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The article addresses further debate and decision-making by the American Public Health Association (APHA) on a public policy statement on safe drinking water. The paper provides the scientific basis and justification for the importance of improving water supplies in the U.S. The quality and safety of drinking water in the U.S. continues to be an important public health issue. Specific contaminants of concern include microbial contaminants and chemical contaminants. Recommended goals for the APHA are to foster greater involvement of the public health professional as advisor, educator and advocate on issues related to drinking water and health, and to promote understanding in public health practice and policy making of the potential public impact of water contamination.

The earthquakes that hit Mexico City in September 1985 caused considerable damage both to the population and to important medical facilities. The disaster took place while the country was undertaking a profound reform of its health care system. This reform had introduced a new principle for allocating and distributing the benefits of health care, namely, the principle of citizenship. Operationally, the reform includes an effort to decentralize the decision-making authority, to modernize the administration, to achieve greater coordination within the health sector and among sectors, and to extend coverage to the entire population through an ambitious primary care program. This paper examines the health context in which the reform was taking place when the September earthquakes hit. After presenting the damages caused by the quakes, the paper analyzes the characteristics of the immediate response by the health system. Since many facilities within the system were severely damaged, a series of options for reconstruction are posited. The main lesson to be learned from the Mexican case is that cuts in health care programs are not the inevitable response to economic or natural crises. On the contrary, it is precisely when the majority of the population is undergoing difficulties that a universal and equitable health system becomes most necessary. [ABSTRACT FROM AUTHOR]

There is the expectation that outcomes research and the promulgation of medical practice guidelines will be able to identify and hopefully reduce the amount of unnecessary or inappropriate medical care through a variety of methods, including utilization review. However, past efforts by public and private insurers to deny claims on the basis of formal technology assessments or practice guidelines have frequently been overturned by the courts for multifarious reasons. This paper examines the court's reluctance to accept a variety of technology assessment methods in coverage policy decisions. The paper reviews the options that have been proposed to restrict judicial involvement in the formulation of coverage policy and then proposes a new option that employs a more precise taxonomy of medical practice assessment. [ABSTRACT FROM AUTHOR]

A widely publicized but unpublished study of the relationship between gun shows and gun violence is being cited in debates about the regulation of gun shows and gun commerce. We believe the study is fatally flawed. A working paper entitled "The Effect of Gun Shows on Gun-Related Deaths: Evidence from California and Texas" outlined this study, which found no association between gun shows and gun-related deaths. We believe the study reflects a limited understanding of gun shows and gun markets and is not statistically powered to detect even an implausibly large effect of gun shows on gun violence. In addition, the research contains serious ascertainment and classification errors, produces results that are sensitive to minor specification changes in key variables and in some cases have no face validity, and is contradicted by 1 of its own authors' prior research. The study should not be used as evidence in formulating gun policy. [ABSTRACT FROM AUTHOR]

Abstract: This paper provides an overview of Japanese occupational health and evaluates the current situation from three perspectives. Major occupational health hazards are assessed using four sources of data, showing patterns similar to those found in other advanced industrial societies. Institutional structures for occupational health policy are then examined, illustrating strengths and weaknesses of the Japanese legal and administrative systems. Trade union activities are presented, indicating the constraints of enterprise unions, and the tendency for a greater orientation toward compensation than prevention. Significant occupational health problems persist among marginal workers in Japan, including women and various minority groups. The analysis demonstrates a record for occupational health in Japan considerably more mixed than the conventional view. [ABSTRACT FROM AUTHOR]

The National Cancer Institute (NCI) estimates on the basis of current knowledge alone that, at a minimum, 30,000 lives could be saved in the year 2000 if Americans would modify their dietary habits. A recent innovative way of responding to this challenge was the Kellogg Company/NCI All-Bran advertising campaign. This paper will describe the campaign, and its impact on consumers, cereal industry sales, food industry advertising practices, health regulatory policy, and the organizational credibility of both NCI and Kellogg. For the past three years, Kellogg has included NCI's cancer prevention messages in their advertisements for All-Bran cereal and on their bran cereal boxes. This collaborative effort has stimulated considerable controversy over whether the health claims made on the cereal label are in violation of federal food labeling regulations. Meanwhile, research has demonstrated the positive impact of the campaign on consumer's knowledge and behavior regarding fiber as well as on Kellogg's profits. Other manufacturers are anxious to jump on the "branwagon"; however, many unanswered questions remain about this new approach to health advertising. [ABSTRACT FROM AUTHOR]

Abstract: This paper reports a case-control study to assess the protective effect of BCG (bacille Calmette-Guerin) vaccination among Indian infants in Manitoba, Canada. A record of past BCG vaccination was found in 49 per ¢ of the tuberculosis cases, compared to 77 per ¢ of the controls, yielding a relative risk of 0.30. Stratified analysis, controlling for age, increased the relative risk to 0.39 (95% confidence interval 0.22 - 0.69). The preventive fraction was 44 per ¢. Non-differential misclassification of exposure status could have occurred; if this was adjusted for, the relative risk would be reduced. If only bacteriologically confirmed cases were analyzed, the age-adjusted relative risk was 0.27. The protective effect of BCG vaccination in the newborn among Manitoba Indians is therefore at least 60 per ¢. The implications for health policy in this population are further discussed. [ABSTRACT FROM AUTHOR]

Abstract: This paper presents analyses of recent natioanl survey data on access to medical care. In particular, information on major access indicators and special problems associated with the economic and political climate of the 1980s collected in a 1982 national telephone survey of 6.610 United Scales adults and children, representing some 4.802 families, is compared with previous national stirrers for kef population subgroups--by age. place of residence, income, race, insurance coverage, and type of regular source of care In general, the findings show that favorable progress has been made, but some inequities continue to persist. Some traditionally disadvantaged groups are more likely to have a regular family doctor, private insurance coverage, have been to a doctor, or had certain preventive tests and procedures than was true for them in the past. On the other hand, compared to the more economically and/or socially advantaged groups in 1982, they have still not "caught up" entirely. There also is evidence that they may be hardest hit by the exacerbation of the financial barriers to care thai result from unemployment, inflation, and cutbacks in health program eligibility and benefits that have characterized the decade of the 1980s. [ABSTRACT FROM AUTHOR]

The World Health Organization's goal of Health for All by the Year 2000 (HFA) has become a major force in national and international health policies. This paper deals with some of the historical roots of HFA and describes ways in which the major components of the health sector--health services, manpower, and universities--have evolved and should evolve in the future if they are to support the idea of HFA. One conclusion is that the changes called for in relation to HFA are not simply incremental extensions of previous values, structures, and functions. Rather a radical break with the past is often required. To expect otherwise is to misunderstand how fundamentally the concepts of HFA differ from values that have governed the health sector in the past. A second conclusion is that recent decades have seen a remarkable progression of new ideas and changes in the health sector, so much so that the changes called for by HFA are not so improbable as one might otherwise think. (Am J Public Health 1984: 74:714-719.) [ABSTRACT FROM AUTHOR]

The design of a comprehensive evaluation of subsidized rural primary care programs on a large national scale is described. Its major purpose is to derive data whose analysis will answer major policy questions about the factors influencing the outcome of the major types of such programs in different communities. This first paper also delineates a typology which was developed of five principal organizational forms of these programs. This classification appears to provide suitable operational definitions of forms of rural practice as a basis for evaluating the differential impact of alternative types of primary care programs. [ABSTRACT FROM AUTHOR]

Abstract: Despite the widespread use of ecologic analysis in epidemiologic research and health planning, little attention has been given by health scientists and practitioners to the methodological aspects of this approach. This paper reviews the major types of ecologic study designs, the analytic methods appropriate for each, the limitations of ecologic data for making causal inferences and what can be done to minimize these problems, and the relative advantages of ecologic analysis. Numerous examples are provided to illustrate the important principles and methods. A careful distinction is made between ecologic studies that generate or test etiologic hypotheses and those that evaluate the impact of intervention programs or policies (given adequate knowledge of disease etiology). Failure to recognize this difference in the conduct of ecologic studies can lead to results that are not very informative or that are misinterpreted by others. (Am J Public Health 1982: 72:1336-1344.) [ABSTRACT FROM AUTHOR]

Abstract: The paper provides an overview of public policy issues pertaining to the use of gene-splicing (recombinant DNA [deoxyribonucleic acid]) techniques in research and for industrial applications. Included is a discussion of the regulatory framework at the federal and institutional levels. The principal limitation of the current federal guidelines is its failure to provide mandatory coverage for private sector activities. Four municipalities and two states have passed their own legislation to remedy the situation. These enactments and their tie-in to the public health sector are examined. (Am J Public Health 69:1252-1259, 1979.) [ABSTRACT FROM AUTHOR]

The article examines how the "American Journal of Public Health," the official organ of the American Public Health Association cope with the changes in the health policy in the U.S. During the period of editorship of Dr. George Rosen, both the Journal's circulation and its sponsoring organization's membership has doubled. The source of offerings to the Journal expanded far beyond the lists of Association members and the papers presented at public health meetings during the years of Rosen's editorship.

During the past two years we have studied the characteristics of state and territorial public health laboratories in an attempt to develop guidelines for considering reorganization of laboratory services in Massachusetts. Only a few recent monographs have dealt with this topic and, to our knowledge, the functional and organizational characteristics of these laboratories have not been reviewed. The state public health laboratory system affords an excellent example of applied laboratory science or technology organized to provide basic public health services. In this paper the programs and organization of the state public health laboratory are reviewed, and a functional basis more responsive to society's current needs is suggested. INSET: Cheap Bubble Fountains. [ABSTRACT FROM AUTHOR]

This paper illustrates how a Bayesian statistical approach was used to estimate the outcomes of the National Tuberculosis Program in India. Such an estimate, it is argued, is necessary for a proper judgmere about a project's social usefulness. The process of medical care delivery is reduced to a set of conditioned probabilities. The numbers are estimated using as source material medical records, the results of medical research, and the opinion of experts. Bayesian methods of estimation are used and their value is discussed. The final discussion contains a brief treatment of the role of project analysis in public decision making. The place of Bayesian methods in project analysis is briefly illustrated, demonstrating their operational value in the field of public health decision making. [ABSTRACT FROM AUTHOR]

This paper argues that if the federal government is to successfully protect the public from the adverse effects of environmental noise, its policies will need to be informed by a scientific understanding of the psychological and social factors that determine when noise results in annoyance and when noise may affect health as an environmental stressor. The overreliance of federal agencies on mathematical modeling of average group responses to physical noise levels is discussed as oversimplifying and limiting the understanding of noise effects in crucial ways. The development of a more sophisticated information base is related to policy needs, such as the need to make accurate predictions about the annoyance of particular communities, the need to understand relationships between public participation in noise abatement efforts and annoyance, and the need to identify populations that may be susceptible to stress-related health effects. [ABSTRACT FROM AUTHOR]

This paper models the prevailing political attack on government as a heuristic, a judgmental strategy that simplifies complex phenomena by applying simple tests to a limited set of relevant data. The heuristic of market individualism offers three tools for analyzing the problems of governing: the supremacy of the free market as a regulatory device, a belief in individual freedom of choice and personal responsibility, and the elevation of individual satisfaction as the chief goal of society. Because public health is inherently concerned with the health of the population rather than individual health, because the market itself is a major source of ill health, and because individual choice is socially mediated, use of the heuristic precludes the recognition of the value of public health work. Although some degree of accommodation to current political realities is a practical necessity, public health advocates must not neglect the task of fashioning radically different alternative visions over the long term. [ABSTRACT FROM AUTHOR]

The article comments on the public health promotion policy in the U.S. proposed by J. B. Richmond and M. Kotelchuck in their paper titled "Coordination and Development of Strategies and Policy for Public Health Promotion in the United States," that was published in the book "Oxford Textbook of Public Health." According to the authors, the health policy model devised by Richmond and Kotelchuck posits that there are three necessary ingredients that make preventive action happen, namely, the knowledge base; the political will to support change; and a social strategy to accomplish change.

Objectives. This paper reviews Russia's health crisis, financing, and organization and public health reform needs. Methods. The structure, policy, supply of services, and health status indicators of Russia's health system are examined. Results. Longevity is declining; mortality rates from cardiovascular diseases and trauma are high and rising; maternal and infant mortality are high. Vaccine-preventable diseases have reappeared in epidemic form. Nutrition status is problematic. conclusions. The crisis relates to Russia's economic transition, but it also goes deep into the former Soviet health system. The epidemiologic transition from a predominance of infectious to non infectious diseases was addressed by increasing the quantity of services. The health system lacked mechanisms for epidemiologic or economic analysis and accountability to the public. Policy and funding favored hospitals over ambulatory care and individual routine checkups over community-oriented preventive approaches. Reform since 1991 has centered on national health insurance and decentralized management of services. A national health strategy to address fundamental public health problems is recommended. [ABSTRACT FROM AUTHOR]

Objectives. This article examines health policy implications of providing smokers with numerical tar yield information in cigarette advertising. Methods. Results of a national probability telephone survey regarding smokers' knowledge and understanding of numerical tar yields and deliveries are reported. Results. Few smokers knew the tar. level of their own cigarettes (the exception being smokers of 1- to 5-mg tar cigarettes), and a majority could not correctly judge the relative tar levels of cigarettes. Smokers were unsure whether switching to lower- tar cigarettes would reduce their personal health risks. Many smokers relied on absolute numbers in making trade-offs between number of cigarettes smoked and their tar levels, thus confusing machine-rated tar yields with actual amounts ingested. Conclusions. The wisdom of the present method of providing tar and nicotine numbers in ads and recommendations for modifying the test protocol are now under discussion. This research indicates that these tar numbers and their implications are poorly understood. The paper recommends revisions in tar ratings to make them more useful and a required statement on cigarette packages to more explicitly relate tar levels to major health risks. [ABSTRACT FROM AUTHOR]

Objects. This paper examines health expenditure growth under two alternative policy approaches competition-based managed care and state government rate regulation. Methods. Data are presented on cumulative growth in real per capita health expenditures between 1980 and 1991 so as to compare California, a state with a pro-competitive policy, with established regulation programs. Results. Real per capita expenditures for hospital services in the United States grew 54% between 1980 and 1991, while in California the growth was half the national rate, or 27%. Real per capita expenditures for physicians services and drug expenditures in the United States grew by 82% and 65%, respectively, white in California these expenditures in creased only 58% and 41%, respectively. California's growth rate was below that of an four regulatory states for all measures of health care cost inflation. Constitution. On the basis of these findings, a properly structured Competitive approach could play a significant role in controlling health expenditures in the United States. [ABSTRACT FROM AUTHOR]

President Clinton recently announced his reform plan for health care in the United States. The United Kingdom, along with other countries, has already enacted reforms in an effort to overcome the basic problem of having insufficient funds to provide a health service to meet modern demands. This paper briefly describes the recent health reforms in the United Kingdom and highlights some lessons for the United States, which include the need to choose procedures that should be universally provided. Health reforms that involve some fundamental restructuring need to be evaluated everywhere and agreed to by the staff in advance. [ABSTRACT FROM AUTHOR]

Abstract: The tobacco industry has lobbied successfully to obtain the support of the United States government for opening Asian Markets to American tobacco products. This paper comments on two issues arising from these efforts: the development of an atmosphere of invasion and resistance to invasion in Asia; and the change in the image of the United States in Asian nations from that of a leader in health to that of an exporter of death. The threat of sanctions and the effects of the open market and United States tobacco company advertising in Japan, Taiwan, and South Korea are noted. Parallels are drawn between the opium wars a century and a half ago in China and the current threat of trade sanctions. Reacting to American policy, an Asia-Pacific Association for Control of Tobacco has been formed and linked with the US Coalition Against Smoking. (Am J Public Health 1990;80:659-662.) [ABSTRACT FROM AUTHOR]

Abstract: This paper presents the prevalence rates of schizophrenia and major affective disorders by age and race among a random sample of male jail detainees. Subjects were administered the National Institute of Mental Health Diagnostic Interview Schedule (NIMH-DIS). The jail prevalence rates were then compared with general population data from the five-city Epidemiologic Catchment Area program using difference of proportion tests and loglinear analysis. After controlling for demographic differences between the jail and five-city samples, the jail prevalence rates were still two to three times higher than those in the general population. These findings suggest several public policy modifications concerning the psychiatric management of our burgeoning jail population. (Am J Public Health 1990; 80:663-669.) [ABSTRACT FROM AUTHOR]

The article presents the authors' comments on the paper "Collapsing the Vertical-Horizontal Divide: An Ethnographic Study of Evidence-Based Policymaking in Maternal Health," by Dominique P. B'ehague and Katerini T. Storeng published in a previous issue of this journal, and a response to the comments by B'ehague and Storeng. The authors comment on three factors affecting health programs--the methods used, how policymakers choose the evidence that determines how programs are designed, and the use of randomized controlled trials in generating data for new maternal health programs. According to B'ehague and Storeng, the authors have misinterpreted their result with the assertion that the article concludes that advocacy efforts for maternal health would benefit from additional evidence.

This paper describes changes in the population for which General Motors provides health benefits using data from domestic personnel records. Total population size grew from 2.01 million in 1983 to 2.14 million in 1987, twice as fast as the US populations. Dependents, particularly spouses, fueled the population growth. Trends suggest that nonworker eligibility for employer-provided health benefits may receive more attention in health care cost containment efforts. [ABSTRACT FROM AUTHOR]