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To the Editor .—We read the article, "Competence of Child Health Associates," by Machotka et al ( Am J Dis Child 125:199-203) with interest. At present the medical profession is under pressure to assure the public that all those who are involved in the delivery of health care are competent (defining competency as having the necessary cognitive, psychomotor, and affective abilities to perform the tasks assigned to an individual within the health care delivery system). To determine the cognitive competency of allied health professionals is, therefore, a highly desirable objective. However, it is essential that research intended to compare the knowledge of various groups of health professionals be as sound as that used in comparing the effectiveness of drugs or different diagnostic procedures. When the authors of the above paper state that their report "documents the extent, adequacy, and relevance of the child health associates' basic science training and knowledge of

Health services should be organized to effectively and efficiently prevent and alleviate disability in some human population. This must be done in relation to a set of priorities as these are continually and dynamically established in a given cultural environment. The priorities will reflect the investment needs of the society at large and the most pressing health problems of the population in question. The emphasis of this paper is on the design, institutionalization and evaluation of alternative forms of organization to better achieve priority goals for enhancing the abilities of our peoples. The discussion of this problem of organization in relation to health services in Colombia is a matter determined by the structure of these deliberations; it is not determined by the extent of the problem. The matter of organization is a world-wide problem, addressed, but not solved, by simple financing schemes. The problem is in no way less acute in the United States. As the health officer of New York State recently stated, "In the average American community Little League baseball is better organized than the delivery of medical services. Here is a crying need for the skills of those presumably proficient in the solution of health problems on a community-wide scale."1 But who among you knows he is proficient in organizing community health services? And if one thinks of himself as proficient in the matter, what publicly verifiable evidence can he assemble to establish the case? The problems of patient participation, information flow, manpower

Manpower is a major cost component in today's health care system, absorbing at least one half of the average health care dollar. Growing pressures to achieve cost containment and rationalization of scarce health manpower will force health care institutions to rely increasingly on management techniques for examination of choices, for guidance of activities and for evaluation of outcomes. In recent years much effort has gone into developing analytic and quantitative techniques for application to the health field, an effort that has produced a rapidly growing literature. Some of the tools are still subjects of pilot testing and further refinement; but others, whose usefulness has been demonstrated, are available for implementation by management of health facilities.l-4 This paper describes a methodology for evaluating manpower utilization in ambulatory health care facilities and illustrates its uses as a management tool. Several applications of the methodology will be discussed: (a) development of staffing standards; (b) assessment of resource allocations relative to objectives; (c) allocation of departmental costs between patient care and non-patient care services; and (d) assessment of cost-effective

The general purpose of this paper is to review the state of a research field, the sociology of medical education. It is fully 15 years since the field became active, and one can now count at least seven attempts, each with the full thrust of major team research organization and support, to study the processes by which medical students selectively acquire the attitudes and values of the physician's social role. If one looks over all of these studies, seeking the patterns of origin, frames of reference, methods, and results, one finds a wide-ranging discourse on the problem. Up to this point, however, the patterns and polemics remain largely implicit, embedded in a considerable volume of separate research reports. Some stocktaking is evident in two recent reviews8' 94a and several bibliographic reports.94b, 95 113 The view of each, however, is limited, centering on selected themes. Becker and Geer,94" for example, review mainly research on medical student culture, recapitulating the lines of inquiry drawn most completely in the particular research in which they were the principal investigators.31 Bloom8l surveyed only studies which related to certain attitudes involved in socialization for the physician's role. Freidson's bibliography is the most complete.95

Use of the medical profession as a model for the study of other professions, particularly in the health field, is understandable. Medicine is clearly a profession, is a relatively old one and has been used as a point of reference for codification of a number of fields. Some of these professions, like dentistry, have recently arrived, and others like nursing, are congeries of activities and norms whose professional status is not yet fully settled. However, because medicine, like any professional system, has a range and an organization of structural and subcultural features that are unique to it, the fact that some of its elements may be shared with other fields can make it a deceptive and unreliable model. This is more than a trivial possibility, inasmuch as the medical profession has been more frequently and more thoughtfully studied by social scientists on both theoretic and empirical levels than is the case for other health professions. The point is that distinguishing between elements that are specific to a profession and those that are generic to it as a profession is not a logical but an empirical matter. The present paper is a contribution to the empirical problem. Essentially, it is a deliberate effort to parallel for the dental profession Hall's study of the informal organization of the medical profession in a specific community. Frankly, one would wish for more certain comparability between Hall's study and this one. Hall's community is identified only as an "eastern American city;" the fact that the community used in this

Public health in Brazil is characterized by a spirit of innovation. It faces the challenge of the need to control contagious diseases, of a high rate of infant mortality and of a low standard of living among the population. How are public health workers trained to meet these demands? How effective do they think their training is? An evaluation given by engineers and doctors who took some of the training courses in public health is the subject of this paper. Public health is under the jurisdiction of local or federal government agencies. However, many Brazilian cities do not have sufficient financial resources to carry the costs of public health services nor to maintain a resident doctor. Therefore, the greater part of the medical expense is the responsibility of the Federal Government, which is also trying to stimulate the activities of the existing agencies in many ways, including international agreements with other countries. One of these federal agencies, the SESP (Servicio Epsecial de Salud Publica), was founded in 1942, by an agreement between Brazil and the United States. This agency has the widest experience in public health and operates throughout the country, particularly in areas where medical services are lacking or very limited. From the time it was established, the SESP gave special training to its staff members by sending them to foreign universities-preferably in North America. Later, new staff members were assigned to the schools of public health in Brazil. The objective of this study is

T HE chronic diseases, chiefly characteristic of middle and old-age persons who are increasing in our population, present a challenge which will increase in force during the next twenty to thirty years. There is need to extend knowledge of these diseases which are now the leading causes of disability and death. A special study of morbidity and particularly the chronic diseases is being conducted among a sample of white families in the Eastern Health District of Baltimore. A preliminary report of certain data of illness observed in the first year's study which ended June, I939 has been published.' This paper presents a more detailed analysis of certain aspects of the problem of chronic disease as observed during that same period of time. The seriousness of the problem of the chronic diseases characteristic of middle and old age has been judged by their rank as leading causes of death. The amount of and need for institutional and other community facilities for the treatment and care of cases of chronic illness, such as cancer, heart disease, mental disease, and tuberculosis, has been another measure of their importance. Both of these criteria imply an unusual risk of complete incapacity and death for the chronic-disease sufferer. Morbidity surveys have afforded an

Most studies and statistics of mortality in the clerical profession have shown that clergymen have a lower mortality than males in the general population, or males in medical and legal professions, that mortality among clergymen differs by faith and denomination, marital status, ministerial specialty and age and cause of death, and that the mortality of British clergymen was nearly constant from 1910 to 1953, though a general downward trend was seen for lawyers, physicians and teachers.l These considerations led to several mortality studies of ministers, with the primary purpose of systematically examining mortality risks and specific causes of death in the clerical profession. The first in a series of such investigations is reported in this paper.

The field of public health has long been aware of the greater resistance to modern medical science and technology among the lower socioeconomic and ethnic minority groups. The nature and underlying causes of this resistance, however, are in general not precisely formulated. The present paper attempts to study the nature of such resistance by analyzing variations in reactions to modern medical care in terms of two major social factors: (1) the structure of the social group to which the individual belongs; and (2) the health orientation or value system to which he adheres.

The purpose of this paper is to indicate briefly some of the problems and needs that are associated with the use of official statistics in sociological research.' Although specifically concerned with problems that graduate students may encounter in using official statistics while preparing their theses, the problems cited are not necessarily limited to students, but are ones that must be faced by virtually all persons who are engaged in research that entails the use of official statistics.

The assumption that private and public programs will fail in the foreseeable future to provide benefits that are close to the total health care expenditures for most individuals has fostered the proposal for "post-payment" coverage. An organization providing postpayment protection would pay for all of at least certain health care expenditures, with the portion thereof not covered by traditional prepayment coverage being considered as a loan to the insured. In addition to considering certain aspects of post-payment coverage, the article evaluates the implications associated with post-payment being offered by various types of organizations, including health insurers, credit card companies and providers of health care. In the Summer of 1968 the author proposed in an article, subsequently published,1 a new arrangement for health insurance under which health insurers wvould expand the objectives and scope of their coverages to include responsibility for the payment of virtually all health bills incurred by a policyholder. The essence of the proposal was an arrangement called post-payment." In the intervening year, at least three organizations announced intentions of providing protection resembling certain facets of post-payment. Thus, this article will: (1) compare the proposals and announced programs involving what may be called "post-payment" and assess the implications associated with different types of sponsorship; (2) evaluate certain possible aspects of the coverage itself; and (3) analyze the potential for Robert D. Eilers, Ph.D., C.L.U., is Associate Professor of Insurance and Executive Director of the Leonard Davis Institute of Health Economics. He was formerly Executive Director of the S. S. Huebner Foundation for Insurance Education. This paper was presented at the A.R.I.A. 1969 Annual Meeting. I Robert D. Eilers, "Post-Payment Mledical Expense Coverage: A Proposed Salvation for Insured and Insurer," Medical Care (May-June, 1969), Vol. 7, No. 3, pp. 191-208. the proposed coverage and tlhe impact it could have on various interested parties. The Post-Payment Approach Under post-payment, responsibility for initial payment of most medical expenses of covered persons would be assumed by the organization issuing the coverage. The original post-payment proposal anticipated that the issuing organization would be a health insurance company or Blue Cross-Blue Shield plan, but other types of sponsoring organizations are possible. Having obtained post-payment coverage, possibly as an addition to group or individual health insurance, an insured would be given a post-payment coverage card to be submitted to liospitals, physicians, dentists, nursing homes, pharmacies and others which would provide health care services and products. The post-payment card would furnish the identification needed by health care providers to send bills to the insurer issuing the coverage, wvhich would then make direct payments to the providers for the covered services and products received by the insured. If post-payment coverage were issued by a health insurer, the insurer would

This paper will examine some of the alleged defects in the present personal health services system, state some assumptions that may condition changes, pose public policy issues that require resolution to effect desirable changes, and set forth specific proposals designed to improve these services. 'lhe viewpoint will be primarily that of the patient and the community, but not to the exclusion of the views of the health professions and institutions. The object will be to identify major issues and nodal points in the health services system that might be influenced by leadership, discussion or programs initiated at the federal level. Personal Health Services means all health services other than Environmental Health Services. Specifically, those things done to ancl for all individuals who request or require health services provided by doctors, nurses and dentists and the allied health professions. No distinction is made between so-called preventive, diagnostic, therapeutic and rehabilitative functions, nor would it be helpful to separate the physical, emotional and social components of illness. These are transient divisions of interest, emphasis, organization and style based more on tradition and arbitrary jurisdictional arrangements than on humanaitarian, scientific or technical constraints. No distinction is made between the various sites of care at which Personal Health Services may be given; for example, the solo practitioner's office, the outpatient dispensary, the voluntary, private or public hospital-their clinics and wards, the health department clinic, the group practice clinic, the home, the factory or the school. Nor is the posture of the patient, vertical or

This book presents a pale reflection of a burning issue. In 1968 the Rockefeller Foundation sponsored a conference in Italy which brought together 22 medical educators, health administrators, government officials, and foundation executives from nine nations and five continents. They met to consider how to study and teach the delivery of health care, especially health care for the rural populations of developing countries. This book is a transcript of the conference and suffers from the predictable faults of such a work: the tone of voice is missing, and the papers do not seem to be addressed to present readers. In addition, the speakers, authoritative though they are, are officials and administrators and are therefore dealing with the subject at a distance. Their concerns are how to reach or investigate community medicine, and only secondarily how to improve the health of the people. There are good ideas in the book. Medical

One of the most visible concomitants of economic development is a fall in mortality rates and a rise in the general level of health. Good health and longevity are not only highly desired in themselves but are also important because of their potential contribution to economic welfare. Although some health improvements can exacerbate population problems, better health can also raise the rate of growth of income per capita by reducing population expansion and increasing the stock of human and physical capital per worker.' Despite the potential contribution of health improvements to the over-all process of economic development, economists have generally remained silent on the subject of programmes of health care and disease control in less developed countries.2 In particular, no attempt has been made to extend the methods of economic optimization to the health care sector. Unfortunately, public health administrators also have neither developed any systematic methods of planning nor sought to integrate health care into the broader context of development planning. The choice of health care activities has not reflected a conscious comparison of their multi-faceted benefits with their use of scarce inputs. Instead, public health administrators have often attempted to treat programme choice as a "technical" question, free of value judgments about the relative desirability of different health improvements. One result of this has been a concentration on diseases such as malaria in which complete eradication is technically feasible. A second result has been the use of the infant mortality rate as an "indicator" of the community's general health level. This has led health administrators into the fallacy of assuming that programmes which reduce infant mortality actually raise the entire level of health. Substantial resources have therefore been devoted to decreasing infant mortality, thus increasing population size but not improving health in other age groups. The current paper reports the first step towards the development of a systematic approach to health sector planning capable of integration into a more general programme of economic development. The aim of the present research has been to devise a potentially operational method for allocating the scarce health sector funds, manpower and facilities among different disease control programmes and individual activities in the way which yields the optimum feasible reduction of mortality

IN MANY PARTS of the world today, inedicine as a social institution is experiencing changes as startling as those occurring in medicine as a science and an art. In a Canadian Province, some physicians accept a system of state medicine for the whole population, while others refuse to treat patients covered by that system. In America., some medical and hospital associations oppose social insurance for medical care of the aged, while all health professional schools and many voluntary hospitals seek Federal funds for research and training. Many American voluntary hospitals recruit interns from foreign medical schools as a means of obtaining sufficient resident staffs. In the United States, public health and preventive medicine are emerging into roles entirely different from those defined by their apostles. These roles are the subject of my discussion. Primarily, the roles of preventive medicine and public health embrace medicine as a social institution. They comprise those functions which relate medicine as a science and art to society, in contrast with those medical functions related to the individua.l patient and those associational functions related to the practitioners of the art as a learned profession. At present, the social functions of medicine are expanding in scope and volume at a rapid rate. Medicine is called upon to deliver judgments affecting critical issues in public policy, such as the effects on human life of manmade radiation, new drugs, and chemical contamination of the environment. In the United States, medicine is expected to provide guidance for thousands of voluntary health agencies which hold large sums of money as a public trust. Medicine is also expected to establish standards for an incredible variety of services which now comprise comprehensive health care. These services must also be so planned, organized, financed, and operated as to insure comprehensive care for each individual in the population. Public health as we know it in the United States has inherited the major responsibility for the development of these new functions, as preventive medicine has inherited the teaching of them in our medical schools. It would be difficult to determine whether this inheritance has been won by virtue or by default. Certain it is, however, that public health has served as a rallying point in American medicine for those physicians whose professional preoccupation is the social role of medicine. And they have been allied with certain clinical practitioners to establish a medical specialty: preventive medicine. When in 1948 the charter members applied for recognition as an American Specialty Board, the terms "public health" and "preventive medicine" already were inadequate to identify the social functions of medicine in the United States. For cultural and political reasons well known to all of us, the definitive term "social medicine," freely used by our colDr. Stewart, formerly chief of the Division of Community Health Services, Public Health Service, is now assistant to the Assistant Secretary for Health and Medical Affairs, Department of Health, Education, and Welfare. This paper was presented at the annual meeting of the North Carolina Academy of Preventive Medicine, Raleigh, N.C., September 26, 1962.

How may communications to the public regarding public health be improved? More specifically, how may the public be persuaded to lay greater emphasis on the prevention of serious mental disturbances rather than on treatment of them after they develop? To find answers, the author of this paper conducted an experiment with communications regarding delusions. Demetrios Papageorgis is an Assistant Professor in the Department of Psychology, The University of Texas.

Eventually school mental health programs will include comprehensive primary prevention as well as rehabilitation, both monitored by systematic evaluation. After the fashion of the community mental health approach, the elements will be built into the ongoing educational process rather than added on. Regardless of the panaceas of the moment, we can anticipate a combination of traditional approaches with newer techniques. The new mosaic has yet to be created, though Biber (1961) gave a thoughtful base and Rhodes (Chapter IV) touches upon the issues involved. Part of the complexity rests with the recognition of the profound interaction among school, family, and community forces as a life system (Bower, 1968). Several authors have considered the nature of overall models. Cowen, Gardner, and Zax (1967) saw school programs as one aspect in their emerging approaches to mental health. In this volume, matters of general theory were related to detection and prevention, the teacher's role, and specific action programs including the use of subprofessionals. It was a broad-gauged source book for serious practitioners with a combination of theory and practice. Sarason and others (1966) also considered generic issues and a "clinic in the school" operation in depth. Awareness of the total system is evident in the attention given to management, authoritative support, and movement from concepts to action. A third approach was taken by Long, Morse, and Newman (1965): the concentration was on identification, school programs, management, and teaching the more disturbed child, with selections on the nature of improvement and research evaluation. Lambert (1964) compiled a useful set of papers which included attention to primary prevention and egobuilding processes in school mental health. Greenwood (1968) described two mental health models, one for the 10 to 15 percent of the population having serious difficulty, the second for the total population. Crisis intervention, seminars for school personnel, diagnosis and consultation services, special classrooms for disturbed pupils as well as "teacher-moms" were advocated for the clinical cases. Greenwood envisioned more attention to feelings in teacher training and inservice training for all staff as a channel to serve the mental health needs of the total population. Hunt (1968) saw the school as the logical focus for a national mental health program because it provides access to the entire child population. He included identification and treatment, with the status and authority of the school system as vital enabling conditions. Bower (1961) developed a basic position for primary prevention in a school

HIS paper is based on a study of the outcome of 240 male chronic mental hospital patients from seven hospitals, which together provide 15,000 of the 37,000 mental hospital beds in the London area. For the purpose of this inquiry chronic patients were defined as those who were discharged from hospital after a continuous stay of at least two years: readmissions were included. The period of two years was chosen because once a patient has remained continuously in a mental hospital for two years his chances of discharge are relatively small: in England and Wales they range from approximately I in 12 in the third year of stay, to 1 in 100 after ten years, and 1 in 200 after thirty years (1, cf. tables M22 and M29). About 80 per cent of the current population of mental hospitals are formed by such chronic patients (1, 2, 3). The major aims of the investigation were (1) to provide systematic data on what happened to such patients once discharged by all methods, including escape, and (2) to make a preliminary evaluation of the influence of social factors on outcome. Other criteria for inclusion in the series were (1) age on discharge 20-65 years; (2) born in the British Isles; (3) discharged to an address in the Greater London area. Information about the patient's outcome was obtained through interviews, in their homes, with key persons who had intimate knowledge of the patient during the first year of discharge, and also, if possible, with persons who knew his preadmission history. Such key persons, typically mothers, wives, sisters, and landladies, and sometimes the patients themselves

To be meaningful social indicators must be components of some social systems model so that changes in the values of these social statistics over time tell us something about the functionimg of the social system. A necessary next step in developing social indicators is constructing models involving interrelated sets of social indicators in each major institutional area of society. This paper reports an initial effort to derive a set of social indicators for the area of health care. A structural equation model has been constructed fox the health care system serving the state of New Mexico. The model includes a network that specifies the causal relationships hypothesized as existing among a set of social, demographic, and economic variables related to the availability and use of health services and to health status; a set of structural equations that indicate the direct effect of variables in the model on each endogenous variable; a set of reduced form equations that indicate the combined direct and indirect effect of each predetermined variable on each endogenous variable included in the model. The model can be used to provide monitoring information pertaining to the effect of a change in a particular variable on all other variables comprising the health care system. Also it provides explanatory information regarding the differences in the availability of health care services, their use, and the health-status of the population in various counties. Finally, predictions of the effects of alternative health care policies that would affect the supply, the organization of care, or patterns of use of health services can be made based on the model.

Singly and together, the foregoing papers make a number of forceful points about the contemporary status of man's continuing struggle to cope with threats to his physical and mental well-being. They speak also to some of the conceptual and methodological problems of scientists who share a common humanity with subjects whose plight evokes sympathy. Scientific canons require us to abstract social structures and ideological patterns from the raw facts of daily existence and to dissect the participants into statistically significant bits of behavior. Yet the findings, perhaps especially in the health field, cry for a deeper interpretation of human aspirations and raise questions that can only be answered with intelligent, compassionate action directed to humanly desired and humanely desirable goals. The analytic approach leads to reliably verified theories of human behavior and social change. The activist approach goes beyond established theory and impartial assessments of feasibility to advocate what is right and just over what is wrong and iniquitous-matters that can be resolved only through a process of conflict and negotiation to reach consensus. In short, as these and numerous other studies demonstrate, health care is a moral and political as well as a technical and managerial issue. At present, the right to use the products of modern medicine is socially restricted and politically limited despite normative rhetoric to the contrary. Small wonder that conflict between the providers and potential users of health services often outweighs consensus or that consensus sometimes masks the coalition of some factions in order to exclude or control other factions.

IN recent years, the American public has become greatly alarmed over an apparent shortage of physicians, a shortage which is expected to reach crisis proportions within the next decade. The predicted shortage stems, in part, from the nation's current efforts to make health care accessible to all income classes and from past neglect of medical-school facilities. However, there is also some evidence that the shortage is further aggravated by widespread inefficiency in the use of medical manpower. It is a matter which is increasingly attracting the attention of health-manpower specialists, but one on which opinions still differ widely. Somne students of the health-care sector have argued, as early as a decade ago, that it would be techniically imnpossible to add to the already hea\y patient load carried by American physicians.' In contrast, Rashi Fein's recent book The Doctor Shortage (1967) concludes with the assertion that physicians could increase their productivity still further, either by joining large-scale group practices or by delegating more of their workload to auxiliary personnel. Fein admits, however, that in the absence of more research, one "cannot be certain whether the gains from group-practice formation and from increased reliance on paramedical aides will be large or more modest." (p. 144) His argument therefore rests on essentially intuitive grounds. Fein's call for more research on the production of physicians' services is entirely justified. For, in spite of the crucial role played by physicians in the production and delivery of health services, there exists very little enmpirical information on the technical and economic determinants of the physician's productivity. This paper is an attempt to contribute to our understanding of this important parameter. Using a simnple model of physician behavior and a nationwide cross-section sample of physicians, the study seeks to identify the effects of auxiliary persoi)nel and of the mode of practice (solo or group) on the physician's rate of output. Our analysis leads to the conclusion that the average American physician could profitably employ roughly twice the number of aides he currently employs and thus increase his hourly rate of output by about 25 per cent above its current level. This figure takes on added meaning when it is recalled that a mere increase of 4 per cent in average physician productivity in the United States would add more to the aggregate supply of medical services than would the entire current graduating class froin American medical schools. Looked at in another way, our results suggest that, in choosing his combination of practice inputs, the average physician in our sample appears to have priced out his own time at a value much below that implicit in his medical fees. On either interpretation, the results therefore support the thesis that American physicians tend to be wasteful in the use of their scarcest and most expensive resource.

Since the field of psychiatric epidemiology has only recently begun to be explored, I should like to emphasize that the methods to be described here are best viewed as exploratory exercises. Most of the paper will be devoted to discussion of the method which we developed during the course of a study in Stirling County, Nova Scotia, Canada, and which we then applied in other areas. A brief characterization of this investigation makes an appropriate starting point. CANADA The Stirling County study initiated in 1952 a survey of 1,010 respondents who formed a probability sample of household heads in a small town and rural county in eastern Canada. The study had the dual purpose of estimating the prevalence of psychiatric disorder and of relating it to factors in the sociocultural environment.l' 2, 3 The instrument used was a lengthy questionnaire administered by nonmedical interviewers, which contained a section on health. This section became the basis for the psychiatric assessment. It included a check list of common adult diseases and a series of psychoneurotic screening questions derived from the Army's neuropsychiatric screening adjunct and other similar sources. Health data 180

T 1 HIS is the concluding paper on the Study of the Nutritional Status of Aircraft Workers in Southern California. It is a summary of the whole Study and discusses the results in the context of related studies and their objectives. The immediate impetus to the undertaking of the Study came from the call for maximum production in the war effort. In the years preceding the National Emergency and the War the general public had become increasingly interested in nutrition, especially in the question of the value of vitamin supplements. A few employers were convinced that production was improved by improving the nutrition of their workers. In most cases this opinion was an interpretation of the results of tests, without controls, of supplementing the diets of workers with vitamin concentrates. There were no adequate studies of the nutritional status of the workers before and after a vitamin supplement was used, nor of precisely what was gained by its use. In most industrial groups in the United States there is probably relatively little severe or acute nutritional deficiency. At the time of the declaration of the National Emergency in I941 the effects of improving the diet of such a population on health, working calThe Study of the nutrition of aircraft workers in California was sponsored by the Nutrition Committee (R. A. Millikan, Chairman), appointed by the Board of Supervisors of the County of Los Angeles, California, and the Committee on the Nutrition of Industrial Workers of the National Research Council. The Study was supported in part by the sponsors and by the following: the California Institute of Technology, The Lockheed Aircraft Corporation, the Milbank Memorial Fund, the War Production Board, and the Work Projects Administration (Project No. 12372). Support was also received from the California Fruit Growers Exchange, the Gelatin Products Corporation, Hoffman-LaRoche, Inc., Merck and Company, the National Oil Products Company, the Research Corporation, E. R. Squibb and Sons, and the Vita-Food Corporation. s California Institute of Technology, Pasadena. 8 Milbank Memorial Fund, New York.

Despite the vastly improved climate of the last decade many physicians health officials and researchers continue to be somewhat indifferent to the implementation of family planning services in the United States although this is a field of health care with both immediate and long-term medical social and economic consequences of some significance. Nevertheless we do have some experience in development of services even if it has not been studied systematically and we can draw on those organizing principles from programs in the developing countries which are applicable to our situation. This paper is an effort to distill from the collected experience a viable if necessarily tentative strategy which can help to guide choices on allocation of resources establishment of priorities and assignment of responsibility among community agencies. (excerpt)

IN THE United States, growing interest in disability and medical care insurance, as well as group plans for provision of medical service presents an increasing need for statistics on the incidence of illness among persons of opposite sex and of different ages. Since 1920 data of this type have been made available for certain population groups by special morbidity studies of families. One of the studies gives illness rates by sex and age for the population of sample areas in the United States: the Committee on the Costs of Medical Care study of 19281931 (1). Two other studies provide data for local areas in Maryland: one made in Hagerstown from 1921-1924 (2) and the other conducted in the Eastern Health District of Baltimore from 1938-1943. A number of preliminary reports of the study in the Eastern Health District of Baltimore have been published (3, 4). The purpose of the present paper is to make available data from this study on illness by age and sex in more detail than has been given in the past.

IN THIS PAPER, we describe how a few simple procedures coupled with the appropriate administrative decisions can combine to produce a significant improvement in our capacity to immunize children, as we know we should, but have never accomplished in practice. Our Children's Hospital outpatient department, with 80,000 visits in 1967, is geared to provide consultation services to a large area in central and southeastern Ohio, while providing total health care to a significant number of children who reside in Franklin County. It serves mainly children from low income families, but in its specialty and diagnostic clinics the hospital accepts some children of the upper socioeconomic classes on referral from their physician. The Children's Hospital is private and nonprofit, but serves as the main teaching facility of the Department of Pediatrics of the Ohio State University College of Medicine. The 32 general and specialty clinics operational during 1967 are all under

NUMBER of longitudinal studies of families have been made in order to observe the incidence of illness among their numbers. It is recognized by those who have conducted such studies that the interval between visits to the family has a marked effect upon the accuracy of reporting past illnesses, especially those of a minor nature. Thus, the memory of the informant constitutes an important factor which may influence the level of illness obtained in any morbidity study. The purpose of this paper is to consider some of the effects of the frequency of family visiting upon the accuracy of reporting minor illnesses. The data are limited to acute respiratory diseases because most illnesses in this class are of a minor

The foster care program in Japan started in 1948 under government subsidy and supervision, following the enactment of the Law of Child Welfare. The scale of the program has been small, and, in fact, both the number of foster homes and of foster children show a decreasing trend in recent years (Table 1). The limited development of foster care in modem Japanese society is in sharp contrast to its popular role in traditional Japanese life. The custom originated at least 600 years ago as a way of child upbringing, and even now many adults who grew up in pre-World War II Japan have memories of time spent in foster homes. The foster home custom in Japan evolved primarily from the aristocratic class and was fostered by the hierarchical class and family system of Japanese society. The custom lost its raison d'etre with the changing concept of class and family in post-war Japan, but still exerts its influence upon present foster care practices. This paper deals with the historical background of the foster home custom in Japan, and reports preliminary findings from a field trip to a suburban community of Tokyo, which has been known as a colony of foster homes in the past, and which still plays an active role in the foster care program of today.

A crucial problem facing voluntary community organizations and the planners who wish to provide more adequate health services is the extent to which the community leaders become involved in that particular area of community life and the forms this involvement takes. Any organization which assumes the responsibility of planning and coordinating the activities of others presumably requires sufficient power resources to accomplish the task. The community health system provides an excellent setting for the exploration of this problem and the influence of community leaders on it. This is because a public awareness of the need for planning and coordination in this area is growing and, consequently, top local leaders are becoming more involved.' This paper is based on an exploratory study of some forms of leadership involvement in health planning bodies and other organizations of the health system in a metropolitan community. The relationship between community influentials and voluntary and official health and welfare associations, and the decisions affecting these associations, have been the object of a wide range of studies. Some of the studies have explored the importance of financial support resulting from connections between organizations and outstanding individuals who occupy positions of community 294

Effective mental health programs can be An earlier version of this paper was predeveloped only if public administrators are sented at the Seventh Annual Conference of able to determine how much the public knows the American Association for Public Opinion about the problem and what its misconcepResearch at Poughkeepsie, N.Y. in 1952. tions are. In this article, the authors describe Robert Felix is Director of the National the components of a national mental health Institute of Mental Health of the Public program and the ways in which survey data Health Service. John Clausen is Chief of the can be useful to those who are charged with Laboratory of Socio-environmental Studies of directing such programs. the same institute.

5T HE morbidity study, conducted from June, 1938 to May, 1943, in the original Eastern Health District of Baltimore, is the first investigation of illness where, due in large part to the method of sampling, families with relatively short periods of observation constitute an important part of the total observed population of families. Preliminary analysis of the morbidity experience of the first year of the study indicated that about one-third of the total families either moved out of or into the study area during that period (1). Movement of families continued throughout the five-year period. This paper presents a study of some of the socio-economic characteristics of the moving and non-moving families-characteristics which form a background for forthcoming analyses of illness. Reed, et al. have presented some general characteristics of the population in the Eastern Health District (Wards 6 and 7) from which the morbidity study population was drawn (2). They found that in 1939, 56 per cent of the white families in the district were home owners. They concluded also that "The population is essentially in the lower middle economic class with a greater proportion of skilled and semi-skilled workers 'relatively' than in the rest of the city."

Health care affects and is affected by the economic system in so many ways as to preclude any attempt at complete enumeration or description. The objective of this paper is more modest. I shall assume that the reader is reasonably familiar with health care, its institutions, technology and personnel, but is less familiar with an “economic system” that is used by economists to describe and analyze economic behavior. Therefore, major emphasis will be given to indicating the place of health care in this system and showing how related economic concepts can contribute to an understanding of problems of health care in the United States. I shall also attempt to indicate some of the limitations of economics in dealing with such a complex area of human activity and concern.

General practice and general practitioners have been so thoroughly dissected by so many special pleaders during the last decade that a volume whose title suggests another exploration of the same old ground is unlikely to cause wild cheering at the bookstalls. Curiously enough, this book probably deserves more readers than it is likely to get. At least half of the eight essays in the collection of papers delivered at the 1961 Edinburgh Conference on the Training of the Doctor for His Work in the Community have something very fresh, if not new, to say about a compelling problem. Although intended for the European community, the issues raised have no geographic boundaries: the essayists are speaking to the health care problems of the mid-twentieth century and not in defense of any system of medical service that may have become familiar through long use or desirable for political ends. The fact that

Tr _HE standard diagnostic nomenclature of mental disorders (1) has been applied to children since the initiation in 1954 of nationwide psychiatric clinic reporting (2). Much criticism has been evoked and numerous difficulties cited in the application of these standard classifications to children (3) (4). We have encountered a number of such problems but even with these limitations have been able to demonstrate large differences in the risk of clinic admission by diagnosis and by population groups (5). In this paper, we should like to consider a corollary issue: to what extent is the psychiatric classification an operationally important variable in determining the course of clinic service for the child patient? We shall use data from one state (Maryland) where an intensive educational effort with clinic professional and clerical personnel preceded and accompanied the collection of reports. Maryland is an eastern seaboard state of 10,000 square miles and three million population; its large urban center, Baltimore City, has approximately one million people. Four Maryland counties met the 1950 census definition of a metropolitan area-Baltimore and Anne Arundel counties, which are contiguous with Baltimore City, and Montgomery and Prince George's counties, adjacent to Washington, D.C. About a fourth of the population was classified as rural in the 1950

This paper presents the historical, social, and economic concepts underlying the framing of Title XVIII of Public Law 89-97; the mechanics involved in implementing the medicare program; and the health services rendered medicare beneficiaries during the first year of operation. Attention is also directed to present and future contributions of the medicare program as a stimulant to the growth of the Nation's health care system. Two years ago, the people of this Nation, acting through their elected Congress, directed national policy to a new commitment that all Americans age 65 years or older should have the financial barrier to a wide and varied spectrum of health care services lifted through social insurance. With that decision a debate in the United States over the role of contributory social insurance in financing health care that had persisted for many years was resolved, and a major blow was struck against a serious socio-economic

The Health Services Research Study Section of the Bureau of Health Services has for some years been concerned with improving the quality and quantity of health services research in the United States. The present survey of health services research in the United Kingdom was planned in 1963 with that basic purpose, as were the previously published Scandinavian study and the series of commissioned papers on needed research into the American system.' The National Health Service of the United Kingdom, representing as it does a national commitment to provide uniform and universally available services, appears to provide a unique environment for health services research; an environment decidedly different from that of the United States, where administrative responsibility and sources of money remain highly diversified and decentralized. A survey seemed particularly appropriate at this point in time when regional and statewide planning, aimed at achieving more general availability of services and reducing wastage of scarce resources, is being encouraged in the United States on an unprecedented scale, offering equally unprecedented needs and opportunities for studies in all aspects of medical care. The study team was composed of three members of the Health

MEDICAL TREATMENT of the mentally retarded patient is one area of mental retardation that often receives minimum attention. In recent years many reports have been published concerning etiology and diagnosis and classification of mental retardation; for example, the classic article by Wright and Tarjan (1) or the three-part series on subnormality by Knobloch and Pasamanick (2). Other reports, such a,s that by the Group for the Advancement of Psychiatry (3), have been devoted to treatment of the family and to the physician's reactions when he enc,ounters a mentally retarded patient. Sorely lacking in this rapidly growing volume of literature are specific references to, lelt alone detailed accounts of, how the physiciarn can directly intervene in the medical problems or the continuing health care of the retarded. Perhaps the best example here is the excellent 192-page manual published by the American Association on Mental Deficiency (4) in which only 10 lines appear under the section titled "Medical Care and Treatment." The physician's tra,ditional concern for his patient seems to have been displaced by his concern for the parents and other members of the patient's family or even the community. In other words, after he makes the initial diagnosis and neatly classifies the retarded, the, physician's role a,s it pertains to treatment becomes focused on the parents. According to the literature, the parent rather than the retardate seems to be in greatest need of treatment. This is not to question the need or importance of counseling for the family, but rather to point out what I believe is an important area of neglect; that is, the need for the physician's interest beyond the initial diagnosis and classification and parent counseling. First, this interest is required in the prevention and correction or at least amelioration of physical handicaps to permit full achievement of whatever functional potential 'may exist. Second, even where no improvement in function can be foreseen, increased personal comfort for the patient and increased ease of attendant care must be considered sufficient indication for medical or surgical intervention. It is generally acknowledged that the true capacities of children with severe physical or sensory handicaps cannot be measured by their inotor abilities. Even the child with normal intelligence appears to lag in development if he is severely handicapped. Korsch and associates (5), in a comparison between the "estimates" of 81 pediatricians and the results of standard psychological tests given by experienced psychologists to 242 children, noted that about two-thirds of the estimates came within 15 points of the test scores. The one group consistently misjudged and underestimated was the children with major physical illnesses. For the retarded child, the effects of additional physical handicaps on developmental function may be almost catastrophic, because of his more limited ability to compensate. Correction or amelioration of the physical defects, therefore, becomes more imperative than for the child with normal mentality. Dr. Pearson, chief of the Mental Retardation Branch, Division of Chronic Diseases, Public Health Service, presented a version of this paper at the annual meeting of the American Orthopsychiatric Association, Cleveland, Ohio, March 1964.

At the annual meeting of three pediatric societies, the Society for Pediatric Research, the American Pediatric Society, and the Ambulatory Pediatric Association, a symposium was held, sponsored by all three societies, on the topic, "Does Comprehensive Care Make a Difference?" The importance of the subject and the interest generated at the meeting suggest that reporting this symposium would serve a wider audience and advance the health care of children. The moderator's introduction, the three speakers' papers, and summary of the discussion are presented for this broader audience.

This essay discusses American dentistry as an organizational system and as a culture of several interrelated, historical, occupational groups. The analysis is general by necessity and omits small exceptions and minor trends. It also runs the risk of being overly programmatic inasmuch as dentistry is an organization and culture largely unknown to American social science, and interesting ideas and fruitful research might go in any direction. However, this institutional approach may not be inappropriate: the study of occupations has been named by Everett Hughes as American ethnology. The paper is organized into two parts. Part one sketches how dentistry is organized today in America. Part two speaks to some of its peculiar cultural themes by way of explaining that organization. In America, dentistry is an independent, autonomous health service, a world to itself. It has its own social structure and is not a part of American medicine, although it presently has benign and legitimate relations with it.

Among the values of cross-cultural exchange is the opportunity for an individual to obtain perspective on his own work through contact with research in another country. The observations to be reported in this paper stem from a year in the U.S.A. during which I was fortunate to have the opportunity to acquaint myself with current thought and investigation in three aspects of child psychiatry: nosology, brain injury and behavior, and behavioral development in children. Because the topics are ones in which advances may have wide implications, I believe that a reaction to American work in these fields by someone from a different psychiatric culture may be of more than private interest. Necessarily a personal reaction is not comprehensive and reflects the especial biases and interests of the writer. Therefore the considerations that follow make no attempt at a complete coverage of current studies in child psychiatry or related fields, several reviews of this kind being available elsewhere.7 34 36 68 For several reasons interest in nos

The purpose of this paper is to develop methods of relating notifiable diseases1 and other key measures reported by small subareas within cities to the socioeconomic characteristics of the people residing in those areas. It is believed that such a study will provide a valuable input for future analyses of illnesses in relation to social groups, and lead towards much needed improvement in urban medical geography. Predictions of future need for health care based on

The 1970 international conference convened with 315 scientists from 41 nations, a striking increase in the number of participants and a more diverse representation of countries with differing health care needs, goals, and mechanisms for implementation of vaccine programs than that of the previous conference in 1966. The 1970 conference gave special emphasis to the utilization of existing vaccines, economic analysis, and the impact of vaccine practice and surveillance techniques. The formal papers and lively discussion focused on infectious diseases as the critical problem in many countries which had established health care services as a high national priority. A broad spectrum of viral, rickettsial, and bacterial vaccines was reviewed. Some of the highlights included discussion of the development of new cell types for the propagation of a safer rabies vaccine, the use of recombinant strains of influenza virus for more effective immunization, and the intranasal inoculation of temperature selected mutants

ranging from the effect of nicotine on respiration to one on the social psychology of smoking. The papers in the final group deal with smoking and cardiovascular disease, allergies, bronchitis, and peptic ulcer. In the current emotionally charged atmosphere-erroneously called "controversy"-about the health effects of smoking, this volume, heavily sprinkled with graphs and tables, presents more facts than opinion. The uninitiated will recognize some of the different points of emphasis but may not easily recognize the subtle difference between the detached objectivity of such authors as Dorn and Comroe and the selective objectivity of a few others. DEAN F. DAVIES