principles of epidemiology is highlydesirable in order that the student quicklyrecognize that he must live and work in anecosystem in which the magnitude of occur-rence of a given disease is the resultant ofa multifactorial display of causes and mod-ifying factors-of a dynamic interactionof the characteristics of the agent (oragents), the host, and the environment. Itis desirable that this be done before he fallsinto the rut of believing that disease isinvariably the result of a single necessaryand sufficient agent acting on a host-anapproach which is all too often, if uncon-sciously, the outgrowth of our microbio-logical regimen.

It is also important that the studentrealize quite early in his career that,whereas the cure of disease may have a

* Professor and Head, Division of Epidemiology,School of Public Health, University of Minnesota.Minneapolis, Minnesota.

27

trace of glamour, a more realistic approachis the control of spread or continued pro-duction of disease in a population or herd,and only the epidemiologic approach canprovide him with the necessary expertisefor such control. Even for the practitionerwho insists on the individualistic approachto diagnosis and treatment of a single mem-ber of the species, the principles of epi-demiology will enrich his approach in termsof the contribution which this single casemakes to the health status of the herd orspecies population. Without a basic under-standing of these principles the practitionercannot appreciate the relative hazard whichhis case represents to the rest of the popu-lation, the milieu in which the disease de-veloped, the risk of more cases developing,and the feasibility of controlling the rele-vant factors contributing to the develop-ment of the disease.

It is not necessary early in the curricu-lum to belabor the details of the epidemi-ology of blocks of representative diseases.These could much more meaningfully beintegrated later with other subject areas inindividual disease study. What is more im-portant is that the student very early inhis career conceptualize the epidemiologicprinciples-learn early the grand overview,lest he become a slave to rote learning ofa flood of details which are all too fre-quently meaningless to him and remain


isolated facts rather than illustrations orexamples of an integrated, dynamicallyinteracting whole. With basic conceptsclearly understood, the facts which the stu-dent must master become easier to handleand, more important, the student has de-veloped the ability to understand the mech-anisms in epidemiologically related diseases,through transfer and application of theseconcepts. With experience he can add theconcentric layers of sophisticated detailsto the core. Disease occurrence then takeson the characteristics of a dynamic processrather than a collection of boring detailsand onily lopefully reialed faclus.

To accomplish these ends the principlesof epidemiology must be presented for theirown sake, as common-denominator truthsfor all diseases, or at least for groups ofepidemiologically related diseases. Empha-sis should be on concepts. Examples andillustrations are to be used not as facts forfacts' sake but to communicate the essenceof the concept. Analogies and models provealso to be quite helpful in this regard.

Although many of the principles areintentionally derived from communicabledisease experience (not only because wehave at this stage of our development moreinformation in this area, but also becausetheir meanings are conventionally easier tograsp in the infectious disease frame, ex-amples, analogies, and models in the chronicdegenerative disease area are neverthelessinterwoven-at every opportunity andwherever applicable-in order to strengthenthe concept and illustrafe its universality.

We begin with a definition of epidemi-ology based on etymologic derivation. Thena sophisticated definition involving the fac-tors influencing the occurrence of diseaseis presented as an elaboration on the skele-tal definition; the concept of epidemiologyas the science of the mass phenomena ofdisease is also presented by analogy. Thecommunity, the population, the herd itself

is conceived of as a living organism andthe manifestation of disease in the popula-tion as akin to disease in the individual.The students are told that the epidemiolo-gist approaches disease in a population inmuch the same way that a physician probesfor the meaning of a presenting symptom.He is warned that the symptoms and signsof disease in a population are qualitativelydifferent from, though analogous to, symp-toms and signs in a patient. The quantityof cases is likened to the intensity of pain,for example; the geographic distribution ofthe disease, its differential occurrence inage, sex, racial, oUecupati Ouial, Ulor buociou-

economic subgroups is likened to the ana-tomical location of the pain; and the tem-poral distribution of the cases is likened tothe relationship, in time, of the symptom toother events in the life of the individual.The student thus comes to appreciate theepidemiologic approach as a diagnostic ap-proach to disease in the community, popu-lation, or herd, with community control ofthe disease as its objective-just as thephysician seeks a diagnosis in the individ-ual in order that he may apply the propertherapy.

The agent-host-environment complex orinteraction is also presented as a conceptof multifactorial causation of disease bygeneralizing with examples rather than bymonotonous, repetitive recitals of its com-ponents, disease by disease. It is at thispoint that the student begins to under-stand the reasons for the rise and fall ofdisease incidence. It is only when he hasbeen shown that the magnitude of ocdur-rence of disease in the population is de-pendent not only on the presence of theagent or agents, their quantity or dose,their virulence, pathogenicity or toxicity,and their infectivity, invasiveness, or pene-trability, but also on the presence and in-fluence of environmental factors such astemperature, humidity, and moisture on

28

Epidemiology: Basic Principles 29

the agents, vehicles, vectors, and even hosts(as well as on variables within the host,such as the competency of the reticulo-endothelial system, its prior challenges byantigens, genetic makeup, age, sex andhormonal status and race)-it is only thenthat the student can fully understand theirinteraction and disease production is amultifactorial phenomenon. In man cul-tural and behavioral patterns (and in ani-mals, behavioral patterns) may, in turn,be determinants of disease and these arealso shown to act via environmental fac-tors such as socioeconomic status and per-sonal hygiene, for example. Once thisconcept has been grasped and its relevancyto any disease demonstrated, the studentcan accept the fact that control need notbe dependent solely on our ability to manip-ulate the causal agent but can be accom-plished by manipulating modifying factorsin the environment or in the host. A linearequation, deliberately simplified by notingonly a few representative variables in theagent, the host, and the environment-andequaling a quantity of disease-assists inpresenting the logic of this multifactorialconcept. It is through such an equationthat the principle of eradication may beexpressed, that the meaning of a necessarybut not sufficient cause becomes clear. Italso becomes clear how control of diseasecan still be achieved even when the causeof the disease is unknown. Such an equa-tion enables the student to grasp the notionof multiple causes of the same disease aswell and the principles involved in decision-making for control, including the variationspossible and the manipulability and feasi-bility of approach.

After a cursory sketch of the agent-host-environment complex, utilizing familiarexamples, the complex is dissected in moredetail, still utilizing examples for illustra-tive purposes. The epidemiologic-asopposed to microbiologic-meanings of the

several characteristics of the agent thatinfluences the magnitude of occurrence ofdisease in the population are clarified. Theyields of cases with agents of high asopposed to low infectivity are demon-strated. The relationship of virulence toseverity of disease and of levels of patho-genicity to the yield of cases and the pro-portion of transient carriers produced ispresented. The phenomenon of the transientcarrier becomes readily understandable bythis approach via the pathogenicity of theparasite.

The student is not left with the impres-sion at this point that, given an agent inlarge numbers with high infectivity andhigh pathogenicity, the population will beoverwhelmed by disease. Although sus-ceptibility will more logically be dealt within detail in terms of host variables, it isat this time that the student is warned thatthe susceptibility of the host is a strongdeterminant and that disease, in the finalanalysis, is the resultant of a number ofvectorial forces in both the agent and thehost.

Although the chain of infection is thestructural model upon which the discussionis based, and although I do draw uponmicrobiologic and clinical data as an aidin understanding, the basic approach is viathe conceptualization of epidemiologic prin-ciples as they derive from the links in thischain. Thus, for example, the approach tothe reservoir of disease is not through anenumeration of sources or habitats of theagents, but rather through the magnitudeof the risk to the rest of the population asposed by each kind of source; and thismagnitude is considered in the frame ofrelative risk as based upon the dose, theintensity, the number of sources, and therelative mobility of that class or source.Thus the student can be taught to disabusehimself of the preconceived notion that theseverity of a case spells greater hazard to


the rest of the population or herd. It canbe shown that the greater number of tran-sient carriers and their normally greatmobility provide a proauct of risk fargreater than the relatively smaller numberof severe cases with relative immobilityand even self-induced isolation. In thisway the reservoirs of disease, as representedby the clinical types of cases of illness andby the incubationary, convalescent, chronic,and transient carriers, are evaluated as aspectrum of risk to the rest of the popula-tion. The concept of the dependence of thesize of the reservoir on seasonal and secularpatterns of prevalence of cases and carriersis also introduced at this point.

Then the efficiency of the several portalsof exit (in terms of organ systems andphysiologic mechanics) is discussed andevaluated. Emphasis is placed here on theepidemiologic principle of the effective frac-tion of the reservoir, i.e., that portion of thereservoir from which the agent can escape.Multiple portals of exit for the same diseaseand their significance as risks to the poten-tially exposed population are discussed. Itis here that the concept of the secondaryattack rate as a relative measure of infec-tiousness or communicability is introduced.The student almost spontaneously recog-nizes the portal of exit as the first link inthe chain of infection where control methodsmay be applied.

The study of the several modes of trans-mission yields a wealth of concepts withepidemiologic significance. Students areinformed that the modes of transmissionpractical for a parasite are dependent onthe ability of the parasite to survive out-side the body of the host-outside the reser-voir. They are told that the danger ofspread and hence the size of the caseloadproduced is in great part dependent uponthe mode of transmission available for thatagent in that place and at that time. Itis here that the characteristics of vehicles

and vectors are brought into the picture,and their availability and utilization byclasses of agents are discussed. Also dis-cussed at tlis puoin is the epiudemioloogicprinciple of geographic limitations of diseasedue to climatic, geologic, and physiographicrestrictions and vector mobility (or lackof it).

In discussing portals of entry, it is empha-sized that, where more than one portal ofentry is possible, the form of the diseasemay be an expression of the portal utilized.Particularly important for epidemiologicinvestigation is the fact that, in a givendisease, the involved part is not necessarilyan indicator of the portal of entry. Even inhitherto unknown diseases, making theirappearance in an area for the first time,the mode of transmission may be inferredfrom considerations of age, sex, race, occu-pational attack rates, and secondary attackrates, as opposed to the assumption of aportal of entry based on the clinical designa-tion of the involved anatomical part.

Our next consideration in the agent-host-environment complex is the host. Aftersome preliminary considerations of primaryfactors of host resistance (which includesuch nonspecific autarceologic factors ofinherent resistance as the first and secondlines of defense and the protective influenceof hormonal activity-and such specificfactors as humoral and tissue immunity andthe antigenicity of the agents), these phe-nomena are blended into a synthesis of thepatterns of development of immunity vianatural and artificial means. The secon-dary factors of resistance, which includethe extrinsic or environmental factors suchas diet, fatigue from overcoming gravity orinertia, temperature, humidity, and ionizingradiation, and the intrinsic factors such asage, sex, and race are then discussed. Fromthese considerations, age selection or dis-tribution of disease emerges as one of themost dynamic of the epidemiologie princi-

30

Epidemiology: Basic Principles 31

ples. By discussing the roles and interac-tions of such factors as passive transplacen-tal antibody transfer, relative resistanceof the skin, pulmonary tree, and gastro-intestinal tract, the state of the reticulo-endothelial system over age, the influence ofselected pathologic states, and the conceptof increasing exposure potential with age-as well as the imprint on the populationor herd of previous disease or exposureexperience-students realize that age pat-terns of disease are the resultants of system-atic combinations of these factors and notsome mystical maturation process.

With this background, the age distribu-tion patterns of disease are syntheticallyevolved, utilizing various combinations ofagent and host factors. There is presentedthe classic situation of a childhood disease,where the agent is endemically present, itsinfectivity, pathogenicity, and antigenicityare high, and there is maternal antibodytransmission in utero. Variations of thistheme are presented where the agent char-acteristics are varied to the oppositeextreme but taken one at a time, with orwithout passive transfer of antibody. Therole of occupation as modifying exposurepotential is also interjected at this point, asis the effect of postponing exposure poten-tial, with physiologic maturity a prerequi-site to sexual exposure as an example. Inaddition to the patterns which may beevolved utilizing agents of high or low anti-genicity, the students are asked to developthe age distribution pattern of diseasesreintroduced into isolated island communi-ties after years of disease absence, or intro-duced for the first time into any community.The reverse procedure is then utilized.Curves are drawn, and the students areasked to discuss the possibilities in terms ofantigenicity and exposure experience. Allin all, this provides a good experience inepidemiologic inference.

An overlay of sex differences in attack

rates on an age basis is then introduced, andthe roles of both hormonal differences anddifferences in exposure potential between thesexes are discussed. Disparities of attackrates by race may provide further epide-miologic clues as to the mechanisms of dis-ease production in the population; these arethen discussed generally. To the veterinarymedical student this would have more mean-ing in terms of animal breeds in a species.Breed differences in resistance or suscepti-bility to disease may readily be explainedon genetic grounds, but in man the overlayof socioeconomic difference leading to quali-tative and quantitative differences in ex-posure very frequently overwhelms pureconsiderations of race as a genetic factor.Nevertheless, such insight into racial pat-terns becomes important in the teaching ofprinciples of epidemiology, for they are pre-requisites to an understanding of shiftingpatterns of disease in time. An illustrativeexperience, such as the shift from higherattack rates of poliomyelitis in whites thanin Negroes to the reverse (and that in evenyounger age groups) following immuniza-tion programs, becomes quite helpful.

These considerations then lead normallyto a discussion of the influence exerted onpatterns of disease occurrence in popula-tions by programs of active immunization,particularly such innovations as the replace-ment of a wild virus in a population withan attenuated transmissible virus throughan orally administered live virus vaccine.

Crowding, or aggregation of populations,and its influence on the occurrence of dis-ease would certainly be easy enough tounderstand much earlier in a course onbasic principles, but the dynamics whichinvolve the ratio of susceptibles to immunesin a population, which in turn is dependentupon the ease of spread, rate of exhaustionof susceptibles, and their replacement bynew births or by immigration to urbanfrom rural communities (or dense as


opposed to sparse populations) must awaitthe considerations of the phenomena of im-munity and age distribution of disease for amore solid conceptualization. Only now,in my opinion, will the student understandwhy urban or dense populations developimmunity earlier to an endemic disease pro-duced by an agent of high antigenicitythan do rural or sparse populations-andwhy the urban community, though having agreater absolute number of cases, usuallyhas lower attack rates and fewer explosionsof disease.

At this time the additional overlay ofsocioeconomie differences in the same popu-lation can be brought before the student.The emphasis is on the epidemiologic mean-ing of such socioeconomic differences interms of earlier and greater exposure to thedisease agent via poorer environmentalsanitation and personal hygiene. If thedisease in question increases in severityand in number of overt cases with inereas-ing age, the student with this backgroundnow understands why the upper socioeco-nomic groups would have higher attackrates. If, on the other hand, the diseasedecreases in severity with age then, underidentical conditions of socioeconomic dif-ferences, the attack rate will be higher andoccur earlier in the lower socioeconomiegroups. Illustrations of disease examplesare here supplied.

This background leads to a considera-tion of changes in the age distributionpatterns of disease over time, particularlyin developing nations, which demonstratethe emergence of man-made disease patternsin a very compressed period of time. Thestudent is presented with the example ofpoliomyelitis, which is clinically rare inunderdeveloped, poorly sanitized countries,where immunity is virtually universal andis acquired very early in life. The studentunderstands that this is the result of acombination of extremely early infectionbecause of poor personal hygiene at a time

when maternal antibody is still present inthe child and when the disease is in anextremely mild clinical form in the veryyoung. With improvement in the stanidardof living and improvement in hygiene,including protection of the young againstindiscriminate exposure, infection is post-poned to a time when passive antibody isgone and the disease tends to be moresevere clinically and hence more overt.

Finally, students are presented with thephenomena of seasonal and secular cyclic-ity as epidemiologic principles.

To round out the students' experiencewith th nrbls inlps nf onidominlngyv anoutbreak problem is posed for class dis-cussion and solution. The disease is notidentified, and the clinical diagnosis andall clinical and laboratory features aredeliberately withheld until the very end ofthe discussion in order that the student mayappreciate the fact that the particulardynamics of production of this disease andits mode of transmission may be derived bysequential logic and inference from theepidemiologic data alone, including the dis-tribution of cases in time, the extent ofminultiple cases in. househoids, arld the ageand sex distributions. Thus the studentsare prevented from following false leadsbased on a priori notions of the reason forthe outbreak, just because they are familiarwith the disease in question.

In summary, it is my conviction thatthe basic principles of epidemiology can betaught conceptually, utilizing specific facetsof specific disease epidemiology only asexamples or illustrations to clarify andaugment the concepts, not as an accumula-tion of facts to be memorized without anyfeeling for their meaning. This conceptuali-zation in the hands of reasonably intelligentstudents should help them to elicit thespecifics in epidemiology without much fur-ther guidance and to engage in problemsolving with confidence.

32

THE TEACHING OF EPIDEMIOLOGY

THE KENTUCKY PROGRAM

HUGH S. FULMER, M.D. *

This paper is presented from the vantagepoint of teaching epidemiology in a medicalschool. Whether the objectives and princi-ples are appropriate for teaching in aschool of veterinary medicine I leave foryour judgment.

I should first present my biases, becausethe evolution of this particular teachingprogram in epidemiology has been affectedby the guiding philosophy of our ownDepartment of Community Medicine atthe University of Kentucky, which repre-sents a unique departure in medical educa-tion. Hence, the teaching of epidemiologyis to be viewed in the larger context ofwhat we call community medicine. Ourteaching approach in Kentucky is, however,only one example of what can undoubtedlybe accomplished in many different ways.

My own experience had some influenceon how we designed our program at thenew University of Kentucky Medical Schoolin 1960. I myself had received virtuallyno training in epidemiology in medicalschool. Throughout my internship and resi-dency training in internal medicine, therewas no exposure to the concepts and prin-ciples of epidemiology. After training, Ihad the opportunity of participating in afield health research program on the NavahoIndian reservation. For the first time I1

*Professor of Community Medicine, Depart-ment of Community Medicine, University of Ken-tucky Medical School, Lexington, Kentucky.

33

was involved in epidemiological researchwithout, however, having had any formaltraining in the discipline. It became mylot to learn the hard way-by my ownmistakes. After two years of this I obtaineddidactic instruction in epidemiology duringan M.P.H. year-what might be termed a"remedial" year. We thought that it wasthe fault of medical educators for havingslighlited so important a discipline and thatwe ought to be able to do better.

Formulation of our own program, there-fore, capitalized on a review of my owncheckered career in painfully learning howit could be done differently and optimally.I was not alone. The original membersof our Department had had similar experi-ences. We were sure that undergraduatemedical students should have a good firmbase in the discipline. Our concept ofmedical education had evolved to the pointwhere we viewed it conceptually as needingto be based on three interdependent parts:laboratory, clinical, and community medi-cine. Community medicine had to have ascientific foundation. One major aspect ofthat scientific base could be designatedepidemiology.

In order to teach epidemiology success-fully, we believed strongly that it had tohave both a didactic and a field phliase.The formal classroom exposure would occurduring the preclinical years, the applicationin the clinical years.


Second-Year Course (Didactic Teaching)

The preclinical teaching occurs in anextensive second-year course in epidemio-logy. It consists of 72 hours of classroomtime, covering the second half of the secondyear. By this time, the students have hadmicrobiology and a good share of pathology,and they are beginning to examine patients.

Once a week for three hours we teachepidemiology. We think that for the subjectto be most palatable it should be bothoriented toward the clinical and rich withillustrations of local and national signifi-can ce.

Our teaching is founded on MacMahon'scomprehensive yet succinct definition ofepidemiology as the science of "the distri-bution and determinants of disease prev-alence in man." Whether the etymologicdefinition (the science of "upon thepeople") might be improved with the inser-tion of a root meaning "disease" (so thatthe word might be modified to epidemio-pathology) is an academic question. Theveterinarian term "epizootiology," thestudy of epizootic disease, similarly suffersfrom the lack of "disease" as one of itsroots.

At any rate, our second-year teachingstresses the MaeMahon definition, thusleading to the strategy implied in thatdefinition. This strategy is that the epide-miologic approach to the study of diseasehas, conceptually, four phases. These are(1) descriptive epidemiology, a study ofrates of disease in subgroupings of thepopulation, leading to (2) hypothesis form-ulation, based on asking why rates ofdisease are as they are; the testing of thesehypotheses of causation is the task of (3)analytic epidemiology, which by itself,either through prospective or retrospectivemethodology, only establishes associationsbetween proposed cause and effect vari-ables by controlled observation; the last

phase is (4) experimental epidemiology,which has the capacity for rigorously con-firming or denying causal hypotheses in thearena of the real world.

Our course is divided into segments. Thefirst series of three-hour sessions consistsof "epidemiologic methods," outlining therole of descriptive, analytic, and experi-mental epidemiology. The balance of thecourse is divided into two parts and isoriented to specific disease or health prob-lems. The first of these two parts dis-cusses the problems of infectious diseasessuch as influenza, tuberculosis, hepatitis,polio, zoonoses, and venereal disease; thelatter part of the course covers the chronicdisease area: coronary heart disease,smoking and atmospheric pollution, cancer,the population problem, mental health, etc.

We have a flexible formula for thisdidactic course. Each session is initiatedby a lecture period one-half to one hourin length. A clinical case is presented at thestart of the lecture to whet the students'interest through the demonstration of a livepatient with the problem of the day. Theentire class of 75 attends the lecture; theclass is then divided into small groups of7-8 students each for a seminar sessionlasting two hours or so. Each group is ledby a faculty member. This allows discus-sion of the topic of the day in some depth,favors a certain degree of individualinstruction, and makes possible a closefaculty-student relationship.

The format of the seminar period is tosome degree structured, but it may beliberalized by the individual faculty semi-nar leader. Each student is assigned aspecific epidemiologic article from the medi-cal literature, pertinent to the subject ofthe day, and is required to report upon itorally during the seminar period. He isinstructed to analyze the article critically,using his knowledge of epidemiologicmethods. There may be three or four such

34

Epidemiology: The Kentucky Program3

readings assigned, with two students in agroup having the same reading assignment,neither knowing who will be called uponto report; the one not reporting acts as acritic of the other. The article may ormay not be scientifically sound. In addi-tion, all students are assigned a generalreading for which all are responsible. Thismay be from a text, or it may be an articlefrom the medical literature, but in eithercase it treats of the subject in a compre-hensive fashion. Also, all students areassigned a homework problem on the day'stopic which emphasizes epidemiologicmethods and principles in relation to thecategorical disease entity. Solution of theproblem is discussed during the seminar.To round out the materials, all studentsreceive the weekly morbidity and mortalityreports issued by the National Communi-cable Disease Center; these are grist for themill of discussion. All seminar groups areassigned the same mix of ingredients, lend-ing uniformity to the teaching of the entireclass. In sum, the seminar period may beused to discuss the patient of the day, thelecture, the general or specific reading, theproblem, or the morbidity and mortalityreport, so as to re-emphasize those easilyrecallable principles that we hope the stu-dent will carry away from the course inlis memory.

The seminar leader may vary the amountof time that he devotes to any of theseteaching devices. We have found someteachers who are problem-oriented, somewho regard dissection of literature as theirparticular joy, some who dwell on "the bigpicture," or the patient, and some whofavor a free-wheeling, pot-boiling discussionaround the over-all theme. To say that allseminar leaders should do their teaching ina predetermined manner is to say there isonly one road to Mecca. It prevents leadersfrom playing to their own strengths. Onthe other hand, the willingness of the

faculty to accept critical evaluations ofteaching ability and of attempts at changeand improvement is to be favored andnurtured.

The development of group dynamicsamong the students and between the stu-dent and his faculty leader is interestingto observe and may be used to promotelearning. To know who the better studentsare, who the peer leaders are, who respondswell to whom, who are the better teachersamong the students themselves, is of greatadvantage in improving the entire teachingprocess. We ought to make more of this;the behavioral scientist could help us here.

Fourth-Year Course (Field Teaching)

The medical students spend the thirdyear in the hospital wards and clinics learn-ing clinical skills. We are involved withthem only indirectly during the third yearby virtue of serving as clinical faculty. Incommunity medicine-epidemiology instruc-tion per se we are not involved at all.

In the fourth (senior) year all studentsspend a full six weeks under our aegis. Itis during this period that we believe the"payoff" occurs in the learning of epide-miology. Again, this is to be viewed in thelarger context of community medicine.

The student is assigned to study a com-munity and its health problems. He movesto that community and lives in it for fiveand a half weeks. He is told to make theanalogy to the patient in the hospital bed.We tell him, "You have learned the clinicalapproach to the patient by working withindividual patients in the ward and theclinics. Now learn the approach to the 'sickcommunity' by being at its 'bedside.' Justas you learn diagnosis and management, thescience and art of clinical medicine, at thebedside of the patient, now learn the identi-fication and solution of community healthproblems in the community." We empha-

35


COMMUNITY EPIDEMIOLOGIC PROJECTS

(Categorized by main emphasis and methodology)

A. Population Description: General and Specific Health Status and Health IndicesFollow-Up

Perinatal mortality and prenatal careSchool children heights and weightsVision testing of school childrenCurrent status of mentally retarded childrenImmunization levels in infantsDomestic water supply evaluation

B. Population Descriptions: Health Attitudes, Knowledge, and BehaviorFamily planning, knowledge and practicesAdolescent prisoners' attitudesAlcoholics Anonymous population studyEpileptics' social problemsOver-65 population needs for knowledge of health servicesConsumers' attitudes about University of Kentucky Medical Center

C. Health Servic Dsrpti, Evauatio and/or 1;tilization ReviewVacation area health services availabilityCholecystectomies in a community hospitalCoroner's office servicesRegional pediatric clinic operationRabies vaccination clinic operationRural doctor's office and hospital utilizationMental health service for childrenPost-partum complication of office deliveriesMedical record data retrieval in general practicePrenatal care utilization by a minority groupCollege health service evaluationEKG screening test evaluationMedical history questionnaire developmentMedical care resources for a factory populationCarcinoma of cervix detection in welfare recipients

D. Disease Detection, Early Diagnosis, and ControlDiabetes detection in school and factoryCervical cancer detection in office practiceTuberculosis detection and follow-upAlcoholism detection in a large factory

E. Infectious Disease Prevalence, Incidence, and Care StudiesGroup A beta streptococcus prevalence in general practiceTuberculosis and histoplasmosis skin test positivity in studentsToxoplasmosis in retarded childrenIntestinal helminths in school children

F. Noninfectious Disease Prevalence, Incidence, and Care StudiesHighway accidentsAccident patients at a community hospitalChronic respiratory disease and smokingGlaucoma in a nursing home populationMental illness in doctor's practice and communityGlaucoma in family practiceAluminum dust and chronic lung diseaseFamilial disease genetic work-up

size that the science he is now going to was all about, and the preparation obtainedhave the opportunity to apply is epidemiol- in the didactic phase is now going to beogy. This is what the second-year course applied in the field.

36

Epidemiology: The Kentucky Program

Therefore, in addition to studying indi-vidual patients and families in the commu-nity setting and making a comprehensivedescriptive study of the medical needs andresources of the community, the student isrequired to complete an epidemiologic pro-ject.

This latter task involves several ele-ments. He selects a disease or health prob-lem in which he has a certain amount ofinterest---one that has significance in thecommunity. He reviews the pertinent litera-ture. He designs the study, selecting aproper sample and detailing the researchprotocol. He presents the study design tofaculty and colleagues at the end of thefirst week of the clerkship. He then carriesit out; the study is modest in scope and isplanned to consume no more than threeweeks in data collection. During the fifthweek he analyzes, interprets, and writes upthe study. At the conclusion of the six-week period he presents the results to afaculty-student seminar group.

The particulars of such studies are item-ized in the accompanying table.

Evaluation

What is the over-all impact of this pro-gram? We really do not know as yet. Wedo not aim to create specialists in this fieldbut rather to widen the horizons of all. Wedo not know whether or not our graduateswill practice medicine with a finer sense of

community medicine than other medicalgraduates. Thus far, we have only gradu-ated four classes.

We would like to see every practitionerapply the epidemiologic approach as hepractices medicine. If not that, we wouldhope that practitioners would recognize itssignificance and know whom they shouldcall upon when problems of epidemiologicdimensions arise in the community and theyhave need of such expertise.

An evaluation ought to be made of ourgraduates; even though we have no controlgroup, we plan to do so. Evaluation forthe long term will have the most meaning.

Conclusions

We are constantly being surprised andeven amazed at how our students havedeveloped sophistication in epidemiology.This reflects our own impoverished under-graduate background in this discipline.Epidemiology, as the diagnostic arm ofpublic health-community medicine, hasbeen sadly neglected in our curricula. Yetits importance cannot be overstated. If weare to make our physicians and health pro-fessionals aware of the magnitude of thehealth problems we face in the comingyears, we have to instill in them the con-cept that the scientific approach is asimportant and meaningful, if not more so,to the study of population pathology as itis to individual patients.

37

THE TACHTING OFr rTOSATTSrTC'

OBJECTIVES AND PRINCIPLES

PAUL LEAVERTON, PH.D. *

Statistical methods and concepts are usedtoday in every field of science. Thisnaturally follows if we accept the fact thatscience is defined on the basis of whetheror not relevant entities can be measured.Statistics is most often defined as the col-lection of methods for summarizing andanalyzing data. Those methods most appli-cable in the biological sciences are calledbiostatistics, and they have long been a partof the curricula in public health and pre-ventive medicine.

Obviously, it would be presumptuous foranyone to offer a set of principles on asubject as though they were universal, andthese comments should not be so construed.What follows, therefore, represents some ofmy personal views on the objectives andprinciples in teaching biostatistics. I willbriefly outline what I consider to be theessentials of the subject and will point outa few topics, which, from my experience,seem to need more teaching emphasis thanthey generally have enjoyed.

The basic subject matter of a first coursein biostatistics may be divided into twoareas:

1. Descriptive methods.2. Statistical inference (analysis).

* Associate Professor, Department of PreventiveMedicine and Environmental Sanitation and De-partment of Statistics, University of Iowa, IowaCity, Iowa.

There is some overlap between the two butthis division will prove to be useful.

Descriptive Methods

The idea of a relative frequency distribu-tion is basic to any attempt to describedata or to perform a "statistical analysis."The histogram, or bar graph of a frequencydistribution, is still the best way to describea set of measurements and it deserves pri-mary emphasis. Of course the familiar,concise, summary measures of central ten-dency and variation are also necessary. Oneof these, the standard deviation, is very fre-quently misused. For some reason peopletend to forget that the standard deviationgives you a useful description of variationonly when the frequency distribution isapproximately symmetric. As an alterna-tive, more attention should be given to theuse of percentiles, which do not depend onthe shape of the underlying distribution.

Statistical methods are based on anabstraction-a model-which is an approxi-mation to real-world phenomena. If theapproximation is a good one, we have a use-ful, sometimes even powerful, tool. If theapproximation is poor, ridiculous conclu-sions can easily result. This critical pointcan be illustrated even with a simple de-scriptive measure such as the average, ormean. When the number of observations is

38

Biostatistics: Objectives and Principles

small and includes one or two extremevalues, the mean gives a figure which simplydoes not describe the "center" of the fre-quency distribution very well. For example,the average of the four numbers 0, 1, 2, and97 is 25. The descriptive usefulness of themean requires that we deal with an approxi-mately symmetric distribution. Obviouslythe underlying assumptions such as this onemust be kept in mind, even when we usesuch an elementary technique, if misleadingconclusions are to be avoided. This decep-tively simple axiom applies to all of statis-tics.

Descriptive methods involve easy con-cepts, which can be covered briefly in acourse. However, it has become apparentthat more emphasis on the specific purposeand limitations of each method is needed.

Statistical inference

The use of statistical methods for mak-ing decisions on a "probability basis" hasbeen a recent development in the historyof science. In fact, it was only in this cen-tury that the methods and concepts ofstatistical inference, principally under theinfluence of R. A. Fisher, became widelyaccepted. These ideas, used to quantitatethe decision process in estimation problemsand in testing hypotheses, are the mainsubstance of statistics today. Thesemethods of statistical analysis may begrouped under the label "statistical infer-ence" to differentiate them from purelydescriptive methods.

Even more attention must be given toour assumptions in this area. This require-ment should not be considered a disadvan-tage of the statistical approach, for when-ever inferences are drawn from observations-whether a formal statistical analysis isused or not-some assumptions about thenature of the data are necessary for valid

conclusions. Not stating an assumptiondoes not affect its requirement, of course.As Hooke (1) puts it, "We do not subscribeto the common fallacy that he who does notmention his assumptions is not restrictedby their limitations."

Statistics is sometimes generally de-scribed as "the science and art dealing withvariation in such a way as to obtain reliableresults" (2). Obviously situations do existwhere variation is not a problem and noformal statistical analysis is needed. Itseems reasonable, in fact, to require thepresence of variation as a prerequisite fora statistical analysis. If there is no vari-ability, then a sample size of one is suffi-cient. As Bradford Hill has pointed out:

If we were to use a new drug upon one provencase of acute leukaemia and the patient made animmediate and undisputable recovery should wenot have a result of the most profound impor-tance. The reason underlying our acceptance ofmerely one patient as illustrating a remarkableevent-not necessarily of cause and effect-isthat long and wide experience has shown that inrespect of acute human leukaemia human beingsare not variable. They one and all fail to makeimmediate and indisputable recovery. They oneand all die (3).

Of course this is an extreme example.When dealing with almost any biologicalphenomenon, remarkable variability usuallyexists between elements in a group orbetween observers. This fact can hardlybe overemphasized. And there certainly isno shortage of examples.

The relative frequency (Neyman-Pearson) concept of probability is the basisfor statistical inference, and its principlesare a necessity in any statistics course. Aconcept of probability (subjective Bayes-ian) based on quantitating one's "degreeof belief" in hypotheses has recently gainedsome support among statisticians. How-ever, this approach to probability has beenmainly of theoretical interest and its even-

39


tual usefulness in helping to solve real-world biomedical problems is doubtful.

Since the main objective of a statisticalanaiysis is to make inferences about popu-lations, it is essential that the idea of apopulation (in the statistical sense) begrasped. Selecting random samples andconsidering the variation among them isbasic. In fact, the concept that data froma study may be considered a sampleresult-from among many possible suchsamples taken from a population-is thebasis of statistical inference and the induc-tive reasoning process (from the particularto the general).

This "population-sample" concept andthe rationale for random sampling are pre-requisites for all of the methods of statis-tical analysis. There are two major reasonsfor selecting samples at random:

1. Chances for bias are minimized.2. The laws of probability may be em-

ployed in evaluation of results.

These are strong advantages which may beillustrated many ways. Perhaps the pointis made most dramatically to students byconsidering examples of inferential diffi-culties encountered when nonrandom sam-ples are chosen.

The use of randomization is not limitedto sampling, of course. In comparativeexperiments random allocation of subjectsto treatments has come to be regarded as afundamental scientific principle for the tworeasons given above.

Randomization allows a judgment to bemade about the compatibility of observedgroup or "treatment" differences with thehypothesis that all groups effects are alike.Making this judgment on a probabilisticbasis is the essence of hypothesis testing.This broad subject may be illustrated bysome of the simpler, but very useful statis-tical tests. Although their calculation is

straightforward, it is the proper interpreta-tion of the resulting statements concerningstatistical significance (p-values) thatseems to elude most persons. It seemsobvious, therefore, that more time shouldbe spent on interpretation than has beenthe case.

A related problem is the failure to dif-ferentiate between "statistical significance"and "practical significance." This semanticdifficulty has been caused by the statisti-cians' unfortunate choice of the term"significant difference." What is meant bythis is that differences as large as thatobserved or larger, could be expected tohave occurred by randomization alone onlya small percentage of the time. Conversely,a difference judged to be not statisticallysignificant is one which might well haveoccurred by chance alone. Being specificabout the expressions "small percentage ofthe time" and "might well have occurred"is what the p-values are all about. But theseexpressions pertain to the reality of a dif-ference, not the magnitude. It is easy to citeexamples of real and statistically significantdifferences between two treatments wherethe actual magnitude is biologically un-important.

The fact that the subject of test "power"is sometimes omitted from statistics coursesand textbooks no doubt contributes to theconfusion about statistical significance.But an understanding of power is absolutelynecessary for proper understanding of allstatistical tests. It needs to be pointed outmore often that mistakes in judgment abouthypotheses can go either way. We may"reject" them when they are true or"accept" them when they are false. A sta-tistical test does not prove or disprove ahypothesis but merely establishes the prob-ability of a judgment error about the realityof a difference.

40

Biostatistics: Objectives and Principles

Experiments and Nonexperimental Studies

The term "experiment" has been bestdefined by Donald Mainland (4) as "aninvestigation in which randomization isperformed and in which throughout theexperiment nothing is allowed to interferewith the effects of randomization exceptthe treatments, if they can do so." In thiscase the investigator has control over theindependent variables and assigns themhimself to the subjects. In nonexperimentalstudies no such control exists over the rele-vant variables. Such investigations aresometimes called "observational studies" orsimply "surveys." Students often fail toappreciate the fundamental differencebetween the two with regard to the infer-ences which may be drawn from each.

Part of the difficulty lies in the fact that,in many instances, the same computationalmethods of statistical analysis are appro-priate in each of the two types of studies.For example, differences between twogroups may be tested for statistical signif-icance in either case, but a cause-and-effectrelationship may appropriately be inferredonly in experiments.

Nonexperimental studies of both a retro-spective and prospective nature are usefulfor suggesting possible cause and effect re-lationships. Such investigations are, ofcourse, the heart of epidemiologic research.However, it needs to be stressed that, whenthe criteria for an experiment are not ful-filled, all we can ever "prove" are associa-tions.

Computers and Biostatistics

The increasing availability of high-speedcomputers enables many statistical analysesto be easily and inexpensively calculated.In fact, there are numerous packaged pro-grams which will perform all the necessary

calculations for standard analyses of vari-ance, bioassays, regression problems, andmany others. As a result, the production ofroutine statistical computations is going up.

One particular area of statistics that owesits recent rapid development to the com-puter is multivariate analysis, in whichmethods are studied for simultaneouslyhandling many correlated variables. Al-though most of the ideas are not new, theirapplication has been limited by the com-plexity of the required calculations. Thedevelopment of computers has removed thisconstraint, and many applications are nowbeing found for these techniques.

Multivariate statistical methods arenaturally of particular relevance to epi-demiology, where measurements of multipledependent variables is usually the case.Many of these methods are techniqueswhich enable a search for "patterns" in largequantities of data. This is sometimes called"data analysis" as opposed to testing hy-potheses. There is nothing wrong with suchprocedures; interesting possibilities areoften uncovered in this manner. (Unfor-tunately a lot of nonsense is also spawned.)However, it is inappropriate to formulatehypotheses and "test" them on the same setof data.

Although the computer is a powerful toolfor the analysis of data, it enjoys an unde-served reputation as a data purifier. Theeasy accessibility of statistical computerprograms allows researchers to producemyriads of impressive statistics, p-values,etc., regardless of how casually a programmay have been selected. Mistakes of greatmagnitude can now be calculated withgreater precision. And somehow the words"analyzed on a computer" seem to lend anaura of dignity and authority to any result,no matter how fallacious it might be. Suchstatements as "the standard deviations werethus developed on the computer" or "the

41-


data were analyzed by computer" are com-mon annotations.

Teaching Biostatistics

This attitude toward computers is ac-tually only a step beyond that of a fairlyprevalent blind faith in "statistical analy-ses." If Hogben's (5) 1950 statement that"less than one percent of research workersclearly apprehend the rationale of statisticaltechniques they commonly invoke" wascorrect almost two decades ago, then thecomputerized simplicity by which statisticaltechniques may now be used has certainlynot made it less so.

One of the best ways to counteract thissituation in biostatistics courses is to pointout and discuss examples of redundant anderroneous use of statistical methods whetheror not the crime was aided by computers.

The basic statistical flaws in most studiesare not complicated but have to do withsome of the ideas already mentioned here,

osuch as roandomi;ao, pr+ob; ; , andexperimental inference. Proper understandingof these basic concepts would do much toalleviate the problem.

Probably the most important singleguideline for teachers of biostatistics to keepin mind is that nature is under no obligationto provide data which fit our mathematicalassumptions. Therefore, we must questionthe suitability of these assumptions inevery instance where a statistical method iscontemplated. No other general principlecan contribute more toward giving studentsthe correct perspective of statistics inbiology. They will see these methods andconcepts not as a panacea-not as ritualisticnonsense-but as a very reasonable ap-proach to formulating and solving manyreal-world problems.

REFERENCES

(1) Hooke, R. Introduction to Scientific Infer-ence. San Francisco, Holden-Day, 1963.

(2) Mainland, D. Elementary Medical Statistics,2nd ed. Philadelphia, Saunders, 1963.

(3) Hill, A. B. Statistical Methods in Clinical andPreventive Medicine. New York, OxfordUniversity Press, 1962.

(4) Mainland, D. Statistical ward rounds-1.Clin Pharmacol Ther 8(1) :139,1967.

(5) Hogben, L. Chance and Choice by Cardpackand Chessboard. New York, ChanticleerPress, 1950, vol. 1, p. 5.

42

THE TEACHING OF BIOSTATISTICS

MINIMUM GOALS FOR VETERINARY STUDENTS

JACOB BEARMAN, PH.D.*

I should like to make but a few briefremarks on this subject.

It is clear that, in the time available toteach biostatistics to veterinary students,the goals must of necessity be rather mod-est. That is to say, we cannot expect tomake statisticians out of these students.However, we can expect to accomplish cer-tain valuable objectives:

a) Veterinarians should be expected tolearn to read their own technical and scien-tific literature critically and with under-standing.

b) They should understand the nature ofbiological variation and the formation ofjudgments in the face of variation.

c) They should understand the uses ofrates and their importance to the interpre-tation of public health problems.

d) Those who will do at least some scien-tific work should do so with some confidenceof understanding the jargon of statistics and

* Professor, Division of Biometry, School ofPublic Health, University of Minnesota, Min-neapolis, Minnesota.

of being able to make use of the help offeredby statisticians.

In order to accomplish these objectives,it is intended that certain principles in-volved in statistical reasoning be clarified:

a) Since chance and chance fluctuationsare at the foundation of biostatistics, thestudent should be presented the elements ofprobability calculations.

b) On such a basis, the principles ofsampling and sample surveys can be devel-oped, and some applications in veterinarypublic health can be used to illustrate theprinciples.

c) In this context, some basic distribu-tions, e.g., the binomial and normal dis-tributions, and their uses should be intro-duced.

d) Estimation of parameters should beemphasized; the student should distinguishbetween precision and accuracy.

e) Methods for averting bias should alsobe included, and the central role of appro-priate random processes should be givenmajor attention.

43

THE TEACHING OF FOOD HYGIENE

MEAT AND POULTRY HYGIENE

JAMES D. LANE, D.V.M.*

In December 1967 the U.S. Congresspassed-and the President of the UnitedStates signed into law-the WholesomeMeat Act. This dramatically focused atten-tion on the quality of meat being served inthe American home.

The states have been given two years inwhich to bring their standards of meatinspection to the point where they are atleast equal to Federal requirements. If atthe end of this period the states are makingprogress toward this standard, they canpetition the Secretary of Agriculture for aone-year extension so that they can meetthe requirements. At the end of this one-year extension the state inspection programsmust either meet the Federal standards orthe Federal Government will operate theinspection program within the states con-cerned. What this means is that by 1971virtually 100 per cent of the meat beingoffered for sale in the United States will beregulated to the extent that it will meet thestandards of the Federal Government. Atthe same time, the Federal Meat InspectionProgram will be expanding its review offoreign inspection programs to ensure thatthe meat imported into the United States isequivalent in every respect to the productproduced in this country.

Just recently, the Administration has in-

* Chief Veterinarian, Meat Hygiene TrainingCenter, Consumer and Marketing Service, U.S.Department of Agriculture, Chicago, Illinois.

troduced a bill in Congress to provide for apoultry inspection act that in substance willbe equal to the Wholesome Meat Act.Should this bill pass, and there is reason tobelieve that it will, all poultry slaughter andprocessing will also have to meet or exceedFederal standards within a given period oftime.

I believe that the impact of these twopieces of legislation on the veterinary pro-fession is just beginning to be felt, andwithin the next two or three years the de-mand for veterinarians in meat and poultryinspection activities, both state and Fed-eral, will be almost more than the profes-sion can meet. The Federal meat and poul-try inspection programs now utilize nearly1,500 veterinarians, and the states hireabout 200-300 additional men. But theWholesome Meat Act and the poultry legis-lation, if adopted, will, within the next twoto three years, require at least a 40 per centincrease in this number. And that is ahealthy segment of the veterinary profes-sion by anyone's standards. I want to pointout, however, that not all of these men needbe engaged full-time in inspection work.There will be many positions open requiringonly part-time inspection duties. Presum-ably, these jobs could coincide with largeor small animal practice or with animalhealth regulatory work at the state orFederal level. And let us not forget thatduring the coming years our meat- and

44

Meat and Poultry Hygiene 45

poultry-consuming public will grow everlarger, the demand for these commoditieswill increase, and the need for veterinaryfood inspectors will continue to inerease.

The critical question, as I see it, is howthe profession can best meet this rapidlyexpanding demand for veterinarians in foodinspection work. It is a serious problem andwe as leaders and advisers in the field ofveterinary education have to provide theleadership for change in the veterinarycurriculum. I think it is generally recog-nized and agreed that many forces are atwork today changing the focus of veterinarymedicine. Large animal practice is chang-ing to the herd or preventive medicine con-cept. Small animal practice is slowly butsurely growing. More graduates each yearare going into biomedical research, and thenumber of veterinarians in one or anotheraspect of public health work is steadilyincreasing. Change seems to be the orderof the day, and frankly I do not envy thecurriculum committees of the variousschools in their efforts to make veterinaryeducation relevant to the needs of to-morrow.

A Program for Food Hygiene

To meet the problems I have outlined, Iwould like to point out a few objectives thatI believe must be substantially met by theschools if they are to provide the manpowerfor food hygiene programs of the future.

As a broad objective I propose that it ishigh time to accept food hygiene as anintegral part and responsibility of the pro-fession as a whole. For too many years foodhygiene has been the poor country cousinwho ends up with the neck of the chicken orthe cheapest cuts of the cow. Food hygieneis becoming a science requiring special skillsand talents just as any other segment of theprofession. Our job in the Consumer and

Marketing Service is to identify and woothe brightest students of veterinary medi-cine that we can find. We need men whonot only have a well-developed knowledgeof anatomy, pathology, and microbiologybut who have the quality of leadership andthe brightness and alertness to come up withcreative answers to problems of controlsystems and statistical analysis and theability to meet and deal with all types ofplant management at the state, local, orforeign government level. We cannot findthese people-and will not be able to-untilthe veterinary faculties as a whole bringfood hygiene concepts into the daily lecturesand discussions carried on in the classroomsand laboratories during the four years ofschool life. This is a large order and I fullyrealize that years may pass before it be-comes a fact, but a start must be made.

More specifically, I am looking for aveterinarian who can walk into a meat orpoultry plant and know what to do withoutgoing through a long training period by astate or Federal agency. In the FederalGovernment we now find it necessary totrain our veterinarians a minimum of 12weeks before they can be allowed to acton their own in making an inspection anddisposition of an animal. This, it seems tome, reflects the underemphasis on foodhygiene in the veterinary schools. Verybasic sanitation principles and practicesmust be taught to our newly hired veteri-narians. True, they have a good back-ground in the sanitation requirements ofsurgery, but at the present time they all toofrequently lack the ability to relate thesesanitary principles to food-handling prac-tices. In pointing to this as one example ofdeficiency in the total veterinary curricu-lum, I do not intend to criticize the foodhygiene teacher. What I am saying is thatfood hygiene is too often taught as an iso-lated segment of the curriculum, and thesegment is all too brief considering the


major role food hygiene will be playing inthe future.

I would like to see the man who entersa meat or poultry plant for the first timehave a better understanding of how ante-mortem symptoms relate to the wholesome-ness of the meat as a food, or a betterunderstanding of how and why the meatfrom the animal may be objectionable froman esthetic viewpoint. There are manylesions of animals and birds, as well asmeat-handling practices during the dressingor processing operation, that would makethe meat repugnant to the consumer if thelatter knew what he was bcing asked toaccept as food for himself and his family.The veterinarian must see that such meatdoes not enter food channels.

This man should also know the techniquesof providing a full post-mortem inspectionof at least one species of animal and oneclass of poultry. With this ability he canvery quickly learn the techniques of in-specting other species of livestock or ofpoultry. Without such a capability by eachgraduating veterinarian, we can expect tocontinue to see the only too familiar cursoryinspection of animals being dressed for foodby the veterinarian who did not have anopportunity for postgraduate training inmeat hygiene and who may be inspectingmeat or poultry on a part-time basis.

He should also know the more commoncauses of condemnation and why these partsor carcasses should be condemned. And hemust be able to recognize this pathologywhen he sees it. Again, I ask you to keepin mind that meat in its various forms is aprime responsibility of the profession. Notall state agencies, for example, can providean extensive training program for veteri-narians starting work in meat hygiene. Inthese cases, the Federal Government willassist the states whenever possible, butcertainly a man leaving veterinary collegeshould already know and recognize the more

common conditions calling for rejection ofmeat as a food.

When the meat is rejected, he must knowwhat to do with it to ensure that it is notand cannot find its way into food channelsafter he has left the plant. All else is oflittle use unless the meat is effectivelydestroyed as a food and he knows that thishas taken place.

These, it seems to me, are the basic ob-jectives of any meat hygiene program, andsuch capability must be obtained by thestudent during his undergraduate years.Meat and poultry inspection will be theiiveiihood, at least partially, of a large pro-portion of our graduates during the comingyears. Consequently, it is the responsibilityof the schools to adequately prepare theirstudents for this work to the same extent,for example, as they do in the case of smallanimal medicine. It would seem to me thatour national board of veterinary examinersshould examine license applicants in thevarious aspects of food hygiene.

Curriculum Objectives

What principles to follow in order to gainthese objectives is a more complex problemand I hesitate to suggest changes that mayseem radical or "far out." But change islong overdue so I will make some sugges-tions that, though not unique or original,will, if followed, go a long way toward meet-ing the stated objectives.

First, I suggest that the history of veteri-nary medicine become an integral part ofeach curriculum. Veterinary medicine, as abiological and medical science, has a richand diverse history, and our students fromthe onset of their training should be orientedto their profession's over-all role in humansociety and alerted to the great variety ofcareer opportunities open to them. As Dr.

46


Calvin Schwabe of the University of Cali-fornia points out, later in this volume, manyAmerican medical schools support depart-ments of medical history while, so far as isknown, not a single chair of veterinaryhistory exists on an American veterinaryfaculty. The effect of emphasizing the studyof veterinary history would be to broadenthe outlook of the student, provide him withbetter tools to chart his future, and tend toguide him away from the concept of veteri-nary medicine as a narrow technical spe-cialty. It certainly is anything but a narrowprofession, and the student body should beable to draw its own conclusions on this ifthey are provided with a wealth of infor-mation on past and present achievementsand the opportunities that exist in veteri-nary medicine.

To further introduce the student to basicmeat hygiene, I propose that each studentspend a minimum of four weeks in a meatand in a poultry packing plant learning thetechniques of inspection and the principlesof determining when and why meat is suit-able or not for use as food for human con-sumption. The U.S. Department of Agricul-ture has attained an exceptional record ofprotecting the public from unwholesomemeat and poultry for many years and iscontinuing to evaluate newly recognizeddiseases and pathology and the effect of suchconditions on the flesh of the affected ani-mals. Learning how to conduct inspectionand to recognize the more common lesionsis a time-consuming process, and actualparticipation by the student in a real situa-tion has proven to be the most effectiveexperience from the learning viewpoint.

The subject of basic statistics is notalways considered to be a vital part of aveterinarian's education. Yet research de-sign as well as food inspection techniquesdepend more and more on the utilization ofthis mathematical tool. Both the militaryand the civilian food control programs now

heavily rely on sampling plans establishedaccording to statistically sound principles.I predict that a veterinarian lacking knowl-edge of this subject will, within a very fewyears, be just as handicapped as a graduateof my era was in entering his professionallife with no knowledge of the powerfuleffect of antibiotics on disease entities.Statistical analysis provides a means tocontrol large volumes of meat and poultryproduction that simply cannot be ade-quately controlled by a casual and randomexamination by a man who looks in nowand then on the manufacture of frank-furters or hams.

Within the past few years, ever sincethe publication of the book Silent Spring,both the public and the profession havebecome more aware of the long-rangechronic effects of consuming foods contain-ing potentially dangerous insecticides,grubicides, herbicides, and veterinary phar-maceuticals. Ecology is a rapidly growingscience today, and man, as a mammal, isnot exempt from the toxicity produced byconsuming contaminated foods. The extentand effects of the resultant toxicity is aserious consideration of the Consumer andMarketing Service, and the Service's meatand poultry inspection programs haveinaugurated broad survey programs of freshmeat and poultry-as well as sausage andother items-in order to identify and con-demn, if necessary, foods containing exces-sive amounts of such chemicals. I believethat the veterinary profession as a wholehas a responsibility to ensure that suchchemicals are utilized only according toinstructions dictated by the U.S. Depart-ment of Agriculture and the Food and DrugAdministration. Perhaps someday thesetoxic chemicals will be even more strin-gently controlled than today. But in anyevent the schools must strongly impress onthe student body the hazards of such potentchemicals and the need for our meat supply


to be as free as possible from traces of thesedangerous, but also beneficial, drugs andchemicals. Where the public health and ourmeat supply are concerned, the veterinarianmust be concerned.

In all honesty, food poisoning seems oflittle concern in many veterinary schoolstoday. Yet the veterinarian is striving tobecome the primary source of concern withpoisoning arising from the mishandling offood of animal origin. This assumption ofauthority, however, is based not on the titleof doctor or veterinarian but on the famili-arity of the individual man with the source,course, andcl syndrome nf fond poisnningcases. The veterinarian can be an invalu-able aid in the field of public health if he isknowledgeable regarding the causes andeffects of consuming toxic meat or poultryproducts and knows how to avoid conditionsleading to such illness. We all recall thefatal cases of botulism poisoning of a fewyears ago brought on by eating canned tunafish and smoked whitefish. Although caseslike these are extremely rare, this is smallconsolation to the families of the victims.

Why, we can ask, has the veterinary pro-fession in America consistently ignoredmarine life as a source of rich protein for thepublic? Fish, too, suffer from pathologyand disease. In future years, fish farmingwill become an important agricultural enter-prise in the United States simply becausefish are an inexpensive source of proteinand our population is growing ever larger.In Japan this is already the case. Theveterinarian has the responsibility from thestandpoint of both agriculture and publichealth to protect this small but growing in-dustry and the people who include fish as aportion of their diet. When the professionrecognizes this, then and then only will theveterinarian become a vital link in this seg-ment of the food chain.

I have been talking a good deal aboutfood and how to see that it meets our high

standards. Now let me turn briefly to theart or science of turning meat and poultryinto the tremendous variety of food prod-ucts seen in our supermarkets today. Freshmeat and poultry are becoming almost old-fashioned compared to the exotic combina-tions in plain and fancy wrappers availableto us. Millions of dollars are spent on foodresearch, testing, and marketing programsin an attempt to grab the magic formulathat will tickle the palate of the Americanwith a new meat, cereal, or other combina-tion of ingredients that is tasty, attractive,and low-priced-and the merchandisers aresucceeding in a remarkably high numberof cases. Meat technology or food technol-ogy graduates are swept up by large cor-porations almost before the ink is dry ontheir diplomas. But if we are really inter-ested in emphasizing our ability to feed themodern American, we had better wake upand start producing veterinarians with someknowledge of meat technology. In my ownorganization, we finally realized that theveterinarian is quite deficient in his knowl-edge of how new products are prepared,why certain chemicals are added to thesefoods, and what, if any, effect the additivesmay have on the long-term health of theconsumer. Also, there are many ways todegrade the quality of food, even thoughwe know the ingredients are perfectly safeto eat. Meat technology is becoming ahighly complex field and, as it continues todevelop, the regulation of these foods be-comes even more difficult. The veterinarianplanning to enter meat hygiene work couldwell use a core of basic information on theprinciples and practices of meat technology.Unless we understand the field we cannotrealistically expect to evaluate and regulatethe flood of new products entering the mar-ket place each year. As a rule these prod-ucts are wholesome, but we in the Consumerand Marketing Service are concerned withquality, and we must be able to assure the

48


buyer that the product he eats is accuratelydescribed on the package so that he is notdeceived into paying meat prices for alower-grade product.

Finally, I suggest that the veterinaryschools and the profession are well advisedto be concerned with the development ofsubprofessional meat technicians. Man-power is critical in the veterinary profes-sion, and the graduate veterinarian is bestutilized in work that is a challenge to himand draws on his reservoir of professionaltalents. Many of the jobs in meat andpoultry inspection work, however, do notmeet these criteria. In these cases, subpro-fessional people should obviously be used.Our problem in the Federal Government(and I am sure it is a problem in the stateinspection programs as well) is to find andattract competent employees who can per-form the tasks of the noncritical aspects ofinspection. By noncritical, I mean thosejobs that are not directly related to healthconsiderations, such as evaluating diseaseconditions in the animals presented forslaughter or during slaughter. There is aneed each year for about 500 new employeesof this type in the meat and poultry inspec-tion programs throughout the country.During the next year or two the demand willrise sharply. I would suggest that a one- to

two-year curriculum be designed by theveterinary profession to properly train suchpeople and that the implementation of theserecommendations in junior colleges or agri-cultural institutes be pushed with vigorbefore state boards of higher education. Itis conceivable that schools of this typemight even be attached to veterinaryschools in the same way that classes formedical technicians are sometimes alliedwith medical schools.

In summary, the needs of our professionare changing rapidly. What was of primaryimportance yesterday quite obviously is notquite so important today. Values in a pro-fession are relative in many respects, selong as the ethical character of our liveli-hood remains strong. We are first of allpeople, but let us remember that we are apeople with a strong vested interest in ourprofession. As such, each hopes to pass thisinterest on to the next generation in theform that they can use best to serve thesociety they are entering. The importanceof food hygiene is growing by leaps andbounds, and we have the responsibility toso alter our profession that graduates in theyears to come can enter this field with theconfidence that their role within the profes-sion will be played with competence andsatisfaction.

THE TEACHING OF FOOD HYGIENE

CURRICULUM OBJECTIVES

MORRIS A. SHIFFMAN, D.V.M., M.P.H., PH.D.*

Proposing objectives for the teaching offood hygiene is difficult for two reasons:(1) food hygiene is not a separate diseiplinebut borrows its subject matter from a num-ber of scientific disciplines and technologies,and (2) the establishment of objectives is adifficult exercise in itself. Recent develop-ments in systems analysis, cost-benefitanalysis, and program-planning-budget-ing systems point to the formidable prob-lems of determining objectives that allowfor the systematic assessment of accom-plishment in terms of criteria for these ob-jectives. It is necessary to deal with objec-tives in terms of:

1. Relevance: Do the objectives reflectthe present problems, conditions, and devel-opments, or do they relate to conditionswhich no longer prevail?

2. Realism: Are the objectives designedto impart a warm and noble feeling or dothey express the operational realities andthe limitations and constraints that besetall objectives?

3. Focus: To what extent are the objec-tives an expression of disciplinary back-ground, experience, and individual valuesrather than a wider expression of societalrequirements?

*Associate Professor, Department of Environ-mental Sciences and Engineering, School of PublicHfealth, University of North Carolina, Chapel H:ill,North Carolina.

50

The predominant teaching objective isthe preparation of a student who is factuallyand intellectually equipped to adapt tochange. Therefore, it is important to havesome knowledge of the history of a field ofstudy. Knowledge of the past and presentstate of the discipline is necessary to plan-ning for future teaching objectives.

Historical Perspective

An account of the highlights of foodhygiene practice over the last 100 yearscould be structured around three phases,beginning with the sanitary reform move-ment of the latter part of the nineteenthcentury and leading to the scientific uncer-tainty of the present day. Dubos (1) hasdescribed the sanitary reform period interms of a reaction to the destruction ofhuman values that accompanied the firstphase of the Industrial Revolution. Thesanitarians of that time observed that dis-ease coexisted with poverty, dirt, and pollu-tion. They had faith that health could berestored to the people by bringing backpure food, air, and water and more pleas-ant surroundings. This assumption wasindeed based on social reform rather thanscientific findings. The era of the sanitaryreform movement lasted till the rise ofscientific medicine and was supplanted byadvances in disinfection and vaccines and

Food Hygiene: Curriculum Objectives

by the development of the environmentalbarriers of pasteurization and water treat-ment.

The second phase in food hygiene prac-tice was the era of the microbiologicalcausation of food-borne illness. We havehardly passed out of this era; however, thethird phase requires that microbiology sharethe stage with physical and chemical con-taminants. The rapid social and techno-logical changes of the post-World War IIyears resulted in the introduction of newchemical and physical contaminants-pesti-cides, additives, and radiation. The natureof the pollution problem has changed dras-tically. The philosophies and strategies forthe containment of pollution must alsochange, since the control strategies of aprevious era may not be applicable tochanged conditions. The point at issue isthat many programs and some teaching infood hygiene are based on a past historicaland developmental phase. Students may belearning (and practitioners may be doing)things which are inappropriate to the pres-ent problem.

Some of the significant changes may besummarized as follows:

1. The change in epidemiological patternsof food-borne disease from patterns in whichcause and effect could be readily related tomore complex multifactorial etiologies,which require prospective epidemiologicalinvestigations in addition to the retrospec-tive approaches.

2. The mechanisms of microbiologicalcontamination are sufficiently complex, butthe newer chemical contaminants add fur-ther dimensions of complexity. Thesemechanisms include the effects of cofactorsand accelerators as well as problems ofsynergism, potentiation, and antagonism.

3. Changes in the patterns of food pro-duction and distribution to large-scale, cen-tralized food production facilities and in-

creased international exchange in foodproducts.

4. Changing consumer patterns which re-sult in the creation of new food products,new food technologies, processes, and food-handling methods.

5. Although there is a greater need forfood protection programs, food hygienemust now compete with other programs ofenvironmental pollution control. Therefore,issues arise which relate to the allocationof resources among competing objectives infood hygiene programs and in competitionwith other programs. The student shouldbe familiar with some of the methodologiesfor measuring efficiency and effectiveness ofprogram design.

6. Food protection programs have beenbased on the untenable assumption thatcontrol should be complete and all-inclusive.The reality of the control situation is un-certainty, limitation of resources, and thenecessity of making choices among compet-ing objectives. The all-inclusive food pro-tection program is usually not feasible.Control strategies will depend on samplingprocedures, selective methodologies forsensing the environment, and surveillance.The student should be familiar with theseapproaches and with the need for dealingwith probabilities rather than certainties.

In summary, a rapidly evolving societyand an expanding technology have dimin-ished some of the risks that were connectedwith food adulteration and microbiologicalcontamination in earlier times. However,these same changes have added factors ofcomplexity to the solving of food hygieneproblems and factors of uncertainty to bothetiology and the solution of these problems.A peculiar aspect of the nature of thesenewer risks is that they have dual, built-invalues of benefit and disability. The choicesfor control are therefore less clear-cut thanever before. With pesticides, for instance,

51`---


there is a legitimate choice as between bene-fits to society and costs in health and de-struction of natural systems. Food andfood hygiene are so closely tied to the fabricof society that students must be introducedto the study of social and technologicalchanges that determine food production andutilization if they are to be at all preparedto make decisions for society.

Objectives of a Food Hygiene Program

The defining of objectives is of little useunless these definitions express the prevail-ing vnalues of a snniety in a realistie manner.The importance of multiple and conflictingobjectives have been ignored by publichealth practitioners. Attempts were madeto compress the rationale for food protec-tion programs within the rigid frameworkof a single objective called "public healthreason." In fact, there are a number ofobj ectives that must be considered:

1. Maintenance of a food supply. Theobjective in this case is the provision of anacceptable level of food to support a popu-lation at a specified nutritional level.

2. Prolongation of the shelf life and keep-ing quality of food. The prevention of fooddeterioration and wastage is the primaryobjective of food protection programs in amajor part of the world.

3. The maintenance of a food supply thatmeets the cultural and esthetic expecta-tions of the consumer.

4. The maintenance of a safe food supply.It is only at this point that the "publichealth reason" becomes the predominantobjective.

Approaches to Teaching Food Hygiene

There are a number of alternatives inorganizing a curriculum in food hygiene.The straightforward approach is to teachon the basis of a food or class of food, e.g.,

milk hygiene or meat hygiene. Or the pre-sentation may be related to the nature of thecontaminant, e.g., microbiological or chemi-cal. These are manageable approaches.However, food hygiene should be consideredwithin the framework of the food systemrather than from the standpoint of an iso-lated food commodity waiting to be con-taminated by an isolated microorganism.Ackoff (2) notes that "we must stop actingas though nature was organized into disci-plines in the same way that universitiesare." The inadequacies of treating foodhygiene within the conventional disciplinaryframework benmes anpparent in the plan-ning of a suggested curriculum for a coursein food hygiene.

We may insist that the foci of study canbe limited to the food commodity and thepertinent microbiological, chemical, andphysical agents. Food control officials edu-cated within these disciplinary frameworks,however, would have missed a number ofimportant elements of food protection. Theessence of food protection is a knowledge ofthe operation of the food system. In thebroadest sense, a system is any set of inter-related components. What are some of thecomponents of the food system which relateto food hygiene? The primary link betweenfood and contaminant is the mechanism ofcontamination. The probabilities the con-taminant will gain entrance to the fooddepends on a number of interrelated factors,including:

Food handling methods, and human fac-tors of care or carelessnessConsumer food habits and food culturalpracticesFood technologyPatterns of distribution and transporta-tionMicrobial ecology

The immediate food-contaminant systemis surrounded by a larger system for the

52

Food Hygiene: Curriculum Objectives

control strategy and the public response.A knowledge of the food-contaminant sys-tem permits the choice of the point in thechain of pollution where the control strategymay be optimal. There are usually anumber of alternate approaches to controlprocedures; these include inspection, tech-nological fixes, laboratory testing, and sam-pling (as opposed to total inspection pro-cedures).

The system is extended further, since con-trol strategies and methods cannot be iso-lated from the agencies and organizationsresponsible for the program. There are,therefore, additional subsystems that mustbe considered. The control may be throughone or all of a number of Federal, state, orlocal agencies. The food industry is anotherorganization involved in the control pro-gram. The mechanism of control is deter-mined by the objectives, which in turndepend on political and social factors. Thesefactors are intimately related to considera-tions of law, economics, and administration.Food hygiene should be taught from theviewpoint of human ecology rather than asa subdiscipline under chemistry of micro-biology or a similar subject.

It would be self-deluding, however, toexpect any teaching program to deal withall these factors in depth. The objective ofa teaching program may be geared to thepreparation of specialists and generalists.Differing programs are required for: (1)research seientists, who require a rigorousand specialized education within a basicdiscipline; (2) technologists, who are edu-cated for the translation and application ofresearch findings into current practice; and(3) technologist-managers, who will followcareer patterns in government or industryin the operation and management of foodprotection programs.

It may be useful to differentiate the edu-cational needs of these groups. Kranzberg

points to the differences between science andtechnology by noting that the technologistmust deal with problems that are invariablycomplex:

He must consider problems of materials,energy, information and control. He must havesome idea of the scientific and technical knowl-edge necessary to his project. He must considermatters concerned with utility such as costs,markets, state of other arts and legal restric-tions. The questions he deals with spill over intothe social sciences, law, health and medicine andeven into history, literature and philosophy.

Scientists have a preference for small, manage-able problems. René Dubos notes that the biolo-gist who decides on a student to study man, soonnarrows to the study of an organ, then to asingle cell, then to the cellular fragments, then tothe molecular groupings, individual moleculesand atoms. Though he is losing sight of man inthe process, he is looking for some fundamentalunderstanding of nature's building blocks (3).

The School of Public Health at the Uni-versity of North Carolina cooperates withthe Department of Food Science at theNorth Carolina State University in prepar-ing students with backgrounds in sciencefor careers in the public health aspects offood science and food product safety. Therequired course work in food processing,food chemistry, and microbiology is givenat the Department of Food Science, and theSchool of Public Health provides the in-struction in food protection, environmentalcontrol, epidemiology, statistics, and ad-ministration. The graduate of this programshould have the basic skills for the under-standing of scientific findings and for thetranslation of these facts into current foodhygiene practice. In sum, he should havethe skills and attitude of the "technologist"described by Kranzberg.

There is a third level of preparation whichhas been suggested: that for the technolo-gist-manager. This educational pattern isintended for those who have achieved theskills of the technologist and are preparingfor managerial functions with government

_�__�___53


or industry. There is increasing recognitionthat scientists and technologists do becomemanagers and that there is a separate andadditional set of skills that must be learnedin this progression. The School of PublicHealth at the University of North Carolinaoffers courses in environmental health ser-vices management for persons concernedwith the direction or supervision of profes-sional and technical programs in environ-mental protection. The curriculum includesprogram planning, administration and man-agement, systematic approaches to decision-making, public policy development, and anappreciation of the significant factors thatare involved in the impiementation of tech-nical solutions to environmental and foodprotection problems.

The foregoing discussion has evaded thereal purpose of this part of the Symposium,which is concerned with the teaching of foodhygiene to veterinary students. The organi-zation of a course or curriculum in foodhygiene for veterinary students is more diffi-cult than that for the preparation of thegraduate student in food protection. Thereis limited time as well as limited interest.There are conflicting educational objectives,

such as those for example, between the rela-tive content of conceptual instruction andpractical instruction, and between coveragein depth of limited subject matter as againsta more superficial coverage of a wider con-tent. I would favor conceptual instructionover practical and breadth over depth. Forinstance, practical instruction in meathygiene inspection methods could be givenin continued education courses to thoseveterinarians who will actually follow thiscareer.

I believe that it would be useful to intro-duce the student to the concept of the foodsystem, its components, and their interrela-tionships. Food hygiene has reached a stageof complexity and specialization that re-quires graduate education. Courses in theveterinary school cannot prepare the stu-dent for effective comprehensive food hy-giene practice. In emphasizing the foodsystem, the few students interested maychoose to pursue graduate study and thenparticipate in the total approach to prob-lems of food protection. The other studentswill have gained some appreciation of thescope and complexity of modern foodhygiene practice.

REFERENCES

(1) Dubos, R. J. Mirage of Health. New York, interdisciplinary research. General SustemsAnchor Books, 1961. 5:6, 1960.

(2) Ackoff, R. L. Systems, organizations, and (8) Kranzberg, M. The disunity of science-tech-nology. Amer Sci 56:21, 1968.

54

THE TEACHING OF ENVIRONMENTAL HEALTH

OVER-ALL OBJECTIVES AND RESPONSIBILITIES

WILLIAM F. MCCULLOCH, D.V.M., M.P.H.*

No socially aware professional woulddeny today that the environment is chang-ing. What we need to understand is how itis changing, why it is changing, and whatare the emerging problems. Although thesequestions may never be completely an-swered, we as educators must prepare our-selves and our students to cope with thischanging environment, both now and in thefuture. "The future," as Blakely states,"belongs to prepared intelligence" (1). Thisobviously means that we must have a plan(2). As teachers of preventive medicineand environmental health, we must not fallinto the rut of believing that all motion isnecessarily progress. As one physician putsit, let it not be said of us that "having lostsight of our objectives, we redoubled oureffort." Conferring together, pooling exper-tise, and sharing experiences are steps to-ward reassessing present objectives andprinciples in teaching veterinary publichealth and preventive medicine.

What, then, is the objective of environ-mental health? Logan (3) states that itis "the improvement of the quality andcharacter of the total environment for thewell-being of mankind . . . and implies theconservation and utilization of natural re-

* Associate Professor of Preventive Medicineand Environmental Health, and Chief, Compara-tive Medicine Section, Institute of AgriculturalMedicine, College of Medicine, University of Iowa,Iowa City, Iowa.

55

sources in such a way as to prevent diseaseand debility, and to assure an environmentwhich is esthetically satisfying and devel-oped in conformity with the highest aspira-tions of the human spirit." According toWeisburd (4), environmental health is anapproach to medicine and public healthrather than a major scientific field in itself.The American Public Health AssociationCommittee Report on the Environment (5)states that "comprehensive health planningmust consider the major role that environ-ment plays in health." The report includesthe following checklist of program areas,together with plans and methods to be usedas guidelines:

I. Environmental Program AreaWastes

AirSewage and liquidSolid

Water supplyHousing and residential environmentFood and drugsRadiationNoiseAccidentsOccupational and institutional hazaiVectorsRecreation

II. Planning Considerations

HealthEconomicDemographic and land useSocial

rds


EstheticResource conservation

III. Methods and TechniquesResearchDemonstrationEducationStandardsLegislationInspectionEnforcementPlanningEvaluationIncentivesSystems analysis

The Committee emphasizes the importanceof other resources, among them, manpower,facilities, and services.

Those in veterinary medicine have a roleto fill in every one of the categories listed.The student, therefore, must be taught thefundamental concepts of integrated plan-ning in environmental health. To do this,he must know who the other participantsare and what they can offer. This will allowhim to understand how he can best serve onthe team in solving environmental healthproblems.

Health care for man is presently one ofthe largest industries in the United Statesand Canada. Because of shortages of"health" professionals, all members of thehealth team will have increasing demandsplaced on their time. These trends willrequire more communication and coopera-tion among the health professions (6, 7).Veterinarians must do their part in revers-ing the daily pollution and deterioration ofthe air we breathe, the food we eat, and thewater we drink.

Educators in veterinary public healthmust share responsibility for improving ourrapidly deteriorating environment. To dothis we must assess our own knowledgebefore we can hope to educate our studentsand fellow faculty members.

The student must be motivated to believethat the health of man and animals is re-

lated, directly or indirectly, to the qualityof the environment. Of the three terms"host," "parasite," "environment," the lastis probably the least understood. In review-ing motivation, Paul (8) states that "so-ciety's mandate to the individual is toachieve or accomplish 'something' whichimplies a goal or objective .... The jobof education is to teach the individual totake care of himself in society and society'sreciprocal obligation is to create an environ-ment conducive to the achievement orattainment of these personal goals." Cer-tainly, this is also true of the objectives andprininciples nf tho pnoahin nf envrirnnmpenfnl

health.Environmental influences on health and

safety include physical, biological, chemical,and social groupings. They have been dis-cussed in detail by Dubos (9, 10), Top (11),and Gordon (12). The by-products ofhuman living and advancing technologyhave polluted the air, water, and soil beyondthe saturation point, especially in and nearlarge cities, both by implosion and explo-sion. Sooner or later, we will have to paythe consequences, unless we work togetherto more fully understand what the environ-ment is and what our role will be, indi-vidually and collectively, in solving presentand future problems. Because of expandinghuman and animal populations, we will haveto "pay" our way into a relatively healthyenvironment. Berry reviews the trends andorganization of agricultural health andsafety programs in this regard (13, 14).

As educators, we must read and listen toaccounts of what society is doing around us.We must teach understanding. We mustteach our students how to keep up, how toanalyze the potential effects of changes and,hopefully, to take early, preventive steps.Unfortunately, it is difficult to sell preven-tion because it is difficult to measure theimpact of what has been prevented.

The veterinary student must be taught

56

Environmental Health: Curriculum Objectives

that to "get it done" he must often join anorganized structure to effect major changesin which timing is an important factor.Good laws do not always pass. What withvested interests, economics, and politics, therole of the future veterinarian in these areaswill become more complex. The studentmust be made aware of these basic facts oflife. He must be taught that interagencylocal, state, and Federal communication isa necessity because of the complexity ofmany of the basic environmental healthproblems (15). He must be taught to under-stand public health administration, methodsof problem-solving, and the role of localboards of health (at present 20 of the 99counties in Iowa have veterinarians on theirlocal boards of health).

Few environmental health problems havesimple cause-and-effect relationships, andmany defy description. Certainly, the con-cept of multiple causation must be im-pressed upon the student. New changes intechnology have and are causing shifts inhost-parasite relationships, many of thembeing detrimental to the health of both manand animals. Therefore, the student mustbe told of some of the "knowns" that resultfrom society's changes so that he might befurther educated to assess the importanceand consequences of future technologicalchanges as they affect the practice of veteri-nary medicine.

The human leptospirosis outbreak causedby swimming in an irrigation canal in theState of Washington typifies how changingthe environment (in this case, reclaimingland by irrigation) alters disease pat-terns (16). Because of man's desire to usehis leisure time for recreational activities,he often becomes exposed to zoonotic agentsshed via urine or feces into farm ponds andstreams by infected animals (17, 18). Often"new" host-agent relationships becomeapparent, as in the human cases of lepto-

spirosis associated with squirrel hunting,reported by Diesch et al. (19).

A man-made problem, not necessarily ofman's "external" environment, but one ofmedical progress, has been the use of im-munosuppressive drugs on human patientsprior to organ transplants and also in thetreatment of Hodgkin's disease (20). Be-cause of the reduction of host resistance, akidney transplant patient died of general-ized toxoplasmosis following such treatment(21). This is an example of an iatrogenieeffect, a result of medical progress (22).Do this and the afore-mentioned exampleshave implications for veterinary-medicalprogress?

A syndrome characterized by acute ab-dominal pain and signs of peritoneal irrita-tion was seen with increasing frequencybeginning in 1955 in the Netherlands. Stud-ies of the involved segment of the small in-testine revealed penetration of the intestinalwall by a nematode. This infection wascontracted by eating raw or improperlycured herring containing larval stages of thenematode that normally mature in thestomach of aquatic animals such as por-poises and seals. The increasing prevalenceof the disease was attributed not only tothe increased consumption of herring as partof the diet, but also to a change in theeconomics within the fishing industry thatled to delayed processing of the fish (23).Heinemann has studied the effects of sonicbooms on the hatchability of chicken eggsand on mink breeding and whelping (24, 25).He raises the question: What will be thelong-range effects of the supersonic trans-port on man and animals?

Dr. William Buck and colleagues at theIowa State University College of VeterinaryMedicine observed an unusual environ-mental problem recently. Although fluorosisin animals had not been a problem in Iowa,changes in the industrial patterns and theestablishment of a chemical plant manu-

- - __ 57


facturing defluorinated phosphate near theMississippi River led to considerable prob-lems in the area where farmers beganreporting a reduction in corn and othercrop yields. Livestock began to show re-duced weight gains and many animals inmilk and calf production became emaciated-a good example of livestock and cropproduction losses associated with industrialair pollution-one more case in which indus-trial technology has changed some of thespecific geographic patterns of certain dis-ease syndromes (26).

Types of farm accidents have alsoehanne pcl ausO nf t.ehnolnogic develop-

ment in farm-machinery design. Knapp(27, 28) states that the power-take-off(PTO) replaced the auxiliary engine onfarm equipment and therefore reduced firesand cranking accidents. However, the PTOproduced entangling accidents such asemasculations, fractures, and amputations,which required the development of newshielding. Further changes have developedwith the use of hydraulic lines to motorsto replace the mechanical PTO drive.Although this has helped to reduce acci-dents of the former type, they have beenreplaced by such consequences as derma-titis, injections of oil into the body, andburns. According to Knapp, the lesionsare not initially visible, and the physicianmust eventually operate to remove "invisi-ble" oil droplets.

Extensive mining and farming of theoceans will take place by the year 2000.It is predicted that approximately one-fifthof the world's food will come from theoceans. What, then, will be the contribu-tion of veterinarians toward understandingpotential environmental health problemsassociated with farming the oceans? Again,a problem of advanced technology.

We must critically observe trends insociety and assess their impact on the healthof man and animals. We must teach stu-

dents how to critically evaluate thesetrends, how to be aware of potential newassociations in man-made relationships, andhow to keep open minds through the use ofscientific methods of observation.

The veterinary student must be told ofthe interrelationships, responsibilities, androles of other disiciplines and professionswith which he will work in solving environ-mental health problems, both present andfuture. He must be taught the principlesand objectives of teamwork. He must betaught that, as a "giver" of advice andinformation, he must understand the "user."He mf.ust underst and that the environment

influences the relationship between giverand user and that political, social, andeconomic trends affect these communica-tions. He must be told of the importanceof client education and motivation and havean understanding of issues and problemsthat affect man (the owner) and hisanimals.

The veterinary public health curriculummust reflect the trends in environmentalhealth and develop in the student a desirefor contributing to the solution of localhealth problems. The cuiirriculum must domore than just impress him with the eco-nomic value of the services he can provideto the community (29). There are only somany hours availabie for teaching, andwith the increasing amount of technicalinformation available daily, the teachermust continually reassess his teaching pro-gram. The student need not know all thefacts, because many will change, but hemust certainly understand the conceptswhich remain fairly constant. More impor-tantly, the student must be taught how tokeep up with the changes by taking advan-tage of continuing education programs andthe printed word. He must continue hiseducation after graduation.

As Osler has stated:

In addition to the various senses, the student

58


needs to have a sense of "responsibility" andmore important, a sense of "proportion." . . .Thoroughness is the most difficult habit toacquire, but it is the pearl of great price, worthyof all the worry and trouble of the search ...What we need is the man who knows the records,who, with a broad outlook and drilled in whatmay be called the embryology of history, has yeta powerful vision for the minutiae of life....The scholar can never feel initiated into thecompany of the elect until he can approach allof life's problems from the cosmopolitan stand-point . . . and it is not only book knowledgeand journal knowledge, but a knowledge of menthat is needed (30).

We must also realize that what studentsare taught and what they learn may notnecessarily be the same thing. Teachersmust understand the background and moti-vations of students if they are to be realisticin their approach to educating them aboutthe impact of environmental health prob-lems and their importance in the practiceof veterinary medicine. Both training andeducation are important in veterinary medi-cine, but "educated" is the key word forthe total professional life of the veteri-narian.

There is a need for coordination ofenvironmental health areas in the presentveterinary curriculum. The teachers of pre-ventive medicine and veterinary publichealth can play an important role in theover-all education of the total faculty inthis regard, and, hopefully, will preventduplication of teaching material in an al-ready too crowded curriculum.

Teachers of veterinary public healthmight also influence information given inlectures in the preveterinary curriculum.The "users" of veterinary services needto be educated as to the value of veterinarymedical professional talents. While I havenot taught formally in a college of veteri-nary medicine, I feel there is a need topursue an expansion of the environmentalhealth or ecology courses that are offeredand/or required.

The student should be made to read basicinformation in environmental health (31-41), including the basic areas (air, food,water, soil) and pollution, whether naturalor man-made (ionizing radiation, chemicals,agricultural waste). Such reading shouldbe assigned as background information, andlecture time should be spent discussing thewhy, where, future applicability, and impor-tance of environmental health in its broad-est concept.

The student, of necessity, will have to betested on subject matter and will have to"regurgitate" certain fundamental facts topass exams; however, it is hoped that"spoon-feeding" will be kept at a minimumand that we, as teachers, will have thecourage, conviction, and ability to stimulatethe student to utilize the scientific-methodapproach in educating himself while inschool-so that he may continue to edu-cate himself after graduation.

It is also important that we know andconsider the human factor in teaching. Wemust understand students' motives for en-tering the school of veterinary medicine.Therefore, the challenge of teachers of pre-ventive medicine and veterinary publichealth will be to continually instill andmotivate the student to believe in the valueof preventive medicine. Top emphasizesthat "wellness" is an attribute that has tobe sought and preserved in addition to theafter-the-fact treating of illness (42). Itmust be realized that the environment hasbeen a great friend. Nature's air, water,and soil have provided natural benefits forman's survival. However, concentration ofanimal and human populations and techno-logical developments in industry and agri-culture have undermined nature's ownmethod of disinfection.

Some students may wish to pursue en-vironmental health training within theundergraduate curriculum, and it is possi-ble that a part-time or summer externship

59

RO T V . Pu H . uu

program could be made available for themin environmental health programs in medi-cal centers, health departments, or veteri-nary colleges. In 1967 a Comparative Medi-cine Externship was initiated at the Uni-versity of Iowa College of Medicine, andtwo freshmen veterinary students spent thesummer working in various areas of ourfield and laboratory studies, primarily onleptospirosis and toxoplasmosis. They wereallowed to participate in and see the variousaspects of a total environmental healthcenter and to confer with the people work-ing in these areas. Such an interchange ofideas not only helps the students directlyinvolved, but is of value in educating theirclassmates in the veterinary school. Theexternship program was continued throughthe summer of 1968. I am sure that thereare many other potential externshipsthroughout the United States and Canadaunder private, state, or Federal sponsor-ship. Vacation time is limited, but themore students become involved in activeprograms of environmental health, thebroader will be their concepts and the moreeffective will be their contribution to societyand their future profession.

I personally feel that if we are to developa curriculum which will enable future vet-erinarians to successfully carry out theirrole in society, then we must:

* Understand the fundamentals of ecology.* Accept the fact that change is inevitable and

that these changes will have both good and badeffects on our ecologic equilibrium, effects whichare often very subtle and difficult to measure.

* Understand natural and man-made factorsaffecting health and disease.

* Understand the effect of man the "invader,"his technology, and his impact upon man-animalrelationships.

* Understand the socioeconomic-political im-plications in controlling and preventing environ-mental hazards to health.

* Understand that multiple causation or acombination of factors is involved in environ-mental health problems.

* Understand the team approach to problem-solving.

* Use the scientific method in assessing theeffect of the environment on host-agent relation-ships.

* Understand and cope with the "diseases" ofmedical and veterinary medical progress.

I inlueunce tlne teaching of the vathuu con-cepts of environmental health in the total veteri-nary medical curriculum, not just in the veteri-nary public health area.

* Educate our students on how to be objec-tive and instill in them a heightened sense ofawareness.

* Keep current with the literature, bothinside and outside of veterinary medicine.

* Volunteer our talents to the solution of en-vironmental health problems and encourage in-terprofessional communication.

* Practice what we preach.

Representative John C. Culver of Iowabest summarizes my thoughts when hestates that '"more than anything else, oursociety needs today the man who can be theskilled professional, yet is not imprisonedby his subject or calling" (43).

The great challenge then, is to developan individual who has the confidence andcourage to actively and intelligently involvehimself in solving the problems of tomor-row.

REFERENCES

(1) Blakely, R. J. The future belongs to preparedintelligence. State University of Iowa Ex-tension Bulletin No. 795, 1962.

(2) Duhl, L. J. Environmental health: politics,planning and money. Amer J PublicHealth 58:232, 1968.

(3) Logan, J. A. Environmental health (panel3). Proceedings of the White House Con-

ference on Health, November 3 and 4,1965.Washington, p. 493.

(4) Weisburd, M. Summary of environmentalhealth problems. Paper presented atA.M.A. Congress on Environmental Health,1965, Chicago.

(5) American Public Health Association Com-mittee. Report: environmental factors in

The Veterinary Public Health Curriculumfi


health planning (guidelines prepared by theCommittee on Environment). Amer JPublic Health 58:358, 1968.

(6) Harrell, G. T. Trends in education, practice,and organization of health services. JAMA196:334, 1966.

(7) McCulloch, W. F. Socioeconomic aspects ofpharmacy-veterinary medical relations. JAmer Vet Med Ass 149:1518, 1966.

(8) Paul, E. J. Motivation: an imperative ofhuman dynamics. Paper presented atDrake University, Des Moines, Iowa, 1967.

(9) Dubos, R. Mirage of Health, World Per-spectives, vol. 22. New York, Harper, 1959.

(10) Dubos, R. Environmental biology. Bio-Sci14:11,1964.

(11) Top, F. H., Sr. Environment in relation toinfectious diseases. Arch Environ Health(Chicago) 9:699, 1964.

(12) Gordon, J. E. Ecologic interplay of man,environment and health. Amer J Med Sci252:341, 1966.

(13) Berry, C. M. Agricultural industry-thechanging pattern. Amer J Public Health49:616, 1959.

(14) Berry, C. M. Organized research in agricul-tural health and safety. Amer J PublicHealth 55:424, 1965.

(15) Terry, L. T. Environment and health: 70years after. Yale J Biol Med 35:133, 1962.

(16) Nelson, K. E., E. A. Ager, M. M. Galton, andR. W. H. Gillespie. An outbreak of Lepto-spira pomona infections in WashingtonState. Proc., 11th Pacific Science Con-gress (University of Tokyo) 6:16, 1966.

(17) Diesch, S. L., and W. F. McCulloch. Isola-lation of pathogenic leptospires from watersused for recreation. Public Health Rep81:299, 1966.

(18) The not-so-healthy outdoors (editorial).JAMA 196:133, 1966.

(19) Diesch, S. L., R. P. Crawford, W. F. Mc-Culloch, and F. H. Top. Human lepto-spirosis acquired from squirrels. New EngJ Med 276:838, 1967.

(20) Cheever, A. W., M. P. Valsamis, and A. S.Rabson. Necrotizing toxoplasmic encepha-litis and herpetic pneumonia complicatingtreated Hodgkin's disease. New Eng J Med272:26, 1965.

(21) Reynolds, E. S., K. W. Walls, and R. I.Pfeiffer. Generalized toxoplasmosis follow-ing renal transplantation. Arch Intern Med118:401, 1966.

(22) Moser, R. H. Iatrogenic disorders. Med Col-lege of Virginia Quart 3(2) :91, 1967.

(23) Van Thiel, P. H., and H. Van Houten. Lo-calization of herringworm Anisakis marina,

in-and-outside human gastro-intestinal wall.Trop Geogr Med 19:56, 1967.

(24) Heinemann, J. M. Effect of sonic booms onthe hatchability of chicken eggs. RegionalEnvironmental Health Laboratory, KellyAir Force Base, Project No. 65-2, 1965.

(25) Heinemann, J. M. Reactions of breeding andwhelping mink to sonic booms. RegionalEnvironmental Health Laboratory, KellyAir Force Base, Project No. 67-5, 1967.

(26) Buck, B. Personal communication, 1968.(27) Knapp, L. W., Jr. Personal communication,

1968.(28) Knapp, L. W., Jr. Agricultural injury pre-

vention. J Occup Med 7:545, 1965.(29) McCulloch, W. F. The role of the practicing

veterinarian in comparative medicine. VetEcon Aug. 1962, p. 52.

(30) Osler, W. The student life. In: A Way ofLife. New York, Dover, 1951.

(31) Environmental Pollution Panel, President'sScience Advisory Committee. Restoringthe quality of our environment. The WhiteHouse, 1965.

(32) Diesch, S. L., and K. R. Long. Starlings andhealth. J Iowa Med Soc Jan. 1967, p. 35.

(33) Beasley, O. C., and K. R. Long. Toxic effectsfrom the use of agricultural chemicals.J Iowa Med Soc Jan. 1966, p. 45.

(34) Upholt, W. M., and P. C. Kearney. Pesti-cides. New Eng J Med 275:1419, 1966.

(35) First, M. W. Environmental hazards-urbansolid-waste management. New Eng J Med275:1478, 1966.

(36) Harrington, J. J. Environmental hazards-operations research-a relatively newapproach to managing man's environment.New Eng J Med 275:1341, 1966.

(37) Ferris, B. G., and J. L. Whittenberger.Environmental hazards-effects of com-munity air pollution on prevalence ofrespiratory disease. New Eng J Med 275:1413, 1966.

(38) Little, J. B. Environmental hazards-ionizingradiation. New Eng J Med 275:929, 1966.

(39) Health is a Community Affair. Cambridge,Harvard University Press, 1966.

(40) Human Resources for Health. MilbankMemorial Fund, 42nd Conference, October17-19,1967, New York.

(41) Stewart, W. H. Manpower for better healthservices. Public Health Rep 81:393, 1966.

(42) Top, F. H., Sr. The D.V.M.'s contributionsto the health of man. Vet Econ Aug. 1962,p.25.

(43) Culver, J. C. New demands on colleges inthe shaping of change. Speech given atLoras College, Dubuque, Iowa, Oct. 1967.

__61

TH wE F, T T G 0. * ENVIT RONMENTAL HEALTH

EXPANDING THE CURRICULUM

J. DOUGLAS MCCLUSKIE, D.V.M., M.P.H.*

Unfortunately, veterinary public healthhas been used synonymously with meatinspection over the years. It is extremelydifficult to correct this impression, not onlyin the eyes of the public but, even moreimportant, in the minds of our fellow vet-erinarians. Such a misconception is pri-marily the fault of our veterinary colleges,our several professional organizations, andveterinarians themselves. Our colleagueshave been guilty of not looking at the fullrange of health activities and determiningwhere the veterinarian can fit into the pic-ture. It should be one of the major goalsof veterinary public health education tocorrect this professionally damaging image.Meat inspection services are an importantconsumer protection funetion. However, itis only one part of the over-all publichealth activity involving the veterinarian.Traditionally the veterinarian has beenassociated only with inspection of the foodsof animal origin, whereas he should beconcerned with the processing of all foods.His training gives him an excellent back-ground for dealing with the problems asso-ciated with canned, frozen, cooked, dried,and other processed foods. We should notexclude ourselves from this area of foodprotection responsibility.

There is no member of a profession more

* Director, Environmental Health Service, Den-ver Department of Health and Hospitals, Denver,Colorado.

adequately trained and equipped to dealin health matters than the veterinarian,with the possible exception, of course, ofthe medical physician. Our basic trainingin microbiology, parasitology, immunology,chemistry, and many other sciences is un-surpassed by the education of any otherprofessional entity and is particularly ofvalue in matters dealing with the health ofthe public. The average veterinarian, how-ever, is not aware of this, as he has hadlittle opportunity to compare his trainingwith that of his fellow professionals andusually does not come into close enoughcontact with an organized public healthdepartment to become knowledgeable in thisrespect. It is therefore the responsibility ofthe teacher of veterinary public health tomake these facts known. The increasedutilization of the governmentally employedpublic health veterinarian in the teachingprogram of veterinary colleges would con-tribute significantly to the improvement ofthis situation.

In certain health matters the veterinarianis the only one that has the professionalknowledge to answer technical health ques-tions and should take a definite stand inresolving such problems. He should notconsider himself inadequate and "pass thebuck". to a physician or other health pro-fessional. If the problem is within thescope of his health competence, he shouldexert his influence and knowledge in a posi-

62

Environmental Health: Expanding the Curriculum

tive manner. I have observed many timesthe reluctance of the practicing veterinarianto commit himself on a technical questionof a veterinary public health nature.

Public health departments, be they local,state, or Federal, are beginning to realizethe multiple values of a veterinarian's train-ing and are more and more utilizing hisskills and expertise in a variety of healthprograms. In my own case, for example, Iwas recently made chairman of the HospitalInfections Committee at Denver GeneralHospital. Being the only veterinarian onthe medical staff of this city hospital pleasesme very much, not only because of thepersonal recognition, but because it showsthat the medical administration of the hos-pital recognizes the knowledge, training, andcapability of the veterinarian. This assign-ment has been particularly challenging andof considerable professional interest, but theassignment of a veterinarian to such aresponsibility should not be too surprising,as the microorganisms found in the hospitalare not unknown to the veterinarian. Fur-thermore, the equipment and unique en-vironment of the hospital are not totallyunfamiliar to us, particularly if we havehad any public health training and experi-ence. The hospital and institutional en-vironment should be an area of environ-mental health interest to the veterinarian.

When considering a topic such as en-vironmental health and what the veterinarystudent should be taught about such a sub-ject, we should first recognize that mostpublic health problems require a team ap-proach. Many health disciplines are a partof the environmental health team. Healthprofessionals-physician, sanitarian, engi-neer, nurse, laboratory technician, andothers, as well as the veterinarian-makeup this health team. A good example ofenvironmental health and the team ap-proach would be our country's space pro-gram, where a great many health special-

ists, including the veterinarian, work in ahighly integrated and complex program witha common objective.

In planning a course in the environ-mental aspects of veterinary public health,one must first consider the administrativeframework of the governmental agencieswith which we deal. Veterinary studentsshould be exposed to training in basicgovernmental administration. Such train-ing should include public health law, gov-ernmental organization, relationship of onelevel of government to another, and rela-tionship of organized health organizationsto the governmental body. Today we fre-quently see local practicing veterinariansappointed to boards of health and othergovernmental bodies, both at the city andstate level. Very often they are elected tostate legislatures, city councils, and boardsof county commissioners or become mayorsof municipalities. Too often they findthemselves lost for the first few monthsbecause of their lack of familiarity withgovernmental organization and adminis-tration. This can lead to their embar-rassment, frustration, and frequently todissatisfaction and withdrawal from govern-mental participation. I realize that thepresent-day veterinary curriculum limitsthe amount of time that can be devoted tosuch a subject. However, some time shouldbe spent on this worthwhile topic, whichis a part of the over-all program of veteri-nary public health. Veterinarians shouldknow how laws are developed and enacted.They should know the basic responsibilitiesof boards of health, state legislatures, citycouncils, and the like. Furthermore, theduties and responsibilities of the state healthofficer and the administrative framework ofthe health department should be coveredfor the veterinary student. This would bevaluable information, even if he were neverto become intimately involved with govern-ment. It appears that we have always had

63


a relationship to departments of agricultureand have been given some exposure to theadministrative organization of those agen-cies. Should not organized public healthbe given equal time?

Webster's dictionary defines environ-ment, as it pertains to biology, as "theaggregate of all the external conditions andinfluences affecting the life and develop-ment of an organism." We can accordinglydefine environmental health as the externalconditions and forces which affect man'shealth and well-being. These are tremen-dous and complex factors, as you can wellunduerstani . V¥ 1eln oriLening new personnel

at the Denver Department of Health andHospitals to the environmental health pro-gram, I usually illustrate my subject byutilizing a rough sketch of a man witharrows coming at him from all directions.Each arrow is labeled with one type ofenvironmental influence or force exertedupon him: the air he breathes, the waterhe drinks, the food he consumes, his animalassociates, his occupation, recreation, andhousing or shelter. I then run several ar-rows back from the figure of the man,indicating his contaminating influence onthe environment in areas such as air, indi-cating man's pollutional influence on hisair supply. The same example applies, ofcourse, to man's waste, both solid andliquid, which influences his water supplyand creates other environmental healthproblems. It is important to visualize manas an organism with various influences act-ing upon him, and with man influencinghis environment in turn.

The principles of sewage disposal, includ-ing the large municipal treatment plant aswell as the small private septic tank sys-tem and lagoons, should be covered in anycourse of public health. Proper and ade-quate treatment of human and animal wasteis an extremely important matter and allveterinarians should have some familiarity

with the subj ect. Therefore, in the teachingof veterinary public health, considerableemphasis should be placed upon treatmentof water supplies and proper waste disposal,as these two processes are vital to thehealth and well-being of all our citizens.In addition, these two environmental con-siderations are extremely important na-tionally at this time. Even though veteri-narians are usually not going to be activelyinvolved in water treatment or in wastedisposal, the principles of such treatmentand processing are important. The com-plex water filtration and chlorination treat-ment principles should be understood bythe veterinarian and he should be able totalk with some authority on this subjectbecause of the relationship to disease pre-vention and health. For example, mosthealth professionals are aware today thatnormal water treatment does not free thewater supply of viruses. The general publicfeels, I am sure, that it does. The veteri-narian should also know of the water-bornediseases of man and animals. Veterinarians,particularly those engaged in public health,should be able to speak with detailedknowledge on this subject. The problemof cross-connections with relationship to thewater supply piping system should also bestressed, as veterinarians can and do createthese problems in veterinary hospitals,in laboratories, and in meat processingestablishments. They should know how toprevent this dangerous back siphonageproblem into potable water supplies. It issurprising the lack of knowledge that vet-erinarians have on this subject of cross-connections. Many of these cross-connec-tions have been noted in establishmentsinspected by the U.S. Department of Agri-culture. The principles of well constructionshould also be given attention in our coursesof veterinary public health, as the veteri-narian can serve as a valuable consultant to

64


the farmer and his community in the prob-lems of water supply.

The problem of solid waste disposal hasbecome a matter of concern to the entirecountry. The tons of waste that are createdeach year is a growing problem with noeasy solution. New and better packagingmethods are multiplying the amount andtypes of wastes requiring proper disposal.Veterinarians must know of the health haz-ards created and should be able to contrib-ute to the solution of the problem. Whenattending veterinary school, many of ushad no thought that we would be engagedin any pursuit other than the practice ofveterinary medicine after receiving our de-grees. I was one of those persons and Icould have used such health information,which I had to gain later through practicalexperience.

The relationship of man to his animalassociates is a close environmental influence.I am certain that you spend considerabletime with veterinary students on zoonoticand epizootic diseases. Today, because ofthe ease and speed of modern transporta-tion, we must further consider the exoticdiseases of foreign origin, both microbio-logical and parasitic, which affect man'shealth. For example, the large numbers ofmonkeys and other animals imported intothis country have contributed to the grow-ing zoonotic disease lists. Two weeks agoI attended a hospital infections course atthe National Communicable Disease Centerin Atlanta. One of the speakers, a medicaldoctor whose practice is in Southern Cali-fornia, was called to examine a patient whohad been injured by a gorilla and subse-quently developed a fever and enlargedaxillary lymph nodes. Upon further investi-gation it was learned that the patient hadbeen scratched earlier by a leopard andthat, through consultation with a publichealth veterinarian, had learned that leop-ards can carry the disease known as cat-

scratch fever. He concluded, therefore, thatthe patient's infection was from the leopardand not the gorilla, as first thought. (Ido not know whether this should be calledan exotic disease or a disease of an exoticpet animal.)

Look at the problem of pet turtles inthe home and the increasing problem ofsalmonellosis. What closer environmentalhealth relationship could we have than this?In many cases man's relationship to hisanimals is occupational rather than recrea-tional or for his own personal enjoyment.The danger of brucellosis to the farmer,veterinarian, and packinghouse worker arewell documented. Here again, man can con-tribute to health problems in his environ-ment by not providing proper care and at-tention to his occupational relationship.Another example might be the problemscreated by fly production on the farm frompoor environmental sanitation practices inthe handling and disposal of organic wastes.There is a tremendous problem today inthe disposing of cow manure, as inorganicchemicals have many advantages as asource of fertilizer over the natural product.The veterinarian should assume the respon-sibility of advising his client as to properwaste disposal methods which do not createa hazard to himself and to his family. Heshould be knowledgeable of the life cycleof the fly and know the methods for con-trolling this health threat. He should stressthe value of good environmental sanitationand convince the farmer that fly controldoes not rest with the use of insecticidesalone. The veterinary student should alsobe taught mosquito control and the manage-ment of other insect vectors of disease.The hazard to animals should not be theonly consideration in dealing with pesti-cides used in vector control; information onmodern insecticides should be current andshould include types, application, and spe-cific uses for distinct problems. Safety

65


factors involving these agents and their useshould be stressed.

The same consideration should be givento the subject of rodent control. Todaywe often forget that rats and other rodentsprovide serious problems and are a threatto man's health. In addition, the rat con-sumes tons of food of both man and ani-mals each year. This dangerous pest, whichlives in close association with man, con-taminates our food supply and destroys ourmaterial goods. This problem has becomeso serious in our large urban centers thatCongress has shown concern and has pro-vided funds, through the U.S. Public HealthService, for grants to cities to conductcomprehensive rat control programs. Ourveterinary graduates should be knowledge-able about this problem and its control-but are they?

Today the veterinary student is exposedto considerable training in the use of X-rayand other gamma radiation sources. Heshould and does, I assume, receive trainingin radiation safety and radiological health.In numerous states and in the U.S. PublicHealth Service, veterinarians have beenemployed as radiological health officers aftersupplemental training. The effects of radia-tion are a very important environmentalhealth consideration, and the veterinariancan play an important role in this field.Our teachers of veterinary public healthshould provide some additional backgroundin this subject area.

Although the subject of civil defense iscommonly an unpopular one, the possiblecivil defense participation of the veteri-narian as it relates to environmental healthproblems should be provided. for. Thiscould be done in a highly palatable mannerby interjecting these topics while coveringwaste disposal, water supplies, food pro-tection, radiation hazards, and other healthproblems of the environment. At a timeof disaster the veterinarian might be called

upon to perform a wide range of healthtasks and would be consulted for answersto a multitude of environmental healthquestions.

I fully realize that the competition forthe course time of veterinary students ineducational subject matter is tremendous.Each department head feels his subject areato be the most important and in need ofsubstantial time increase. In any event,additional time should be provided to coversome of the basic principles of environ-mental health. Veterinary education shouldtake into account that the activities ofveterinary medicine have an environmentalhealth influence and that the environmentaffects the practice of veterinary medicineand the health of our citizens as well asour animal associates.

With the observed population shift lead-ing to greater numbers of our nation'scitizens moving into the urban areas of ourcountry, environment plays an increasedrole in the health of man. The veterinarianis also becoming more prominent in theurban scene than was the case 15 or 25years ago. The practicing veterinarian willbe confronted with an increasing numberof questions pertaining to diseases of ani-mals and their relationship to the healthof their owners and the public. With thismore congested living situation, the veteri-narian must assume his proper place in theurban scene.

In summary, teachers of veterinary pub-lic health must assume the important re-sponsibility of making known to theirstudents the numerous problems of the en-vironment as it affects the health of man.After all, man too is an animal and shouldnot be excluded from our consideration justbecause he is of a higher order. No otherarea of the veterinary curriculum can pro-vide this important health training. En-vironmental health encompasses a broad

66


range of complex problems, the list ofwhich grows longer each day. The veteri-narian cannot escape participation in thedevelopment of solutions to these problems.It is therefore the responsibility of collegesof veterinary medicine, through the veteri-

nary public health divisions, to make theseproblems known to the student and to de-fine his part in the over-all picture. Let usmake the veterinarian and the public awareof our professional credentials and broadenour participation on the public health team.

67

THE TEACHING OF VETERINARY COMMUNIT- Y MEDICINE

CHANGES IN EMPHASIS AND METHODS

HENRY M. PARRISH, M.D., DR.P.H.*

AND

DONALD C. BLENDEN, D.V.M., M.S.t

Change is inevitable in society. Profes-sions supported by society must change tomeet social needs. The past 50 to 100 yearshave been characterized by acceleratedchanges in scientific knowledge, in the num-ber and distribution of people and theiraspirations for better health, in the func-tions of health practitioners, and in educa-tional aims and pedagogies. Lane (1) hasstated that "a profession, to remain viable,must serve the society in which it lives andbreathes." Anderson (2) believes that vet-erinary medicine "must respond to changeby acquiring new knowledge and by adapt-ing our services to the needs of the times ifwe are to be useful and productive, not onlyas citizens but professionally." Accordingto Burney (3), "the university is an instru-ment of society, an instrument for socialchange." One must keep in mind that thestudents being trained today must functionin society 10 to 25 years from now. Are we

* Professor of Community Health and MedicalPractice, School of Medicine, and Associate Pro-fessor of Veterinary Microbiology (Public Health),School of Veterinary Medicine, University of Mis-souri, Columbia, Missouri.

t Associate Professor of Veterinary Microbiologyand Chief of the Section on Veterinary PublicHealth, School of Veterinary Medicine, and Asso-ciate Professor of Community Health and MedicalPractice, School of Medicine, University of Mis-souri, Columbia, Missouri.

providing those students with the trainingthey need to funetion effectively andefficiently?

There are innumerable similarities be-tween human medicine and animal medi-cine. Likewise the aims and methods ofteaching students in these two health pro-fessions are similar. During the past 10years there has been tremendous improve-ment in and expansion of the teaching ofpreventive medicine and public health inAmerican medical schools. Almost all newmedical schools are planning large depart-ments of community medicine. The Shep-ard-Roney report (4) describes the statusof the teaching of preventive medicine inschools of medicine prior to these recentdevelopments. Historically, preventivemedicine was characterized by few separatedepartments, inadequate numbers of poorlytrained staff members, lack of budgetarysupport, and unimaginative teaching pro-grams. Coker and associates (5), in a studyof medical students' attitudes, showed thatpublic health ranked low as a career choice.

Knowledge of the teaching experiencesand innovations in medical schools mayprove useful to those teaching communitYmedicine (public health) in schools of vet-erinary medicine. Therefore, the purposes

68

Changes in Veterinary Community Medicine

of this paper are: (1) to review some of theimportant changes in society, medical sci-ences, and medical education; (2) to indi-cate why more emphasis should be placedon community medicine in schools of veteri-nary medicine; and (3) to suggest somemethods that may prove useful in teachingveterinary community medicine.

Changes in Society

Perhaps the most dramatic change insociety in the past 100 years has been thepopulation explosion. Steele (6) in 1963pointed out that the world population isestimated at 3 billion people and that thisfigure probably will double by the end of thecentury. Moreover, better than one-half ofthe world's population subsists on a sub-standard diet. Add to this the aspirationsof developing nations and we face a criticalpublic health and socioeconomic problem,to which birth control is only a partial an-swer. The veterinary profession and agri-culture are faced with the immediate prob-lem of increasing livestock and food produc-tion. Widespread animal diseases limit foodproduction in many countries. Obviously,veterinary practitioners will never conquerthese diseases by treating individual sickanimals. A public health approach is neededin animal populations to prevent diseasesbefore they occur. In the United States thepopulation is increasing rapidly and movingfrom rural to urban areas. The number ofpeople operating small farms is rapidlydecreasing. Large farms and stock opera-tions are the emerging pattern. These trendsemphasize the need for veterinarians trainedin herd medicine (public health) and inter-national health.

During the past 10 years there has beenincreased social legislation in the UnitedStates to improve health care and health

protection. This legislation includes theregional medical programs (Heart, Cancer,and Stroke), Medicare, Medicaid, the Com-prehensive Health Planning Act, and theAllied Health Professions Act. Governmentis becoming more interested in safer foodand drugs, environmental health, and ani-mal health. This trend in health legislationis likely to continue. The health industrynow ranks as the third largest industry inthe country and employs between 3 and 4million people (7).

Increases in population and new healthprograms have resulted in a decline in thenumber of veterinarians, physicians, anddentists per 1,000 population. In addition,there is poor distribution and inappropriateuse of available health personnel. How isveterinary medicine helping to meet thisproblem? According to Health ResourcesStatistics (8), 22.4 per cent of all veteri-narians in this country are employed inveterinary public health and regulatoryanimal medicine. Because of inaccuracies inreporting there is reason to believe that be-tween 25 and 30 per cent of veterinariansare employed by agencies directly or in-directly related to public health. Veteri-narians are performing jobs today that werenot even envisaged 50 years ago. Theserange from air pollution control and inter-national health to medical care administra-tion and the Air Force's new civic actionprograms in various countries (9).

Looking at the other side of the coin-what do practicing veterinarians do?Strangely enough, no one really knows.There have been no detailed time studies ofveterinary practice, either small-animal orlarge-animal practice. For human medicine,a recent time study of 25 rural general prac-titioners' office hours (10) showed that thephysician's time was apportioned asfollows:

69


Personal activitiesPreventive medicineAdministrationHealth information and counselingTreatmentDiagnosis

Per cent8.6

10.916.317.22027

A surprising finding was that less than 50per cent of the physician's time was spenton diagnosis and treatment. Most likelysimilar findings apply to the everyday prac-tice of veterinary medicine. There may bea great disparity between what veterinarymedical educators and students think vet-erinarians do and what they actually do!

Changes in Science

What are some of the changes in scientificknowledge and technology that should betaken into account when planning the train-ing of future veterinarians? There has beenan explosion of scientific information since1900. The number of outstanding scientistscurrently living exceeds the total numberof such individuals throughout history upto the present time. The number of scien-tific papers published has increased in ageometric fashion. Yet reviews of thesepublications in human medicine journalsindicate that many of them are not basedon sound experimental and statistical meth-ods (11, 12). Similar findings probably aretrue for veterinary medicine journals. Stu-dents must have enough knowledge of bio-statistics to be able to evaluate the articlesappearing in their professional journals.Otherwise, true scientific discoveries maynever be translated into effective veterinarymedical practice in local communities. Com-puters have opened new vistas for research,medical diagnosis, and the handling ofmasses of scientific data. Pharmacologyand therapeutics have emerged from therealm of empiricism to rather exact bio-logical sciences. Over 75 per cent of the

drugs used to fill prescriptions today had notbeen discovered 100 years ago. Superficialdiagnoses and symptomatic treatment ofanimrnals and tender loving care to clientsare no longer acceptable in modern practice.Today many diseases can be prevented orcontrolled. Where these measures fail, po-tent methods of cure are available throughthe use of drugs and surgery. Professionalschool is but a brief interlude in the con-tinuing education of a veterinarian. Arewe motivating and preparing our studentsfor a lifetime of learning?

The United States citizens have indicatedthrough their Congressmen that they arewilling to support health-related researchon a large scale. This is reflected by theproliferation and growth of the NationalInstitutes of Health. Universities haveentered into partnership with governmentto produce this research. This has affectedschools of veterinary medicine in severalways: (1) a sizable number of faculty mem-bers are being supported by grant funds;(2) more emphasis is being given to researchby the faculty and administration; and (3)more students are becoming interested inresearch careers. Laboratory animal medi-cine has evolved as a specialty, owing inpart to increased demands for animals formedical research. Veterinary public healthis firmly established as a specialty. Com-parative medicine has finally come of age.Multidisciplinary research is past the talk-ing stage.

Changes in Medical Education

A university and its professional schoolsmust meet the needs of society. They can-not operate effectively in an academicvacuum. They must extend their influencebeyond their granite walls into the com-munity. They must anticipate the needs ofsociety and prepare their students to meet

70


these needs. Curricula and courses shouldbe reviewed and revised periodically if theyare to stay in the mainstream of social andscientific progress.

Some recent changes in the organizationand educational aims of schools of medicineare pertinent to improving the teaching ofcommunity medicine (public health) inschools of veterinary medicine. These are:

Creating separate departments of communitymedicine.

Financing departments of community medi-cine on the same basis as other preclinical de-partments.

Providing adequate time in the curriculum forteaching community medicine.

Introducing subjects such as behavioral scien-ces, biostatistics, epidemiology, medical careorganization, and clinical preventive medicineinto the curriculum.

Establishing preceptorships with medicalpractitioners and/or preceptorships in com-munity medicine which all students are requiredto take.

Providing more free time in the curriculumfor electives of the student's choice.

Moreover, schools of medicine have be-come more and more active in the healthaffairs of the communities which surroundthem. Examples of this are the RegionalMedical Programs (Heart, Cancer, andStroke), Operation Headstart, and the com-munity health centers financed by thePoverty Program.

Departmental Status

Schools of medicine have recognized forsome time that community medicine cannotfunction successfully as the poor stepchildof a department of microbiology or a de-partment of medicine. Thus, separate de-partments of community medicine wereestablished. Owing to the broad, multidis-ciplinary nature of community medicine,one-man departments are grossly inade-quate. A school should provide basicsupport for at least three full-time staff

members, a secretary, and a laboratorytechnician.

What categories of professionals might befound in a department of veterinary com-munity medicine? A veterinary epidemiolo-gist, a veterinarian specializing in regula-tory animal medicine, a veterinarian withexperience in veterinary public health prac-tice, a biostatistician, an environmentalhealth specialist, and a comparative medi-cine specialist-all might prove useful, de-pending on the teaching objectives of aparticular department. Most members of adepartment of veterinary community medi-cine should have graduate training in publichealth leading to an M.P.H. or M.S.P.H. de-gree in addition to their basic professionaltraining. It is highly desirable that theveterinarians on the staff be certified by theAmerican Board of Veterinary PublicHealth or be working toward this goal.Adequate office and laboratory space shouldbe provided for the professional and non-professional staffs and for resident physi-cians and/or graduate students.

Schools of veterinary medicine have notused the "clinical faculty appointment" asextensively as schools of medicine. Forexample, public health veterinarians in localor state health departments might be givenclinical appointments in the department ofveterinary community medicine. This aca-demic appointment usually carries no salarycommitment from the school. Another use-ful administrative procedure that we haveused at the University of Missouri is the"joint faculty appointment." Selected mem-bers of the Department of CommunityMedicine in the School of Medicine aregiven joint appointments in the section onveterinary public health in the School ofVeterinary Medicine. The reverse is alsotrue. In most instances the school of theprimary appointment pays the facultymember's total salary. In other cases thefaculty member's salary is shared by both

71


schools. The joint appointment might beused even if both professional schools of auniversity are not located on the samecampus. Similar joint appointments couldbe used with schools of public health andschools of engineering. In our experiencedoctors of medicine are very willing to teachin schools of veterinary medicine.

Teaching Program

What subjects should be taught by a de-partment of veterinary community medi-cine, either within the department or incooperation with other departments? Thereare certain subjects that are basic to com-munity medicine and that would be appli-cable to both schools of veterinary medicineand schools of human medicine. Severalauthorities (13-17) agree that the followingsubjects are appropriate: biostatistics, epi-demiology, medical (veterinary) care or-ganization and administration, and clinicalpreventive medicine or clinical publichealth. Meat and food hygiene and certainaspects of environmental sanitation shouldbe added to this list for veterinary schools.Zoonoses and comparative medicine couldbe taught within the framework of epide-miology. We believe that some aspect ofveterinary community medicine should beoffered during all four years of the curricu-lum. It is unrealistic to believe that asingle lecture series presented to fourth-yearveterinary students will ever meet theirneeds in community medicine. In our ex-perience the sooner community medicinecan be introduced to a student the morelikely he is to become interested in thissubj ect.

A suggestion of courses to be taught andthe time they might be presented in thecurriculum follows:

1. Biostatistics. This course should beintroduced during the first year of the cur-

riculum. At least 20 contact hours areneeded to introduce basic statistical con-cepts. The object of the course is not tomake a statistician out of the student butto impress on him that measurement isessential in basic and clinical veterinarysciences.

2. Epidemiology. This course shouldoccur during the second year of the curricu-lum. It is a basic science of communitymedicine and should be taught at the sametime other basic sciences are taught. Thirtycontact hours are needed for adequate cov-erage of this subject.

3. Meat and food hygiene. This coursemay be taught during the third year of thecurriculum. At this time the student hascompleted his basic microbiology and path-ology courses. Some environmental sanita-tion can be taught in this course whichshould consist of both lectures, practicaldemonstrations, and field trips. This sub-ject might be taught jointly by the depart-ment of veterinary community medicineand pathology. About 40 to 50 hours areneeded to present this material.

4. Regulatory animal medicine. This sub-ject would be taught during the third orfourth year of the curriculum in a clinicalsetting. The department of veterinary com-munity medicine could cooperate with thedepartment of large animal medicine inteaching this subject.

5. Veterinary community medicine. Thiscourse is taught during the third year ofthe curriculum and emphasizes the role ofthe veterinarian in the community and theorganization of community health services.Thirty hours are required for this course.

6. Electives and free time. These assign-ments are for students especially interestedin veterinary community medicine. Theyare designed to get the student outside thefour walls of the veterinary school and intothe community. The elective should be atleast four weeks in duration. It may be

72


taken during the summer months or duringfree-time or elective blocks in the curricu-lum. Helwig (18) has pioneered in train-ing veterinary students in health depart-ments, in abattoirs, in regulatory agencies,and with state-institution-owned herds andflocks. Other types of electives includecommunity health surveys, epidemiologicalresearch, and preceptorships with practi-tioners. Elective assignments in developingnations is a very effective way to teach theinternational aspects of community medi-cine. Community medicine should be taughtin the community as well as in the class-room (16,17).

Other Activities

The Third National Conference on PublicHealth Training (19) recommended to theSurgeon General that training grant fundsprovided by Sections 306 and 309 of thePublic Health Service Act be extended toschools other than schools of medicine,osteopathy, engineering, and public health.If this recommendation is approved by Con-gress, schools of veterinary medicine willbecome eligible for training grants tostrengthen the teaching of public health.The project, apprenticeship, and residencytraining grants covered by the Public

Health Service Act and what they couldprovide schools of veterinary medicine wererecently reviewed by Parrish and asso-ciates (20).

Departments of veterinary communitymedicine should organize residency trainingprograms which would qualify graduateveterinarians for certification by the Ameri-can Board of Veterinary Public Health. Anexperimental two-year residency program inveterinary public health recently wasstarted at the University of Missouri (21).One year is for formal training leading to aMaster of Science in Public Health degree.This training may be taken at a school ofpublic health or another institution provid-ing comparable training. One year of addi-tional training is taken in a department ofveterinary community medicine in a schoolof veterinary medicine. This training in-cludes research, teaching, and field experi-ence in an agency which practices someaspect of veterinary public health. Thephysical presence of residents and graduatestudents in veterinary community medicineis a powerful stimulus to interest under-graduate veterinary students in this spe-ciality.

Research and participation in continuingeducation are two other functions of adepartment of veterinary community medi-cine.

REFERENCES

(1) Lane, J. D. Meat hygiene in the veterinarycurriculum. Seminar on the Teaching ofPreventive Medicine and Public Health inSchools of Veterinary Medicine. ScientificPublication No. 96. Washington, PanAmerican Health Organization, 1964, p. 50.

(2) Anderson, R. K. Public health teaching asrelated to needs of government agencies.First Seminar on the Teaching of PublicHealth and Preventive Medicine in Schoolsof Veterinary Medicine in the Americas,sponsored by the Pan American HealthOrganization, Kansas City, Mo., 1959.

(3) Burney, L. E. The university and communityhealth services. Amer J Public Health 56:394, 1966.

(4) Shepard, W. P., and J. G. Roney, Jr. Theteaching of preventive medicine in theUnited States. Milbank Mem Fund Quart42(2) :1, 1964.

(5) Coker, R. E., K. W. Black, T. G. Donnelly,N. Miller, and B. S. Phillips. Public healthas viewed by the medical student. Amer JPublic Health 49:601,1959.

(6) Steele, J. H. Role of the veterinarian in thesocioeconomic nutritional welfare of the

73-


community. Seminar on the Teaching ofPreventive Medicine and Public Health inSchools of Veterinary Medicine. ScientificPublication No. 96. Washington, PanAmerican Health Organization, 1964, p. 20.

(7) Darley, W., and A. R. Somers. Medicine,money and manpower-The challenge toprofessional education. III. Increasing per-sonnel New Eng J Med 276:1414, 1967.

(8) Health Resources Statistics: Health Man-power, 1965. Public Health Service Publi-cation No. 1509. Washington, GovernmentPrinting Office, 1965, p. 157.

(9) Williams, J. T., and T. P. Griffin. Militaryveterinarians in civic action programs. JAmer Vet Med Ass 151:1751, 1967.

(10) Parrish, H. M., F. M. Bishop, and A. S. Baker,Time study of general practitioners' officehours. Arch Environ Health (Chicago) 14:892, 1967.

(11) Ross, O. B., Jr. Use of controls in medicalresearch. JAMA 145:72, 1951.

(12) Schor, S., and I. Karten. Statistical evalua-tion of medical journal manuscripts. JAMA195:1123, 1966.

(13) Terris, M. Social medicine as an academicdiscipline. J Med Educ 33:565, 1958.

(14) Morris, J. N. Social medicine. J Med Educ34:1159, 1959.

(15) Acheson, R. M. The role of the departmentof social medicine in undergraduate medi-cal education. J Med Educ 38:676, 1963.

(16) Deuschle, K., and H. Fulmer. Communitymedicine-A "new" department at the Uni-versity of Kentucky College of Medicine.J Med Educ 37:434,1962.

(17) Parrish, IH. M. Teaching medical studentstheir responsibility to society. World MedJ 14:25, 1967.

(18) Helwig, J. HI. The teaching of public healthin our schools of veterinary medicine. Semi-nar on the Teaching of Preventive Medi-cine and Public Health in Schools of Vet-erinary Medicine. Scientific PublicationNo. 96. Washington, Pan American HealthOrganization, 1964, p. 79.

(19) Third National Conference on Public HealthTraining: Report to the Surgeon General.Publid calth Sc'v-ice Publication NTo1728. Washington, Government PrintingOffice, 1967.

(20) Parrish, 1H. M., D. C. Blenden, and F. Szata-lowicz. Need to strengthen public healthtraining in schools of veterinary medicine.J Amer Vet Ass 151:1757, 1967.

(21) Blenden, D. C., E. R. Price, and IH. M.Parrish. Experimental residency programin veterinary public health. Public HealthRep 82:545, 1967.

___�___74

THE TEACHING OF VETERINARY COMMUNITY MEDICINE

ARE OUR VETERINARY SCHOOLS EQUAL TO THE TASK? *

CALVIN W. SCHWABE, D.V.M.t

In a penetrating little book entitled Sci-ence and Human Values, Jacob Bronow-ski (1) espoused the view that a real under-standing of any science "disputes the pettyview which many scientists take of theirown work." As a veterinarian, I havethought a great deal about this statement.For a long time I have wondered whetherwe veterinarians fully understand our work.Do we as a group clearly see our profes-sion's role in society at this critical juncturein man's history? Or do many of us-perhaps even most of us-tend to take the"petty view" of our responsibilities andour obligations as a profession?

If, as I believe, we are not completelycertain of our role, then should we notbegin to engage in somrne frank introspection?Should we not begin to query ourselvesabout those influences which determine ourhorizons-the limits of our outlook-andour purposefulness as members of a learnedprofession? It seems clear that the problemof horizons in veterinary medicine lieschiefly in our schools. More than any otherfactor, I believe that it is the influence ofour schools upon each of us, i.e., the impact

* Originally presented as the Annual Phi ZetaLecture at Michigan State University, 19 July1967; adapted from the Michigan State UniversityVeterinarian, Fall 1968, pp. 9-15.

t Professor and Head of Department of Epi-demiology and Preventive Medicine, School ofVeterinary Medicine, University of CaliforniaDavis, California.

75

of our professional education, which shapesour future outlook and either restricts orenhances our vision as veterinarians. I amconvinced personally that our schools ofveterinary medicine do not today assumethe leadership role in this regard whichsociety has every right to expect of them.This is the utmost importance to us all.

For example, are our schools truly serv-ing our profession as its germinal center?Are they opening up new horizons and newvistas of service for each new class ofgraduates? At the same time are theyconstantly re-examining, redefining, and re-vitalizing our old and established relation-ships? Are our schools truly innovative andvisionary in their approach, or are ourfaculties content more often than not tobask in the deceptively secure warmth ofan unbecoming professional smugness anduneritical self-conceit?

To be sure, we do ocecasionally ask our-selves whether our veterinary schools arefulfilling well the more traditional of theirresponsibilities to private practice? But howfrequently do we inquire beyond this as totheir alertness in identifying and respond-ing to new and potentially exciting pro-fessional responsibilities? We might askourselves, do our veterinary schools oftenreflect a conservatism in this respect and anintroversion which is uninspiring at bestand certainly unbecoming to a learned and


dynamic profession? In short, the questionis simply this: Are our veterinary schoolsreally equal to their task? Are they provid-ing us with the leadership which we musthave if we as a profession are to render ourfull measure of service to society?

In all honesty I do not personally believethat they are. I say this as no prognostica-tor of doom (far from it) but as one who isconvinced that our schools can and mustbecome what society and enlightened vet-erinarians everywhere have the right toexpect them to be-and they must becomethis soon. But to bring this about will re-quire nothing short of a revolution in vet-erinary education, a revolution certainly noless dramatic than that earlier one whichforced the closing of the veterinary diplomamills and private profit schools in this coun-try.

We in veterinary education are guilty-guilty not only of failing to lead our pro-fession today but, in many respects, offailing even to keep pace with our profes-sion. At times we do little better than"follow the crowd" and even then we some-times do that ever so reluctantly.

As an example, let us consider just for amoment our uninspiring record with respectto laboratory animal medicine. Did theveterinary schools take the lead in identify-ing laboratory animal medicine as a vet-erinary specialty, or, once this need wasdemonstrated to us by others, did we pio-neer in establishing programs of graduatestudy which would enable veterinarians tomore effectively assume positions of respon-sibility in this area? Did we even take thelead in developing this increasingly im-portant sphere of veterinary service bycreating within our own schools modelphysical facilities or standards of care forlaboratory animals? Did we develop re-search programs or research institutes whoseaim was to identify, breed, domesticate, anddefine the characteristics and particular re-

search uses of new species, breeds, or strainsof laboratory animals? We did none ofthese things! Where, for example, were ourveterinary schooi centers for germ-free andspecific pathogen-free animal research atthe time when veterinarians in other insti-tutions were pioneering in this field?

Is the record of our schools really anybetter in public health, in wildlife diseases,in primate biology and medicine, in experi-mental surgery, in food science, in animalreproduction, in nutrition, in fish diseases,in diseases of invertebrates, or in experi-mental aspects of the behavioral sciences?These are just a few important facets of thefield in which veterinarians are workingtoday and in which they individually orcollectively have made their mark. Why isit that leadership in each of these new direc-tions in veterinary service has come notfrom our veterinary schools but from veteri-narians and others situated in other types ofinstitutions? Have we in the schools evenattempted to solve the acute yet long-stand-ing problems associated with the perform-ance of such routine veterinary tasks asmeat inspection, artificial insemination, andmass testing, perhaps by setting up coursesor qualifying standards for veterinary tech-nicians on our own campuses?

If our schools are failing us professionallyin providing leadership in these and manyother areas, are we not forced to ask thequestion as to what role our schools doenvision for themselves? I believe that therole which they recognize is very mucha role which conceives of veterinary medi-cine almost exclusively in terms of its pri-vate practice and increasingly, I am afraid,of its more lucrative luxury practice. Butis the private practice of veterinary medi-cine really the sum total of veterinarymedicine? Is this the only, or even the mostimportant, outlet for veterinary service? Ofcourse not. Then why do our schools giveevery indication that they assume that it is?

76

Are Our Schools Equal to the Task?

It is certainly self-evident to many of usin and out of the profession that veterinarymedicine represents, and historically hasalways represented, three overlappingspheres of activity and service-agricul-ture, public health, and the general bio-logical sciences. This is our real source ofprofessional strength and of our utility tosociety.

Our profession, unlike most others, de-rives its sustenance not from a single rootbut from deep roots in each of these threeequally important areas. Herein lies ourunique usefulness as a profession. It strikesme as absolute folly therefore to think,as some of us do, that we must deny one oranother of these parental roots in order topersonally identify with or to strengthenour ties to the second or the third. It illbecomes us and demeans us to do this. Itshows that we do not really understand ourown work.

All the administrative maneuvering andpetty rationalization in the world cannotalter our profession's overriding responsi-bility to agriculture-for helping in a verysignificant way to ensure that mankind hasan adequate supply of food. Verbal skull-duggery will not alter by one iota our role asa health profession, the character of ourbonds to our sister health professions, ourdirect responsibilities to public health, or oureven more important role in basic biomedi-cal research. An individual obsession withany of these admittedly important aspectsof veterinary service, agriculture, or publichealth, should never obscure for a momentthe fact that veterinary medicine is synony-mous with pathological zoology. Veterinarymedicine is the field of study specificallyconcerned with problems of disease in alllower animals. While representatives ofmany different disciplines and professionscontribute directly or indirectly to the solu-tion of the disease problems of man and thedisease problems of lower animals, it is the

physician and the veterinarian, respec-tively, who bear the major obligation inthese areas. Are we assuming our broadresponsibilities as biological scientists?

The tasks and the opportunities in vet-erinary medicine are, in fact, crystal clear.Why then are not the obligations and theresponsibilities of our schools equally clear?I do not for a moment believe that there isa simple panacea to this dilemma which ourveterinary schools now face, nor do I be-lieve that there is any single solution. Wecan, however, begin here to consider someof the things which we can do about oursituation.

What I believe is needed above all is forus to open up more effective channels ofcommunication within our profession sothat we as veterinarians may begin to sharemore effectively with each other ourthoughts with respect to veterinary educa-tion and types of veterinary service. Someof our sister professions are doing this farbetter than we are. For instance, the WorldHealth Organization has published a 391-page annotated bibliography of the litera-ture on medical education (2). Its 2,600entries represent the literature on medicaleducation for only one 10-year period!Each year the Association of AmericanMedical Colleges through its Journal ofMedical Education and through the pro-ceedings of countless conferences and semi-nars adds impressively to this literature.As a result of these attempts to communi-cate, many medical school faculties todayare in the throes of self-criticism, experi-ment, and drastic reorientation. Are we?

Why is there so little literature on vet-erinary education? Our profession certainlydoes not lack ideas, nor do we lack potentialsponsors for conferences or seminars onveterinary education. It seems that wemembers of veterinary faculties communi-cate our original thoughts far more effec-tively to our students than we do to each

77


other. It is ironic, but I am sure at thesame time most fortunate, that each newcrop of veterinary graduates finds itselfvery much in the vanguard of ,such new

ideas as we individually generate. In ourcontacts with them they receive and acceptfrom us individually our own half-formedhopes and aspirations for the profession andour most "far-out" thoughts. To the newgraduate who hears them and accepts them,as our colleagues seldom have the oppor-tunity to do, these points on the veterinaryhorizon at which we teachers have so labori-ously arrived serve our students as theirimmediate points of departure. In truththey collectively begin at a point at whichwe collectively have yet to arrive.

In a recent graduating class at the Uni-versity of California, for instance, therewere at least 15 students who were deeplyconcerned about (and, from a career stand-point, seriously interested in) workingabroad in an underdeveloped country inorder to help face the critical problems offood production and livestock disease con-trol. Four or five of them were as keenlyinterested in veterinary aspects of marinebiology; several others were interested indisease of terrestrial wildlife. Having in-dividually aroused their interests and con-vinced some of them of the needs and theopportunities, have we collectively providednew graduate programs and the like whichare required to channel students along theroad to these careers of service?

As we carry out our existing programs ofeducation, I wonder whether we who runthe schools understand at all that the pri-vate practice of veterinary medicine is aluxury most countries have never experi-enced-that almost the entire veterinarycomplement elsewhere in the world is en-gaged either in research, in governmentalservice, or in academic life. Even in WesternEurope the pet hospital as we have cometo experience it in this country in recent

years is a virtually unheard-of-commodity.Do we intend that the pet hospital is tobe the ultimate product of our professionallife in America--and that it is to be theprincipal reason our schools exist? If so,then we are certainly shortchanging thepublic as well as ourselves.

Let us examine a few of our profession'sneeds, such as the need, for example, toprovide governmental services. The fact isthat 25 years ago the U.S. Public HealthService was as unattractive to young phy-sicians and as uncompetitive for their ca-reers as the U.S. Department of Agricul-ture's veterinary divisions are to mostyoung veterinary graduates today. Yet to-day the Public Health Service offers agreat variety of attractive and excitingcareer opportunities not only to physiciansbut to veterinarians and others-in the Na-tional Institutes of Health, the NationalCommunicable Disease Center, and manyother branches of the agency.

Topnotch scientists are found in theseorganizations today. Their work is interest-ing and the positions they occupy are at-tractively competitive. Bright young stu-dents and graduates are being exposed toopportunities in the Public Health Servicethrough two-year appointments in theNCDC's Epidemic Intelligence Service orthrough such imaginative devices asCOSTEP-the Public Health Service'scareer development summer training pro-gram for professional students. It has notalways been that way. We in veterinarymedicine should not forget for one momentthat outstanding veterinary scientists in theearly decades of the U.S. Bureau of AnimalIndustry were making medical history inthe United States at a time when the NIHand the NCDC were not even dreamed of!The accomplishments in fundamental re-search of the young Bureau of Animal In-dustry, more than those of any other U.S.institution, first attracted world attention to

78

Are Our Schools Equal to the Task?

American medicine. The pioneering effortsof Daniel Elmer Salmon and his colleaguesin microbiology, immunology, parasitology,food hygiene, and disease control and era-dication constitute one of the brightestchapters of our profession's history.

The greatest share of the blame for thefact that the governmental veterinary ser-vices today do not compete, as they oncedid, for the careers of our brightest gradu-ates lies with our schools. If these govern-mental organizations have tended to becomedull or unexciting it is because we in theveterinary schools have failed in our re-sponsibilities to society. Today's generationof veterinary students, like all universitystudents in America, is up to its ears indeeply felt concerns for society and for ourfellowmen. Is it necessary that they shameus into action?

They come into my office-and I amsure into your office-every day asking ushow they are going to bring their veterinarytraining to bear upon human needs, howthey are going to really do somethingworthwhile. They do not necessarily haveto go to Africa or Asia to do these thingsas so many of them believe. They can dothem right here in the United States, andperhaps more effectively, by helping torevitalize the governmental veterinary ser-vices.

The problems and the challenges are atour very doorstep. What activities are in-herently more exciting or more worthwhilethan efforts to combat and eradicate dis-eases, to lift these tremendous burdens fromsociety, and, in a concrete way, to contrib-ute to a solution of the overwhelming foodshortage and disease problems which facethe people of the world today? In otherwords, the U.S. governmental veterinaryservices in agriculture must become again

the pioneering organizations they once were,and for this to come about we in the veteri-nary schools must accept the fact that gov-

ernmental research and disease control ca-reers constitute an extremely importantavenue of veterinary service and one forwhich we must prepare our students.

What can we do? First of all I believethat our students must, from the very onsetof their training, be better oriented toveterinary medicine's over-all role in hu-man society and properly alerted to thegreat variety of career opportunities opento them. They must be exposed much moreto the history of veterinary medicine thanthey are now so that they will have thecultural background upon which to trulybecome not only "citizens in their profes-sion" but citizens in the world. This is nota frill; it is absolutely basic.

To me it is utterly fantastic that in a daywhen many American medical schools sup-port departments of medical history thereis not, to my knowledge, a single chair inveterinary history on an American veteri-nary faculty. Is this not a disgrace? Is notsuch an appointment really more important,for example than an eighth or ninth mem-ber of an already quite adequate physiologydepartment? Are we proud of the fact thatwe veterinarians probably know less of theaccomplishments of our profession-of itsvery sizable accomplishments-than themembers of any other professional groupof which I am aware?

We must completely overturn the falla-cious and almost uniquely American notionthat the teaching of clinical veterinaryskills should be directed solely to the de-mands of private veterinary practice andincreasingly, I am afraid, to the limiteddemands of a luxury type of pet practice.To do this the schools must in every waypossible strengthen the natural herd basisof clinical veterinary medicine by engagingmore actively in such things as feedlot prac-tice, contractual herd health plans, andpoultry practice, rather than in concentrat-ing more and more-and to the exclusion

79


of all else-upon the intensive treatmentof the valuable individual sick animalwithin the unnatural confines of a veteri-nary hospital.

Ours is herd medicine. Our goals as aprofession are not a carbon copy of thoseof human medicine and they never will be.We should completely integrate a portionof each of our school's clinical staff into thecooperative Federal-state livestock diseasecontrol activities of our area. We shouldwork with the U.S. Department of Agricul-ture and our state veterinary authorities toset up model disease control districts inwhich basic and operational research canbe carried out as part of these activities,where new disease reporting and epidemio-logical surveillance techniques can be triedout, where the requisites for exciting andattractive careers can be established, andwhere our students can be exposed to atype of veterinary practice which has amore lasting and meaningful impact uponpressing problems of our society.

We can speed up the process of upgrad-ing the governmental veterinary services bysetting up imaginative graduate programsin preventive veterinary medicine for thosepromising yuung veterinarians who are al-ready serving in these agencies, as well asfor those whom we will help attract to thesepositions in the future. It is not that re-sponsible veterinarians in government havenot been asking for our interest and ourassistance for many years, for they have.It is rather a question of when are wegoing to begin to respond?

Turning to another, and perhaps equallyimportant, problem area, that of the veteri-nary role in the general biological sciences,provides us an opportunity to consider fora moment the rigidity of most of our ex-isting academic programs and some of theways in which we might begin perhaps tomake them more flexible. Most of us areaware, for example, that veterinarians have

been concerned about diseases of fish atleast from the time of the compilation ofthe Egyptian veterinary papyrus of Kahunsome 4,000 years ago!

Many veterinary schools in Europe, inJapan, and elsewhere have had departmentsor organized research units concerned withthe diseases and pathology of fish and othermarine forms practically from the begin-ning, and they have had the same for dis-eases of economically important insects. Isthis not precedent enough? Yet is there asingle elective course in either of these im-portant fields in an American veterinaryschool? If so, I am not aware of it. Doesany American veterinary schooi other thanthat at Guelph, Ontario, in Canada evensupport a regular staff position in either ofthese fields? We know that there are sev-eral academic departments of invertebratepathology already in existence in the UnitedStates-but not in veterinary schools-andwe know that practically every marine bio-logical or fisheries research institute in thiscountry is engaged in disease-related studiesof one kind or another.

Why are we not doing something to de-sign graduate programs for veterinarianswho wish to enter veterinary specialtiessuch as these? Why are we not working outcooperative research and teaching arrange-ments with the departments of marine biol-ogy, entomology, and zoology in our univer-sities and creating positions on our facultiesfor veterinarians who become trained inthese fields? Who else should more logicallydo research or offer courses on diseases ofwild vertebrate and invertebrate animals oron their important roles in the epidemiologyof diseases of man and domestic animals?Such courses would not only serve as elec-tives for our own students but could alsomeet the special needs of graduate studentsin the other branches of zoology. We saythat veterinary medicine is comparativemedicine. We say it often, and there is

so

Are Our Schools Equal to the Task? 81

good historical evidence for our claim, butso long as the veterinary schools in thiscountry fail to see their real responsibilitiesas extending beyond concern for a fewimportant domestic animal species, how truereally can our claim be? Until at least someattention to disease and disease-relatedproblems in the whole spectrum of the ani-mal kingdom is evident on our veterinarycampuses, the full benefits of our profes-sion's traditionally comparative approach todisease will not be realized.

We must not let the limited demands ofits private practice obscure the fact thatveterinary medicine is a broad academicdiscipline in its own right and that ourschools, at least through a wide variety ofelective professional courses, specializedgraduate training programs, and researchactivities, have the responsibility to de-velop and communicate the knowledge andskills which are required if veterinariansand others are really to raise the veil ofignorance in these areas and to help com-parative medicine become something otherthan the undifferentiated monster it now is.

These then are a few of the serious questionswith which we in academic veterinary medi-cine must, in all urgency, begin to moreactively concern ourselves.

In concluding I would say that it hascertainly not been my intent to detract inthe slightest from private veterinary prac-tice as an established and valuable typeof veterinary service nor to imply that ourschools are not now meeting the require-ments of our future private practitioners ofveterinary medicine quite effectively, forthey are. What I would leave you with,however, is the thought that, if the veteri-nary profession is to serve mankind as itcan and as I think it must, then we in theschools of veterinary medicine must graspthe reins of leadership and begin to guideour unique veterinary team not only downthis well-trod pathway of private practicebut simultaneously down the three principalavenues of veterinary service to mankind-agriculture, public health, and general biol-ogy. To do anything less than this, I be-lieve, is to fail in our task.

REFERENCES

(1) Bronowski, J. Science and Human Values, rev. (2) World Health Organization. Medical Educa-ed. New York, Harper & Row, 1965. tion: Annotated Bibliography, 1946-1955.

Geneva, 1958.

,O, .A I' TTT"!T ^I'r '~T1rl?)TT A CTMMTu'

f'fiJ.'JTT'L.TY'r,17'JTHE TlnAHITTNTL Or VETETRNARY COXMU. lTTY i MEDlCITNE

AN APPLIED PROGRAM

JOHN H. HELWIG, D.V.M.*

The teaching of community medicineshould be incorporated in the over-all publichealth training of veterinary students. Anearly understanding and introduction ofstudents to community health problemswill better orient and prepare them to ap-preciate the team effort in applied preven-tive medicine. The teaching result is moreeffective when the student is provided anopportunity to participate in solving actualcommunity problems. Perhaps it would bean ideal situation to use a neighboringcommunity for studying all aspects of ap-plied community medicine. This approachwould be effective in acquainting studentswith the good as well as the bad conditionsand practices that prevail. The learning ex-perience would very likely be an interestingone since a first-hand evaluation of theapplication of principles and objectives ofcommunity medicine could be made.

The applied preventive medicine trainingprogram of the College of Veterinary Medi-cine at the Ohio State University utilizesan adjoining community with a populationof approximately 39,000. This communityprovides the laboratory for applying theprinciples and objectives of food hygiene.We have limited the student assignmentsto those areas that would be least likely tocause concern and resentment by officials

* Professor and Chairman, Department of Pre-ventive Medicine, College of Veterinary Medicine,Ohio State University, Columbus, Ohio.

of the municipality. This latter point isimportant and should not be overlooked.

If we exercise care in selecting problemswhen cooperating with local communities ina teaching program, there is much to begained by both students and the commun-ity. Restricting the problems also ensurescontinued cooperation and confidence on thepart of officials. Selected community prob-lems can be effectively supplemented in ateaching program by using data that per-tain to hypothetical communities. An ex-cellent example is the Dixon-Tiller Countymaterial that is available through the Com-munity Service Training Section of theNational Communicable Disease Center.The only request made by the Center is forinformation as to the application of thematerial.

The hypothetical community acts as ateaching reference for a population of about170,000. The material incorporates all thenecessary statistics, maps, slides, and datathat are relative to an average community.The data are flexible and lend themselvesto uni- or multidiscipline training in veteri-nary preventive medicine. Contents arereadily adaptable to many problems andwith minor modifications and supplementsallow for data relative to the distributionof domestic animal populations, wildlifeconservation practices and populations, thestatus of animal disease eradication pro-

82

An Applied Veterinary Community Medicine Program

grams, and the like. The use of a hypo-thetical community as a substitute for theactual community is not ideal but is aboutas close to ideal as one might hope for.

The teacher will find that through dele-tion or rearrangement of data, he can con-vey a real community working feeling tothe student. The course content should bespecific and definite when possible anddesigned for flexible application to environ-ment and circumstances that will differfrom community to community. This learn-ing experience should help the student toacquire an applied understanding of the fol-lowing five levels of prevention:

Health promotionSpecific prevention

Early diagnosis and treatmentDisability limitationsRehabilitation and program appraisals

These represent the core of the course andare just as applicable today as they everwere. Objectives and principles have notchanged but communities have. There isnot a great need to influence adults to con-tinue their education. We must exerciseleadership and communicate to these per-sons our objectives and principles so thatthey will be incorporated into a philosophythat will become a part of the everydaylife of the community.

"Continuing education" for adults of allages is the present-day keynote to thesuccessful teaching of community health.

83

FIELD TRAINING PROGRAMS

THE OHIO PREVENTIVE MEDICINE PROGRAM

JACK H. RUSSELL, D.V.M.*

At the Ohio State University College ofVeterinary Medicine, inqtruction in pre-

ventive medicine is culminated by a fullquarter (10 weeks) of study during eachundergraduate student's senior year. Thesenior class is divided into three groups andone group each quarter rotates into thisprogram from the autumn through thespring quarter. The remainder of the classis assigned to the veterinary clinics duringany given quarter.

Prior to their senior year all studentshave already been exposed to the basicacademic aspects of preventive medicine,including meat hygiene, epidemiology, bio-statistics, and the control of specific infec-tious diseases, including the zoonoses.

The objective of this quarter of preven-tive medicine during the student's senioryear is to apply the basic principles he haslearned to real-life situations. Thus in avery real sense the world outside the con-fines of the university can be consideredto be a laboratory to these students, whetherthey are being exposed to a public agency,a meat or food processing plant, or a state-owned dairy herd. To give an idea of thelearning experience each group is exposedto each quarter, I have listed below the widevariety of field assignments that are given

* Chief Public Health Veterinarian, Division ofCommunicable Diseases, Ohio Department ofHealth, Columbus, Ohio.

to students during their senior year at theOhio State College of Veterinary Medicine.

Preventive Medicine Program

Animal health and disease control-Theentire group of approximately 24 studentsis given four days of instruction in stateand Federal quarantine regulations bymembers of the Animal Health Division ofthe U.S. Department of Agriculture and theBureau of Animal Industry of the OhioDepartment of Agriculture. Lectures in thecontrol of specific animal diseases and epi-demiological techniques used in the tracingof animal disease sources are also given.Clinical demonstrations of testing and diag-nostic procedures are included.

Meat hygiene-Four days of "in-plant"instruction in meat and poultry inspectionprocedures are given by Meat InspectionDivision personnel of the Federal Depart-ment of Agriculture. At this time the in-structional groups are broken down intounits of five or six students.

Milk hygiene-One day is devoted todairy farm inspection with regular sanita-tion workers who perform this duty for theColumbus, Ohio, Health Department.Another day of instruction is given by theDepartment of Dairy Technology at OhioState University with respect to milk proc-

84

The Ohio Field Training Program 85

essing and pasteurization. Factors affectingmilk quality are discussed. Equipment usedin milk processing is broken down, and theoperational aspects are explained.

Organization and responsibilities of thelocal health department-A one-day visit tothe Health Department of the city ofColumbus (about 500,000 population) ex-poses the students to the organization, func-tion, and philosophy of local health depart-ment structure in Ohio. This Departmenthas well-organized programs utilizing vet-erinarians in many ways. The DeputyHealth Commissioner and Chief of theEnvironmental Health Section is a veteri-narian.

Military preventive medicine-A one-dayvisit to the nearby Lockbourne Air ForceBase gives the student a chance to see mili-tary preventive medicine in action. Thebase veterinarian lectures on this subject atthe University during the quarter.

Vector and rodent control-Pest control,its industrial and agricultural applications,and its economic importance are presentedby the district agent representing the Preda-tor and Rodent Control Branch of the U.S.Department of the Interior. Control meth-ods and the use of poisons are covered, aswell as the importance of rodents and preda-tors as disease vectors.

Food hygiene-The basic principles offood hygiene are covered in two days. Thisincludes food-borne disease, Ohio laws andregulations on food service, and inspectionvisits to restaurants, food stores, and baker-ies in a nearby suburb of Upper Arlington.The students fill out inspection forms to-gether with the instructor, who is DeputyHealth Commissioner of the local healthdepartment. They are expected to explainand justify their inspection reports.

General sanitation-Students travel withColumbus Health Department sanitariansto see public water supply treatment, sew-age disposal, landfill operations, and sub-

standard housing and its effects on publichealth. The veterinarian's role in generalsanitation is discussed from the standpointof veterinarians in both private and publicpractice.

Humane society animal shelter-TheFranklin County Humane Society by con-tract serves as the official agency for thecity of Columbus and Franklin County inenforcing stray dog control, licensing, andthe confinement of biting animals. Theshelter's operation is explained by the Hu-mane Society staff and the students havean opportunity to see how a modern, we l l-equipped animal shelter operates.

Aerospace research-The entire group of24 students tours the aerospace researchfacilities of the Wright-Patterson Air ForceBase at Dayton, Ohio, about 50 miles fromColumbus. In addition to the base veteri-nary staff, several veterinarians are engagedin research on aerospace travel studies.The Air Base has the ultimate in laboratoryanimal medicine facilities.

Laboratory animal medicine-One day isspent on Ohio State University campus atthe College of Medicine. General principlesand the scope of activities are covered.

Animal foods inspection-A modern plantthat manufactures a variety of pet foodsand slaughters horses under U.S. Depart-ment of Agriculture inspection is visitedfor one day.

Pilot Dogs, Inc.-A training facility forSeeing Eye dogs enables the student tobetter understand special problems asso-ciated with the care and treatment of ani-mals used for this purpose.

Columbus Zoo-Special problems asso-ciated with zoo management are discussedduring a tour of facilities with the Zoo Di-rector, who is a veterinarian.

Equine health problems-Preventivemedicine problems associated with equinepractice are discussed with staff cliniciansand private practitioners.


Ohio Department of Agriculture AnimalDiagnostic Laboratory-Diagnostic ser-vices offered to veterinarians, toxicology,feed additives, and chemical residues arecovered.

State herds and flocks-Visits are madeto herds and flocks at state prison andmental institution farms for the purpose ofapplying the principles of preventive medi-cine to herd health problems, especiallymastitis control.

Ohio Department of Health Laboratory-One-half day is devoted to the adminis-tration and operation of a state publichcalth laboraatory. Tests and servces--1 use-ful to veterinarians for diagnostic purposesare covered, and literature categorizingthese services and containing the interpre-tation of test results is given to each stu-dent.

Ohio Department of Health VeterinaryMedical Unit-Two days are spent present-ing and discussing various aspects of prob-lem assignments relating to veterinary pre-ventive medicine.

I think it is obvious that the students inthis program have an opportunity to applybasic concepts and principles regarding pre-ventive medicine to an infinite variety ofenvironmental and community health prob-lems. The most important aspect in the stu-dent's favorable response to this type ofteaching is student participation. Everyattempt is made to involve the studentrather than to let him merely tour theseagencies and facilities.

OfJficial Health Agencies

The part played by the Ohio Departmentof Health in this program will be discussedin more detail, since this is the portion ofthe program that I personally am involvedin.

The students participating in the programare divided into four groups of six studentseach. Each of these small groups has a two-hour informal, discussion-type seminar with

a veterinarian from the State Health De-partment staff. The programs and responsi-bilities of the Veterinary Medical Sectionof the Ohio Department of Health aredescribed, and students are encouraged toask questions and discuss any particularinterests they may have regarding publichealth. This often involves topics such astheir legal responsibility after graduationin regard to health agencies and diseasereporting, personal protection (includingpre-exposure rabies vaccination), employ-ment opportunities in veterinary preventivemedicine and public health, rabies control,xrUbi vy aIi.IO, a un la raUUly sbU V iuC

available at the state health laboratory. (Avisit to the Ohio Department of HealthLaboratory is always scheduled the morn-ing of this seminar.) Printed health educa-tion and public health materials issued bythe State Health and Agriculture Depart-ments are discussed, and students are urgedto contribute, after graduation, to the news-letter Animal Disease Trends and also tomake good use of the State Health Labora-tory and the Ohio Department of Agricul-ture Animal Diagnostic Laboratory. Theimportance of the reporting of zoonoticdiseases to the detection of human zoonoticinfections is stressed. This two-hour semi-nar is presented to each of the four groupsof students each quarter.

Near the end of the quarter all fourgroups (24 students) are given public healthproblem assignments. Each of the groupsis given a problem and assigned a three-hour period for its presentation and discus-sion. While a given group is presenting itsproblem, the other three groups listen and,after the presentation, are encouraged tojoin in the discussion, with the leader of thepresenting group acting as discussion chair-man.

Some of the problem assignments are asfollows:

* As members of a county veterinary medicalassociation, prepare a workable rabies control

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The Ohio Field Training Program 87

program and present it as you would to a localboard of health that had requested you to do so.(Specific situations are set up involving differenttypes of rabies problems. Complete data-suchas incidence of rabies over recent years and typeof species involved-are included.)

* Make recommendations for a complete andworkable meat or poultry hygiene program fora local health department.

* Prepare a plan for setting up better inter-professional relations and liaison in relation todisease reporting and sharing of knowledge be-tween a local veterinary medical society, a medi-cal society, and the local health department.

* Prepare a plan for the ideal reorganizationof all veterinarians working at the state level, bydepartments, programs, and responsibilities.

* Discuss the veterinarian's role in disastermedicine programs.

* Recommend solutions to a number of prob-lems based on situations involving specific zoo-notic diseases, either single cases or epidemics,and state your reactions to them as private prac-ticing veterinarians. (Occasionally one of theseproblems involving an epidemic is to be consid-ered from the official health agency's point ofview rather than from the standpoint of the pri-vate practicing veterinarian.)

* Prepare guidelines for state legislation con-cerning some problem involving veterinary pre-ventive medicine (e.g., rabies control, compul-sory immunization, or psittacosis regulations).

Always the students are asked to be pre-pared to defend their recommendations andto give reasons for any decisions. They areasked to make their proposals practical andworkable and to conform to Ohio Law andto the restrictions or data presented withthe problem.

The problems are always based on actual,confirmed disease outbreaks ocourring inOhio or on actual health needs existing inOhio, with the obvious exception of thedisaster medicine and veterinary services instate government problems. It is realizedthat it is perfectly possible to prepare prob-lems based on purely hypothetical situa-tions. However, it is felt that by utilizingactual situations the student will be moreinterested and motivated.

If any special reference material is neededfor solving a problem (state dog laws, dis-

ease incidence data for Ohio, etc.), this isfurnished to the group at the time they areassigned the problem. Otherwise, studentsare expected to find their own resourcematerial.

A group is allowed to make its entirepresentation before being challenged orquestioned. After correction of any glaringmistakes and discussion by everyone con-cerned, the public health veterinarian sum-marizes the discussion, presents alternativesolutions, if any, and relates the problemassigned to the situation actually existingin Ohio at that time.

While this is by no means a perfect solu-tion to the problems of teaching publichealth, it does accomplish the following:

1. It motivates the student to listen andlearn to a much greater extent than hewould if he were merely to listen to a lec-ture on the same topic.

2. It involves the student and encourageshim to participate more than he usuallywould. Each student must participate tosome degree, at least in the problemassigned to his group.

3. It acquaints the student with thestandpoint of a private practicing veteri-narian and his responsibility as such, andat the same time gives him an understand-ing of the health official's responsibility inthe same situation.

4. It requires the student veterinarian toconsider client relationships, responsibilitiesto public agencies, personal protectionagainst infection, and other points he mightnot think of if he merely writes a paper ona chosen topic.

5. Actual participation in a disease in-vestigation is rarely possible for a numberof reasons, but this method permits the useof epidemiological data and confirmed out-breaks for teaching purposes and providesa substitute for participation in epidemio-logical activities involving veterinariansworking in official health agencies.


VETERINARY STUDENT ORIENTATION IN THEU.S. DEPARTMENT OF AGRICULTURE

DANIEL F. WERRING, D.V.M.*

In the veterinary student orientationprograms of the U.S. Department of Agri-culture, remarks center on activities of theFederal veterinarian attached to the Agri-cultural Research Service, the parent or-ganization of the Animal Health Division.We also refer to the Animal Disease andParasite Research Division, which providesmany of the tools and much of the know-how applied in the control and eradicationprograms. We identify the following facili-ties of the latter Division and their areas ofresearch: (1) Plum Island (foreign animaldiseases); (2) National Animal DiseaseLaboratory (native diseases); (3) South-east Poultry Research Laboratory (poultrydiseases); and (4) Beltsville ParasitologyLaboratory. These facilities also maintaina diagnostic capability that is of impor-tance to the field programs. The student ofveterinary medicine today, we have ob-served, is increasingly research conscious,as indicated by the questions posed andthe interest voiced in possible employmentin the Animal Disease and Parasite Re-search Division.

Another agency of importance is theVeterinary Biologics Division, which isresponsible for the regulation of veterinary

*Veterinarian in Charge, Animal ltenlth Divi-sion, Agricultural Research Service, U.S. Depart-ment of Agriculture, St. Paul, Minnesota.

biologics production and the testing of su'!products for safety, purity, and potency.The recognized association of immunizingagents with a relatively large percentageof hog cholera outbreaks makes biologics aprime topic of concern today. The removalof a number of the products as unsafe hasspurred interest in the field. Discussions onthe use of various approved products undervarying situations will assist the studentwhen in practice to select the one mostindicated. These decisions will be impor-tant to the industry as well as to the hogcholera eradication effort.

The Animal Health Division's activitiesare naturally covered somewhat more indetail since many of them, particularly thestate-Federal programs, directly involvethe general veterinarian practitioner and,to some extent, the small animal practi-tioner. The Division, however, has uni-lateral programs that elicit student interestand are therefore given attention. One ofthese involves the precautions taken toprevent the introduction of foreign diseasesby controlling the imports of animals,animal products, and certain other relatedmaterial. This is accomplished by theenforcement of health requirements atpoint of origin, veterinary inspection atports of entry, or in some instances, totalexclusion of imports from countries where

88

Department of Agriculture Student Orientation

certain diseases exist. For example, nodomestic cloven-hoofed animals are per-mitted entry into the United States fromareas where foot-and-mouth disease orrinderpest is present. Similar restrictionsare imposed with respect to African horse-sickness and contagious bovine pleuro-pneumonia. As a result there are verylimited movements of many animal speciesinto this country other than from countrieson the North American continent.

Public stockyard inspection is anotherunilateral program of the Animal HealthDivision that is stressed with the student.One half-day is devoted to a tour of thestockyards at South St. Paul. Explanationsand discussions supplement observations.Here the student is introduced to the mar-keting procedure-receipt, sorting, yard-ing, weighing, and disposition by slaughteror reshipment of aimals-and the part thatveterinary and lay inspection play in theorderly flow of healthy livestock in com-merce. The special handling of reactoranimals is observed, with emphasis onprecautions to avoid exposure to susceptiblenonslaughter animals. The practitioner'sresponsibility in this area is pointed out, asis the danger of recommending that ownersuse public facilities to dispose of non-reactor diseased animals with possiblecontagious diseases. Additional studentobservations are made of Market CattleTesting tag application, vehicle cleaningand disinfecting, testing activity in theyards, tissue specimen collections, patrolinspections, and other aspects of the opera-tion. Yard orientation is concluded with asummarization and discussion of observa-tions and the distribution of printedmaterials.

The rest of the training is concerned withcooperative state-Federal programs and ispresented separately at two half-day ses-sions by veterinarians of the MinnesotaLivestock Sanitary Board and the Animal

Health Division. The organizational struc-ture, background, authority, responsibili-ties, and operative policies of each agencyis described and current field programs(there are 10 major programs and a numberof lesser scope) are presented.

The State Veterinarian's Office discussesactivities at the state level, while we fromthe Federal Animal Health Division pre-sent the national situation. Emphasis isplaced on practitioner involvement andactual participation in many of the pro-grams. The practitioner's knowledge andsupport of all programs is in the interest ofindustry and public acceptance.

Students are alerted to the need for sur-veillance against the introduction of foreigndiseases and the urgency of prompt report-ing of suspicion of such diseases. Thepracticing veterinarian would normally bethe first to encounter these conditions andhis immediate action could be the key topreventing extension. Attached to the forceis a foreign animal disease diagnosticianwho recently returned from England, wherehe assisted in the foot-and-mouth eradica-tion operation. He is available to assist indiagnosis or to collect material for labora-tory examination. In case of confirmation,there is within the state an EmergencyDisease Organization, composed of jointagency professional and subprofessionalpersonnel, which could institute eradicationmeasures on short notice. This groupperiodically takes part in hypotheticalexercises and would suffice to handle small-scale outbreaks or at least to containthings until additional help arrived in caseof larger outbreaks. We are prepared toemploy all the eradication measures ofinspection, quarantine, appraisal, depopula-tion, cleaning, disinfecting, and whateverelse might be necessary.

Training at the Animal Health Divisionoffice is concluded with a discussion of theexport-international shipment of livestock

89


and the involvement of the practitioner incertifying to the health of the animals tobe exported. Minimum requirements, byspecies, are explained, including test inter-pretations and other details. A healthcertificate exercise is then presented inwhich each student prepares a "John Doe"mock certificate from a list of animals ofvarying status, of which some are qualifiedfor export and others are not. The exerciseends with a review of entries made and acritique of the exercise.

Many areas have been identified in theforegoing where the practicing veterinarianis directly involved in conoperative pro-grams. There are a number of other ob-jectives we in the joint agencies strive forin student training:

1. Our foremost objective is to instill in thestudent the philosophy of prevention, control,and eradication of animal diseases. A preventivedisease attitude is being developed in preferenceto individual treatment as a total answer toproblems.

2. A personal relationship is being establishedthat will lend itself to mutual benefit in diseasecontrol.

3. A briefing on the significance and responsi-bility of veterinary acereditation is made. Mate-rial is generally covered that should assist inwriting the acereditation examination.

4. Various documents, such as test charts,vaccination records, quarantines, and shippingpermits, are discussed and their proper executionand use is stressed.

5. We impress on the student that we in the

cooperating agencies are in fact service groupswhose funetion is to assist the professional andthe industry in maintaining a healthy livestockpopulation.

6. The Minnesota Livestock Sanitary Boarduses the occasion to advise on the necessity ofobtaining permits for administration of certainbiologics and to explain other Board controls.

The methods or principles employed inthe training have been incorporated in partin a discussion of objectives. Presentationsare very informal and questions are invitedat all times. Discussions are initiated atfrequent intervals to stimulate interest.Visual aids, including slides and charts, areused in Uorler to avoid dry narralion. Exer-cises involving student participation areused whenever possible and appear to bewell received. Published materials outlin-ing agency organization and functions aredistributed.

In addition to the type of training dis-cussed above, members of the joint agen-cies participate periodically in seminarswhich deal with certain programs in greaterdepth than is possible at the briefing ses-sions. Two such seminars have recentlybeen held for senior students on tuberculosisand brucellosis. Epidemniologists periodi-cally make presentations.

Working with the students has been apleasant and rewarding experience. Ifthey have profited to the extent we have,the training can be considered a success.

90


THE ST. PAUL PROGRAM

PAUL J. COX, D.V.M., M.P.H.*

In St. Paul, senior veterinary studentswho are to take field training are scheduledto appear in the office of EnvironmentalHygiene at the Bureau of Health, in groupsof four to five students, one day a week dur-ing the fall quarter. The period of indoc-trination is approximately two hours. Thesessions are informal and the students areencouraged to participate in the discussions,which are based on the following points.

1. Discuss with the students the functionof a veterinarian in a local health depart-ment charged with the directorship ofenvironmental hygiene.

2. Identify the public health significanceof disease processes in animals and man.

3. Indicate that experience and knowl-edge gained in practice and formal educa-tion are adaptable to the field of publichealth.

4. Compare the application of a vet-erinary education in private practice topublic health.

5. Construct the administrative organi-zational chart and the plan of activities of atypical health department.

6. Identify the student's formal vet-erinary education with the field of publichealth and state why he is qualified to

* Director, Environmental Hygiene, Bureau ofHealth, St. Paul, Minnesota.

function effectively in an organized environ-mental hygiene program.

The general objectives of this field train-ing can be summarized as follows:

1. Create an awareness of the functionsof a veterinarian in a health department.

2. Discuss additional educational require-ments for a veterinarian in public healthwhich may be required.

3. Cite public health problems whichstimulate feedback from the students.

4. Allow each student to give his per-ception of a veterinarian's function inenvironmental hygiene.

5. Contrast the ability of other disci-plines to funetion as effectively as a vet-erinarian in environmental hygiene.

6. Illustrate how the basic veterinaryeducational requirements equip a veterinar-ian to be actively engaged in public healthmatters while in private practice.

7. Discuss the fact that veterinarians inpublic health are using their education to asgreat a degree as a practitioner.

8. Contrast working conditions betweena public health official and a practitioner.

9. Allow free discussion among studentson points of difference.

10. Truthfully and freely answer per-sonal questions relating to the position of aveterinarian in public health.

91


THE U.S. DEPARTMENT OF AGRICULTUREMEAT INSPECTION PROGRAM

V. L. DAHL, D.V.M.*

The Meat Inspection Program of theU.S. Department of Agriculture hasexperienced greater advancement in thebasic and continued training of its in-spectional personnel in the last decadethan during the first 50 years of its exist-ence. This is not to imply that all earlytraining practices were unacceptable. Mostsupervisors have always recognized theimportance of training and have had adeep interest in seeing that personnel wereproperly trained. Some enjoyed theadvantage of having personnel on theirrosters with exceptional training talents,and others had geographic concentrationsof personnel providing the advantage ofassignment flexibility during the periods oftraining need.

Deficiencies of early training practiceswere generally recognized to be lack ofprogram uniformity, delayed employeedevelopment and self-fulfillment, andreduced manpower flexibility because ofincomplete work qualifications of the in-spectional force. Three problem elementsappeared to be most significant.

First, no time was specifically allotted to

training. This problem was most detrimen-

* Assistant to the Director, North Central MeatInspection District, Consumer and Marketing Ser-vice, U.S. Department of Agriculture, Chicago,Illinois.

tal in the training of the new employee,since it is most important that the newinspector is introduced to the what, why,when, and how-to of correct procedure.Program policy, however, always gave firstpriority to having an employee fill an in-spectional assignment at the earliest possi-ble moment. His first job was usually asimple one, and from that time on hiscareer consisted of a series of delays intraining for new tasks. Manpower short-ages caused by vacations, sickness, retire-ments, resignations, and economic austeritydirectives were some of the factors whichblocked orderly and progressive employeedevelopment.

The second significant problem was thelack of training aids and quality trainerpersonnel. On-the-job training was con-ducted in most instances by whichever moreexperienced inspector happened to beassigned to the inspectional station at thetime the trainee was to be qualified. Thereexisted in these temporary trainers greatvariation in technical competence, teachingcapability, and interest. Even when thesequalities were present in the trainer, train-ing was just another responsibility added tohis already demanding job.

The third and probably major underlyingcause for the lack of uniform training

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USDA Meat Inspection Training Program

practices in those years was the absence ofcentral program direction. The good train-ing programs that did exist at some loca-tions were the result of local initiativeand ingenuity. Training information wasnot disseminated broadly so it could beutilized where creativity and talent werenot strong. Most of the effective training(it was carried out by design rather thanby accident) was accomplished throughunauthorized use of personnel. Trainingwas always recommended and encouraged,but there were no directions for carrying itout, and there was no provision for time,personnel, and training aids.

Early in 1964 the first nationwide pro-gram of in-plant slaughter inspectiontraining was adopted by the Federal MeatInspection Program. This training was ini-tially applied to veterinarians just enteringthe inspection service. Recently it has beenextended to nonprofessional personnel aswcll. Basic characteristics of this planinclude providing adequate and exclusivetime for training, during which training isthe sole duty responsibility of the trainee.Qualified trainers are selected on the basisof tecIhnical competence and teaching talent,and training is their only duty assignment.Teaching is accomplished by a combinationof classroom lectures, laboratory work, andin-plant instruction and practice. The goalis to prepare the employee to be basicallyfunctional before reporting to his first dutyassignment.

This basic training is now carried outunder the direction of the U.S. Departmentof Agriculture Livestock Slaughter Inspec-tion Division at four strategically locatedtraining centers: South St. Paul, Minne-

sota; Omaha, Nebraska; Fort Worth,Texas; and Los Angeles, California. Vet-erinarians currently receive 12 weeks ofbasic training and nonprofessional in-spectors, four weeks. These centers have aprojected capability of training 300 vet-erinarians and 800 nonprofessional in-spectors annually.

Another type of training which hasrecently received considerable attention iscontinuing education of field inspectors.The goal here is to broaden the capabilitiesof inspectors already on the job. The pur-pose is to increase proficiency in currentassignment responsibilities and to prepareemployees for advanced grade positions.

The "package concept" has been devel-oped in order to provide training aids andguidance to field supervisors in conductingtheir local, continuing education programs.The scope of each package is a limited areaof inspectional responsibility, such as plantsanitation, sanitary carcass dressing proce-dures, or trades labels. A package essen-tially consists of a prepared instructionbooklet for the trainee's prestudy use, adiscussion guide, and visual aids for thetrainer's use in classroom presentation.

Field supervisors have a great need forthese training aids for scheduled training,as well as for use during unexpected op-portunities arising from nonoperationalplant stand-bys. The package concept isconsidered to have great potential valuefor orderly and uniform employee develop-ment in the field. Singularity of subjectmatter, authenticity of content, and readyavailability are basic qualities of thisconcept.

93

THE TEACHING OF DISASTER PREPAREDNESS

DONALD C. BLENDEN, D.V.M., M.S.*

The ever-present threat of disaster hashaunted mankind all through history.Under this threat, man has learned topredict certain events of nature so that theeffects are minimized. Other natural eventscannot be predicted, as evidenced by thefact that citizens of our country are beingcontinually exposed to disasters of differenttypes with little or no warning. Man-madedisasters also seem to be an ever-presentpotential, especially those that might resultin widespread trauma, death, or exposureto radiation. Accidental explosions andfires oocur from time to time because ofhuman error or neglect. The remote butever-present threat of enemy attack withnuclear weapons cannot be ignored byresponsible professional persons, eventhough most people prefer to ignore, ratherthan to nourish, the health concepts ofprevention and preparedness. It is thispotential of disaster that stimulates multi-disciplinary thought in the teaching of dis-aster preparedness. The involvement ofdifferent professional groups, specificallythe veterinary medical profession, seemsvery important, as the disaster itself mayeliminate some of the medical care capa-

*Associate Professor of Veterinary Microbiologyand Chief of the Section on Veterinary PublicHealth, School of Veterinary Medicine, and Asso-ciate Professor of Community Health and MedicalPractice, School of Medicine, University of Mis-souri, Columbia, Missouri.

bilities of a particular population, or thedisaster may overwhelm available capa-bilities for providing medical care.

The purpose of this paper is to describethe reasons for presenting disaster pre-paredness to undergraduate students inveterinary medicine and to relay some ofthe principles of disasters and post-disasterbehavior which are used in this teaching.

It would seem necessary first of all,before discussing the implications of dis-aster and disaster preparedness, to definethese terms as they are discussed withstudents. There are two legitimate schoolsof thought concerning the definition ofdisaster. These are represented (1) bythose most affected and closest to the dis-aster, and (2) by those who must record,classify, and analyze disasters in order topredict future events or to render themedical care necessitated by the event. Wemust assume at this point that the defini-tion of disaster is variable and relative forthe individuals involved and that forpresent purposes a disaster consists of anunforeseen happening resulting in the deathor serious injury of 25 or more persons. Bythis administrative definition, few peoplerealize that about 1,300 deaths haveoccurred in disasters every year of thiscentury, with an additional 13,000 to15,000 persons injured annually. This initself is a staggering figure, but if one were

94

Disaster Preparedness 95

to include all "minor disasters" such asautomobile accidents, fires, and drownings,the figure might well be unbelievable.Disasters, then, present a serious problemin terms of individual and public health.Even more unfortunate than the lossesincurred is the fact revealed by retrospec-tive studies that many or most disasterlosses and deaths are preventable. TheUnited States has a rather modest incidenceof disaster injury; some countries have hadsingle events killing more persons than allof those killed in one-half century of ourown disaster history.

Review of disaster situations where lossof life has been extensive reveals that theuse of any one of the several preventivemeasures available at each incident wouldhave greatly reduced the loss of life.Experience proves that once the chain ofevents leading to disaster has been initiated,it is too late to institute effective casualty-reducing measures. For this reason ade-quate preventive measures must be builtinto community, professional, and individ-ual thinking so that they are more or lessa part of everyday life. Then, when anevent begins that can potentially becomea disaster, the preventive program auto-matically takes up where preparednessprograms leave off. To accomplish thisobjective, the philosophy of preparednessmust be instilled during the educationalyears when persons are receptive to ideasand are actively engaged in the learningprocess and then maintained on a continu-ing basis.

This, then, is the concept of disasterpreparedness, or adequate preparation fordisaster. Veterinarians, by and large, havetaken a head-in-the-sand approach untillately. It appears quite obvious that thisconcept will be properly accepted onlyduring the learning years of an individual.Members of the health professions must bewell acquainted with the concept of disaster

preparedness, as they are the ones who willbe called on for leadership and for thevarious ramifications of management andmedical care. For example, what com-munity is prepared to accommodate 50,100,or even 1,000 persons injured at the sametime, with all the attendant problems infood and water handling, sanitation,animals, utility breakdowns, and the manyother problems that few persons think ofuntil they do occur? These, of course, arenot unreasonable figures to contemplatewith natural disasters and would be mag-nified manyfold in the more unlikely eventof a nuclear disaster.

Importance of the Concept of Disaster Pre-paredness in the Veterinary Medical Cur-riculum

Disaster preparedness programs havebeen in effect for several years in medicalschools under the Medical Education forNational Defense (MEND) Program. Sincedisaster preparedness is being recognized asa multidisciplinary endeavor, the otherhealth professions are now becoming in-volved. Programs are under way in schoolsof nursing, dentistry, and pharmacy. Thepurpose of the program in schools of veter-inary medicine is to acquaint the potentialveterinarian with the fact that he does havea role and a community responsibility in apost-disaster situation. It is obvious thatthe veterinarian has a great background oftraining and experience in the concepts ofhealth care and will be looked to as a com-munity leader in a situation of this sort.

A secondary but equally important facetof the teaching of disaster preparednessexists. Disaster preparedness is used as adramatic tool to illustrate to students thatpublic health embraces more than the tra-ditional areas of meat and milk hygiene oreven infectious disease epidemiology. The


student is quite interested in the fact thatpublic health encompasses a variety offields which have little to do with the tra-ditional infectious disease control approach.

Principles of Disasters

It is interesting that the epidemiologicmethod can be applied in describing disasteroccurrences and in selecting the bases forcontrol programs of future disasters. It istrue that there is a basic host-agent en-vironment relationship. Also, the incidentmay be related to the basic epidemiologicparameters of time, place, and person. Forexample, tornadoes and hurricanes haveboth a seasonal and a geographic distribu-tion. Earthquakes have a geographic dis-tribution. Municipal riots seem to haveseasonal and social relationships. In manyinstances, disasters can be characterizedaccording to the persons that are affected;indeed, it seems that there would actuallybe risk groups to certain types of disaster.The epidemiologic principles involved indisaster can be used to minimize casualtiesand deaths by the prediction of so-calledwarning times of the events. In the teach-ing of epidemiology to veterinary medicalstudents, disasters can be used as examplesjust as realistically as cardiovascular dis-ease or an outbreak of food poisoning.

The principles of disaster and disasterbehavior should be presented to students.They should be oriented to the fact thatpost-disaster behavior can be divided intofour distinct phases. The first two phasesare undergone by all persons, includingresponsible health and disaster-orientedindividuals. The prime purpose of disasterplanning is to minimize the length of timeinvolved in adjusting to these two phasesso that the disaster is not entirely a newexperience to all people. The four phasesare:

Phase 1. This is a stage of apathy and disbe-lief, in which persons are dazed and stunned andundertake purposeless activity.

Phase HI. This is a stage of gratitude for anyhelp that can be given. The individual yields toany suggestions but is highly inefficient.

Phase III. This phase is distinguished byeuphoria, feelings of brotherhood, and pleas to"take care of everyone else first as they needhelp worse than I."

Phase IV. This phase develops after severalweeks, when disaster victims are recovering fromthe effects of the disaster and are beginning tocome back to the realism of life. During thisphase people become annoyed and criticize theway officials handled the disaster.

In the post-disaster period the so-called"phenomenon of convergence" is of specialimportance. This is a rather formidableterm applied to the simple principle thatall things seem to flow into a disaster areaand very few things seem to flow out. Thiscan cause tremendous problems in restoringservices with emergency personnel and inthe management of casualties and deaths.For example, immediately after a disaster,people descend upon the area to see whathas happened. Some rush home to see whathas happened to relatives or friends. Others,perhaps a majority, are simply curiosityhunters and thrill-seekers. In any event,the disaster scene becomes choked withpeople, automobiles, airplanes, motorcycles,and many other basically nonessential per-sonnel and vehicles. Convergence has be-come so extreme in some disasters thatofficials have seen fit to organize conductedtours through certain parts of the area tocontrol traffic rather than let it roam in ahaphazard fashion.

The Veterinarian's Role

A fact easily overlooked by relief officialsis that the veterinary hospital and clinichas a large stock of dressing, drugs, anti-biotics, sedatives, sutures, instruments, andplaster bandages, as well as facilities for

96

Disaster Preparedness 97

sterilization, radiography, administration ofoxygen, first aid, and minor surgery, not tomention intravenous setups, clinical labora-tories, and so on. Consider, too, the largeanimal practitioner who possesses portablerefrigeration units, mobile clinics completewith sinks and hot running water, steriliz-ers, refrigerators, and two-way radios, andwho has an intimate knowledge of roads,bridges, and terrain. Equipment and facili-ties are tangible things, easily evaluated asto whether or not they are adequate. Moredifficult to evaluate are the professionaljudgment and skills of veterinarians. Itwould appear that the most obvious func-tion of the veterinarian during and afterdisaster would consist primarily of expan-sions of his routine functions modified tothe new and stressful situation.

The activities of a veterinarian followinga disaster might be expected to follow thispattern:

1. Like everyone else, the veterinarianwill take action to safeguard his own lifeand that of his family. Certainly, asidefrom any aspects of basic self-preservation,persons who are incapacitated will be of noservice in a post-disaster period. Also, ithas been demonstrated, even in personsexperienced in disaster management, thattheir first impulse is to make sure their ownfamilies are secure.

2. Following the immediate post-disasterperiod, the veterinarian should determinehow he can be of greatest service, preferablyby acting according to a prearranged disas-ter plan or else by checking with the healthofficer or other responsible officials. Imme-diate needs will depend on the nature of thedisaster, the available medical care, pre-vious disaster plans, transportation, com-munication facilities, and so forth.

3. Perhaps the most obvious and impor-tant contribution that the veterinary pro-fessional can and should make is to super-vise sources of food of animal origin and

assure that foods provided the survivingpopulation are safe for consumption. Thistype of work should be closely coordinatedwith sanitarians of the local health units.

4. Veterinarians should participate insurveillance for communicable diseases inthe surviving population by the applicationof epidemiologic methods. They should helpdefine and eliminate or control sources ofinfection for human populations.

5. Able and highly trained veterinarians'assistants could be invaluable aid in disastersituations.

It must be remembered that physicians,only some of whom may be able to funetion,will be overwhelmed with direct medicalcare services and must be relieved of allservices which the paramedical professionscan adequately handle. Should it happenthat the veterinarian is called upon to givedirect medical care to injured individuals, itwould seem that in most, if not all, casesthis care would be first aid, which mostpersons are qualified to give, or that suchcare would be under the direct supervisionof a physician, who would therefore beresponsible. While many veterinarians ex-press great fear of this type of endeavor, itseems doubtful that many would relinquishthese responsibilities when confronted withan actual emergency situation.

Applications of Principles in SpecificDisasters

Many types of disasters that occur regu-larly throughout the United States providerealistic examples of what might be ex-pected of the veterinary student. For ex-ample, the severe floods of northern Cali-fornia and the Northwestern coast illustratesome primary and secondary effects thatmight be anticipated. This particular typeof disaster illustrates that large numbers ofdead and injured animals, as well asfrightened but otherwise normal animals,


must be dealt with. The veterinarian is, ofcourse, in one of the best positions to assistand supervise operations of this nature.Sometimes assistance will take the form ofhelping to establish a portable water supplyto be used by surviving populations. Occa-sionally large numbers of deaths of domesticanimals occur, so that the disposal of car-casses presents a tremendous problem.Chaos resulted from an unusual situation inwhich a recent tornado swept through To-peka, Kansas, and destroyed the physicalfacilities of the health department itself.In such an instance, of course, a disasterplan will fall apart if the health departmentis the main focal point of supervised re-sponsibility.

It is also of great importance that disasterplans be given a test of their effectiveness atregular intervals through the performanceof disaster exercises. It is only through thistype of exercise that the effectiveness of adisaster plan can be evaluated.

Summary

Disasters are thrust upon us at frequentintervals, and disaster preparedness is the

responsibility of all of the health-relatedprofessions. The benefit of advanced train-ing and disaster preparedness becomes clearwhen we consider that most disaster injuriesand deaths are preventable.

Disaster preparedness should be taughtin the undergraduate curriculum of veteri-nary medicine for two reasons: (1) Thedisaster-oriented veterinarian merely modi-fies his normal routine enough to provideexpanded service in the new situation; and(2) disaster preparedness can be used as amodel to illustrate the noninfectious aspectsof disease, with which veterinary publichealth has professional concern.

Disasters can be studied by the epide-miologic method. They have predictablephases of human behavior. The phenome-non of convergence occurs at all disastersites. Disaster plans and regular disasterexercises help minimize the effects and in-crease speed of rehabilitation. The veteri-narian should be oriented toward disasterpreparedness and, should the occasion arise,find his role as a respected communityhealth leader.

98

Part II

BIOMEDICAL COMMUNICATIONS

SOME IMPLICATIONS OF RESEARCH FOR THE DESIGN OFINSTRUCTIONAL MATERIAL*

WILLIAM T. STICKLEY, PH.D.t

Research and development in the prep-aration and employment of instructionalmaterials are essential if the design of in-structional systems is to pass throughprogressive stages of refinement. Change inany social system is notably difficult toachieve. Those who are concerned with thepreparation of instructional materials andwith innovation in education, especially inhigher education, must accept as fact thisreluctance to change. In The Prince,Machiavelli described the danger of initi-ating a new order of things:

It must be considered that there is nothingmore difficult to carry out, nor more doubt-ful of success, nor more dangerous to handle,than to initiate a new order of things. For thereformer has enemies in all those who profit bythe old order, and only lukewarm defenders inall those who would profit by the new order,this lukewarmness arising partly from fear oftheir adversaries, who have the laws in theirfavour; and partly from the incredulity ofmankind, who do not truly believe in anythingnew until they have had actual experience of it.Thus it arises that on every opportunity forattacking the reformer, his opponents do so withthe zeal of partisans, the others only defend himhalf-heartedly, so that between them he runsgreat danger (19).

In a theoretical and research-basedstudy, Evans (5) documented the reluc-tance to change in higher education by re-cording many of the difficulties which

* Supported in part by a grant from the CarnegieCorporation of America.

t Assistant Professor, Division of Research inMedical Education, School of Medicine, CaseWestern Reserve University, Cleveland, Ohio.

emerged from the introduction of instruc-tional television into higher education.

Yet the proper approaches to change mayincrease the likelihood of its occurrence. Ina discussion of the Case Western Reserveprogram, Ham (10) described one way toprovide an environment receptive tochange: "Change is built into this organi-zational structure so that the curriculumhas never been fixed or static. Change isconsidered inevitable, essential, predictable,and to be a steady state itself."

It is impossible in a paper of this size tosummarize experimental findings for themultifarious variables that concern the pro-ducer and user of instructional materials. Amere outline of these variables would proveextremely long (7). Several reviews of theliterature are available, however, that fur-nish the producer with listings of the chiefexperimental studies (8, 12, 15, 22, 25).

This paper will focus on a few principlesof programmed instruction that apply tothe preparation of many types of instruc-tional materials. The delineation of prin-ciples and guidelines should assist the sub-ject-matter expert when he considers thetransformation from traditional instruc-tional methods to newer methods of in-struction.

The works of Fry, Lysaught, Taber, andLange, as well as other writings, set downthe principles of programmed instruction(7, 14, 17, 18, 30). I myself am not a strongadvocate of the kind of programmed in-struction that is exemplified by many of

101

102 Biomedical Communications

the commercial programs now available be-cause of their low degree of sophistication,with regard to the quality both of the in-formation they attempt to impart and ofthe techniques they employ. However, theprinciples which underlie programmed in-struction offer basic approaches to thepreparation and use of instructional mate-rials of many types and to the relation ofresearch to practice. Although programmedinstruction principles are an outgrowth ofoperant conditioning (despite Skinner'sdisclaimer), they are similar to the learningprinciples generally accepted by most learn-ing theorists (11, 28, 31).

This paper will emphasize four principlesfor the design of programmed instruction:(1) preparation and use of instructional ob-jectives, (2) active student participation,(3) logical sequencing of material, and (4)feedback of information.

Preparation and Use of InstructionalObjectives

Ralph Tyler, as early as the 1930's,stressed the importance of defining educa-tional objectives in behavioral terms. Notuntil the 1950's, however, was formulationof objectives accepted as an essential andregular principle by a significant number ofproducers of instructional materials. Em-phasis on explicitly stated objectives hasbeen supported by Bloom's Taxonomy ofEducational Objectives (3) and by RobertMager's engaging book entitled PreparingInstructional Objectives (21). The stress ontask specification and task analysis in mili-tary and industrial training programs hasalso had an important effect. Some pro-ducers of programmed materials have eventaken the position that it is impossible toprepare programmed instruction withoutthe statement of objectives in behavioralterms.

Despite the recognized importance of in-structional objectives, they are not in wideuse in higher education. The number ofexperimental studies that attempt to assessthe value of objectives is indeed small. Inpart, this paucity results from the difficultyof defining objectives and the time requiredto do so. In summarizing research on learn-ing from television, Schramm (24) com-pared learning from television with learningfrom ordinary classroom instruction. Thefindings from 393 reported experimentsshowed that 83 favored television instruc-tion, 255 revealed no significant difference,and 55 favored the traditional classroominstruction. While many of these studiescan be criticized from the standpoint oftheir experimental design, it is possible thatthese equivocal results occur because ex-plicit objectives for both the television in-struction and conventional instruction wereabsent.

Active Student Participation

Student involvement is a long-term goalof producers of instructional materials(23). Lumsdaine (15) and Allen (1) re-port that high student involvement is one ofthe most fruitful areas of advance in educa-tional research in recent years. In the earlystages of the programmed instruction move-ment, an active student response was con-sidered identical to high student involve-ment and was thus thought to assurelearning. Most programmed instructionmaterial commercially available was there-fore of the linear type, providing space forthe student to write a short answer for eachframe. It was surprising when some studiesreported that those students instructed toonly "think" the response often performedas well on post-test evaluations as did thosestudents instructed to write in the response.And the covert (thinking the answer)

Some Implications of Research

group frequently completed the program inless time than the overt (writing the an-swer) group.

The results, however, are not surprisingwhen the programs are examined uponwhich these studies are based. Instructionalprograms that call for one-word responsesare boring and usually will not spark theimagination of the bright graduate student.He is accustomed to attacking difficult, pro-vocative questions and to focusing attentionfor long periods of time before resolvingproblems. When preparing materials formedical students and other adult learners,the aim is to seek how best to structure theinstructional environment to assure in-volvement and participation to a degreethat fits the learner. Student participationthat "builds in" little challenge will not re-sult in high involvement but will lead torejection of the material. Conversely, ma-terial that is too difficult and too challeng-ing leads to frustration.

Glaser (9) has pointed out that the fullspectrum of response variables has not yetbeen touched, despite the numerous re-search reports on student participation.Continued research in exploring new waysof providing heightened interaction be-tween the student and the environment fur-nished by the instructional material isclearly needed.

The Division of Research in MedicalEducation of the School of Medicine, CaseWestern Reserve University, is currentlyengaged in a study that demonstrates highstudent involvement in a structured en-vironment. This study uses a programmedunit titled Labor (29) for fourth-yearmedical students in their clerkship on ob-stetrics-gynecology. Subject-matter spe-cialists determined that a certain amount ofcore information should be learned by stu-dents during the clerkship. The traditionallecture was considered an inappropriatemeans of imparting that information, and

many of the existing textbooks on the sub-ject were reported to be difficult to under-stand. After examining alternate methods,a workbook was devised that was similar,in some respects, to the programs developedby Wilds and Zachert (32, 33). The firstpart of the Stenchever-Kitay workbook isdevoted to a written description or syllabusof basic information about labor and in-cludes many matching, multiple-choice,and constructed-response questions. Theanswers and a short explanation of thequestions are included in this part. Thesecond part consists of six case problems,each containing a series of questions thatattempt to place the student in the role ofthe physician as he goes through the deci-sion-making process. Some of the questionscontained in the first case are presented inFigure 1.

Each case is graded in difficulty so thatthe student encounters a simple first caseand challenging last case. Students on theclerkship have delivery floor duty everythird night, and that setting was judged ap-propriate for the use of the workbook. Afterthe student reads the first part of Labor andworks through the cases in the second part,he is requested to arrange a conference withhis resident preceptor to discuss the cases.The student's environment has been ar-ranged so that he has little alternative butto become highly involved with the mate-rial. The material is available to each stu-dent to keep and use in a manner to fit hisneeds. Our initial studies with this work-book indicate that students are enthusi-astic about this approach. Resident pre-ceptors also respond well, because theirconferences with students can be conductedat high levels of sophistication.

Logical Sequencing of Material

Early investigators who prepared pro-grammed materials pointed out the im-

103


CASE PROBLEM 1

22-year-old gravida 1 para 0 white female at term. Past history: uneventful. Antepartumcourse: uneventful. Pelvis: adequate gynecoid clinically. Contractions began, six hoursprior to admission but were somewhat irregular and between 7 and 20 minutes apart. Duringthe hour lower case p.t.a. contractions are every 5 minutes, lasting 30-35 seconds. On ad-mission the EFW is 7#, cervix 100% effaced, 4 cm. dilated and the vertex is at station 0with membranes intact and bulging slightly. Fetal heart is heard at 144 in RLQ.

1. What is your impression of this patient?

Page 60

A PRIMIGRAVIDA IN THE LATE LATENT STAGE

The best bet on the basis of the data given. The head is engaged, all anatomical relation-ships are probably normal, and the labor seems to be progressing as one would predict.

go on to page 63

Figure 1. Sample questions and pages from the Stenchever-Kitay workbook (29).

1~Tr1-tUL~ ~.t Page 582. uh:!h ol the following besb describes this patient?

A primigravida with uterine dysfunctiongo on to page 59

A primigravida in the late latent stagego on to page 60

A primigravida in false laborgo on to page 61

A primigravida with cephalo-pelvic dispropor-tion and dystocia

go on to page 62

Page 59

A PRIMIGRAVIDA WTIH TUTERINE DYSFUNCTION

Uterine dysfunction may be of the hypertonic or hypotonic variety. In the former, con-tractions are strong and frequent and may be accompanied by evidence of fetal distress.In the latter case, contractions are usually poor and irregular and are associated with failureof progress in dilatation. This patient has not been observed long enough for such a diagnosis,but on the basis of facts given, she is probably not a problem of uterine dysfunction to thispoint.

Ref. Williams' Obstetrics, p. 823-837,then go back to page 58 and selectanother possibility

Some Implications oJ Research 105

portance of logical sequencing in arrange-ment of information. Difficulties arose,however, when it was realized that the se-quence considered logical by the subject-matter specialist was not always the sameas that regarded as logical by the student.Branching programs of the multiple-choicetype were included in early attempts atflexibility in the sequence of presentation.Students who readily grasped the materialcould proceed directly through the programwith little or no remedial help. The studentwho made an incorrect response was re-ferred to a frame that "told" him he wasincorrect. An explanation was provided;then he was sent back to the original frameto select another response, hopefully thecorrect one. When branching programs arecompared with linear programs, resultshave shown no large differences in studentlearning (15, 25).

Although material can be sequenced ac-cording to several different schemes, it isthe sequence viewed as logical by thelearner that probably has the greatestvalidity. A necessary corollary is the valueof testing instructional materials beforepublication. Lumsdaine proposes such anapproach, which he calls product-testing(16), sometimes referred to as formativeevaluation by other writers. He cites, how-ever, the scarcity of studies that reportstudent learning improvement from oneversion of the program to the next. One ob-stacle to prepublication product-testing isthat it significantly increases the total pub-lication cost.

Mager reported (20) an approach thatplaced the learner in the position of gener-ating his own sequence. If the studentknows what is expected of him and wherehe is, he is perhaps the person best able todetermine the sequence of instruction. Thisapproach has a certain appeal, in that thelearner will need to apply precisely this

method after the conclusion of his formaleducation.

The use of the computer to prescribe se-quences of instruction is now under inves-tigation. Using the computer to prescribeinstruction to fit individual needs is some-what different from the concept of com-puter-assisted instruction. In contrast tocomputer-assisted instruction, in which thestudent may spend long periods of time ata computer terminal at an almost prohibi-tive cost, computer-prescribed instructionrequires minimal computer time per stu-dent. The computer can administer diag-nostic tests, keep a running record of a stu-dent's progress, and prescribe sequences ofself-instruction on an individual basis. In-dividual prescription of instruction hasbeen described by Glaser (9), Flanagan(6), Kooi (13), Silberman (26), and others.

Feedback of Information

Many writers, in discussions of the feed-back of information to students, try toequate feedback, or knowledge of results,with reinforcement. If reinforcement is de-fined as making the occurrence of a givenresponse more probable, then under someconditions when a student responds cor-rectly to a question and receives immediateconfirmation, reinforcement may be said tohave occurred. Annet (2) and others, onthe other hand, have raised questions aboutequating knowledge of results with rein-forcement. The positive effects of feedbackon performance and learning are probablydependent upon the type of task requiredand the level of the learner. If involve-ment of the learner with a problem is heldat a high level, it may be necessary to with-hold knowledge of results for a finite period.In a recent study, Daniel (4) compared twogroups of students who took an achiev..ment test after instruction in experimental


psychology. One group was immediatelygiven the correct responses on the test; theother group did not receive the proper re-sponses until 24 hours later. Both grouipswere tested again one week later. Althoughit might have been predicted that thegroup that received immediate feedbackwould show the greatest gain on the post-test, this was not the case. The studentswho received the delayed feedback scoredsignificantly higher. When one observesthe amount of student interaction in thehall outside the classroom after a "good"examination, this result is not surprising.Sustained involvement appears to increasethe retention of information.

When one extrapolates the research onparticipation and feedback to the develop-ment of instructional materials, it becomesevident that these are vital factors to con-sider in the technology of displays of mo-tion picture and television. If these mediaare treated as just another means of "spray-painting" the student with information,then we are guilty of limiting the use ofthis technology to didactic methods. Filmsthat show phenomena without an interpre-tive sound track can be used effectively toincrease participation between students andteachers and to provide feedback on ques-tions that concern the student. Examplesare some recent films produced by the Edu-cation Development Center in Boston. Re-search indicates that television and motionpictures can be used appropriately to re-quire student participation through discus-sion or programmed instruction, accom-panied by adjudication of responses. Smithdiscusses, in great detail, the value of feed-back in instructional systems (27).

A Sample Program

A study under investigation at the Schoolof Medicine of Case Western Reserve Uni-versity will be described in some detail to

relate the principles of instruction describedabove to the design and preparation of acomplete teaching unit. The subject is con-genital heart disease as taught to second-year medical students during a period ofapproximately nine hours. The program ofinstruction was prepared in conjunetionwith Dr. Jerome Liebman, a pediatric car-diologist. Congenital heart disease had tra-ditionally been taught by lecture and labo-ratory demonstration. A brief descriptionof the material prepared for the new pro-gram is included, to show how certain prin-ciples were applied to transform the in-structional system in order to incorporateintensified student participation and to en-courage in the student the responsibility tolearn on his own.

1. Objectives. Each student received afive-page outline of objectives that includeda clear-cut description of what the studentshould be able to do upon completion of theunit. At least one example of test questionswas included for each objective. Answersto these questions were not made availableto the student. He had to seek the answeron his own. The rationale was that if astudent could answer these questions hewould know that he had attained a satis-factory level of competency. A samplingof the objectives and questions follows:

Example of Congenital Heart Disease Objectives

Given data on the catheter position, bloodoxygen saturation, and the pressures, the stu-dent should be able to:

A. State the anatomic diagnosis.B. Describe the degree and direction of any

existing shunt.C. Predict other pressures and oxygen satu-

rations not given.

Example of Congenital Heart Disease TestQuestion

A 25-year-old male had cardiac catheteriza-tion. The catheter was passed through the right

Some Implications of Research 107

brachial vein into the superior vena cava, rightatrium, right ventricle, and pulmonary artery.

Data were:

Oxygensaturation(per cent)

7070808098

Cathetertip

positionSuperior vena cavaRight atriumRight ventriclePulmonary arteryBrachial artery

mm Hgpressurem=3m=3100/320/3

120/80

The diagnosis is:

1. Anatomie diagnosis2. Physiology, including direction of shunt_

3. Characterize the probable pulmonary vas-cular bed

2. Lecture material. Information tradi-tionally given in four one-hour lectures wasdistributed in syllabus form to the studentstwo weeks prior to class instruction. Theseprinted lectures gave details of the basicpathology and physiology of congenitalheart disease. Professors were thus nolonger committed to dispensing a stream ofinformation during the scheduled lectureperiods and could devote time to answeringquestions and discussing unknown caseproblems that are described below. In an-ticipation of possible student queries, basicdiagrams on heart physiology were pre-pared on overhead-projection transparen-cies. Many students did not attend thescheduled question-and-discussion periodssince they were satisfied with their compre-hension of the material and preferred to usethe time in other ways.

3. Motion picture film. "Roentgen Anat-omy of the Normal Heart," prepared byDr. Mason Sones, Jr., was an 8-mm con-tinuous-loop film, with sound, for use in acartridge in the Fairchild Mark IV projec-

tor. Two copies of this film were placed in

the laboratory for students to view at their

convenience as reference materials.

4. Case problems. Six case problems oncongenital heart disease were prepared in

writing and distributed to students as un-knowns. Each case problem included 10 to20 questions for students to answer. Thecorrect responses to these problems wereavailable at the end of each case. The stu-dent was encouraged not to "peek" at theanswers until he had worked through thecase. At the end of each case, the studentwas instructed to view a cineangiogram toconfirm his diagnosis. The cineangiogramwas a short (10 to 20 second) motion pic-ture which showed the injection of radioopaque dye into various chambers of theheart. The motion picture was prepared asan 8-mm continuous-loop film in a cart-ridge for use on a technicolor projectorwithout sound. Students were able to stopthe film or advance it one frame at a time.Since the film was an endless loop, it couldbe viewed any number of times with mini-mum inconvenience. The vigorous natureof the students' discussion as they at-tempted to solve the case problems with thecineangiograms was evidence of their ex-tremely high involvement with this mate-rial. It was apparent that students partici-pated actively in the process of solvingclinical cases.

5. Slides with script. Slides (35 mm),with descriptive material, were supplied ontwo topics, Cardiac Catheterization andPathology of Congenital Heart Disease.The slides were encased in a Carousel pro-jector and made available to students in thelaboratory in a rear-screen projection sys-tem. Although this projection system couldhave been controlled by an audio tape thatadvanced the slides automatically, thismethod was not used because it might haveinhibited discussion by the students. It hadbeen observed in preliminary trials that,while students read the script and lookedat the slides, they discussed the materialand occasionally drew on the chalk board.An audio presentation with the slides, it


was felt, would discourage this type ofresponse.

6. Laboratory. The pathology laboratoryperiod was structured around a televisiondemonstration of common congenital heartdefects, allowing close-up magnification ofthe method of examining the heart. Afterthe demonstration, small groups of studentsexamined gross specimens themselves. Thiswas a "view it, then do it" type of exercise.Clear presentation, followed by individualparticipation, appeared desirable.

In summary, there was a conscious, con-sistent effort throughout the planning forthis unit to relate programmed instructionprinciples to the production of instructionalmaterials and the arrangement of learningexperiences. The student was told the ter-minal behavior expected of him; active par-ticipation was included; the student de-cided the sequence for use of the materialand set his own pace; and the student him-self could know where he was and how hewas doing.

REFERENCES

(1) Allen, W. H. Research on film use: studentparticipation. Audio Visual Communica-tion Rev 5:423, 1957.

(2) Annet, J. The role of knowledge of resultsin learning: a survey. In EducationalTechnology. New York: Holt, Rinehartand Winston, 1964, p. 279.

(3) Bloom, B. S. (ed). Taxonomy of EducationalObjectives, Handbook 1: Cognitive Do-main. New York: McKay, 1956.

(4) Daniel, K. B. The effects of immediate anddelayed reinforcement treatments with re-spect to knowledge of test results. In H.Hausdorff (ed.), A.E.R.A. Paper Abstracts.Washington: American Educational Re-search Association, p. 158.

(5) Evans, R. I. Resistance to Innovation inHigher Education. San Francisco: Jossey-Bass, 1968.

(6) Flanagan, J. C. Program for learning inaccordance with needs. Paper presentedat the American Educational ResearchAssociation Conference, Chicago, Feb. 1968.

(7) Fry, E. Teaching Machines and ProgrammedInstruction. New York: McGraw-Hill,1963.

(8) Glaser, R. (ed.). Teaching Machines andProgrammed Learning, II. Washington:National Education Association, 1956.

(9) Glaser, R. Adapting the elementary schoolcurriculum to individual performance.Proceedings of the 1967 Invitational Con-ference on Testing Problems. EducationalTesting Service, 1968, p. 3.

(10) Ham, T. H. Research in medical educationparticipation of faculty and students. AnnNY Acad Sci 128(Art. 2):501, 1966.

(11) Hilgard, E. R. Theories of Learning. NewYork: Appleton-Century-Crofts, 1956.

(12) Jaspen, N. Effects on Training of Experi-mental Film Variables Study II: Verbali-zation, "How it Works," Nomenclature,Audience Participation, and SuccinctTreatment. SDC Technical Report 269-7-11. Port Washington, N. Y.: Special De-vices Center, 1959.

(13) Kooi, B. Y. Definition of course objectivesand preparation of diagnostic tests forIMS. Paper presented at the AmericanEducational Research Association Con-ference, Chicago, 8 Feb. 1968.

(14) Lange, P. C. (ed.). Programmed Instruc-tion, The Sixty-sixth Yearbook of theNational Society for the Study of Edu-cation. Chicago: University of ChicagoPress, 1967.

(15) Lumsdaine, A. A. Instruments and media ofinstruction. In N. L. Gage (ed.), Hand-book of Research on Teaching. Chicago:Rand McNally, 1963, p. 583.

(16) Lumsdaine, A. A. Mass Communication andeducational media. Ann Rev Psychol16:475, 1965.

(17) Lysaught, J. P., and C. M. Williams. AGuide to Programmed Instruction. NewYork: Wiley, 1963.

(18) Lysaught, J. P. (ed.). Programmed In-struction in Medical Education. Rochoster,N. Y.: Rochester Clearinghouse, 1963.

(19) Machiavelli, N. The Prince. New York:New American Library, 1962, p. 49-50.

(20) Mager, R. F. On the sequencing of instruc-tional content. Psychol Rep 9:405, 1961.

(21) Mager, R. F. Preparing Instructional Objec-tives. Palo Alto, Calif.: F. P. Pearon,1962.

(22) Reid, J. C. and D. W. MacLennan. Researchin Instructional Television and Film.

Some Implications of Research

Washington: Government Printing Office,1967.

(23) Saettler, P. A History of Instructional Tech-nology. New York: McGraw-Hill, 1968.

(24) Schramm, W. Learning from instructionaltelevision. Rev Edue Res 32(2):156, 1962.

(25) Schramm, W. The Research on ProgramedInstruction: An Annotated Bibliography.Washington: U.S. Office of Education,1964.

(26) Silberman, H. F. Design objectives of theinstructional management system. Paperpresented at the American EducationalResearch Association Conference, Chicago,8 Feb. 1968.

(27) Smith, K. U., and M. F. Smith. CyberneticPrinciples of Learning and Educational

Design. New York: Holt, Rinehart andWinston, 1966.

(28) Staats, A. W. Human Learning. New York:Hiolt, Rinehart and Winston, 1964.

(29) Stenchever, M. A., and D. Z. Kitay. Work-book in Obstetrics and Gynecology: La-bor. Unpublished manuscript, 1967.

(30) Taber, J. I., R. Glaser, and H. IHI. Schaefer.Learning and Programmed Instruction.Reading, Mass.: Addison-Wesley, 1965.

(31) Tyler, R. W. New dimensions in curriculumdevelopment. Phi Delta Kappa, Sept. 1966.

(32) Wilds, P., and V. Zachert. Applications ofGynecologic Oncology. Springfield, Ill.:Charles C. Thomas, 1967.

(33) Wilds, P., and V. Zachert. Essentials ofGynecologic Oncology, 2nd ed. Springfield,Ill.: Charles C. Thomas, 1967.

109

APPLICATION OF LEARNING RESOURCES IN THE VETERINARYCURRICULUM

ROBERT GETTY, D.V.M., M.S., PH.D.*

Within the past two decades the scope ofveterinary medicine has been broadenedto include many new courses in the curric-ulum in addition to the time-honored studyof such basic courses as anatormy and phys-

iology. New courses are continually beingadded to the curriculum and existingcourses are being expanded. More and morestudents must be taught with little increasein available manpower. In addition, wemust fit into the same time allocation vastamounts of new material. Faced with simi-lar educational problems, the armed forces,industry, and educators in other fields havemet this challenge by instigating variousvisual and audiovisual methods of presen-tation (1, 2). Computers and other elec-tronic systems for retrieval and correlationof stored information are now occupying adominant position in the broad concept ofautomation. Their application in medicineis increasing. However, in this paper I shallconfine my remarks to the various audio-visual methods of presentation available,rather than discuss data retrieval systemsin general.

For the past 50 years medical educationand veterinary medical education have pro-gressively raised their standards. Formalmedical education and training now re-quires a minimum of seven years and vet-erinary medical education a minimum of

*President, Audiovisual Conference of Medicaland Allied Sciences, Chairman, Audiovisual Com-mittee, College of Veterinary Medicine, and Pro-fessor and Head, Department of Veterinary Anat-omy, Iowa State University, Ames, Iowa.

six years. The majority of students spendmore time in the academic environment,and a lifetime of learning is universally en-dorsed in principle, if not in fact. Everyfleld neeus more trained bteaeiiers ald per-sonnel, and certainly medicine and publichealth are not exceptions. Continuing edu-cation is equally vital.

In recent years there has been an in-creased demand for veterinarians trained inpublic health and preventive medicine.Human health and welfare are dependentupon an adequate food supply. Thus, theveterinarian has a dual responsibility, botheconomically and toward his fellowman, forhis efforts are also concerned directly withhuman health problems. Consequently,there will continue to be a great demandand a need for more individuals trained notonly in veterinary medicine in general but,more specifically, in veterinary publichealth and preventive medicine.

Two questions can logically be raised:How can we meet this challenge? And howwe go about finding the means, the money,the men, material, and motivation to ac-complish our goals and objectives?

Audiovisual Aids

To remain within the confines of mytopic, I shall first list the audiovisual aidsthat we have at our disposal and mentioncertain advantages of a few:

1. Old-fashioned blackboard and chalk2. Overhead projection

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Application of Learning Resources 111

3. Color pictures4. Three-dimensional camera and slides5. Plastic-mounted specimens6. Corrosion specimens7. Dry specimens8. Moist specimens9. Sound films

10. Polaroid transparency systems11. Microprojection12. Television

It is interesting to note that I listed thesesame audiovisual aids in 1956 in a paperentitled "Teaching Aids in VeterinaryMedicine" (3). I also discussed some ofthe advantages of these visual aids in 1954in a paper entitled "Visual Aids and TheirApplication to the Teaching of VeterinaryMedicine" (4). I mention these previouspresentations to emphasize the fact thatmany of the visual aids that are beingdiscussed today in educational cireles wereavailable 15 and even 20 years ago. Rela-tively few new teaching devices have be-come available in recent years, namely,videotapes, cartridge film, and the cartridgeprojector, which can be synchronized witha standard tape recorder.

Before discussing the merits of the olderso-called multimedia approaches to audio-visual education and the advantages of thenewer hardware, we should ask ourselveswhy we continue to suffer from the century-old predominance of the spoken word in theusual teacher-student classroom lectureprocedure.

One educator has indicated that thereis a strong alliance by the students aswell as the staff and the administration toadhere to the old. This may have beentrue in the past, but the present generationof students-even medical students-nowreject this passive role. They demand theright to participate in educational decisionsand policy-making (5). The students oftoday want to take an active part in theirown education. This changing attitude is,in itself, a compelling reason for the use of

the newer concepts that utilize audiovisualdevices for individual self-instruction. Thestudent can set his own pace if physicalplant facilities, such as carrels equippedwith modern audiovisual self-instructionalhardware and software, are available (6).

Before discussing the newer audiovisualmedia in detail, it would be remiss not toemphasize again the fact that many of thevisual aids that are now at our disposalhave been readily available for many years,but unfortunately their true potential hasnot been fully exploited (7).

The infrequent use of the overhead pro-jector is a good example. In spite of themany advantages of these projectors, thereare those who shy away from them simplybecause they do not know all that can bedone with them. Others who do use themfail to recognize the full extent of theirversatility. With the use of an overheadprojector, for example, radiographs maybe projected. Overlays may be made indifferent colors, thus building up a detailedconcept such as the ascending and descend-ing tracts of the spinal cord. The overheadprojector enables the speaker, while hetalks, to create visuals that are immedi-ately enlarged and projected on a viewingscreen. The illuminating system is suchthat one can leave the lights on in the roomand still obtain satisfactory projection.The operator can face the audience whilepresenting his material. The instructor candraw or write on a cellophane roll and havethe image of what he is writing or drawingprojected on the screen. The projecteddrawings can be used as negatives for theprinting of pictures and graphs, which canbe passed out to the student during thelecture or used in continuing education.Thus, the student or practitioner has apermanent, accurate record of the drawing.This saves the student the time that wouldotherwise be spent in copying the drawingfrom the blackboard. There are many other


relatively inexpensive visual aids whosetrue potential has not been completely ex-ploited.

Even colored movies and three-dimen-sional pictures are not beyond the realmof the average departmental budget. Wehave been producing our own movies foryears in the Department of VeterinaryAnatomy at Iowa State University on whatwe consider to be a shoestring budget, andyet the movies have not only been wellreceived in our own University but havebeen purchased by fellow institutions,translated into several languages, andshipped abroad, which certainly indicatesthe need for material of this type. One doesnot have to have a budget of $30,000 or$40,000 to make a single movie or an audio-visual aid. Our films were made at a costof approximately $300 each (4, 8, 9, 10).

It is quite evident that we have had atour disposal for many years ample visualaids and the hardware that would lend itselfto alleviating some of the problems thathave been raised in recent years becauseof the information explosion and the mas-sive amount of material that must be as-similated in formal education in shorterperiods of time. Until our faculties andadministrators fully appreciate and recog-nize the value of modern biomedical com-munications technologies, we will continueto suffer from not employing to the fullestextent the technology that is at our dis-posal. I feel that the inertia in this areais due to a lack of knowledge.

Workshops

In order to remedy this situation in part,I propose that workshops be set up at indi-vidual professional schools about the coun-try and, hopefully, within each veterinaryschool-during which the staff, students,and administrators (and practitioners aswell) would become educated in the use

of existing facilities and in the use of multi-media devices for large and small groupsand individual learning situations. Theseworkshops could discuss photography,closed circuit television, programmed learn-ing material, videotapes, and the properand effective use of the time-honored 2 x 2"lantern-slide projectors and movie projec-tors. The net result, I believe, would be abetter appreciation of biomedical communi-cations in general and an upgrading ofeducation at all levels. The multimediaapproach to education, while not a substi-tute for the good teacher, should and canbe used to improve the level of teachingby reaching larger audiences miore effec-tively and efficiently. We have the hard-ware; it is only a matter of knowing howto put it to good use.

A second factor to consider is the lackof software. This situation could be im-proved if workshops were conducted in thisand other countries. With an increasedrealization of the many values and poten-tials of the hardware in existence, moreand more time could be spent in the pro-duction of software.

Core Material and Integration

The basic concept of modern teachingemphasizes the need for conceptual meth-ods of teaching broad principles-or corematerial. Gaps must be filled in by newerand different teaching methods. The in-tegration of subject matter can, in manyinstances, be accomplished with pro-grammed material as well as with conceptfilms and videotapes. The need for addi-tional staff and larger budgets to prepareand obtain this material is evident.

Separate Department of BiomedicalCommunications

It is hoped that all U.S. colleges of vet-erinary medicine will soon have a depart-

Application of Learning Resources 113

ment of biomedical communications. Manyof our health-related professions have fora long time recognized the need for suchdepartments. Dr. Ian C. Bennett, speakingat the Ninth Annual Meeting of the Councilon Medical Television in New York Cityin May 1967-on "Why a Division ofCommunication in a Medical Center?"-stated that 25 out of the existing 88 medicalschools then had a medical communicationsexpert and a division of medical communi-cations.

In our opinion (6, 7, 9), this departmentshould be charged with the responsibilityof developing audiovisual material andstimulating the use of audiovisual equip-ment as well as aiding in the technical andprofessional aspects of visual aids in gen-eral and television in particular. Theestablishment of such a department wouldfacilitate undergraduate, graduate, andcontinuing education in our veterinaryschools. In many medical schools, the di-rector of such a program is listed as theDean of Medical Communications. Hisstaff should include a full-time artist, aprofessional photographer, computer anddata retrieval experts, and assistants withPh.D. degrees in education.

Learning Resource Center

With the possible advent of new physicalplant facilities at Iowa State University,it is hoped that a Learning Resource Centerwill be built which will utilize and capi-talize on the many available and newerfacets of audiovisual education. ThisLearning Resource Center should be com-posed of rooms in which the student can,on his own time, use any and all availablevisual and audiovisual aids such as conceptfilms, videotapes, and programmed mate-rial. It would be a library of visual andaudiovisual aids instead of textbooks. Thiswould allow the student to preview and

review material, to correct errors in histhinking which might be revealed by ex-aminations, and actually to assume re-sponsibility for his own education. Thestudent's dependence on repetition in for-mal lectures would be nullified in time bythe realization that his progress is largelyhis own responsibility and by putting athis disposal at all times of the day thisLearning Resource Center, which wouldpermit him literally to dial informationfrom a retrieval center encompassing visualaids of all types.

Anatomy Teaching Modules

I would like to discuss briefly my conceptof an anatomy teaching module and itsintegration into the over-all biomedicalcommunications approach to veterinaryeducation. This particular module (Figure1) is for 20 students and one instructor andcould be used for many disciplines in bothundergraduate and graduate teaching. Theroom is designed to accommodate studentsstudying both macroscopic and microscopicanatomy. The installation of TV monitorsand a two-way audio system would enablethe instructors in the module to communi-cate with the professor who presents thedemonstration from another portion of themedical complex. The student can directquestions either to the instructor in hismodule or, by way of the audio system, tothe demonstrator himself. Combining theteaching of both macroscopic and micro-scopic anatomy in one module will save notonly space but also money and, in addition,will provide a more effective and efficientmeans of presenting the material.

Closed Circuit Television and Videotapes

The closed circuit TV arrangement wouldinclude the use and preparation of video-

_ _~~~~~~~~~~~~~~_ ~ ~ ~ ~


Figure 1. Proposed teaching module for a department of veterinary anatomy (gross andmicroscopic).

tapes for the teaching of both macroscopicand microscopic anatomy. We already areutilizing this method at Iowa State Uni-versity in the Department of VeterinaryAnatomy (6). The videotapes for the les-sons (or at least the core material) of eachsubject would be shown during classroom-teaching time and would also be availablefor student use in the carrels that are to bebuilt in our audiovisual research center.

The role of television in medical educa-tion has been clearly outlined and de-fined (11, 12, 13), and the general field ofbiomedical communications, its problemsand its resources have been summarized inexcellent fashion by Lieberman (14). Inhis introductory remarks, made at a con-ference on this subject, Dr. Liebermanstated: "In the field of medicine, man'sdiscovery of knowledge threatens to bogdown because of unequal efforts to assess

and apply that knowledge. This is notbecause of a lack of technology with whichto move information but rather because thenew tools are not being employed. I wouldconcur with this statement completely andadd that veterinary medicine, in my opin-ion, should lead in the use of audiovisuals,since it is concerned with more than half adozen species, whereas the other health-related sciences are concerned primarilywith only one species-man. Thus, in onerespect, time is a greater factor in theteaching of veterinary medicine. It is im-perative that our veterinary colleges andour state and national organizations catchup with the other health-related sciences ineducational methodology (15). I have pre-sented possible solutions to some of theseeducational problems in several publica-tions (7, 9). The use of television in teach-ing large university classes has been well

Application of Learning Resources

described by Drs. Roberston and Pyke (16).Winifred Hector (17) discussed the theoryof programmed learning, emphasizing thatthe student should progress at his own speedand respond actively at every stage in orderto demonstrate his understanding of eachstep in the logical sequence of the lesson;Hector concludes that learning must takeplace at the student's own pace and out-lines the steps necessary to present a lessonin programmed learning.

Dr. Novak, in the opening speech to theAudiovisual Conference of Medical andAllied Sciences held in Washington, D.C.,in 1966, pointed out that individualizedstudy units with integrated multimediapresentations produced a higher achieve-ment level than did conventional labora-tory presentations. This was attributed tothe fact that students were able to controltheir own rate of learning through the com-bined facilities of closed circuit TV, indi-vidual audiotaped lessons, 8-mm loop films,printed study guides, and small-group semi-nars. The integrated approach to learningwith emphasis on independent study hasalso been evaluated by Drs. Postlethwait,Novak, and Murray (18).

Cartridge Film Projectors and AudiovisualTapes

In my opinion, two of the most significantaudiovisual innovations since the 1950'shave been the development of the cartridgefilm projector and the development ofaudiovisual tapes. Movable audiovisualtape recorders are now available at priceswithin the reach of many university depart-ments.

The advantages of cartridge projectorsand films lie in the fact that the studentboth in the classroom and in the field canproject short concept films at a time andplace of his own choosing. The staff andadministration does not have to be con-

cerned about the possibility of destructionof expensive equipment or film, since car-tridge film is almost foolproof. There is nofilm threading or rewinding, and one canchange the film in a matter of seconds. Thesmall Technicolor Super 8 Instant MovieProjector also lends itself to self-instruc-tional procedures.

As the cost of videotape recorders con-tinues to decline, the simple storage of un-usual or complicated demonstrations (sea-sonal syndromes, rare clinical cases, animalsshowing toxicity symptoms, etc.) may becaptured on film and placed on tape or oncartridge films, to be rerun at a later timeby the staff or the student, or shipped toother areas of the world. Dangerous, com-plicated, or time-consuming demonstrationsneed only be performed once if they arecaptured on videotape. In a matter ofminutes material can be demonstrated thatwould ordinarily take hours of preparationand many hours to demonstrate to smallgroups of students. The integration of pre-clinical and clinical subject matter can inmany instances be brought about by pro-grammed material, concept films, andvideotapes.

Classroom without Walls

There is a saying that we now have class-rooms without walls. This is a referencenot only to open and closed circuit TV butalso to the fact that videotapes can now besent by mail to various parts of the state,the country, and the world. In March 1968videotape classroom lectures were initiatedat industrial sites in many cities of Iowawhere engineers and industrial managerswere attending the lectures as graduatestudents of the Iowa State University Col-lege of Engineering. The courses were giventhrough videotape instructional television incombination with direct telephone hookupwith the instructor on the Iowa State Uni-

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versity campus. Closed circuit televisionand videotapes had been utilized for partialpresentation of many courses at Iowa StateUniversity for some time, but this was thefirst time that a complete off-campus coursehad been offered in this way (19). Anothercourse (Nutrition during Human Growthand Development) was offered by the HomeEconomics Department, using a similarcombination of videotape and telephone, theinstructor visiting the off-campus site atleast once a week. The fact that the smallAmpex 1-inch tape recorder, which is com-patible with all Ampex tapes and whichsold (in 1968) for $995, weighs only about60 pounds make this type of extensionteaching possible. The advantages of sucha system are as follows:

1. The tapes can be made on the campusin black and white or in color (if the moreexpensive Ampex tape recorder is avail-able).

2. The viewing audience is not requiredto listen to a certain closed circuit TVhookup at a specific time (or at a particularplace); videotapes can be sent anywhere foruse by any audience.

3. The material can be repeated severaltimes in one day or several times during theweek for those who may have missed oneor more lessons.

It is my understanding that the entireState of Colorado has now been classifiedas a residence campus for the use of video-tapes and that credit is now being given inmany courses at the Master's level for thistype of teaching (19).

In our own profession of veterinary medi-cine it requires but little imagination toforesee the time when much short-coursematerial, including courses for credit, willbe placed on tape and mailed to area exten-sion offices or hand-carried by extensionveterinarians to regional veterinary associa-tion facilities, where they can be shown and

questions can be asked. Another methodwould be to ship the tapes out on a weeklybasis, followed by a visit of the extensionveterinarian (or the instructor or professorin charge of the course), thus updating vet-erinarians throughout the state on newermethods of treatment, diagnoses, surgicalprocedures, and public health problems.

The time may not be too distant whenpracticing veterinarians in the field, as wellas those in governmental and other institu-tional positions, can take many courses forcredit which must now be obtained by per-sonal attendance and on-campus residence.The fact that Colorado has now declareud

the entire state a residence campus forvideotaped courses indicates a trend whichwill probably be accepted state by statethroughout the country.

Audiovisual education has grown beyondthe classroom stage. It has spread fromuniversity campuses to the countryside andto communities throughout the nation. Withthe growing availability of audiovideotaperecorders and the production of more audio-visual educational material by properlytrained and audiovisual-oriented collegepersonnel, with the blessings of college ad-ministrations and (hopefully) the financialassistance of both state and Federal govern-ment, all the health-related professions willbe able to remain abreast of the constantlychanging modern health sciences.

Distribution of Audiovisuals on a World-Wide Basis

It seems reasonable to hope that, withinthe near future, television monitors, video-tapes, and cartridge films will be as commonto the teaching process as the blackboardor the textbook. The following four-partproposal, which I made at a meeting of theAssociation of Land Grant Colleges in Den-ver in 1956 and subsequently published in

Application of Learning Resources

the Association's Proceedings (3), is asapplicable today as it was in 1956.

1. Perhaps it would be wise if all colleges anduniversities would have a committee or depart-ment of medical communications charged withthe responsibility of developing and stimulatingthe use of audiovisual equipment, films, etc., attheir disposal in their respective institutions.

2. Perhaps a quarterly or biannual newsletter,circulated to various institutions throughout thecountry by a central agency such as the Ameri-can Veterinary Medical Association, could keepus abreast of new films, contemplated and inproduction, and the availability of 2 x 2" lanternslides, kinescopes, and other audiovisual aids andtools.

3. Perhaps the publication and circulation ofan audiovisual handbook enumerating the audio-visual materials available in the field of veteri-nary medicine would prove useful. The selec-tion, evaluation, and proper utilization of thenumerous multisensory materials available couldbe outlined and emphasized. It is hoped thatthis information would prove helpful to bothadministrators and teachers.

4. It seems imperative that we evaluate thepresent audiovisual methods now at our com-mand and appraise their strength and theirweaknesses as they contribute to our own uni-versity educational program.

I believe that the above recommenda-tions, which I made over 12 years ago, arestill worthy of consideration. In fact, weneed only add that today the above sug-gestions are applicable not only on the stateand national levels but on a world-widebasis.

With the advent of the cartridge film andcartridge film proj ectors and with the avail-ability of videotapes and lightweight, mov-able videotape recorders, the most recentdevelopments in public health and preven-

tive medicine can be distributed to thosecountries and areas that the World HealthOrganization deems most appropriate. Theold saying that "the sky is the limit" maybe literally true, for the time is near whencommercial and noncommercial educationalprograms will be transmitted across thecountry and around the world by means ofsatellite television systems. In many in-stances, this would eliminate the necessityof personnel spending many months oryears as technical advisers in other parts ofthe world.

Audiovisual material produced for the useof one college could be translated into anylanguage and sent to any country whichdoes not have the hardware to produce itsown audiovisual materials. The alreadyexisting system of international cooperationbetween colleges could be extended, or evenslightly revised so that, instead of sendingtechnical advisers out of the country atconsiderable cost, audiovisual materialsmade for the use of a university in thiscountry could be converted and translatedby that university (or the World HealthOrganization) and sent to a sister universityin another country. By using tapes easilymade on inexpensive portable tape re-corders, specific questions and on-the-spotadvice could be conveyed back and forthvia the mail.

Unquestionably, the need and the chal-lenge are here, and our only deterrents areour lack of vision and the lack of funds atour disposal to explore these challenges andtheir many far-reaching ramifications.

REFERENCES

(1) Bildersee, M. U. Closed-circuit TV in Dar-ien. Educational Screen and AudiovisualGuide 43:644, 1964.

(2) Borza, J. Locally produced films do doubleduty in Cleveland. Educational Screen andAudiovisual Guide 43:646,1964.

(3) Getty, R. Teaching aids in veterinary medi-cine. Proc Ass Land Grant Colleges 70-71:383, 1956-57.

(4) Getty, R. Visual aids and their applicationto the teaching of veterinary medicine.Iowa State Univ Vet 17:33, 1954-55.

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(5) Sanazaro, P. J. Emerging patterns in medicaleducation. Mayo Clin Proc 42:777, 1967.

(6) Getty, R. The multi-media approach toveterinary education. J Amer Vet MedAss.q 150:74, 1967.

(7) Getty, R. New audiovisual methods in vet-erinary medical education. Iowa StateUniv Vet28:113, 1966.

(8) Getty, R. Recent developments in veteri-nary anatomy at Iowa State University.Iowa State College Vet 16:145, 1954.

(9) Getty, R. Possible solutions to some educa-tional problems in veterinary medicine.Vet Med 61:1033, 1966.

(10) lHassen, A. New developments in anatomy atIowa State University. Iowa State CollegeVet 29:35, 1961-62.

(11) Judge, R. D. Television: its role in medicaleducation. Visual Med 1:28, 1966.

(12) Judge, R. D., and M. T. Romano. HealthScience T'elevision: A Review. Ann Ar-bor: Edwards, 1966.

(13) Audette, L. G. The teaching of anatomy

with CCTV. Visual Sonic Med 2(5):16,1967.

(14) Lieberman, J. (ed.). Biomedical communi-cations: problems and resources. Ann NYAcad Sci 142(Art. 2) :335, 1967.

(15) Getty, R. Report to the A.V.M.A. of the14th annual meeting of the AudiovisualConference of Medical and Allied Sciences.Proc Business Sessions, A.V.M.A. AnnualMeeting, Dallas, 9-13 July 1967, p. 65.

(16) Robertson, G. J., and H. F. Pyke, Jr. Tele-vision in continuing medical education.Med Biol Illus 18:4, 1968.

(17) Hector, W. Programmed learning and theeducation of nurses. Med Biol Illus 18:33,1968.

(18) Postlethwait, S. N., J. Novak, and IH. Mur-ray. An Integrated Experience Approachto Learning-with Emphasis on Indepen-dent Study. Minneapolis: Burgess, 1964.

(19) Personal communication, J. Davis, AssociateGeneral Manager, WOI Radio-Television,Iowa State University, Ames, Iowa.

THE COMPUTER FACT BANK

MULTIDISCIPLINARY LABORATORY INTERRELATIONSHIPS

FRED W. CLAYTON, D.V.M.*

The Fact Bank Project at the Universityof Missouri is designed to locate, mobilize,and display for members of the health teamappropriate selections of the latest biomedi-cal information available. Practicing phy-sicians and paramedical personnel alike willfind the Fact Bank helpful (1) in improvingtheir understanding of mechanisms and pat-terns of health and disease; (2) in con-tributing to and stimulating their interestin lifelong learning; and above all, (3) incontributing to quality patient care.

The Fact Bank itself is an open-endedcollection of several hundred thousandpages of selected current facts, definitions,and basic science, clinical and research in-formation. A small but exceedingly im-portant portion of the Fact Bank will be inmachine-readable form (i.e., on magnetictape). The major portion of the collectionwill at first be on 16-mm microfilm in car-tridges, or on microfiche. Any one of thesepages, or any item in the machine-readableportion of the file may be displayed auto-matically within a few seconds, by means ofexisting programs with existing equipment.

When increased volumes of machine-readable textual information become avail-able, almost as by-products of the printingindustry, more and more of the Fact Bankwill be on magnetic tape, because this form

* Deputy Director, Computer Fact Bank, Mis-souri Regional Medical Program, University ofMissouri, Columbia, Missouri.

permits multiple low-cost transformationsof input data.

The key that unlocks the wealth of detailin the Fact Bank is the unique Depth Index,or thesaurus, now under construction. TheDepth Index will be entirely in machine-readable form on magnetic tape and willdisplay important relationships between keywords and concepts with the aid ofcarefully framed definitions and word asso-ciation maps. Emphasis will be on inter-disciplinary usage and quantitative rela-tionships.

Several rich sources of condensed medicalinformation are now available and will beused in constructing the Depth Index.These include the American Medical Asso-ciation's Current Medical Terminology, theNational Library of Medicine's MED-LARS-MESH System, and the AmericanCollege of Physician's Systematized No-menclature of Pathology, all available inmachine-interpretable form. Combined theywill furnish (1) thousands of key words andconcepts; (2) important synonyms, near-synonyms, and related words; and (3)cross-references, nomenclature code num-bers, and hierarchical relationships.

The Depth Index will be far more than aconventional thesaurus. It will be used asan authorized list for indexers in indexing,for searchers in locating answers to specificquestions, and for users generally, who.

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through its use, will become aware of im-portant new knowledge and hitherto un-suspected relationships.

The user will (1) enter the Fact Bankvia the Depth Index, using the key wordor concept of his own choice; (2) be ledrapidly to the preferred terms in the sys-tem; and (3) be shown the present wordassociation map, or universe of discourse,centering around these terms. In effect, hewill be negotiating the question himself andwill secure direct machine output when itis available from machine-readable stores.The indexes will be keypunched to selectedrelevant literature in the microfilm collec-tion (with page numbers), which will pro-vide additional important keywords forconsideration. These keywords can be ma-nipulated with the aid of such computerprograms as B. G. Lamson's "English In,English Out" system for surgical pathology.Dr. Lamson's system can display hier-archical relationships, to seven levels in all,and will accept new terms, if desired, andestablish links with other terms as appro-priate.

In summary, the Fact Bank and its asso-ciated Depth Index will enable the user:

1. To choose material containing answersto his specific questions at the time of hisgreatest interest and clinical need.

2. To become aware at the same time ofthe availability of additional new informa-tion, somrne of which, perhaps, he was notconsciously seeking.

3. To re-establish active contact with anongoing information system designed to

challenge him and to promote habits of life-long learning in his chosen profession.

In accordance with important require-ments of the Kansas-Missouri RegionalMedical Program, the Fact Bank Projectwill concentrate on information about heartdisease, cancer, and (especially) stroke,emphasizing basic medical science and clini-cal and research information. It will alsoinclude representative collections on con-genital, neonatal, renal, and infectious dis-eases, emphasizing pathophysiology andcausal mechanisms of disease.

A specialized collection of some 100,000pages of carefuilly selected bas scierice andclinical information is needed to workeffectively in any major discipline, such aspathology, or in any categorical researcharea, such as stroke, cancer, or heart dis-ease. The American Medical Association'sCurrent Medical Terminology containsmuch machine-readable information relatedto all of these areas. We have contacted theeditors of major medical journals who seemreceptive to the idea of making machine-readable text available for experimentaluses (almost as a by-product of their pub-lishing processes). Our policy will be touse such sources of authentic and up-to-date information on tapes to the maximumextent possible, in order to permit the mul-tiple low-cost transformations of input datarequired to assemble, condense, and inte-grate information from many disciplines.For many years to come, microfilm collec-tions will be needed to supplement ma-chine-readable information, especially incovering the older literature.

AUDIOVISUAL COMMUNICATIONS

AN ACTION PROGRAM

NORMAN L. COLE, PH.D.*

Almost daily, communications problemsare brought to representatives of the Na-tional Medical Audiovisual Center of theNational Library of Medicine for solution.The problems are posed by professionalpersons from leading schools throughout theUnited States, from schools abroad, fromregional medical programs, or from nationalhealth and medical organizations. In manyinstances, a person with great expertise inhis own medical specialty finds himself in afull- or part-time situation requiring com-munications knowledge that he does notpossess but which is necessary to solve anotherwise seemingly insoluble problem. Orthe problem may have originated with anational organization which, realizing themagnitude of a problem in continuing edu-cation, desires to reappraise its position anddevelop a plan for action.

The time for such action plans is now,and some organizations are moving rapidlyin this direction. Viewing the situationin toto, however, we find that there havebeen many plans, much talk, and surpris-ingly little action, except on an individualbasis.

The various reactions to our discussionsof audiovisuals at the National MedicalAudiovisual Center give insight into someof the problems and concerns of profes-

* Chief, Educational Studies and DevelopmentSection, National Medical Audiovisual Center,National Library of Medicine, Atlanta, Georgia.

sional persons related to the use of suchmaterials. Instructors welcome the possi-bility of using audiovisual materials tocommunicate routine information. Theycomplain that they spend so much timeanswering such questions as "What's atibia?" that they are unable to serve thepurpose for which the school hired them.Their attitudes toward communicationproblems vary from placing the burden oflearning entirely on the student to assum-ing that the student must be "spoon-fed."Their attitudes toward the purchase of newaudiovisual equipment vary from a desireto purchase the latest equipment withoutconsideration as to whether it is reallyneeded to a hesitancy to make any pur-chases because, next year, better equipmentwill undoubtedly be available. In addition,some instructors express a dislike for theidea of putting their presentations intoaudiovisual form. They do not have timefor the advance planning required and occa-sionally express fear of criticism that mayresult when colleagues view their presenta-tions. I am not surprised at their resistance,for in attempting to use audiovisuals as weknow them today, many instructors havemet with justifiable frustration.

The instructor cannot be expected to useaudiovisual material in conjunetion withclassroom presentations unless its use iseasy. He does not want the embarrassment

121


of mechanical failures. And, last but cer-tainly not least, he does not want to usematerial that is not specifically fitted to hisneeds.

A school that wants its instructors to useaudiovisuals should plan to provide a per-son-other than the instructor-to be re-sponsible for the acquisition, maintenance,and distribution of audiovisual equipment,if not also for its operation, and for thelocation and procurement of software suchas films and videotapes.

In addition, each classroom should be sodesigned and equipped as to provide bothan ideal learning environment for the stu-dent and an ideal teaching environment forthe instructor. To some degree, mostschools, even the most modern, have fea-tures which we consider to result from poorclassroom design. We see these problemseven in the blueprint stage when plans arebrought to us for review. Effective audio-visual communication demands adequatefacilities. Therefore, any plan for actionat the local level should include a carefulstudy of learning spaces and of the require-ments of those who will use them and areview of all architectural plans in progress.Faculty and students should not have toadapt themselves to adverse environmentaland structural conditions. Rather, thebuilding and environment should be adaptedto meet human needs and, parenthetically,there should be a functional relationshipamong the various buildings and their parts.

You may be able to perform this surveyyourself, or you may wish to secure theassistance of an architect specially trainedin classroom design. Unfortunately, thereare few specialists so trained. Students'viewing angles should be checked. Bothacoustics and physical comfort are of majorimportance. Consideration should be givento the way in which each room is to beused. Such features as console control ofprojection equipment and room lights by the

instructor, low-level illumination for stu-dent note-taking, and access to audiovisualpnuinment when and where it ;is needed are"musts."

On many occasions, we at the NationalMedical Audiovisual Center have beenasked to visit schools which want an evalua-tion either of their existing facilities or ofplans for new or modified facilities. Gen-erally, when construction is contemplated,we discuss ideas and review blueprints withthe architects. It would be conservative tosay that such a review is well worth while.We find that, from an architectural andengineering standpoint, the drawings arewell done. But the architect produces hisdrawings from the requirements given him,and he cannot be expected to produce anadequate plan unless he is told in detailhow each room will be used-each labora-tory as well as each classroom-both todayand 10 years from now. Only then can heconsider the feasibility of various plans,such as vertical and horizontal access fortelevision cable. Without information as tospecific needs, he can design little more thanboxes.

The question of whether it is practical toproduce audiovisual materials locally tomeet one's own needs is not an easy one toanswer. However, it is both possible andpractical to produce audiovisual material atthe local level with a minimum of means.A plan for action at the local level should,therefore, include a study of the feasibilityof producing materials for use with any oneof the more common delivery systems. (Inits simplest form such a plan would beconcerned perhaps with slides, then withslides plus audiotapes, and so on.)

In addition to documentation of visualmaterial on slides, film, or videotape, onemight consider the possible advantage ofpreparing more sophisticated productions.Such productions are time-consuming, how-

Audiovisual Communications 123

ever, and may require skills which the aver-age instructor may not have.

The instructor cannot be expected to pro-duce audiovisual material unless its pro-duction is easy. To assist in this-and forother reasons stated earlier-we thereforerecommend, as Dr. Getty did as far back as1956, that each school of veterinary medi-cine seriously consider the feasibility ofestablishing a department of biomedicalcommunication. The staff of such a depart-ment would be competent in those skills andtalents required to work with faculty mem-bers, to analyze curriculum content andspecific communications problems, and tocome up with means or products for theirsolution. Such a department would alsoserve as the focal point for ordering andmaintaining audiovisual equipment, so asto ensure ease of operation and compati-bility throughout the school.

We envision the administrator of such anactivity as having either department chair-man status or operating out of the dean'soffice. Ideally he should have in-depthfamiliarity with the fields of veterinarymedicine, education, and audiovisual com-munications. Such persons are now beingtrained in at least one graduate program.Under this administrator's supervision, asbudget allowed, would be project directorsand technicians with specific communica-tions skills-artists, photographers, and anelectronics specialist, to mention but a few.

The administrator's first task might wellbe the analysis of school needs and theexploration of ways in which the schoolmight work cooperatively with other com-munications resource persons and organiza-tions within the university and community.A community medical television systemsuch as that in Atlanta, which utilizes the2,500-megahertz bandwidth, is an exampleof one such cooperative relationship.

Often, excellent motion picture footageor slides are photographed by individual

faculty members. Regrettably, much of thismaterial is not accessible to others whocould use it.

Its inaccessibility may be due to aninternal communications problem-one in-structor does not know what another hasstored in his desk, and the students, unlessthey happened to see the material used inclass, are also unaware of its existence.Therefore, in every school, we recommendexpansion of the library to provide a com-prehensive service for the storage and re-trieval, by both faculty and students, ofinformation in as wide a variety of forms aspossible. Ideally, this learning resourcecenter should not only be staffed by at leastone full-time librarian but should be pro-vided with a mechanism for duplicating thestill photographs, slides, motion picturefootage, audiotapes, and videotapes of thefaculty. These duplicate materials would beavailable for use on demand, with the origi-nals protectively stored. Moreover, a cen-tral card catalog would list all availablematerials on a specific subject, regardlessof the medium. It would thus refer the userto texts, other publications, films, video-tapes, still photographs, etc., in a singlesearch operation.

Learning resource material produced atthe local level might also be of use nation-ally. Much of it, unfortunately, is notavailable for national use. It is conceivablethat, in individual schools of veterinarymedicine, money and time are expendeddocumenting or producing instructionalmaterials of essentially the same type asthose produced in other schools. This dupli-cation is, of course, wasteful wherever itoccurs.

To avoid duplication and provide assist-ance at the local level, any plan for action,therefore, should take into account theproblem of locating what has already beendone and is being done, both locally andnationally, in the area of audiovisual pro-


duction. I do not have even the remotestidea of the number of separate items in anysingle medium that might potentially beuseful to veterinarians, but I assume thenumber would be considerable. In our ownexperience, an intensive search for films inthe area of cancer turned up approximately1,300 titles, of which 1,200 were found to bestill available. A comparable number offilms were located in the area of neurologi-cal and sensory diseases. Whether they areuseful and current, one can only surmise,for no attempt was made to review andevaluate them.

Catalogs at various levels of sophistica-tion, and consequent usefulness, will requircevaluations of several types, varying withthe information sought:

1. At the first level, there is an urgentneed for a comprehensive catalog of allavailable materials in a particular subjectarea. Learning of such materials is not aneasy task. It requires surveying schools andproducers, searching the literature, andgetting one's name on distributors' mailinglists. These steps only begin to solve theproblem. The information obtained willvary in format and completeness. Some-times the information will be inaccurate;sometimes the items listed will be out ofdate or no longer available.

I would estimate that there are severalthousand audiovisual productions that,according to the standard informationgiven, would appear to be of use to instruc-tors of veterinary medicine and publichealth. The available listings of this typeneed to be assembled and put into somesort of order. Duplicate listings, which occurwhen the same item is distributed and pub-licized by several sources, must be elimi-nated. Since many present listings describefilms of peripheral interest, titles and de-scriptions must be culled and items of littleapparent value eliminated.

An investigation of this type might reveal

that the amount of available material whichwould be of use to veterinarians is limited.If such should prove to be the case, a ser-vice will still have been performed. Evena negative report regarding resource ma-terial in specific subject matter areas isvaluable. Until such a survey has beenmade, we will not know what is availableand what is not and cannot be sure thattime and money spent on new productionswill not be wasted through duplication.

Perhaps a search of the type outlinedabove has already been made. To myknowledge, however, not even the scope ofsuch a search has been defined, or a sum-mary of subject categories outlined.

2. At the next level, there is need for acatalog of audiovisual productions beingused in the profession and recommended ashelpful. Such a catalog could be preparedas a result of a survey in which reportingforms might be sent to every school of vet-erinary medicine and publie health in theUnited States and Canada. In addition totitle and description, the form could includethe information required to key the useof the material to a specific point in thecurriculum.

A second method of compiling a catalogof the above type would be to establish acommittee of subject-matter specialists toevaluate those slides, films, and other audio-visual materials which have promisingdescriptions. Logistically, however, this isa time-consuming task, since someone needsto borrow the items, arrange for their re-view, and return them to their sources.

Evaluations of this type would be sub-jective. While subjective evaluations canbe helpful, they should not be acceptedwithout reservations, for they do not mea-sure whether the material will or will notactually be effective when used by the stu-dents for whom it was designed.

3. At the highest level, there is an urgent

Audiovisual Communicattons

need for a comprehensive catalog in whichall audiovisual materials useful in veteri-nary medicine and public health are ade-quately described. The instructor planninga series of presentations (perhaps a seriesof videotapes), the researcher wanting toknow what has already been done in aparticular area, the practitioner with a par-ticular problem, the student seeking infor-mation-all could use such a catalog. Acatalog adequately describing educationalmaterial should provide information thatwill assist the user in judging the instruc-tional potential of available materials withhis particular group.

Who should undertake the task of locat-ing and evaluating useful audiovisual learn-ing resource material? It is my opinionthat the individual instructor should dowhat he can to help improve his own com-munications at the local level. It is also myopinion that the job of satisfying total cata-loging and evaluation needs, especially asthey relate to continuing education, is toobig a job for any one instructor to handle,with the limited resources of a single school.

If a school cannot do the job, who can?The instructor is in a better position toanalyze the curriculum, the audience, andthe possible uses of audiovisual materialsby his students than is a committee repre-senting a group of schools or a nationalorganization. On the other hand, a nationalgroup is in a better position to provide per-sonnel, equipment, and time-resourcescritical to the development of effectivecommunication materials. A broadly based,well-organized, coordinated effort is theonly solution to the problem. Whether sucha time-consuming and costly effort wouldbe worthwhile, only you can decide. Whoshould take the leadership and assume the

responsibility? Again, only you can decide.One advantage of documenting the avail-

ability and usefulness of audiovisual ma-terials is that it uncovers the possible need

for new production by the profession. Re-view of a well-prepared catalog, in con-junetion with analysis of the total need forlearning resource materials, would result ina clear picture of gaps which might be filledthrough audiovisual means. Priorities couldthen be set and a broad coordinated produc-tion program started.

It will not be easy to determine thoseparts of the curriculum where audiovisualsupport might be useful. I suggest, how-ever, that there might be merit in establish-ing an ongoing program to identify suchareas and to produce, periodically review,and update learning resources. This doesnot necessarily mean the establishment of acore curriculum, because I realize that needsvary, but it does mean that I recommendconsideration of the production, on a prior-ity basis, of a wide variety of materials thatcan be put into learning resource centers-so that faculty and students can draw, cafe-teria-style, as with texts on shelves, thoseitems which best suit their immediatepurposes.

Just as an individual instructor will notpersonally attempt to produce every textthat will be useful to him, neither will hetry to produce every videotape or motionpicture that he might deem useful. Andjust as specialists write texts in specificsubject areas, they might produce othermedia in their specialties. The learningresource center, then, would house a com-prehensive series of productions, represen-tative of existing opinions and methodolo-gies. Thus the instructor, in planning hisown presentation, would not be limited bylack of supportive material and would havea wealth of material from which to draw,the production of any item of which mightbe beyond his individual resources.

A new day will come if we want it to

come. There are many things possible with

the technology we now have. Whether we

really want to do something about it is

125


another question. The old shoe is comfort-able and can be worn as long as it holdstogether. As to the age-old problem oflearning, there are undoubtedly other solu-tions which I have not touched upon andof which I have not dreamed-but I dohope I have directed attention to the possi-ble advantages of working toward the de-velopment of a plan of action for the im-proved production, storage, retrieval, anduse of audiovisual resource material.

The plan I have suggested involves bothlocal and national participation. Questionsof leadership need to be decided and coursesof action apped out. I hopo cducators inveterinary public health and preventivemedicine will give this matter careful con-sideration and that, individually or as agroup, they will explore further the oppor-tunities that will result from more intensiveactivity in this area.

Part III

EVALUATION

EVALUATING THE STUDENT'S LEARNING

EDWIN F. ROSINSKI, ED.D.*

HOW WE DECIDE WHAT TO TEACH

Before the question of objectives, ordeciding what to teach, is considered, a par-ticular educational term must be defined.That term is evaluation. To the educatorthis term has a specific meaning and con-tains certain ingredients. These ingredientsare (1) objectives, (2) criteria, and (3)measurement. Therefore, in the process ofevaluation the first step is to decide whatto teach (objectives); the second step is tospell out the standards by which theseobjectives should be achieved (criteria);and the final step is to develop the toolsfor appraising whether the objectives are afact (measurement).

This is quite different from the normalor lay use of the term. In its common usagethe concern is usually with the measure-ment or appraisal part of the term. In thispaper, evaluation as defined above will serveas the frame of reference.

Now to consider the first part of evalua-tion-objectives-or, to state it anotherway, how to determine what it is that ourstudents are to achieve. To this end, severalquestions will be posed and answered.

Why Do We Need Objectives?

There are three paramount reasons whywe need objectives. Others may come to

*Deputy Assistant Secretary for Health Man-power, Office of Assistant Secretary for Healthand Scientific Affairs, Department of Health, Edu-cation, and Welfare, Washington, D.C.

your attention, but these three seem to bethe most significant.

1. Curriculum design depends on objec-tives. In all the literature dealing with cur-riculum development, a sina qua non ofsound curriculum planning is the develop-ment of objectives. A curriculum cannot bedesigned until it is firmly decided what thecurriculum should achieve. Thus, an objec-tive in veterinary medicine might be for astudent to be able to integrate and corre-late all his knowledge in physiology andanatomy so that he can effectively utilizeit in a clinical setting. A curriculum (withall its ramifications and complications) willhave to be designed so as to provide thiskind of experience. Or, if another objectivestates that a student should develop skillin the practical application of his knowl-edge in veterinary medicine, then the cur-riculum will have to be so designed as toprovide opportunity for him to put intopractice the knowledge he has gained inveterinary medicine.

Obviously this point could be discussedin considerable detail, but the discussionabove should suffice.

2. Teaching methodology depends on ob-jectives. The particular teaching materialsand methods to use cannot be decided untilobjectives have been stated! As an ex-ample, if an objective veterinary medicinecalls for a student to develop proficiency4nperforming skills, obviously he will notachieve this proficiency by merely listeningto a teacher lecturing about them. True,

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130 Evaluation

some proficiency can be imparted in a lec-ture, but the student will also have to seedemonstrations of these skills and have theopportunity to actually perform them withpatient care. Three different kinds of teach-ing methods have been considered here be-cause of the way the objective was stated:lecture, demonstration, and clinical per-formance. The same kind of thinking willhave to take place when making plans onhow to achieve any particular objective.

3. Appraising student progress dependson objectives. It should be obvious thatwhat a student has achieved cannot be mea-sured unless lt, is first elearly undersLoodwhat he was to achieve. For example, if astudent is to acquire certain knowledge,devices to measure this knowledge will haveto be developed. If he is to develop a certainskill, then ways by which the skills can beobserved will have to be formulated. Inthis case the kind of measuring device to bedeveloped depends entirely on the objective.

Is There a Difference between the Kindsof Objectives We Have?

There appear to be three major kinds ofobj ectives.

1. Objectives dealing with structure.These would be objectives that provide thebroad physical setting for a particular edu-cational program. These types of objec-tives are few and encompass an entireeducational program. Under this headingmight be listed such objectives as: "Todevelop an operational school of veterinarymedicine." This objective deals with merelyproviding a school of veterinary medicine.This classification may seem elementary;nevertheless, objectives can be classified inthis category.

2. Objectives dealing with process. Theseobjectives provide the particular setting inwhich something will take place in a school

of veterinary medicine. Such objectives asproviding a lecture, a laboratory, a demon-stration, or a clinical setting, can be classi-fied as objectives dealing with process.Process objectives are satisfied when theparticular teaching exercise takes place.These objectives are not concerned withwhether a student has actually achieved.

3. Objectives dealing with product. Theseare the objectives with which all (or most)teachers are concerned. They deal withbehavioral changes in the student. It isuniversally agreed that the primary purposein teaching veterinary medicine is to bringabout changes in the student so that heacquires certain kinds of knowledge, skills,understanding, and attitudes. In short,certain changes are to occur in the indi-vidual by virtue of teaching-learning.

What follows deals with such productobjectives, i.e., the changes that occur instudents.

Are There Different Levels of ObjectivesDealing with Product?

To answer this question it is necessaryto classify objectives into specific cate-gories. Here, again, three classificationsseem appropriate.

1. Over-all objectives. These might legiti-mately be called institutional objectives,such as the objectives of a school of veteri-nary medicine. Specifically, these deal withthe kind of end product a school of veteri-nary medicine wishes to produce. Usuallythis product is a student so educated thathe or she can be certified as a veterinarianupon completion of the educational pro-gram. To achieve this objective, the kindsof knowledge, skills, attitudes, and under-standing a student is to possess will haveto be stated in general terms. While theseare classified as over-all objectives, they arestill the concern of every teacher, for unit

Evaluating the Student's Learning 131

and teaching objectives as described belowmust be in harmony with the objectives ofthe institution.

2. Unit objectives. These are the objec-tives of a particular department, such asphysiology or anatomy. In unit objectivesa particular department refines the insti-tutional objectives to an operational level.Unit objectives are an attempt to particu-larize the objectives stated by an institu-tion. A department of physiology (oranatomy) will clearly have to spell out whatit is that a student should acquire duringhis tenure in the department.

3. Teaching objectives. As teachers, theseare the objectives with which each of us isconcerned. The daily lesson plan is for allintents and purposes an attempt to satisfyteaching objectives. Every time a teacherlectures, runs a laboratory, gives a demon-stration, or teaches in the clinic, he isattempting to satisfy certain teaching ob-jectives.

How Do We Decide What Our ObjectivesShould Be?

Again, it seems that three major factorsdetermine objectives. Stated another way,there are three major sources which mustbe considered when developing objectives.

1. The health needs of society. If we con-sider society in general, we can readily seethat our population is growing; that it willhave a larger proportion of younger andolder citizens; that it will be highly mobile;that a larger portion of our population willcarry hospitalization (ergo, larger numberswill be hospitalized); and that greateremphasis on ambulatory patient care willbe stressed. If it is agreed that all of theseare factors of our society, then they willundoubtedly affect the kind of medicalservice veterinary medicine will have toprovide. Therefore, in developing objectives

for veterinary medicine, the needs of societywill have to be considered.

2. The needs of the profession. Is, or will,veterinary medicine be content with merelyproducing practicing veterinarians? Willthere be a greater need for practitioners inhospitals, for practitioners in private offices,for practitioners in federally supported in-stitutions, or for teachers in schools ofveterinary medicine? Is there going to bean increased need for veterinarians inter-ested in research, and is there going to be aplace for technical assistants for veteri-narians? All of these questions will haveto be considered in terms of how they willaffect the future program in veterinarymedicine. The significant and crucial prob-lems of the profession will have to be con-sidered when objectives are being devel-oped.

3. Scientific developments. As discover-ies in medicine and medical care develop,these will have a role to play in the develop-ment of veterinary medicine programs.With the development of new drugs andtechniques, the content of a veterinarymedicine program will depend a great dealon scientific discoveries. The contributionsof science must always be considered whendeveloping objectives.

How Can We Decide Whether ObjectivesAre "Good"?

This question can be answered only by afaculty that is charged with the responsi-bility of developing objectives. However,there are criteria that can be applied toobjectives to determine if they qualify as"good." The following questions representthese criteria and can be applied to any setof objectives, whether they be over-allobjectives, unit objectives, or teachingobj ectives.

1. Are the objectives understandable? Or,asked in another way, does everyone know

132 Evaluation

the meaning of the stated objectives? Tosatisfy this criterion, objectives should bestated in such a manner that there is nodifference of opinion as to the meaning ofthe words used. This calls for the best useof language so that misunderstanding doesnot occur. The importance of this criterionshould be obvious; if objectives are notunderstood by all the faculty, then it islikely that, in teaching, members of thefaculty will be working at cross-purposes.What this criterion implies is that objec-tives should be stated in terms that meanthe same to all readers.

2. Are the objectives real? Objectivesshould be practical. They should not dealin sweeping generalities or in such futuristicconcepts or in such altruistic ideals that itwould be impossible for any educationalprogram to achieve them. Ideals are laud-able and have a place in the educationalprogram but being too idealistic borders onthe unrealistic. Objectives should deal withspecifics and should, if possible, be attain-able within the educational program.

3. Are the objectives measurable? Aneducational program, in order to prove itseffectiveness, should be able to producesome data that will prove that what it setout to do has been accomplished. To achievethis, objectives should be stated in termsthat can be measured. Measurability canbe classified into three additional categories.

Imnmediately measurable. At the completionof a particular teaching session, various mea-surement devices can be used to see whether astudent has actually achieved the desired out-comes. Immediately measurable objectives arethose that are part of the teaching objectives.

Intermediately measurable. These are theunit objectives that can be measured at the endof a particular course of study. In addition,the outcomes of an entire educational program,such as certification examinations, can be classi-fied as devices for measuring the intermediateprocesses of an educational program. Perhapsthe sole difference between immediately andintermediately measurable objectives is the

difference in the time span. However, both typesof objectives apply to the formal educationalprogram.

Ultimately measurable. This is the most diffi-cult type of measurability to achieve since, oncea student has left the confines of an educationalsetting, it is difficult to attest whether he isactually achieving and performing that whichthe educational program had hoped to instill ordevelop in him.

There is a strong relationship betweenthis and the preceding criterion (are objec-tives realistic?). If objectives are unreal-istic, it is impossible to tell in an immediate,intermediate, or ultimate setting if they areactually being achieved. While ultimaterieasu-rei7en'i, is di"'cult to accomplish, itshould not be discounted. There are plentyof ways in which follow-up studies can beconstructed to determine whether, in asetting outside the educational institution,a student is actually performing as heshould perform. As previously stated, thisis an extremely difficult means of measure-ment.

MEASURING WHAT WE HAVE TAUGHT

AND WHAT THE STUDENT HAS LEARNED

Before considering the measurementphase in the process of evaluation, it wouldbe appropriate to discuss the interval be-tween the time that objectives are statedand the time they are measured.

During that interval the whole teaching-learning process takes place. It is at thistime that the individual teacher must decideon the teaching methodology he will useto achieve the objectives, and it is then thathe must select the appropriate teachingmaterials to supplement the teaching meth-odology and decide on the learning theoriesmost suitable for his students. In addition,the teacher will have to display a sensitiv-ity to individual student differences and anawareness of individual student problems


and of all the other factors that comprisethe educational environment. Between thetime that the objectives are stated and thetime that they are actually measured, awhole galaxy of teaching-learning activitiestakes place.

This brief summary is not intended tominimize the effects of the teaching-learn-ing process but merely to bring into per-spective all the other material covered atthis Symposium and how it ultimatelyaffects the process of evaluation. No singleentity-teaching-learning, teaching method,evaluation-is of itself the most single im-portant factor but, woven together, theseentities create the pattern for an educa-tional program.

At the beginning, measurement was men-tioned as a part of evaluation. Another waythat this might be stated is that, in thisphase of evaluation, the concern is withappraising the extent to which studentsactually achieve the formulated objectives,whether they be over-all, unit, or teachingobj ectives.

Before deciding on a particular measur-ing device, it is important to consider theessentials that comprise a good measuringdevice. These criteria, or essentials, areapplicable to either a classroom or a labora-tory situation. They are concerned withmeasurement per se and, as such, haveapplicability to any kind of measurementtechnique or device.

There are several criteria for a "good"measurement device:

Objectivity

In interpreting the results of a test-ifthe test is to be perfectly objective-therecan be one and only one answer. This iswhat is meant by objectivity. If a student'sresponse to a test item was made availableto a group of judges in order to meet thecriterion of objectivity, regardless of the

number of judges looking at the student'sresponse, all would have to agree as to therightness or wrongness of the answer. Ifthe judges disagree, this particular testitem would not satisfy the criterion ofobjectivity. What objectivity means, then,is that there can be no difference of opinionas to what constitutes an interpretation ofan answer.

Often references are made to the termsobjective and subjective. In examinations,test items also fall into these categories.The usual paper-and-pencil test, consistingof such items as multiple-choice questions,can be classified as an objective examina-tion. Essay-type or discussion examinationsfall into the category of subjective becausemore often than not there is a difference ofopinion as to what should be the correctresponse to a posed question.

Even when dealing with essay questions,there are specific techniques that can beused to make essay-type examinationsmuch more objective than they are at pres-ent. In developing test items, examina-tions, or any kind of a measurement device,objectivity should always be a goal.

Practicability

A synonym for practicability might beeconomy. What this criterion means isthat measurement devices should notbecome so elaborate, complicated, or ex-pensive that the actual process of produc-ing, administering, or scoring the examina-tion is so time-consuming that it would beimpossible to accomplish in a reasonabletime. Undoubtedly it is possible to createmeasurement devices that could actuallyachieve all that they were designed to do,but these devices would be so involved andcomplicated that their use would be quiteunrealistic.

Therefore, in developing a measuringdevice certain sacrifices will have to be

134 Evaluation

made. Perhaps the examination cannot bequite as objective as it might be if it werelonger and more detailed. Individual judg-ment will have to play an important rolein deciding what measurement devices arepracticable for classroom use.

Reliability

By reliability is meant that a measure-ment device must have consistency. Forexample, if a student took an examinationon Tuesday and then took the very sameexamination on Thursday-all things beingequal-he should obtain the same score onThursday that he obtained on Tuesday.This is what is meant by reliability. Now,because certain things do happen betweenthe time the student takes the examinations,perfect reliability in educational measure-ment is never obtained. All things arenever equal! The goal, then, is a measure-ment device that is as reliable as possible.

To make sure that an examination devicedoes approximate perfect reliability, am-biguous statements, double-barreled state-ments, leading statements, and the likeshould be avoided. By avoiding these pit-falls in constructing measurement devices,the reliability of the instrument is improved.

Validity

Validity can best be defined by a ques-tion: Does the measuring device measurewhat it is suppose to measure? Or, to putit another way: What is the relation be-tween the measurement device and its crite-rion? Validity, while one of the mostimportant criteria, is in its purest sense themost difficult to obtain. The more elaboratemeans of obtaining validity will not be con-sidered here.

Generally speaking, making an empiricaldecision as to whether a measurement

device actually does measure what it issuppose to measure is a form of validity.If an examination in physiology is supposedto measure understanding of physiology,obviously merely looking at the examina-tion and seeing if physiology questions areincluded satisfies a superficial type ofvalidity. If the examination contains ques-tions on microbiology, it would obviouslynot be a valid examination because it isnot measuring what it is supposed to mea-sure. This is a very elementary form ofvalidity, but it is an accepted form.

There are other ways of obtainingvalidiy, buu these are statisticai. Themeans of obtaining statistical validity aremore complicated than those for obtainingreliability. But, again, they are worthinvestigating.

Once the essentials of a "good" measuringdevice are clearly established and accepted,it is possible to consider what to measure.

A close scrutiny of any set of over-all,unit, or teaching objectives reveals thatnormally they deal with such areas asknowledge, skills, and attitudes. Each ofthese will be considered in turn and illus-trations of the various ways in which theycan be measured will be cited.

Knowledge

The usual procedure for measuringknowledge is through paper-and-penciltests. These take various forms. They maybe essay-type or the more common "objec-tive" (or multiple-choice) type of examina-tions. Essay examinations have fallen fromfavor in the past few years. This is an un-fortunate development, since this type ofexamination has a definite place in atesting program, especially in measuring astudent's understanding. The reason theyhave fallen into disfavor is the poor wayin which the essay questions were posed.


Often such words as "discuss," "describe,"and "outline," are used as introductorystatements in essay examinations. Thefailure of teachers to state essay questionsin clear, concise terms so that a studentclearly knows what he is supposed to dohas also caused problems in scoring. Whatone individual instructor may consideran appropriate discussion of a question,another may not. What has happened isthat essay examinations have failed to beobjective.

To correct this situation there has been atrend in the use of objective, multiple-choice questions. Multiple-choice questionsfall into several categories: true-or-false,completion, matching, or actual multiple-choice questions, where several options orchoices are provided for each question.These types of questions have gained inprominence in the past few years because,while they are not necessarily easier to con-struct, they are considerably easier to score.If well constructed, they are highly objec-tive, but even in the construction of theseobjective-type questions there are numerouspitfalls which a test constructor mustavoid.

Another way to measure knowledge isthrough interview or a form of oral exami-nation. The laboratory is a good exampleof a place where interviews or questionscan be asked students to determine theirlevel of comprehension of a particularsubject. Well-worded questions can divulgemore than basic knowledge. They can alsogive some indication of a student's level ofcomprehension and his ability to synthesizeand correlate the basic information that hehas gathered.

The formal interview, as a technique formeasuring knowledge, will be discussed ingreater detail in the section on measuringskills, below.

Another good way to measure knowledgeis through observation, but observation of

itself is not enough, since a clear delineationof what is to be observed has to be formu-lated. Observation as a measuring tech-nique will also be discussed in greaterdetail in the section on skills.

These are the three major ways to mea-sure knowledge. The paper-and-pencil testis perhaps the most practical since it pro-vides specific data about those objectivesdealing with knowledge. These testingtechniques have their place but should bestudied more carefully.

Skills

In the field of physical therapy theacquisition of certain skills is of the utmostimportance. Yet little formal effort is madeto discover whether skill objectives haveactually been achieved.

The first way to measure skills involvesthe process of observation. Normallystudents are observed performing in alaboratory or in a clinical setting, and somegeneralizations as to student proficiency aremade, but when the teachers are asked todefine proficiency in finite terms, many areat a loss. It is not enough to say that anindividual is proficient in, say, doing aphysical examination. The observer mustdetermine what it is in a physical that thestudent does or does not do.

In the final analysis, observation, ingross terms, is not enough. The specificsto be observed must be listed so that astudent's strengths and weaknesses can bepointed out to him. This may involve thedevelopment of some sort of rating scaleby which a student's proficiency in each ofthe skills can be checked. The more refinedthe instrument, the more information itprovides. The use of rating scales has abeneficial effect on the learning process ofthe student, since he actually comes toknow his own weaknesses and strengths andcan take steps to correct deficiencies andfurther improve his ability.

136 Evaluation

Another way to measure the student'sskill is through the development of per-formance tests. These are not too dis-similar from the tests in which a studentplaces blocks in assigned spaces or stringsvarious sizes of beads. I do not knowwhether this approach is practical forveterinary medicine. I would, however,pose the question of whether this approachhas ever been fully investigated by veteri-narians in their educational programs. Itmight be possible to develop a test in whicha student actually has to perform a par-ticular activity while being checked to seewhether he has achieved the required levelof proficiency.

For all intents and purposes it is safe toassume that the best single way to measureskills is through the process of observation.The observation itself can be refinedthrough use of an observation form orthrough some sort of performance test.

Attitudes

Every professional school seems to agreethat one of its primary objectives is thedevelopment of "sound, wholesome, ethical,attitudes." Whether these attitudes con-cern fellow human beings or ethical be-havior in the profession is irrelevant; thefact that such attitudes should be developedis important. Yet, when a member of thefaculty is asked how he measures whetherstudents have actually acquired theseattitudes the answer is usually a blankstare or an indefinite response such as "Iknow what they have (or have not)acquired." When faculty members areasked to provide objective evidence as towhether these attitudes have actually beenachieved, nine times out of ten there is noevidence.

One of the reasons for this is that thedevices to measure attitudes, such as in-

ventories and scales, are rather complicatedand detailed as described in the literature.Understandably, the faculty avoids thedevelopment of such devices. There arecertain other steps, however, that can betaken to measure-although not quite soperfectly-whether attitudes are beingdeveloped.

One of the best and most simple waysthis kind of information on attitudes can beobtained is through anecdotal data. Thisinvolves maintaining a file on each student.Whenever a member of the faculty observesor hears some negative or positive state-ment about a student's behavior-whetherit concerns a fellow student, a patient, orthe faculty-this bit of evidence is enteredin the student's folder. After several yearsa number of these anecdotes become avail-able, and a pattern regarding the student'sbehavior can be detected. The use ofanecdotal records is perhaps the mostpractical approach for classroom teachers,since it does not involve the amount oftime that would be required in the creationof more refined instruments. Whileanecdotal records are not perfect, they atleast provide soine information about thestudent's attitudes.

These, then, constitute some of the majorways in which knowledge, skill, and atti-tudes can be measured. The measurementof understanding has been deliberatelyomitted, since there are differences ofopinion as to what constitutes understand-ing. The kinds of devices usually used tomeasure understanding are classified underpaper-and-pencil tests and have been dis-cussed above, under the heading of Knowl-edge.

Recent years have seen the creation ofvarious hybrid forms of examinations.These are now being investigated. The useof a test for diagnostic skills developed byDr. IH. J. Rimoldi of Stritch Medical Schoolat Loyola University in Chicago may be


adaptable for use in veterinary medicineeducation. The University of ColoradoSchool of Medicine has developed a seriesof films that measure a student's ability toobserve patient behavior and to correlatethis measurement with other data. Thework of other schools actively engaged inpreliminary work in the field of measure-ment shows tremendous promise.

It would seen expedient for every schoolof veterinary medicine to actively considerthe development of new measurement tech-niques. There is enough evidence in theliterature to indicate that the measurementdevices developed for public education andfor medical and dental education can beapplied to problems in veterinary medicine.They deserve your attention.

Appendix

PARTICIPANTS

Pedro N. AchaChief, Veterinary Medical Services, PanAmerican Health Organization, Regional Officeof the World Health Organization, Washing-ton, D.C.

Gaylord W. AndersonMayo Professor and Director, School of PublicHealth, University of Minnesota, Minneapolis,Minnesota

Robert K. AndersonAssociate Dean, College of Veterinary Medi-cine, and Professor, School of Public Health,IJniversity of Minnesota, St. Paul, Minnesota

Jacob BearmanProfessor, Division of Biometry, School ofPublic Health, University of Minnesota, Min-neapolis, Minnesota

Everett D. BeschProfessor and Head, Department of VeterinaryParasitology and Public Health, College ofVeterinary Medicine, Oklahoma State Univer-sity, Stillwater, Oklahoma

C. H. BiglandWestern College of Veterinary Medicine, Uni-versity of Saskatchewan, Saskatoon, Saskat-chewan, Canada

Donald C. BlendenAssociate Professor of Veterinary Microbio-logy and Chief, Section on Veterinary PublicHealth, School of Veterinary Medicine, andAssociate Professor of Community Health andMedical Practice, School of Medicine, Univer-sity of Missouri, Columbia, Missouri

A. B. ChildersDepartment of Veterinary Public Health,College of Veterinary Medicine, Texas A. & M.University, College Station, Texas

Gus CholasAssociate Professor, Department of Microbiol-ogy, College of Veterinary Medicine and Bio-medical Sciences, Colorado State University,Fort Collins, Colorado

Fred W. ClaytonDeputy Director, Computer Fact Bank, Mis-souri Regional Medical Program, Universityof Missouri, Columbia, Missouri

Daniel CohenProfessor and Chief, Section of Epidemiologyand Public Health, College of Veterinary

Medicine, University of Pennsylvania, Phila-delphia, Pennsylvania

Norman L. ColeChief, Educational Studies and DevelopmentSection, National Medical Audiovisual Center,National Library of Medicine, Atlanta, Geor-gia

Paul J. CoxDirector of Environmental Hygiene, St. PaulBureau of Health, St. Paul, Minnesota

R. P. CrawfordAssistant Professor, Institute of AgriculturalMedicine, College of Medicine, University ofIowa, Iowa City, Iowa

V. L. DahlAssistant to the Director, North Central MeatInspection District, Consumer and MarketingService, U.S. Department of Agriculture, Chi-cago, Illinois

Stanley L. DieschAssistant Professor, Department of VeterinaryMicrobiology and Public Health, College ofVeterinary Medicine, and Assistant Professor,School of Public Health, University of Min-nesota, St. Paul, Minnesota

Norman A. FishAssociate Professor, Department of VeterinaryBacteriology, School of Veterinary Medicine,Guelph, Ontario, Canada

A. I. FlowersProfessor and Head, Department of Veteri-nary Public Health, College of VeterinaryMedicine, Texas A. & M. University, CollegeStation, Texas

Dean M. FluhartyAssociate Professor, Department of VeterinaryPathology, College of Veterinary Medicine,Washington State University, Pullman, Wash-ington

Hugh S. FulmerProfessor of Community Medicine, Depart-ment of Community Medicine, University ofKentucky Medical School, Lexington, Ken-tucky

Robert GettyProfessor and Head, Department of VeterinaryAnatomy, College of Veterinary Medicine,Iowa State University, Ames, Iowa

138

Appendix 139

Joyce GogginAssistant Professor, Department of Epidemiol-ogy and Preventive Medicine, School of Vet-erinary Medicine, University of California,Davis, California

John H. HelwigProfessor and Chairman, Department of Pre-ventive Medicine, College of Veterinary Medi-cine, Ohio State University, Columbus, Ohio

Harold B. HubbardAssociate Professor, Department of MedicalMicrobiology, School of Veterinary Medicine,University of Georgia, Athens, Georgia

Ephren M. JacquesDirector, Ecole de Médecine Vétérinaire de laProvince de Québec, Saint-Hyacinthe, Quebec,Canada

William E. JenningsProfessor, Department of Microbiology, Col-lege of Veterinary Medicine, Auburn Univer-sity, Auburn, Alabama

David O. JonesProfessor, Department of Preventive Medi-cine, College of Veterinary Medicine, OhioState University, Columbus, Ohio

Russell K. JonesProfessor, Department of Microbiology,Pathology, and Public Health, School of Vet-erinary Science and Medicine, Purdue Uni-versity, Lafayette, Indiana

R. F. KahrsNew York State Veterinary College, CornellUniversity, Ithaca, New York

Donald C. KelleyAssociate Professor, Department of InfectiousDiseases. College of Veterinary Medicine,Kansas State University, Manhattan, Kansas

Ronald J. KolarDirector, Department of Education and Licen-sure, American Veterinary Medical Associa-tion, Chicago, Illinois

James D. LaneChief Veterinarian, Meat Hygiene TrainingCenter, Consumer and Marketing Service,U.S. Department of Agriculture, Chicago,Illinois

Paul LeavertonAssociate Professor, Department of Preven-tive Medicine and Environmental Sanitationand Department of Statistics, University ofIowa, Iowa City, Iowa

James LiebermanDirector, National Medical AudiovisualCenter, National Library of Medicine, Atlanta,Georgia

J. Douglas McCluskieDirector, Environmental Health Service, Den-ver Department of Health and Hospitals,Denver, Colorado

William F. McCullochAssociate Professor of Preventive Medicineand Environmental Health and Chief, Com-parative Medicine Section, Institute of Agri-cultural Medicine, College of Medicine, Uni-versity of Iowa, Iowa City, Iowa

W. J. MackeyVeterinary Director of Research Animal Hos-pital, College of Medical Science, Universityof Minnesota, Minneapolis, Minnesota

Angel MarquezProfessor, School of Veterinary Medicine, Uni-versidad Central de Venezuela, Maracay,Venezuela

Edward L. Menning, Lt. Col. USAFInstructor, Department of Veterinary Medi-cine, Medical Service School, U.S. Air Force,Sheppard Air Force Base, Texas

Victor S. MeyersAssistant Professor, Department of VeterinarySurgery and Radiology, College of VeterinaryMedicine, University of Minnesota, St. Paul,Minnesota

Ralph W. MohriAssociate Professor, Department of VeterinaryMicrobiology and Preventive Medicine, Col-lege of Veterinary Medicine, Iowa State Uni-versity, Ames, Iowa

Bennard L. MoseleySchool of Veterinary Medicine, University ofMissouri, Columbia, Missouri

John P. NewmanProfessor, Department of Microbiology andPublic Health, and Assistant Dean, College ofVeterinary Medicine, Michigan State Univer-sity, East Lansing, Michigan

Joseph E. OrthoeferInstructor, Department of Veterinary Micro-biology and Public Health, College of Veteri-nary Medicine, University of Minnesota, St.Paul, Minnesota

W. M. Osteen, Col. U.S. ArmyOffice of Assistant for Veterinary Services,OTSF, DH, Washington, D.C.

Henry M. ParrishProfessor of Community Health and MedicalPractice, School of Medicine, and AssociateProfessor of Veterinary Microbiology (PublicHealth), School of Veterinary Medicine, Uni-versity of Missouri, Columbia, Missouri

140 Appendix

John R. Riddel, Major U.S. Army5th A Student, 2277 Carter Ave., St. Paul,Minnesota

Hians P. -iem.a.n.Associate Professor, Microbiology, Depart-ment of Epidemiology and Preventive Medi-cine, School of Veterinary Medicine, Univer-sity of California, Davis, California

Edwin F. RosinskiDeputy Assistant Secretary for Health Man-power, Office of Assistant Seeretary for Healthand Scientific Affairs, Department of Health,Education, and Welfare, Washington, D.C.

Jack H. RussellChief Public Health Veterinarian, Division ofCommunicable Diseases, Ohio Department ofHealth, Columrnbus, Ohio

Walter W. SadlerProfessor, Department of Epidemiology andPreventive Medicine, School of VeterinaryMedicine, University of California, Davis,California

Ernest E. SaulmonDirector, Animal Health Division, Agricul-tural Research Service, U.S. Department ofAgriculture, Hyattsville, Maryland

Jay H. SautterProfessor of Veterinary Pathology, College ofVeterinary Medicine, University of Minne-sota, St. Paul, Minnesota

Paul R. SlchnurrenbergerBureau of Epidemiology, Division of Preven-tive Medicine, Department of Public Health,Springfield, Illinois

Leonard M. SchumanProfessor and Head, Division of Epidemiology,School of Public Health, University of Min-nesota, Minneapolis, Minnesota

Calvin W. SchwabeProfessor and Head, Department of Epide-miology and Preventive Medicine, School ofVeterinary Medicine, University of California,Davis, California

Morris A. ShiffmanAssociate Professor, Department of Environ-mental Sciences and Engineering, School ofPublic Health, University of North Carolina,Chapel Hill, North Carolina

Donald K. SmithAssociate Vice-President, Academic Adminis-tration, University of Minnesota, Minneapolis,Minnesota

James H. SteeleChief, Veterinary Public Health, U.S. PublicHealth Service, National Communicable Dis-ease Center, Atlanta, Georgia

H. J. SteinmetzAssociate Deputy Administrator, Consumerand Marketing Service, U.S. Department ofAgriculture, Washington, D.C.

William T. StickleyAssistant Professor, Division of Research inMedical Education, School of Medicine, CaseWestern Reserve University, Cleveland, Ohio

H. L. StoddardProfessor, International Veterinary IvMedicine,College of Veterinary Medicine, University ofMinnesota, St. Paul, Minnesota

W. Ri. StrieberChief Staff Veterinarian, Technical and Pro-fessional Development, Animal Health Divi-sion, Agricultural Research Service, U.S. De-partment of Agriculture, Hyattsville, Mary-land

F. T. Szatalowicz, Capt. U.S. Air ForceChief~ Geographic Zoonoses Branch, A.F.I.P.,Washington, D.C.

W. T. S. ThorpDean, College of Veterinary Medicine, Uni-versity of Minnesota, St. Paul, Minnesota

Sebastián Viale-RigoProfessor, School of Veterinary Medicine, Uni-versidad Central de Venezuela, Maracay,Venezuela

E. E. WedmanAssociate Director, Veterinary Medical Re-search Institute, College of Veterinary Medi-cine, Iowa State University, Ames, Iowa

Daniel F. WerringVeterinarian in Charge, Animal Hlealth Divi-sion, Agricultural Research Service, U.S. De-partment of Agriculture, St. Paul, Minnesota

L. P. Williams, Jr.Assistant Professor, School of Public Health,Tulane University, New Orleans, Louisiana

George T. WoodsAssociate Professor, Department of Pathologyand Hygiene, College of Veterinary Medicine,University of Illinois, Urbana, Illinois

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