A Dangerous Curve: The Role of History in America’s Scoliosis Screening Programs [American Journal of Public Health]

In 2004, the US Preventive Services Task Force called for an end to scoliosis screening in US public schools. However, screening endures, although most nations have ended their screening programs. Why? Explanations range from America's unique fee-for service health care system and its encouragement of high-cost medical specialism to the nation's captivation with new surgeries and technologies. I highlight another, more historical, reason: the persistence of the belief that spinal curvature is a sign of a progressive disease or disability. Despite improved health and the mid-20th-century discovery of antibiotics and vaccines that all but eradicated the diseases historically associated with scoliosis (e.g., polio and tuberculosis), the health fears associated with spinal curvature never fully dissipated. Scoliosis is still seen as a "dangerous curve," although the exact nature of the health risk remains unclear. (Am J Public Health. 2012;102:606-616. doi:10.2105/ AJPH.2011.300531)

IN 2004, THE US PREVENTIVE Services Task Force (USPSTF) called for an end to a centurylong practice of screening adolescent schoolchildren for scoliosis.1 According to its panel of medical and public health experts, scoliosis screening did not meet the criteria of evidence-based medicine, standards first articulated and upheld by the USPSTF and the US Public Health Service in 1984. The diagnostic tool-a visual inspection of a child performing a forward-bending test- remained unreliable, often leading to a sizable number of false-positive results.2 Schoolbased screening not only diagnosed scoliosis in children who did not really have it but also often led those who did have a mild curvature to endure painful and unnecessary brace wear.3 With this assessment, the USPSTF attempted to put America on the same path as many other industrialized nations (e.g., Canada, Great Britain, and Australia) that have overturned the long tradition of mandatory spinal screening of its school-aged citizens.4

Despite the USPSTF's stance, 33 US states still either mandate or recommend school-based scoliosis screening.5 Proponents of scoliosis screening maintain that early detection is necessary to catch and treat spinal curvatures before they become severe enough to cause chronic pain and negatively affect cardiopulmonary functioning.6 Although researchers at the University of Iowa have questioned the benefit of medical intervention in certain cases of idiopathic scoliosis, the Academy of Orthopedic Surgeons, the American Academy of Pediatrics, and the Scoliosis Research Society all endorse screening and bracing adolescents who have curvatures of greater than 10 degrees.7 These medical professionals believe that failure to screen for scoliosis would put thousands of adolescents at risk for developing a very real and, at times, disabling condition.

That more than half of US states still conduct school-based scoliosis screening, despite the USPSTF's recommendation against it, points to the examination's deep historical roots. At the turn of the 20th century, many US public schools and colleges began to subject their students to posture tests, precursors to today's scoliosis examinations. 8 School officials instituted these surveillance programs in the belief that poor posture begot bad health. Yet the medicalization of slouching persisted in the United States even after the widespread midcentury distribution of antibiotics and vaccines had largely eradicated disease-based scoliosis (i.e., spinal curvature that arose as a result of a concrete disease process). The threat was now "idiopathic scoliosis," a spinal irregularity for which the physiological cause is unknown. Although medical experts have long disagreed about what kind of (if any) health risks are posed by idiopathic scoliosis, the general trend in the United States has been to aggressively treat and screen for the condition. There are many reasons for this trend, ranging from America's unique fee-forservice health care system and its encouragement of high-cost medical specialism to the nation's captivation with new surgeries and technologies and an unswerving belief that every condition-deadly or not-can and should be cured.9

Skepticism about scoliosis screening has been voiced at numerous points over the last several decades, mostly by medical researchers outside the United States whose opinions have been drowned out by proscreening patient and medical advocacy groups, an assemblage of professional and lay activists who claim that arguments about cost containment and efficacy smack of socialist health care rationing. Screening skeptics do not deny that for a small segment of the population, scoliosis is a serious condition that can, in extreme cases, lead to intolerable pain and compromised organ functioning; they know, as do physicians who advocate screening, of cases like that of Louise F. Sohrabi, a self-identified "scolie" who, because of the severity of her back pain, regularly contemplated suicide before undergoing a risky surgery that brought about temporary relief.10 However, skepticism about screening does not imply doubts about the existence and physical reality of the condition. Screening is a highly targeted public health measure that must meet specific standards to be judged economically warranted and valuable to the overall health of a nation's citizens. Among its many purposes, an effective screening program should identify an important health threat by means of a simple, reliable test that is acceptable to the population being screened. The purpose of identification is to provide a proven treatment to those who show signs (but not necessarily symptoms) of the condition. Most important, the benefits of treatment must outweigh the costs of screening.11 Critics of scoliosis screening have questioned the test's effectiveness on all of the above counts but to no avail, at least in the United States. Why is this?

One answer lies with the long history of scoliosis and posture testing in the United States. Many current methods of spinal measurement and surgical treatments (including bracing) grew out of US-born, early 20th-century attempts to remedy spinal curvatures caused by poliomyelitis and tuberculosis. In response to a post-1960s generation of young idiopathic scoliosis patients, who largely took antibiotics and vaccines for granted and whose primary worry about spinal curvature was how it affected their cosmetic appearance, old-guard scoliosis activists in the United States insisted that the condition was an "insidious" threat to one's health. Indeed, concerned that attention to spinal deformities would wane in the wake of the pharmacological revolution, patient advocacy groups and certain orthopedic specialists retained the language of risk and fear used decades earlier, calling idiopathic scoliosis "a dangerous curve" that needed to be stamped out with early detection and treatment. Although the exact nature of health risk remained unclear, the "dangerous curve" message stuck and still shapes US screening policy and practice today.

By the turn of the 20th century, the US public school system had become a target of large-scale medical inspections. Certain Progressive Era policymakers and physicians worried that school made children sick.12 In the wake of the bacteriological revolution, school and public health officials understood all too well the danger of close person-to-person contact when it came to the spread of contagious diseases. But germs did not pose the only threat. Concerned physicians and schoolteachers believed that the actual schoolhouse environment could have a deleterious effect on students. Sitting long hours hunched over desks in poorly ventilated, darkly lit classrooms, they argued, contributed to poor eyesight, diminished hearing, and deformed bones. To better assess the ramifications of school learning on the blossom of youth, the Society of Medical Inspectors of the New York Health Department instituted a system of physical examinations in 1905 that specifically targeted physical disabilities rather than contagious disease.13 By 1925, a physician at Columbia University estimated that more than 75% of America's schoolchildren were "defective." Fifty percent had rotting teeth, 25% had poor vision, 5% had tuberculosis, and some 20% (4 million children) had orthopedic deformities, ranging from rounded shoulders and "pigeon chests" to flat feet.14 In response to these alarming numbers, the US Children's Bureau recommended that public schools physically examine their pupils once at the beginning of the school year and then again at year's end.15

By today's standards, a posture examination might seem like a quaint oddity compared with the more enduring practice of testing the eyes and ears, but the medical profession of the early 20th century believed that assessing bodily carriage held great predictive and diagnostic value. To them, the curves, bumps, and protrusions of an individual's body served as a topographical map for understanding the physiological workings under the skin, a kind of phrenological reading of the entire body. Before the midcentury discovery and mass production of antibiotics, dietary supplements, and polio vaccines, a hunched back could indicate a variety of possible disease processes, such as bone tuberculosis (better known at the time as Pott's disease), rickets, infantile paralysis, and empyema (pleuritis).16

The medical experts who researched posture in the first decades of the 20th century believed that poor bodily comportment was not only a sign of disease but also a causative factor of ill health. Harvard orthopedist Joel E. Goldthwait published widely on the matter. Goldthwait used the latest roentgenography technologies to show how a slouching posture cramped the lungs, pinched off circulation, and caused the vital organs of the abdomen and chest to descend downward.17 Poor posture wreaked havoc on the physiological functioning of the body, he concluded, thus weakening an individual's ability to fight off infectious and chronic diseases.18

Lay posture advocates popularized the link between health and posture, framing it in language intended to captivate the fears and imagination of everyday Americans. In a 1915 bestseller, How to Live: Rules for Healthful Living, Based on Modern Science, Yale economist Irving Fisher and Eugene Lyman Fisk19 wrote, "one of the simplest and most effective methods of avoiding self-poisoning [i.e. disease] is by maintaining an erect posture." A follower of John Harvey Kellogg's biological living and an avid eugenicist, Fisher blamed his own faulty posture-what he called a "consumptive stoop"-for his physical demise in 1898 when he contracted tuberculosis. Although Fisher saw upright posture as a sign of (and path to) racial betterment, not all posture advocates were eugenicists. Most, like physical educator Jessie H. Bancroft, believed that the country was facing a "posture epidemic" that could be controlled only through public health measures. In her popular 1915 guide, The Posture of School Children: With Its Home Hygiene and New Efficiency Methods for School Training, Bancroft20 advocated school posture evaluations and founded the American Posture League in 1914 to assist in both the surveillance and the maintenance of proper posture among the nation's youngest citizens.

After a 1920 report from the US Army estimating that at least 10% of American draftees for the Great War had postural deformities, governmental agencies and life insurance companies quickly came to adopt the gospel of good body mechanics.21 The US Children's Bureau, the US Department of Labor, and the US Public Health Service all sponsored research and published educational materials in an effort to make Americans upright.22 The Metropolitan Life Insurance Company, which required all of its applicants to undergo posture screening, also produced promotional materials and sales literature such as The Importance of Posture (1927), Posture From the Ground Up (1939), and Standing Up to Life (1950). Bureaucrats liked posture screening because the examination could be conducted relatively quickly (30 seconds) and at little cost.23 Most important, posture tests provided a seemingly holistic account of the entire body, a physical examination with one glance of the eye.

Despite its extended reach and appeal, the posture campaign remained focused on the nation's youth. Posture experts believed that because of their growing bodies, children and adolescents could be more easily remolded than adults.24 Public schools and private universities became the preferred sites for such reshaping. At the beginning of every school year, school officials would conduct a baseline survey of each student's posture, measuring unclad bodies with the use of wall charts, graphs, plumb lines, silhouettes, and, most frequently, photographs.25 The American Posture League, with the help of physicians such as Goldthwait, established a posture norm through "wall charts," print reproductions of human models who exhibited correct posture.

Examiners compared the photographs of their students with the photographs on these wall charts and diagnosed postural abnormalities on the basis of deviations from the norm. Students with flat feet, "pigeon chest," knocked knees, curved backs, and drooping heads were encouraged to make similar comparisons between their own silhouettes and the picture perfect models. Students with poor posture received classroom instruction on how to improve muscle tone and pliability, followed by gymnasium drills in chest lifts, heel cord strengthening, and tummy tucks.26

As a way of encouraging students and parents to remain evervigilant about carriage, general interest magazines featured advice columns on how to persuade children to maintain good bodily alignment. The American Medical Association's popular health magazine, Hygeia (1923- 1950), regularly featured posture plays, songs, games-and even "The Ten Commandments of Good Posture"-to prick the conscious and pique the interest of the young. Another tactic was to heighten a student's sense of vanity.27 Dr. Clelia Mosher maintained that when "abnormals" saw their own silhouettes and how bad posture detracted from their "good appearance," they would become "sufficiently interested" in and cooperate with gymnasium work. With full participation from the student, Mosher concluded, "correction [would] only be a matter of time."28 From The Delineator and Ladies Home Journal to Scientific American and Physical Culture, popular style and health magazines regularly advised men, women, boys, and girls on how to "cut a fashionable figure" by doing posture exercises as a way to simultaneously attain an attractive shape and a healthy body.29

With the discovery and largescale manufacture of antibiotics, the link between poor posture and infectious disease weakened in post-World War II America because conditions such as tuberculosis (both pulmonary and bony) could now largely be cured with pharmacological interventions. Bancroft and other leaders of the American Posture League seemed to understand the implications of the new wonder drugs because they disbanded the organization just as World War II was coming to an end.30 A decade later, with the success of Jonas Salk's polio vaccine, it seemed more than ever that contorted spines would become a thing of the past. For all intents and purposes, posture examinations could have easily become historical artifacts, victims of the pharmacological revolution.31

However, they did not become artifacts, at least not entirely. Despite the successful management of diseases that caused bony deformities earlier in the century, postwar orthopedic specialists continued to see patients with spinal curvatures in the clinic and wondered why such malformations still existed. To determine the incidence of nondisease- related spinal curvature in his home state of Delaware, orthopedic surgeon Alfred R. Shands Jr acquired chest X-rays of approximately 82% of the state's population.32 Shands borrowed the films from the Delaware Anti-Tuberculosis Society, which had conducted a statewide pulmonary tuberculosis survey decades earlier. Shands measured spinal curvatures with a geometrical technique first developed by John R. Cobb to determine the severity of scoliosis among polio patients and concluded that about two percent of the state's population had nondisease- related scoliosis, a condition he defined as a spinal angle greater than 10 degrees. Of that two percent, White, middle-class, teenage girls were three times more likely to have scoliosis than were any other age or racial group. Most alarming about Shands's results was not the incidence but rather the medical profession's inability to explain why spinal curvature occurred in an otherwise healthy population of adolescents.33 With many of the diseases that caused spinal deformities earlier in the century at bay, orthopedic surgeons saw a new condition on the rise: adolescent idiopathic scoliosis.

In 1962, Shands and his colleagues at Delaware'sAlfred I. DuPont Hospital for Children teamed up with physical therapists, educators, and public health officials at the State Department of Public Instruction and the State Board of Health to modify existing school posture examinations, transforming them into spinal screenings for idiopathic scoliosis.34 At first, little differed between a pre-World War II posture examination and a postwar scoliosis screen. In both cases, school nurses and physical educators often performed the examination on site, usually in a school gymnasium, where they would line up 30 partially clothed children at a time, inspecting shoulder height, leg length, spinal curvature, and foot shape. A physician (usually an orthopedic surgeon) would be consulted only if a child had a severe enough deformity to warrant medical attention. In the 1970s, as more states began to legislate mandatory screening for idiopathic scoliosis, the examination became ever more simplified, targeted, and efficient. Most states reduced the pool of examinees to include only sixth, seventh, and eighth graders (the population with the highest incidence) and restructured the examination to include only one test. The preferred examination became the Adams Forward Bend Test, whereby examinees, standing disrobed from the waist up, would bend over in front of the examiner. If the examiner detected a rib hump, then the student would be considered at risk for scoliosis.

Although there appeared to be no causal link between idiopathic scoliosis and infectious disease, many orthopedic surgeons and popular health writers perpetuated the language of fear that grew out of early 20th-century medical theories concerning bad posture and illness. The fact that adolescent idiopathic scoliosis remained "idiopathic" (cause unknown) contributed even further to feelings of doubt and anxiety about the condition. Certain orthopedists used Winston Churchill's famous description of World War II-"a riddle wrapped in a mystery inside an enigma"- to depict the deformity.35 Others liked to refer to adolescent idiopathic scoliosis as "the cancer of orthopedic surgery."36 It was an apt analogy, at least up to a point. Much like breast cancer physicians who, without understanding the etiology of the disease, endorsed the "do not delay" message and mammograms, orthopedic surgeons were in the dark concerning causality but nevertheless thought that adolescent idiopathic scoliosis could be cured as long as it was detected early enough, before the symptoms of back pain arose.37

Unlike cancer, idiopathic scoliosis was not (and never has been) a leading cause of death. Indeed, as early as 1969 two orthopedic surgeons from the University of Iowa reported that the death rate among adolescent patients with idiopathic scoliosis was similar to that of the population without scoliosis.38 Dennis Collis and Ignacio Ponseti39 conducted a 25-year follow-up on 400 scoliosis patients and observed that "most [scoliosis] patients led normally active and productive lives, worked, married, and engaged in activities little different from those of the normal population." Although Collis and Ponseti found that scoliosis curves frequently progressed beyond adolescence (on average, 15°-25° more severe in adulthood), they concluded that if left untreated-or treated conservatively with exercise and short-term bracing-young adolescents with idiopathic scoliosis could go on to lead healthy lives, comfortable with their curvatures, both physically and psychologically.

Most orthopedic surgeons who specialized in scoliosis treatment, however, did not share the sanguine views coming out of the University of Iowa. In the early years of adolescent idiopathic scoliosis, the Scoliosis Research Society-a nonprofit professional organization that continues to raise money for scoliosis research and treatment-shaped the majority opinion on how the condition should be understood and managed. John H. Moe, a University of Minnesota orthopedic surgeon, founded the Scoliosis Research Society in 1966 and served as its first president.40 After working as an intern in New York under the tutelage of Cobb and Russell Hibbs (both of whom helped developed spinal fusion and casting for disease-based scoliosis), Moe founded a scoliosis service at Gillette Children's Hospital in 1947 and insisted that, no matter the etiology, it was always "better to overtreat rather than undertreat."41

An aggressive interventionist, Moe had his first exposure to scoliosis as a physician treating children with infantile paralysis and tuberculosis (a disease he had experienced himself); his treatment protocols thus grew out of disease-based scoliosis. He was an early adopter, for example, of the "Harrington rod" technique, an invasive, internalfixation surgery originally created to treat paralytic scoliosis during the 1952 polio epidemic. 42 Moe was also active in developing and promoting a nonoperative bracing system-known as the Milwaukee brace-first used in the late 1940s to provide postoperative passive correction to polio patients who had spinal correction. Once adolescent idiopathic scoliosis became a legitimate diagnostic category in the late 1960s, Moe and many other specialists simply adopted disease- related treatments and applied them to a non-diseaserelated spinal deformity, with few questions asked about the medical and scientific validity of such a transference. Before a time when medical researchers were expected to conduct randomized controlled trials, Moe had proven to his own satisfaction that bracing worked, but only if the condition was detected early before the curve became too severe (in his judgment, greater than 60° necessitated surgery) and before the adolescent patient had reached skeletal maturity.43 For bracing to work, in other words, time was of the essence.

With the help of the Scoliosis Research Society and his colleagues who sat on the association's "advocacy committee," Moe began a "do not delay" campaign for scoliosis, promoting universal screening in all the nation's schools. 44 Moe used various promotional strategies to convince state legislators, educators, parents, and other medical professionals of his cause. Because adolescent idiopathic scoliosis was neither a terminal nor a contagious condition, the Scoliosis Research Society advocacy committee conveyed worse-case-scenario stories from the clinic to heighten fears about scoliosis, thus providing both a rationale for mass intervention and a justifiable means to motivate American adolescents (and their parents) to seek medical care.45 Moe and his 2 junior colleagues Robert B. Winter and John E. Lonstein told heart-wrenching stories of young children and adolescents who had to undergo life-threatening surgery because their medical intervention came too late. In their 1974 "A Plea for the Routine School Examination of Children for Spinal Deformity," the Minnesota surgeons46 claimed that physicians were "morally obligated to detect [scoliosis] early," because if they did not, more and more children would have to endure radical surgery. "One of the saddest problems in orthopaedics," the Minnesota group wrote,

is to see a child come with a severe curve requiring surgery with X-rays taken many years before showing a mild curve that could have been easily treated with a brace.46

In another article promoting screening, the same Minnesota group conveyed how one of their 19-year-old patients, who refused treatment of her scoliosis when it was first detected at age 14, died on the operating table while undergoing a corrective spinal fusion.47

Instead of emphasizing the limits of surgical intervention (or even the necessity of it) for adolescent idiopathic scoliosis, Moe and his colleagues shifted the blame to recalcitrant parents, uneducated physicians, and obstinate adolescents, making anyone but themselves responsible for bad outcomes. Moe found the same people culpable for brace-wear failure as well. In his 1973 coauthored textbook, The Milwaukee Brace, Moe contended that nonoperative treatment of adolescent idiopathic scoliosis would work only if an orthopedist had complete patient (and parent) compliance.48 For those patients who underwent his treatment, this was a rather tall order, for he mandated that the brace be worn 23 hours a day (requiring day and night wear) for approximately 34 months. A metal, turnbuckle cast that extended from the buttocks to the chin, the Milwaukee brace proved to be a rather cumbersome device, often causing skin irritation, jaw pain, and, not insignificantly, low self-esteem among its wearers.49 Rosalie Griesse, who was fitted for a brace at age 13 in the mid-1940s, recounted that she "was very self-conscious about the way [she] looked" and often felt "embarrassed." "No matter how carefully Mother made my clothes," Griesse wrote, "I felt sure the brace showed, and I never wanted anyone to touch me."50 Moe, however, insisted that the "emotional obstacles to brace treatment ha[d] been greatly overemphasized." "An understanding orthopedic surgeon who maintains good rapport with an emotionally well adjusted child," he wrote, "will have no difficulty." Children and adolescents who did not comply, Moe reasoned, were "psychotic" or had "pre-existing . . . emotional problems."51

Moe's doggedness in convincing others that "procrastination [was] the most pernicious problem" in adolescent idiopathic scoliosis eventually swayed the American Academy of Orthopedic Surgery to make an official stance in 1974 endorsing nationwide mandatory spinal screening. That same year, adolescent idiopathic scoliosis patients and family members organized a patient advocacy group called the Scoliosis Association. In addition to publishing its own newsletter, "Backtalk," and holding local chapter meetings where patients and families could discuss "common problems and solutions pertaining to the nonmedical aspects of scoliosis," the Scoliosis Association established a congenial and mutually supportive relationship with the Scoliosis Research Society, donating its proceeds to medical research and lobbying efforts to achieve nationwide mandatory school screening.52 Indeed, the Scoliosis Association created some of the most alarmist pro-screening campaigns during the 1970s and 1980s-most notably, "The Dangerous Curve!" and the "Straight as an Arrow?" health messages. In both campaigns, the Scoliosis Association, much like the Scoliosis Research Society, used fear to motivate schools and public health agencies to establish screening programs. In the absence of compelling morbidity or mortality rates, the Scoliosis Association relied on a simple, aesthetic message-curvature is bad-without explaining why scoliosis posed a danger to one's health.

"Dangerous Curve" campaigns won the hearts and minds of many US state legislators as well as the American public. By 1989, twenty states had signed scoliosis screening into law.53 Media outlets seized on the medical stories of technological triumph over a dangerous foe, at once fueling and quelling fears about adolescent idiopathic scoliosis. Popular newsmagazines such as Time, Newsweek, Seventeen, and the Saturday Evening Post regularly featured the marvels of Harrington's rods (what Time magazine dubbed "Spines of Steel") and the miracles of Moe's Milwaukee brace, technologies billed as "life-saving" devices.54 Best-selling youth fiction author Judy Blume55 added credibility to these triumph-overscoliosis stories through her 1973 hit book Deenie, in which an 11-year old New Jersey girl is cured of adolescent idiopathic scoliosis by wearing a Milwaukee brace. Public health officials liked the story of Deenie so much that some states assigned it to students to read before mandatory spinal screening.56 Rare, if nonexistent, were stories-autobiographical or fictive-of young adolescents (or their parents) refusing medical intervention and living to tell about it.

Most striking about the American enthusiasm for scoliosis tests was that it occurred at the same time that medical researchers in other industrialized nations began to raise serious doubts about the efficacy of both screening and treatment. Writing for the Lancet in 1981, British physician Michael Warren57 insisted that because so little was known about the natural history of idiopathic scoliosis, there was "a real danger of unnecessarily treating large numbers of normal adolescents." Three years later, Canadian physician Elizabeth J. Wynne58 concluded that because no reliably effective treatments for scoliosis were available, screening appeared to accomplish very little in terms of population health. In stark contrast to the triumphalist portrayals of scoliosis treatment in US medical and mainstream media circles, Wynne58 found that "bracing efficacy [was] questionable" and that 50 percent of those braced eventually required surgery. In response to a 1985 Canadian study that denounced scoliosis screening, pediatrician Donald M. Berwick,59 (current outgoing administrator of the Centers for Medicare and Medicaid Services), penned a scathing editorial in the American Journal of Public Health arguing that Americans "have better uses for [thei]r time and dollars than screening for scoliosis." Berwick spoke of the potential psychological "morbidity of labeling people with insignificant conditions." "The vast majority of children with positive forward bending tests on scoliosis screening," he wrote, "have curvatures of no current or future significance, and yet they and their parents must adapt to a new label with the potential for insult to self-image and peace of mind." In his view, the perils of scoliosis had been blown out of proportion, making spinal screening a public health folly.

Interventionists like Moe made one crucial assumption that underpinned the argument for treatment and screening: that adolescent idiopathic scoliosis curves would progress and become ever more severe if left untreated. But some researchers began to question that assumption, wondering if certain curves would spontaneously correct themselves or if the positive outcomes from bracing were the result of a natural correction rather than brace wear.60 In the face of such potentially damning questions, Moe remained stalwart in his protreatment views. Although early in his career he once admitted that "in many cases [scoliosis] treatment may be superfluous and unnecessary," he still reasoned that

[medical intervention did] no harm either to the emotions of the mother, the child or to anyone else . . . even though in many instances [the curve] might . . . spontaneously resolve. 61

Despite mounting evidence throughout the 1990s that scoliosis screening was ineffective, costly, and potentially harmful psychologically, more and more US states instituted school-based procedures for spinal testing. As of 2003, a total of 21 states mandated screening, and 12 additional states recommended it. These states have the backing not only of several prominent professional medical organizations but also of State Divisions of Maternal and Child Health, Departments of Health, and Boards of Education. The steady uptick of spinal screening programs in the United States occurred while other nations abandoned the practice. Canada officially brought its nationwide screening program to an end in 2003 because evidence showed that many treatments were ineffective. 62 In the 1990s, the British Orthopedic Association ruled against screening as a national policy, as did the Australian government, partly because of cost but also because the benefit of such a program remained unclear.63 Nations with universal health care and limited orthopedic services worried about overburdening the system with an ostensibly ineffectual surveillance measure. To solve the matter, Australia introduced a "National Self-Detection Program for Scoliosis," urging a more autonomous approach to care by having adolescents and their families seek out spinal examinations from their primary care physicians.64 Such questions about cost and supply of specialists gained little traction in the United States, where screening actually fueled the privatized, fee-for-service health care marketplace, creating new consumers of the latest medical technologies and devices and bolstering the specialty of orthopedic surgery.

One of the few US institutions to bring spinal screening into question is the USPSTF. Because of its stance, the USPSTF has come under repeated attacks. Some accuse the USPSTF of failing to recognize scoliosis as a legitimate health problem, whereas others complain that the agency wrongly doubts the efficacy of bracing and surgery as treatments.65 The USPSTF does not deny that for some people, scoliosis is a painful and debilitating condition. Nor does the USPSFT want to take medical remedies away from those individuals who seek treatment. But as an institution that evaluates the effectiveness of all screening programs-from cancer to cholesterol screening-it must assess whether the benefits of a largescale screening program outweigh the economic and psychological costs.

At this juncture, it is difficult to predict what policy changes, if any, will be made regarding spinal screening in the United States. Since the 2010 passage of the Patient Protection and Affordable Care Act, much of what is taken as status quo in the realm of US health care policy and economics has come under scrutiny. With the Patient Protection and Affordable Care Act prohibiting insurance companies from charging copayments and deductibles for preventive care and medical screening, it would seem that scoliosis screening is here to stay. Regardless of what happens in the future, one fact is clear: the tradition of scoliosis screening- and the unquestioning belief that, if caught early, idiopathic scoliosis is a condition that can be cured-runs strong in the United States. Most of the parents with children in public schools today have undergone some kind of posture and scoliosis screening themselves, just as their parents did a generation before that. Spinal screening has become ritualized, a kind of rite of passage for adolescent public school children, even though many Americans are apt to have anxiety-ridden memories of the examination. Experience has taught us that screening is the norm, and bracing a small price to pay. As one researcher put it,

scoliosis screening will be continued in many school districts in the belief that the effort is worth the benefit to the few children who receive brace therapy.66

Scoliosis screening gives parents and school administrators a sense of security, even if those wedded to evidence-based medicine believe it is a false one.

As someone who would like to see scoliosis screening laws repealed, Dr. Grant Higginson pointed out in a 1999 Journal of the American Medical Association editorial that "a bottom-up approach must occur" to bring the ineffectiveness of scoliosis screening to the attention of policymakers. 67 In his view, such grassroots opposition would have to include physicians, parentteacher associations, and school officials. Before such a movement could arise, pro-screening medical and educational professionals would have to be convinced that evidence-based medicine is superior to more experiential knowledge of the condition that has driven scoliosis care and surveillance for more than 100 years. For physicians, educators, and parents to have an informed choice about screening, both sides of the debate need to be equally represented. A lesson in history-how scoliosis screening arose from early posture tests and how it is rooted in an early 20th-century conviction that curvatures correlate with deadly disease- would also advance this effort, giving all parties concerned a clearer perspective on a practice that is largely taken for granted.

Endnotes

1. US Preventive Services Task Force, Recommendation Statement: Screening for Idiopathic Scoliosis in Adolescents (AHRQ Pub. No. 05-0568-A. November 2004), accessed February 18, 2011, http:// www.uspreventiveservicestaskforce. org/3rduspstf/scoliosis/scoliors.pdf. For more on the establishment of the US Preventive Services Task Force (USPSTF), see Steven H. Woolf, Carolyn G. DiGuiseppi, David Atkins, and Douglas B. Kamerow, "Developing Evidence- Based Clinical Practice Guidelines: Lessons Learned by the U.S. Preventative Task Force," Annual Reviews of Public Health 17 (1996): 511-38. The US Public Health Service established the USPSTF in 1984. The USPSTF is a nongovernmental expert panel that reviews evidence regarding the effectiveness of clinical preventive services and makes recommendations for health professionals regarding which preventive services to include in the periodic health examination.

2. Even when examiners used a scoliometer, a device that results in fewer false-positive results than the forwardbending test, researchers still found significant interreader errors. See Thomas W. Grossman, John M. Mazur, and R. Jay Cummings, "An Evaluation of the Adams Forward Bend Test and the Scoliometer in a Scoliosis School Screening Setting," Journal of Pediatric Orthopedics 15 (1995): 535-8. See also George A. C. Murrell, Ralph W. Coonrad, Claude T. Moorman, and Robert D. Fitch, "An Assessment of the Reliability of the Scoliometer," Spine 18 (1993): 709-12.

3. US Preventative Services Task Force, "Screening for Idiopathic Scoliosis in Adolescents: Recommendation Statement," accessed February 12, 2011, http://www.uspreventiveservicestaskforce. org/3rduspstf/scoliosis/scoliors. htm.

4. For Great Britain and Australia, see Theodoros B. Grivas, Marian H. Wade, Stefano Negrini, Joseph P. O'Brien, Toru Maruyama, Martha C. Hawes, Manuel Rigo, Hans Rudolf Weiss, Tomasz Kotwicki, Elias S. Vasiliadis, Lior Neuhaus Sulam, and Tamar Neuhous, "SOSORT Consensus Paper: School Screening for Scoliosis: Where Are We Today?," Scoliosis 2 (2007): 1-23. For Canada, see Marie Beauséjour, Marjolaine Roy-Beaudry, Lise Goulet, and Hubert Labelle, "Patient Characteristics at the Initial Visit to a Scoliosis Clinic: A Cross-Sectional Study in a Community Without School Screening," Spine 32 (2007): 1349-54.

5. Twenty-one states mandate it through law, and twelve additional states recommend screening. See Grivas, "SOSORT Consensus Paper," 2.

6. Han Jo Kim, John S. Blanco, and Roger F. Widmann, "Update on the Management of Idiopathic Scoliosis," Current Opinion in Pediatrics 21 (2009): 55-64. See also See also John H. Moe and John E. Lonstein, Moe's Textbook of Scoliosis and Other Spinal Deformities, 3rd ed. (Philadelphia: WB Saunders, 1995).

7. For Iowa results, see Stuart Weinstein, Lori A. Dolan, Kevin F. Spratt, Kirk K. Peterson, Mark J. Spoonamore, and Ignacio V. Ponseti, "Health and Function of Patients With Untreated Idiopathic Scoliosis: A 50-Year Natural History Study," Journal of the American Medical Association 289 (2003): 559- 67.

8. For more on the history of posture in America, see David Yosifon and Peter N. Stearns, "The Rise and Fall of American Posture," The American Historical Review 103 (1998): 1057-95.

9. David J. Rothman, Beginnings Count: The Technological Imperative in American Health Care (New York: Oxford University Press, 1997).

10. Louise F. Sohrabi, The Crooked Journey: The Story of a Woman's Fight Against Scoliosis (Alameda, Calif: Rima Press, 1983).

11. As of 2000, Barbara and Roy Yawn estimated that screening could cost as "little as $0.06 to as much as $194 per child . . . with the higher estimate defined as all children with curves of 5 degrees or more." Barbara P. Yawn and Roy A. Yawn, "The Estimated Cost of School Scoliosis Screening," Spine 25 (2000): 2387-91. For a discussion of the principles of screening, see Grant Higginson, "Political Considerations for Changing Medical Screening Programs," Journal of the American Medical Association 282 (1999): 1472-4.

12. A more thorough account of this history can be found in Richard Meckel, "Going to School, Getting Sick: The Social and Medical Construction of School Diseases in the Late Nineteenth Century," in Formative Years: Children's Health in the United States, 1880- 2000, ed. Alexandra M. Stern and Howard Markel. (Ann Arbor: University of Michigan Press, 2002), 185- 207.

13. "Physical Examination of School Children," Boston Medical and Surgical Journal 152 (1905): 587.

14. George T. Stafford, "First Problem in Education to Prevent or Correct Physical Defects," School Life 10 (1925): 114-5. For more on the history of such "defects," see Beth Linker, "Feet for Fighting: Locating Disability and Social Medicine in World War I America," Social History of Medicine 20 (2007): 91-109.

15. US Children's Bureau, Posture Exercises: A Handbook for Schools and for Teachers of Physical Education (Washington, DC: US Department of Labor, 1926). Dr. Armin Klein, director of a posture clinic at the Massachusetts General Hospital, and Leah C. Thomas, director of corrective gymnastics at , served as the key researchers for this educational initiative.

16. Robert W. Lovett, Lateral Curvature of the Spine and Round Shoulders (Philadelphia: P. Blakiston's & Company, 1907).

17. Joel E. Goldthwait, "The Relation of Posture to Human Efficiency and the Influence of Poise Upon the Support and Function of the Viscera" (paper read at a meeting of the Boston Medical Library held in conjunction with the Suffolk District Medical Society, Boston, MA, December 2, 1908). Joel E. Goldthwait, "An Anatomic and Mechanistic Conception of Disease," Boston Medical and Surgical Journal 172 (1915): 881-98. See also Joel E. Goldthwait, Body Mechanics in the Study and Treatment of Disease (Philadelphia: J. B. Lippincott Company, 1934).

18. Goldthwait was not alone in his belief that one's constitution determined one's health. See Sarah W. Tracy, "George Draper and American Constitutional Medicine, 1916-1946: Reinventing the Sick Man," Bulletin of the History of Medicine 66 (1992): 53-89.

19. Irving Fisher and Eugene Lyman Fisk, How to Live: Rules for Healthful Living, Based on Modern Science (New York: Funk & Wagnalls Company, 1915). See also Laura D. Hirschbein, "Masculinity, Work and the Foundation of Youth: Irving Fisher and the Life Extension Institute, 1914-1931," Canadian Bulletin of Medicine 16 (1999): 89- 124.

20. Jessie H. Bancroft, The Posture of School Children: With Its Home Hygiene and New Efficiency Methods for School Training (New York: The Macmillan Company, 1913), 1.

21. Office of General the Surgeon, Defects Found in Drafted Men (Washington, DC: Government Printing Office, 1920). See also Beth Linker, War's Waste: Rehabilitation in World War I America (Chicago: University of Chicago Press, 2011).

22. US Public Health Service, Flat Foot and Other Troubles (Washington, DC: Government Printing Office, 1920). Louis Schwartz, Studies in Physical Development and Posture: Postural Relations as Noted in Twenty-Two Hundred Boys and Men (Bulletin of the U.S. Public Health Service 199) (Washington, DC: Government Printing Office, 1931). US Department of Labor, Posture Exercises: A Handbook for Schools and for Teachers of Physical Education (Washington, DC: Government Printing Office, 1926). White House Conference on Child Health and Protection, Body Mechanics: Education and Practice; Report of the Subcommittee on Orthopedics and Body Mechanics (New York: Century Company, 1932). US Department of Labor Children's Bureau, Good Posture in the Little Child (Washington, DC: Government Printing Office, 1933). US Department of Labor, Posture Clinics: Organization and Exercises (Washington, DC: Government Printing Office, 1926). Margaret T. Mettert, Women's Effective War Work Requires Good Posture (Special Bulletin of the US Women's Bureau 10) (Washington, DC: Government Printing Office, 1943).

23. Stafford, "First Problem," (1925).

24. For more on the history of children's health, see Janet L. Golden, Richard A. Meckel, and Heather Munro Prescott, Children and Youth in Sickness and in Health: A Historical Handbook and Guide (Westport, Conn: Greenwood Press, 2004) and Stern and Markel, Formative Years.

25. The method for evaluating posture varied from school to school and largely depended on the examiner's preference, comfort with various technologies, and constraints of space and time. One popular posture-measuring device in the early decades of the 20th century was the schematograph, an instrument codeveloped by Stanford University professors Dr. Clelia D. Mosher (better known among today's scholars for her sex studies) and Everett Parker Lesley (a mechanical engineer who would go on to design airplane propellers for the National Advisory Committee on Aeronautics during the interwar years). Using the technology of a clear glass reflecting camera along with tracing paper, an examiner could trace a full-body silhouette of an unclad school student. Mosher preferred her device over photography because it preserved a student's anonymity and dignity-she made plain her worries that photographs of individual students could fall into the wrong hands, and confidentiality between doctor and patient-student would be breeched. Clelia Duel Mosher, "The Schematogram: A New Method of Graphically Recording Posture and Changes in the Contours of the Body," School and Society 1 (1915): 642-5. Mosher was prescient about what would happen if school examiners began to rely solely on photography. See Ron Rosenbaum, "The Great Ivy League Nude Posture Photo Scandal," New York Times Magazine, January 15, 1995, SM26-30, 40-1, 46, 55-6.

26. Bancroft, The Posture of School Children.

27. For a sampling, see Ethel M. Hendriksen, "Posture Work for Preschool Children," Hygeia 4 (February 1926): 76-8; "Good Posture as an Aid to Beauty," Hygeia 4 (July 1926): 399- 400; Phillip P. Lewin, "Ten Commandments of Good Posture," Hygeia 6 (January 1928): 3-5; "Flower Garden: A Posture Play Adapted for Kindergarten and First Grade Pupils," Hygeia 7 (July 1929): 728; "Kin Arthur Posture Play," Hygeia 7 (August 1929): 826-7; Lillian C. Drew, "Ode to Posture," Hygeia 13 (March 1935): 224; Henry Eastman Bennett, "Toward an Upsitting Generation," Hygeia 13 (September 1935): 836-9; Frank H. Krusen, "Willie, Pull Your Stomach In!," Hygeia 14 (November 1936): 970-2; Mae Kelly, "Cutting a Fashionable Figure," Hygeia 17 (March 1939): 212-5.

28. Mosher, "The Schematogram," 642.

29. For a sampling, see Dr. Florence Richards, "Desk Exercises for Business Girls," Ladies Home Journal, March 1913, 72; Dr. Alan DeForest Smith, "Correct Posture for Children," The Delineator, February 1922, 46; Donald A Laird, "There Is a Lot to Just Sitting and Standing," Scientific American 104 (November 1928): 402-4; Nora Mullane, "Physical Exercise, Moderate Eating, and a Correct Posture Prevents Obesity," Good Housekeeping, March 1922, 82; Anna H. Delavan, "To Sit Correctly With Dignity," Good Housekeeping, January 1925, 92; Marie Beynon Ray, "Cutting a Fine Figure," Collier's, August 18, 1934, 21, 80.

30. Yosifon and Stearns, "American Posture."

31. For more on the history of the pharmacological revolution, see Dominque Tobbell, Pills, Power, and Policy: The Struggle for Drug Reform in Cold War America and Its Consequences (Berkeley: University of California Press, 2012); Robert Bud, Penicillin: Triumph and Tragedy (Oxford, UK: Oxford University Press, 2007); Andrea Tone and Elizabeth Siegel Watkins, eds., Medicating Modern America: Prescription Drugs in History (New York: New York University Press, 2007).

32. A. R. Shands Jr. and Harry B. Eisberg, "The Incidence of Scoliosis in the State of Delaware: A Study of 50,000 Minifilms of the Chest Made During a Survey for Tuberculosis," Journal of Bone and Joint Surgery 37 (1955): 1243-9.

33. The age range for teenage in this study was ages 15-19. For more on medical definitions and treatment of adolescence, see Heather Munro Prescott, A Doctor of Their Own: The History of Adolescent Medicine (Cambridge, Mass: Harvard University Press, 1998).

34. Samuel Cronis and A. Yvonne Russell, "Orthopedic Screening of Children in Delaware Public Schools," Delaware Medical Journal 37 (1965): 89-92.

35. For an example of this usage, see Walter P. Blount and John H. Moe, The Milwaukee Brace, 1st ed. (Baltimore, Md: Williams and Wilkins Company, 1973), vii.

36. Joseph C. Risser, "Scoliosis: Past and Present," Journal of Bone and Joint Surgery 46 (1964): 167-99.

37. See Robert A. Aronowitz, "Do Not Delay: Breast Cancer and Time, 1900- 1970," Milbank Quarterly 79 (2001): 355-86 and Robert A. Aronowitz, Unnatural History: Breast Cancer and American Society (New York: Cambridge University Press, 2007). See also Barron Lerner, The Breast Cancer Wars: Hope, Fear, and the Pursuit of a Cure in Twentieth- Century America (New York: Oxford University Press, 2001) and Ilana Löwy, Prevention Strikes: Women, Precancer, and Prophylactic Surgery (Baltimore, Md: Johns Hopkins University Press, 2010).

38. Dennis K. Collis and Ignacio V. Ponseti, "Long-Term Follow-Up of Patients With Idiopathic Scoliosis Not Treated Surgically," Journal of Bone and Joint Surgery 51 (1969): 425-45.

39. Collis and Ponseti, "Idiopathic Scoliosis Not Treated Surgically," 444.

40. Robert B. Winter and William J. Kane, ": In Memoriam," Spine 13 (1988): 442.

41. John H. Moe, "Correspondence: Postural Scoliosis," British Medical Journal 2 (1965): 1431-2.

42. Paul R. Harrington, "Treatment of Scoliosis: Correction and Internal Fixation by Spine Instrumentation," Journal of Bone and Joint Surgery 44 (1962): 591-611.

43. John H. Moe and David K. Kettleson, "Idiopathic Scoliosis," Journal of Bone and Joint Surgery 52 (1970): 1509-33. Moe evaluated 169 patients from his private practice who had adolescent idiopathic scoliosis and who had worn a Milwaukee brace for at least 12 months. He estimated that at least 33 of these patients showed "poor cooperation" in their brace wear, so he removed them from the study. To better convey his results, he broke down the study group into types of curvatures: high thoracic (HT), thoracic (T), and lumbar (L). After brace wear, curves of HT patients ranged from as much as 5 percent worse to 30 percent improvement. T patients saw a median correction of 23 percent, with a range of -10 to 80 percent. L patients had a median improvement of 18 percent, with a range of 0 to 100 percent.

44. Behrooz A. Akbarnia, "Embracing Opportunities in Exciting Times: 2006 SRS Presidential Address," Spine 32 (2007): 2153-7. Scoliosis screening should be understood within the larger story of medical surveillance. Beginning with tuberculosis screening early in the 20th century, to Papanicolaou tests, mammograms, and detecting phenylketonuria in neonatology, medical practice has increasingly moved toward evergreater screening as a form of preventive health care. For more, see Diane Paul, "Contesting Consent: The Challenge to Compulsory Neonatal Screening for PKU," Perspectives in Biology and Medicine 42 (1999): 207-19; Barron H. Lerner, "'To See Today With the Eyes of Tomorrow': A History of Screening Mammography," Canadian Bulletin of Medical History 20 (2003): 299-321; Monica J. Casper and Adele E. Clarke, "Making the Pap Smear Into the 'Right Tool' for the Job: Cervical Cancer Screening in the USA, Circa 1940-95," Social Studies of Science 28 (1998): 255-90; and Alan Derickson, "'On the Dump Heap': Employee Medical Screening in the Tri-State Zinc-Lead Industry, 1924-1932," The Business History Review 62 (1988): 656-77.

45. Aronowitz makes the same argument about the use of fear in raising breast cancer screening awareness. See "Do Not Delay," 357-9.

46. Robert B. Winter and John H. Moe, "A Plea for the Routine School Examination of Children for Spinal Deformity," Minnesota Medicine 57 (1974): 419-24.

47. John E. Lonstein, Robert B. Winter, John H. Moe, Anthony J. Bianco, Ronald G. Campbell, and Mildred A. Norval, "School Screening for the Early Detection of Spine Deformities: Progress and Pitfalls," Minnesota Medicine 59 (1976): 51-7.

48. Walter P. Blount and John H. Moe, The Milwaukee Brace (Baltimore, Md: Williams and Wilkins Company, 1973).

49. Moe blamed certain cases of ill-fitting braces on "zealous parents" who took it upon themselves to adjust their child's brace in between office visits. As of 1973, parents were "forbidden to adjust the braces, except under the direction of an orthopedic surgeon." Blount and Moe, The Milwaukee Brace, 6.

50. Rosalie Griesse, The Crooked Shall Be Made Straight (Atlanta, Ga: John Knox Press, 1979), 45.

51. Blount and Moe, The Milwaukee Brace, x. Emphasis added.

52. Marie Balzer, Scoliosis: An Annotated Bibliography (Raleigh, NC: The Scoliosis Association, 1989), back plate.

53. Grivas, "SOSORT Consensus Paper." How screening became legislated-and to what end it served-differed state by state. Some states mandated screening by amending their educational codes, whereas others created legislation through their departments of health. The rationale for screening also varied, but most states agreed that the chief goal was to "ensure that all children and youth . . . [would] have a normal development and a normal life." See California State Department of Education, Standards for Scoliosis Screening (Sacramento: State of California, 1985), 1. See also Missouri Bureau of Maternal and Child Health, Screening Guide for Use in Missouri Schools (Jefferson City: State of Missouri, 1979).

54. See, for example, "Spines of Steel," Time, November 14, 1960, 56; "A Dangerous Curve," Time, February 24, 1975, 66-7; Dr. Cory Servess, "Medical Mailbox," The Saturday Evening Post, December 1975, 72-3; Carrie Holtman, "Braced for the Best," Seventeen, May 1977, 36; Michael P. Scott, "A Simple Test for Scoliosis," Better Homes and Gardens, August 1977, 71-2; Robert J. Trotter, "Preventing the Curve," Science News, May 1979, 298-302; Matt Clark and Dan Shapiro, "Righting the Spine," Newsweek, November 26, 1979, 94; <person>Ralph Schoenstein, "I Fell Out of a Plane but Everything's OK Now," Today's Health, November 1973, 50-3; and Maria Cerniello, "Children's Back Troubles: Catching Them Early," McCall's, July 1981, 40.

55. Judy Blume, Deenie (Scarsdale, NY: Bradbury Press, 1973).

56. Asha Wallace, "A Scoliosis Screening Program," Journal of School Health 47 (1977): 619-20.

57. Michael Warren, Jane Leaver, and Anne Alvik, "Letters to the Editor: School Screening for Scoliosis," The Lancet 2 (1981): 522. Calling for more scientific, population-based research, Warren argued that "We do not know the natural history of scoliosis-that is, the causes of adolescent idiopathic scoliosis and the determinants of its progression . . . .Epidemiologists emphasize that studies of the natural history of the disease must be based on all cases (mild and severe) arising in a defined population and cannot be limited to severe cases seen in special clinics" (522).

58. Elizabeth J. Wynne, "Scoliosis: To Screen or Not to Screen," Canadian Journal of Public Health 75 (1984): 277-80.

59. Donald M. Berwick, "Scoliosis Screening: A Pause in the Chase," American Journal of Public Health 75 (1985): 1373-4.

60. The first of these arguments can be found in the 1960s. See, for example, J. I. P. James, "Postural Scoliosis," The British Medical Journal 1 (1966): 46. The Department of Orthopedic Surgery at the University of Iowa carried out its longitudinal study throughout the remainder of the 20th century and continued to voice doubts about the findings of Moe, Winter, and Lonstein. See "Correspondence," Journal of Bone and Joint Surgery 79 (1997): 954-55. For more recent findings from the University of Iowa, see Stuart L. Weinstein, Lori A. Dolan, Jack C. Y. Cheng, Aina Danielsson, and Jose A. Morcuende, "Adolescent Idiopathic Scoliosis," The Lancet 371 (2008): 1527-37 and Stuart L. Weinstein, Lori A. Dolan, Kevin F. Spratt, Kirk K. Peterson, Mark J. Spoonamore, and Ignacio V. Ponseti, "Health and Function of Patients With Untreated Idiopathic Scoliosis: A 50-Year Natural History Study," Journal of the American Medical Association 289 (2003): 559-67.

61. Moe, "Correspondence," 1432. One 1995 study concluded that 60 percent of patients treated with bracing "felt that [it] handicapped their life," and 14 percent believed that it "left a psychological scar." A. L. Nachemson and L. E. Peterson, "Effectiveness of Treatment With a Brace in Girls Who Have Adolescent Idiopathic Scoliosis: A Prospective, Controlled Study Based on Data From the Brace Study of the Scoliosis Research Society," Journal of Bone and Joint Surgery. 22 (1995): 815-22.

62. Penny Hatcher, Adolescent School Screening for Scoliosis in Minnesota (Minneapolis: Minnesota Department of Health, 2008), 13.

63. Grivas, et al., "SOSORT Consensus Paper," 3.

64. Ibid.

65. See, for example, Dr. Robert Winter's response to the first US Preventive Services Task Force report expressing concerns about the effectiveness of scoliosis screening. Robert Winter, "Screening for Scoliosis," Journal of the American Medical Association 273 (1995): 185-6. See also B. Stephens Richards and Michael G. Vitale, "Screening for Idiopathic Scoliosis in Adolescents: An Information Statement," Journal of Bone and Joint Surgery 90 (2008): 195-8.

66. Alan W. Cross, "Health Screening in Schools, Part II," The Journal of Pediatrics 107 (1985): 653-61.

67. Ibid.

Beth Linker, PhD

About the Author

Beth Linker is with the Department of the History and Sociology of Science, University of Pennsylvania, Philadelphia.

Correspondence should be sent to Beth Linker, PhD, Department of the History and Sociology of Science, University of Pennsylvania, 365 Cohen Hall, 249 S 36 St, Philadelphia, PA 19104 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking on the "Reprints" link.

This article was accepted October 9, 2011.

Acknowledgments

The author thanks the Robert Wood Johnson Foundation Health & Society Scholars program at the University of Pennsylvania for its financial support.

Thanks also to Jessica Martucci, Whitney Laemmli, and Jennifer Goldsack for their research assistance. I am grateful for the comments of Dominique Tobbell and the anonymous reviewers of the American Journal of Public Health.