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A physician looks at Holt Health

Editor's Introduction -- In The Textbook Letter for July-August 1994, an article titled "Leading Students into the Clutches of Quacks" described how the high-school textbook Holt Health promotes quackery and superstition. Now a pediatrician takes a broader look at Holt Health and cites many other reasons why this book is unfit for use in schools.
from The Textbook Letter, January-February 1995

Reviewing a high-school book in health

Holt Health
1994. 691 pages. ISBN of the student's edition: 0-03-075324-4. Holt, Rinehart and
Winston, Inc., 1120 South Capital of Texas Highway, Austin, Texas 78746.
(This company is a subsidiary of Harcourt Brace & Company, which is a part
of General Cinema Corporation.)

This Disappointing Textbook
Has Too Little That is Good

Philip R. Ziring

By almost any criterion that one can name, the overall state of health and well-being among teenagers in the United States is unacceptable. Furthermore, the health of some subpopulations (chiefly the teenaged members of minority groups, growing up in poverty) is deteriorating so badly that it may soon pose a threat to public health in our country as a whole, and it may even become a threat to national security.

The major elements of this picture are familiar to one and all. We see more and more violence directed at children and teenagers, including homicides committed by children and teenagers. We see large numbers of unintended pregnancies among our young girls (the spectacle of "children having children"), and we know how this helps to perpetuate subpopulations trapped in ignorance, poverty and pain. We see teenagers suffering high rates of sexually transmitted diseases, especially HIV infection and AIDS. We see poor levels of physical fitness among young people, alarming rates of malnutrition (including the malnutrition that is manifested as obesity), and widespread abuse of both legal and illegal drugs. And we see pervasive despair, in the affected subpopulations and in the rest of our society as well, over our apparent inability to develop culturally sensitive, caring and cost-effective approaches to solving these problems.

There certainly is enough work to go around, and it includes the task of teaching our country's youth about the real world and about how to maximize their chances of surviving, intact, into adulthood. This was the perspective that I brought to my reading of Holt Health. I hoped that Holt's book would turn out to be a modern instrument of health education -- a resource that classroom teachers could use in helping their students to learn about real life.

I have been disappointed. Although it displays frank writing in several places, Holt Health is not the bold, tell-it-like-it-is book that our high-school students need in these difficult times. It is too long on rambling passages about inconsequential topics like snakebite and "relaxation exercises," and it is too short on information about violence, about easy availability of handguns, about unwanted pregnancies, and about the other serious dangers that today's teenagers face. (Abortion is not discussed anywhere in the book, not even in any of the "Ethical Issues in Health" articles.) Nor do Holt's writers give guidance for seeking reliable information and confidential help from qualified medical professionals. (The existence of specialists in adolescent medicine is not even mentioned.)

In the matter of accuracy, too, Holt Health leaves much to be desired. It has a few sections that are relatively accurate and well written, but these are outnumbered by chapters that seem to have been produced by writers who knew very little about the subject matter. The book is filled with contradictory statements and outright scientific and medical errors, and it even subjects students to reverential claims about faith healers. Such claims have no place in a text that purports to present a modern, scientific view of the human body and human health.

I have given particular attention to five of the book's eight units, and I shall focus on those five in the rest of this review.

An Anti-Medical Bias

Unit Three, "Health and Your Mind," has some good aspects, such as its insights into building self-esteem and its six-page section titled "Death and Dying." In this same unit, however, the writers betray an anti-medical bias. For example, the use of psychotropic drugs to treat mental or emotional disorders is dismissed in one perfunctory paragraph titled "Chemical Therapy." In that paragraph, the writers perpetuate the myth that a well known antidepressant, representing a new class of drugs that have brought benefit to millions of patients, "appears to cause violent or suicidal behavior." Such misleading statements can discourage troubled students from seeking or accepting help from psychiatrists or other qualified physicians. Physicians are not on Holt's list of "Some Adults Who Might Be Helpful in a Crisis" (page 235), even though the student eventually will see, much later in the book, a reference to the importance of having a primary-care physician.

Unit Four, "Protecting Your Health in a Drug Society," and Unit Five, "Family Life, Sexuality, and Social Health," show too much confusion and misinformation. For example, on page 285 the writers state that "over 90 percent of lung cancer cases are caused by smoking," but on page 288 they say that "cigarette smoking causes 80 percent of all cases of lung cancer in the United States." (Those statements seem to contradict each other, and students may well wonder whether either statement is reliable.) On page 334 the writers say that some girls do not begin to menstruate until they are 17 or 18 years old, and that this is "perfectly normal." On page 338, however, the writers warn that "A girl who has reached the age of 16 and has not menstruated should probably see a doctor to make sure she doesn't have a medical problem." (The latter statement is the correct one.) The writers seem to think that only a male can attain an orgasm, and their one reference to orgasm (on page 327) is incorrect: "When a man ejaculates, he is said to have an orgasm." (Ejaculation and orgasm are two different things. Ejaculation is a mechanical event, orgasm is a subjective, emotional experience, and either may occur without the other.) On page 425 the writers make the strange statement that when men are raped, the rapists are usually "heterosexual men." On page 251 a table of "Drug Types" shows "hypertensives" as agents that "Work to prevent high blood pressure." (The writers presumably are referring to antihypertensives.) That same table says that antisera are "Stronger than vaccines." (Antisera and vaccines are important agents for preventing infection, but they have different mechanisms of action. They cannot be compared directly, and it is meaningless to claim that antisera are "stronger.")

Poor writing and editing have also led to inappropriate statements that bear on emotionally charged topics. An example is the claim that "The main job of the uterus is to provide a place for a baby to grow before birth" (page 333). First, the conceit that an organ has an appointed "job" is a vestige of the notion that nature is purposeful and that organisms have been rationally designed. That notion has no standing in modern science or medicine. More to the point, the claim that the uterus's "job" is "to provide a place for a baby to grow" implies that anyone who has a uterus also has an ordained duty to produce babies. That implication can only make it harder for pregnant teenagers to understand their circumstances and their choices.

Another example is the passage about acquaintance rape, or "date rape" (on pages 426 and 427). The writers' treatment of this important topic consists chiefly of two fictitious "accounts of an acquaintance rape" -- one account by the young woman who supposedly was involved (Ann), the other by the young man (Jim) whom Ann accuses of raping her. But these fanciful "accounts" are simple-minded and have been heavily rigged. Jim, who apparently doesn't grasp that he stands accused of a crime, relates a story that seems to confirm Ann's, so the student gets the impression that Ann's accusation must be valid and there is no need to examine the case with care. This doesn't reflect the real world, and there is great danger in leading students to think that an accusation is necessarily true and should be accepted without question. In the real world, an accused person may deny the charge, or may give an account that differs radically from the one given by the accuser, and investigators may be unable to reach any supportable conclusion about what actually happened. In the real world, an accusation may even be wholly false -- a story invented as an instrument of spite, vengeance or extortion. Holt's writers say nothing about these possibilities. The lesson presented to the student is dangerous and unacceptable.

I am pleased to report that Unit Six, "Diseases and Disorders," contains at least some material that is potentially valuable to today's teenagers. In chapter 22, the section on "Preventing Sexually Transmitted Diseases" includes an important passage about how to use condoms. (This passage would have even greater educational value if it were supported by illustrations.) The same section gives important information about the availability of public-health clinics where teenagers can seek help if they think they may have contracted an STD, and the Holt writers correctly emphasize that such clinics observe strict confidentiality: "You will not be required to get permission from your parents, and your parents will not be notified. . . . Public health clinics will keep your name, your diagnosis, your treatment, and any information you give them completely confidential."

I also must give some praise to chapter 23, "HIV Infection and AIDS." It is generally accurate and tells things that young people need to know.

Unfortunately, the remainder of Unit Six is marred by much confusion and by errors of fact. For example:

The writers are unable to give a clear statement of the difference between a communicable disease and an infectious disease, although any physician could have helped them to understand what the difference is. They don't seem to know that diseases such as tetanus or staphylococcal food poisoning are caused by bacterial toxins. They allege that "The most effective way to prevent hepatitis A is to wash your hands frequently when you prepare or serve food." They seem unaware that hepatitis A can now be prevented by the use of a vaccine, or can be attenuated by the use of gamma globulin. On page 455 they offer some advice that is just foolish -- to "see a doctor if you think you have a bacterial disease." How is a sick teenager to deduce whether he is suffering from "a bacterial disease," a viral infection, an allergic reaction, an endocrine derangement, an emotional problem, or some other condition? Why lead the student to imagine that he can perform such self-diagnosis? Isn't diagnosis one of the things that physicians are for?

On page 476 the writers make a claim that is deceptive: ". . . the truth is that many teenagers are not sexually active." But that vague statement has no quantitative meaning, and it is not an accurate representation of the quantitative information that we actually have in hand: Of the teenagers who stay in school, some 70% are sexually active by the time they are in the 12th grade. When Holt's writers make their claim about "the truth," they are not being truthful at all. They are promoting wishful thinking as if it were fact, and they are misrepresenting an important aspect of life among today's teenaged population. Students will know this.

Later in the unit, the chapter on "Noninfectious Diseases and Disorders" teaches serious misconceptions. Under the heading "Genetic Screening," the writers confuse genetic diseases with chromosomal anomalies. Under "Cerebral Palsy," they make misleading claims and perpetuate myths: "Lack of oxygen during a difficult birth is one possible cause [of cerebral palsy], but it can also be caused by exposure during pregnancy to radiation, certain drugs, and some diseases." (In fact, only a small minority of cerebral-palsy cases can be attributed to a deficiency of oxygen during birth, and most cases are inexplicable. We can only say that they have been caused by unknown prenatal factors that adversely affected the fetal circulation.) Under "Epilepsy," the writers wrongly assert that "Once the proper drug therapy is prescribed, an epileptic may go for many years, or for the rest of his or her life, without a seizure." (There is no medical justification for such a sweeping claim, and it is unfair to create such an illusion in the minds of children who may suffer from epilepsy or who may have epileptics in their families.)

Unit Seven, "Health and Society," offers a cursory chapter about environmental matters and then a chapter titled "Being a Wise Consumer." The latter chapter briefly compares traditional health-insurance policies with HMO contracts, but it fails to provide an accurate account of how the recent, dramatic growth of managed-care programs has wrought changes in our health-care system. This is a complicated subject, but students have to know something about it and have to understand that access to care is becoming increasingly restricted -- not only for adolescents but for members of all the other age groups as well. More and more consumers are dealing with managed-care organizations (which vary widely in their structures and practices), for-profit corporations are buying hospitals and health plans everywhere, and we now are preparing for capitated Medicare and Medicaid arrangements. Teenagers need all of the guidance that they can get in securing their access to health services.

That same chapter includes a feature article which implies that aboriginal faith healers are equivalent to medical doctors because the faith healers "must undergo years of special training" as they "learn the right ceremonies and rituals to perform for the different types of imbalance." How can such a thing get into a health book? Isn't it possible to describe aboriginal beliefs or practices, in a proper anthropological context, without equating "healers" to physicians trained in scientific medicine? Don't the writers understand that such misleading material may induce students to rely on dubious practices and to delay seeking scientific diagnoses and life-saving treatments?

Like various other health books, Holt Health has a lot of illustrations that are not closely related to the subject matter and do not give any real information. Of the illustrations that do try to convey information, some are good but others are erroneous or lack adequate captions. Figure 12-6, for example, indicates that asthma medications are inhaled through the nose. (In fact, they are taken through the mouth.) Figure 17-13 is a graph showing pregnancy rates among adolescents in six countries of the West, but the caption merely says, "The United States has the highest teen pregnancy rate of any industrialized nation in the Western world." (There is no interpretation of the graph as a whole or of the curves for other countries, and the book says nothing about correlations that might suggest why the United States has the highest rate.) Figure 22-8 shows a mass of blue, white or violet shapes while the caption says, "One of the early signs of hepatitis B is yellowing of the skin." In figure 24-5 an asthmatic girl is holding a peak-flow meter, not an "inhaler" as the caption says. (Nowhere in the book is there any reference to a peak-flow meter or to its value in helping patients to monitor their asthma.) The caption for figure 24-11 mentions "cancer" but doesn't tell what the figure shows. (Is that red object supposed to be a cancer cell? Is the figure intended to teach the false idea that cancer cells are red while other cells are not?)

In summary, Holt Health takes some important steps in trying to inform students about mental-health issues and about some aspects of human sexuality, but it also presents many errors of fact, shows serious distortions, and fails to give adequate coverage of important issues. It can't be recommended for use in our high schools.


Philip R. Ziring is a physician. He is chairman of the Department of Pediatrics at Cook County Children's Hospital (in Chicago) and chairman of the Department of Pediatrics at The Chicago Medical School.

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