International Journal of Health Services

Many U.S. military veterans lack health insurance and are ineligible for care in Veterans Administration health care facilities. Using two recently released national government surveys--the 2004 Current Population Survey and the 2002 National Health Interview Survey--the authors examined how many veterans are uninsured (lacking health insurance coverage and not receiving care from the VA) and whether uninsured veterans have problems in access to care. In 2003, 1.69 million military veterans neither had health insurance nor received ongoing care at Veterans Health Administration (VHA) hospitals or clinics; the number of uninsured veterans increased by 235,159 since 2000. The proportion of nonelderly veterans who were uninsured rose from 9.9 percent in 2000 to 11.9 percent in 2003. An additional 3.90 million members of veterans' households were also uninsured and ineligible for VHA care. Medicare covered virtually all Korean War and World War II veterans, but 681,808 Vietnam-era veterans were uninsured (8.7 percent of the 7.85 million Vietnam-era vets). Among the 8.27 million veterans who served during "other eras" (including the Persian Gulf War), 12.1 percent (999,548) lacked health coverage. A disturbingly high number of veterans reported problems in obtaining needed medical care. By almost any measure, uninsured veterans had as much trouble getting medical care as other uninsured persons. Thus millions of U.S. veterans and their family members are uninsured and face grave difficulties in gaining access to even the most basic medical care.

The World Health Organization faces allegations that it attempted to secure a $10,000 donation from a pharmaceutical company by asking a patients' group to act as a covert channel for the funds, an arrangement that would break the WHO's own rules on accepting money from the pharmaceutical industry. The WHO denies attempts to bend its donation rules.

The past several years have been difficult for the Cuban people. The economies of Cuba's major trading partners have collapsed. The 33-year U.S. embargo was tightened with passage of "The Cuban Democracy Act of 1992" to include trade--mostly in food and medicines--by subsidiaries of U.S. companies in other countries. The March 1993 "Storm of the Century," which devastated communities from the Caribbean to Canada, caused an estimated $1 billion in damage to Cuba. A mysterious disease known as neuropathy, which can affect vision, appeared in late 1991 and has spread throughout the island. All this has created a situation of scarcity and uncertainty that has affected all aspects of Cuban society, including its health care system. In June 1993 a delegation that included members of the American Public Health Association traveled to Cuba to investigate the current health situation in the country, with an emphasis on the impact of the U.S. embargo. The delegation found that compared to two and three years ago, the general standard of living in Cuba and the quality of health services have declined dramatically. It concluded that while the overall health of the Cuban population has not yet seriously eroded as a result of the economic decline, severe problems threaten to emerge in the future. The delegation called for lifting of the embargo as part of a new approach in U.S. policy toward Cuba.

Labor unions that represent health care workers encounter unique circumstances. This study focuses on 1199--the largest health care workers' union in the United States, based in New York City--and describes how the union and its National Benefit Fund have structured a managed indemnity health insurance program that provides extensive benefits for its members. The authors detail the workings of the National Benefit Fund and the ways in which it can improve the health care of its members through its union structure. The Fund represents a model for improving the provision of health care to Americans.

In 2006 the McKinsey Global Institute published an analysis of the Swedish economy, with the finding that the "de facto" unemployment rate in 2004 was 15 to 17 percent, about three times higher than the official unemployment rate of 5.4 percent. These estimates were cited in the media as part of critiques of recent Swedish economic performance. To arrive at the 15 to 17 percent "de facto" unemployment rate, McKinsey included "people who don't work, even though they should be able to" in the pool of the unemployed. The analysis reported here accepts the McKinsey methodology and applies it to the United States. The resulting "de facto" unemployment rate for the United States is 13.8 percent, compared with the 5.5 percent official U.S. unemployment rate, and the estimated 15.5 percent "de facto" Swedish unemployment rate. If the two countries' prison and jail populations are also included in the "de facto" unemployment rate, the U.S. rate rises to 15.2 percent, just 0.5 percentage points lower than what McKinsey's equivalent figure would be for Sweden--15.7 percent.

This article is concerned with the establishment and extension of health care and medical services in British colonial Malaya. Initially, medical care was provided for the colonial elite and those in their direct employment. With the expansion of colonial control beyond trade centers into the hinterland and with the growth of agriculture and mining. Western medicine was extended both to labor involved in these export industries and to others whose ill health might jeopardize the welfare of the colonists. Public health programs in the twentieth century continued to focus on medical problems that had direct impact on the colonial economy, but programs were extended to ensure the reproduction as well as the maintenance of the labor force. This article develops the notion of a legitimation vacuum, and the role of the state provision of social services, including medical services, in legitimizing colonial presence and control. PIP This article is concerned with the establishment and extension of health care and medical services in British colonial Malaya. Initially, medical care was provided for the colonial elite and those in their direct employment with minimum medical care provided to the immigrant and local population when their health status, or rather the presence of infectious disease, implicated the health of the expatriate population. With the expansion of colonial control beyond trade centers into the hinterland and with the growth of agriculture and mining, Western medicine was extended both to labor involved in these export industries and to others whose ill health might jeopardize the welfare of the colonists. Public health programs in the 20th century continued to focus on medical problems that had direct impact on the colonial economy, but programs were extended to ensure the reproduction as well as the maintenance of the labor force. The move from the provision of curative medicine to preventive health care represented a final stage in all levels of social life. This article develops the notion of a legitimation vacuum, and the role of the state provision of social services, including medical services, in legitimizing colonial presence and control.

The information content of 6,710 advertisements for medicines in medical journals was surveyed to provide a baseline for monitoring the effect of WHO's Ethical Criteria for Medicinal Drug Promotion. The advertisements (ads) appeared during 12 months (1987-1988) in 23 leading national medical journals in 18 countries. Local participants, mostly doctors or pharmacists, examined them. The presence or absence in each ad of important information was noted. In most ads the generic name appeared in smaller type than the brand name. Indications were mentioned more often than the negative effects of medicines. The ads gave less pharmacological than medical information. However, important warnings and precautions were missing in half, and side effects and contraindications in about 40 percent. Prices tended to be given only in countries where a social security system pays for the medicines. The information content of ads in the developing countries differed surprisingly little from that in the industrialized countries. Almost all the ads (96 percent) included one or more pictures; 58 percent of these were considered irrelevant. The authors believe it is a mistake to regard ads as trivial. If they are not considered seriously they will influence the use of medicines as they are intended to do, but read critically they can provide useful information.

The resonance between scientific theory and ideology is starkly revealed by the medical debate on slavery, alleged black inferiority, and racial differences in disease: opposing doctors invoked the same science, but relied on contrary assumptions, to reach antagonistic conclusions. Reductionist, biological determinist, and ahistorical premises underlay the dominant belief that innate racial differences led to black bondage and racial disparities in health; an anti-reductionist and historical approach supported the minority view that social factors rooted in the planters' need for cheap labor explained both. From 1830 to 1850, doctors debated the accuracy, validity, and interpretation of their findings. In the 1850s, "apolitical" doctors sought to purge medicine of politics to regain scientific objectivity, yet the first generation of black physicians argued that politics inevitably affected medical inquiry. The Civil War and Emancipation spurred studies relating the health of blacks and poor whites to social conditions, while the destruction of Reconstruction led to the resurgence of racist medicine. Comprehending how politics set the terms and tempo of this polemic can provide insight into current controversies on racial differences in disease.

The mortality rates of the various age groups within the population of England and Wales fell dramatically between 1870 and 1914, and this period has been used to examine McKeown's thesis of an inverse relationship between a population's mortality rate and its standard of living. Using real wages as a measure of living standards, McKeown's thesis is found to hold for most age groups for most of the period. Several anomalies are identified, however, and it is argued that these can best be reconciled with the original thesis by taking account of the economic cycle.

This article compares two views on the relationship between the business cycle and mortality for the years 1871-1900. First, the views of Robert Higgs, a prominent mainstream economic historian, of the working and living conditions of this period are examined so that we may trace the reasons for his dependence on immigrants and the germs they bring with them as explanations for the procyclical relationship between mortality and short-term economic growth. This explanation is then criticized by re-examining the working and living conditions of this period and by linking these conditions to a disease theory that does not depend on exogenous forces to explain mortality patterns but rather one that focuses on historically specific political and economic processes and decisions.

An international body of scientific research indicates that growth of job insecurity and precarious forms of employment over the past 35 years have had significant negative consequences for health and safety. Commonly overlooked in debates over the changing world of work is that widespread use of insecure and short-term work is not new, but represents a return to something resembling labor market arrangements found in rich countries in the 19th and early 20th centuries. Moreover, the adverse health effects of precarious employment were extensively documented in government inquiries and in health and medical journals. This article examines the case of a large group of casual dockworkers in Britain. It identifies the mechanisms by which precarious employment was seen to undermine workers and families' health and safety. The article also shows the British dockworker experience was not unique and there are important lessons to be drawn from history. First, historical evidence reinforces just how health-damaging precarious employment is and how these effects extend to the community, strengthening the case for social and economic policies that minimize precarious employment. Second, there are striking parallels between historical evidence and contemporary research that can inform future research on the health effects of precarious employment.

For over two centuries, U.S. vital statistics routinely have been stratified by age, sex, and race, but not by social class. The usual explanation is that U.S. government officials have not considered social class relevant to health. During the first third of the 20th century, however, questions of socio-economic inequalities in morbidity and mortality ranked high on the agenda of federal and other public health agencies, and routine reporting of U.S. vital statistics and health survey data by socioeconomic measures was nearly institutionalized. This history has largely been lost. In this article, the authors focus on the period from 1900 to 1950 and examine how public health researchers and agencies conceptualized and analyzed socioeconomic inequalities in health. Highlights include production, for 1930, of the first U.S. national death rates stratified by social class, in work sponsored by the National Tuberculosis Association and Bureau of the Census, and the Public Health Service's 1935-1936 National Health Survey, which reported morbidity data stratified by socioeconomic measures. Efforts like these were cut short by the onset of World War II and their legacy erased by the Cold War. Recovering this rich history can help inform current debates about collecting and evaluating data on social inequalities in health.

This article analyzes crude death and infant mortality rates for the different population groups in Johannesburg, the largest city in the Republic of South Africa. The analysis is based on official statistics collected by the Department of Health between 1910 and 1979. Over this period, death rates have declined for white, black, Colored, and Asian citizens. However, the present situation reflects the gross inequalities in the health status of the different population groups in South Africa, a country where disease patterns and access to medical resources are as stratified as any other index of social class.

Between 1910 and 1970 the number of physicians in the United States increased 2.5 times, in Soviet Russia almost 25 times. The number of physicians per constant unit of population remained fairly stable in the United States, rising slightly in the last few years. In the U.S.S.R. that number increased 16 to 18 times, and now stands about 50 per cent higher than in the United States. About 10 per cent of American physicians are women; in the U.S.S.R. it is about 70 per cent. Neither society has resolved the problem of deploying physicians to the rural areas. American physicians are more specialized than their Soviet colleagues. The article concludes with general remarks about the two health systems, pointing out resemblances and divergences. The hypothesis of a possible "convergence" is entertained.

Before the 1920s, a birth control movement arose in the United States out of socialist, feminist, and other radical groups concerned with women's rights and sexual freedom. After 1920 the birth control movement became gradually transformed into a respectable, nonradical reform cause, the recipient of large grants from big business, with women's rights secondary to an overriding concern with medical health and population control. This transformation was achieved through the professionalization of the birth control movement-that is, its takeover by professional experts, almost all male, in place of the radical amateur women, fighting for their own interests, who initiated it. The article examines two groups of professionals who were particularly influential in this transformation: doctors and academic eugenists. The former made birth control a medical issue, held back the development of popular sex education, and stifled a previously developing feminist approach to women's birth control needs. The later contributed racism to the birth control movement, helping to transform it into a population control movement with racist and anti-feminist overtones. Both groups, while they made contributions to the technology of contraception, simultaneously held back the spread of birth control by transforming the campaign for it from a popular, participatory cause to a professional staff lobbying operation.

Between 1930 and 1990 Denmark's hospital sector and hospital policy underwent radical changes. In 1930 the sector was dominated by many small hospitals, with care as the central task. By 1990 the number of hospitals had almost halved, specialization had developed, and diagnostic and therapeutic procedures were hospitals' most important functions. There have been many claims that the shape of the health care sector is determined by the development of medicine. This article demonstrates that changes in other areas of society have greatly influenced the development of the Danish hospital sector. In the 1930s and 1940s, the focus was on equity and specialization; in the 1950s, on growth, rationalization, and division of labor; in the 1960s, on growth and planning; and during the last decades, on management, productivity, and cost containment. Since 1980 the specialization, growth, and political acceptability of the specialized hospital sector have decreased, a change that can be characterized as the incipient decline of the specialized hospital sector.

It has recently been argued that British health policy of the 1990s has a number of similarities with that of the 1930s. In other words, recent years have seen a return to earlier policies, which has been termed "back to the future." The author critically examines these assertions under a number of themes: comprehensiveness, services free at the point of use, inequality, planning, coordination, adverse selection, and democracy. In many of these areas there is a good deal of similarity between the periods. Moreover, both periods appear to be inferior to the intervening period of the "classic" National Health Service. A different temporal pattern is observable in the area of democracy, where there appears to be a clear deterioration over time. However, in many ways, the ghost of health services past may return to haunt the future.

To go back to a period more than five decades ago to talk about the health left is to enter not just another time, but another world. Between the Great Depression and the postwar period, challenging and contradictory social, political, and professional developments were brought to the surface in U.S. life. The health left shared in the opportunities and confusion, enriching the American spirit and participating in both the pleasures and the pain. The 1930s saw economic depression, wars, the birth of fascism, and fears of social collapse. In medicine, despite sporadic scientific advances, the social response was remote and narrow. But social activism motivated medical students and medical practitioners. The 1940s marked a change in both attitudes and values. The left was divided, and bitter factionalism stymied cooperative action. Participation in the war against fascism promoted solidarity, despite the sadness of the evidence of brutality and lack of humanity. The 1950s are sometimes considered regressive, but seeds germinated as the complexity of medical life engendered new approaches to meeting sociomedical needs. As we entered the 1960s a different and more hopeful story unfolded as the rebellions of the poor, blacks, and women brought about a new era of social action.

There have been many studies of the development of an industrial work force with all its attendant hardships as newly proletarianized peasants were thrown off the land and into factory labor. The author postulates that a similar process occurred in the creation of at least one modern “profession”—nursing—as the traditional autonomy of private practice nursing was displaced by institutional nursing in hospitals and nursing homes. Prior to the Depression, most nurses worked in private duty—as independent entrepreneurs—without the regimentation, rigid division of labor, and intense supervision characteristic of modern hospitals. The collapse of the U.S. economy made it impossible for most nurses to continue to earn a living privately at the same time that hospitals required cheap labor power in order to develop as viable businesses. Despite the promise of job security in hospital work, most nurses resisted the change by criticism, sabotage, walking away from jobs, and attempts at unionization. Hospitals sought in response to inculcate loyalty by a variety of methods, including screening of applicants, in-service training, and professional ideology. In some instances, hospitals coerced private nurses into “staff jobs by threatening their ability to secure business on their own. By the end of World War II, the majority of nurses were employed, for the first time, as wage earners for institutions. The entire period was marked by such discord and revolt on the part of nurses, however, that the American Nurses' Association was transformed as an organization in order to avoid massive unionization. The study points out that this unwritten history of nursing has been obscured by professional nursing leaders who are still suppressing revolts of rank-and-file nurses against the conditions of hospital work.

During international or civil wars, private citizens of noncombatant nations often provide medical aid to one of the contending factions, particularly when they support a participant not favored by their own government. This paper details and analyzes the prominent campaign in the United States, Canada and Great Britain to provide medical aid to the Republicans during the Spanish Civil War (1936 to 1939). The substantial medical aid that was provided clearly alleviated some suffering, but one of the major objectives of the campaign was to arouse public opinion sufficiently to end the boycott of military aid to Republicans; this objective was never achieved. Whether it be in Republican Spain, Vietnam or El Salvador, even a successful medical aid campaign to people in a military conflict may save some lives but may not affect substantially the course of the conflict. Those who are primarily interested in influencing political or military developments, hoping to advance the cause of a particular contending faction, may find tactics other than medical aid campaigns more useful in accomplishing their goals.

By the mid-1930s, U.S. coal miners could no longer tolerate company doctors. They objected to the misuse of preemployment and periodic medical examinations and to many other facets of employer-controlled health benefit plans. The rank-and-file movement for reform received critical assistance from the Bureau of Cooperative Medicine, which conducted an extensive investigation of health services in 157 Appalachian communities. This study not only substantiated the workers' indictment of prevailing conditions but illuminated new deficiencies in the quality and availability of hospital and medical care as well. The miners' union curtailed the undemocratic, exploitative system of company doctors and proprietary hospitals by establishing the United Mine Workers of America Welfare and Retirement Fund in 1946.

This article analyzes (within the conceptual frame defined in the previous article) the impact of political variables such as time of government by political parties (social democratic, Christian democratic or conservative, liberal, and ex-dictatorial that have governed the OECD countries during the 1950-1998 period) and their electoral support on (1) redistributional policies in the labor market and in the welfare state; (2) the income inequalities measured by Theil and Gini indexes; and (3) health indicators, such as infant mortality and life expectancy. This analysis is carried out statistically by a bivariate and a multivariate analysis (a pooled cross-sectional study). Both analyses show that political variables play an important role in defining how public and social policies determine the levels of inequalities and affect the level of infant mortality. In general, political parties more committed to redistributional policies, such as social democratic parties, are the most successful in reducing inequalities and improving infant mortality. Less evidence exists, however, on effects on life expectancy. The article also quantifies statistically the relationship between the political and the policy variables and between these variables and the dependent variables--that is, the health indicators.

It has been argued repeatedly that British health policy in the 1990s had a number of similarities with that of the 1930s. This article, while accepting that a comparison of these two periods may be useful, argues that comparing policy in the 1950s with that in the 1980s and 1990s is even more illuminating. To demonstrate this the author outlines first the similarities in policy between the early and later periods, then the differences, and the events that led to each. These comparisons suggest that there is evidence of path dependency in British health policy, and although the United Kingdom appeared to break away from the policy path for a short time in the late 1980s, the changes proposed then do not appear to have been as radical as first suggested. Many of the issues highlighted in the 1950s seem to remain unresolved today.

In spite of the economic hardships during the 1990s, Cuba has achieved health indicators that are among the best in the world. This article describes the development of the Cuban health system over more than four decades and analyzes its dynamics. Four stages can be identified. The system's foundations were laid during the first post-revolutionary decade (1959--1970) and consolidated during the succeeding decade (1970--1979). In the third stage, from 1980 onward, the system reached its full expansion with the development of family medicine. Following the crisis of the 1990s, a fourth stage began with reforms and adjustments to the new situation after the collapse of the Soviet Union. Today, health care continues to be of high quality and free for all Cubans. It remains exclusively in the hands of the public sector, and privatization is not an option. This is exactly the opposite of what is happening in other parts of the world where public services are underfunded and people are made to believe that privatization is the only way to ensure high-quality care.

Recent research on the post-1980 widening of U.S. socioeconomic inequalities in mortality has emphasized the contribution of smoking and high-tech medicine, with some studies treating the growing inequalities as effectively inevitable. No studies, however, have analyzed long-term trends in U.S. mortality rates and inequities unrelated to smoking or due to lack of basic medical care, even as a handful have shown that U.S. socioeconomic inequalities in overall mortality shrank between the mid-1960s and 1980. The authors accordingly analyzed U.S. mortality data for 1960-2006, stratified by county income quintile and race/ethnicity, for mortality unrelated to smoking and preventable by 1960s' standards of medical care. Key findings are that relative and absolute socioeconomic inequalities in U.S. mortality unrelated to smoking and preventable by 1960s' medical care standards shrank between the 1960s and 1980 and then increased and stagnated, with absolute rates on a par with several leading causes of death, and with the burden greatest for U.S. populations of color. None of these findings can be attributed to trends in smoking-related deaths and access to high-tech medicine, and they also demonstrate that socioeconomic inequities in mortality can shrink and need not inevitably rise.

An exploratory time series analysis was performed on selected indicators of structural change, health behavior, and ill health in Sweden in the years 1963-1983. Both synchronic (nonlagged) and asynchronic (lagged) analyses were made. The synchronic analysis of variations in the suicide rate reveals two main contributory factors: level of employment and overtime work. For cardiovascular mortality in men, the synchronic and the two-year time lagged analyses reveal that the sale of alcohol and, to a certain extent, the length of the period of unemployment play a major role. In an analysis with a three-year time lag, only one significant factor for both men and women is revealed, namely the level of employment. In the synchronic analysis of cirrhosis mortality in men, the sale of alcohol plays a dominant role. The results of the synchronic analysis of the variations in sick leave show a similar pattern for both men and women. In both cases, the sale of alcohol is positively associated and the proportion of unemployed industrial workers negatively associated with sick leave. The results give rise to a number of questions. For example, how should these findings be interpreted and how should they be related to existing knowledge about the links between business cycles and changes in the health of the population? The answers to such questions are of importance both from a scientific viewpoint and with regard to health policy. We argue that the answers require further studies of the characteristics of the periods in the business cycle and of how these periods affect people's lives, living conditions, and behavioral patterns in general.

Death rates in the United States have fallen since the 1960s, but improvements have not been shared equally by all groups. This study investigates the change in inequality in mortality by income level from 1967 to 1986. Comparable death rates are constructed for 1967 and 1986 using National Mortality Followback Surveys as numerators and National Health Interview Surveys as denominators. Direct age-adjusted death rates are calculated for income levels for the U.S. noninstitutionalized civilian population 35 to 64 years old. A summary measure of inequality in mortality adjusts for differences in the size and definition of income groups in the two years. In both 1967 and 1986, mortality decreased with each rise in income level. Measured in relative terms, this inverse relationship was greater in 1986 then in 1967 for men and women, blacks and whites. Between 1967 and 1986, death rates for those with maximal income declined between two and three times more rapidly than did rates for the middle and low income groups. The greatest increase in relative inequality was seen among white males.

A marked improvement in health status for black adults took place over the last decade in the United States. Life expectancy for black men increased 4.6 years between 1968 and 1978, while for black women the increase was 5.7 years. Death rates for the age group 35-74 decreased approximately 25 percent for blacks over the same period. The largest contribution to this improvement was made by cardiovascular diseases (coronary heart disease and stroke). Although similar improvement was observed in the white population, on both a percentage and absolute basis the change was greater for blacks. For the first time in the U.S., important progress was made in the effort to narrow the gap in mortality rates between black and white adults. Hypertension detection and control appears to have played the key role in this positive public health trend. The community-based demand for greater access to medical care, which emerged from the social struggle of the 1960s, also can be accorded a major social role. The current policies of the Reagan Administration pose a serious threat to these antiracist programs, as well as to the effort to close the gap in black-white mortality.

This paper addresses some enduring issues concerning prevention of environmental and occupational cancer. The first part reviews methodological problems of estimating cancer risks and outlines some research priorities. The second part documents countervailing trends in chemical production during the past two decades, noting the doubling of some synthetic organic human carcinogens and the leveling off of some heavy metal carcinogens. The final section details recent increases in site-specific causes of cancer mortality for men old enough to have developed workplace cancers (ages 35 to 84), considering those cancers that have been linked with exposures to toxic chemicals and to cigarette smoking. This paper points out that Doll and Peto's (1981) analysis of U.S. cancer trends does not indicate some important increases in older males; they conclude that apart from cigarette smoking, there is no generalized increase in cancer for persons up to age 64. In fact, there has been a sharp reduction in cancer mortality for those under age 45. This reduction more than offsets increases in some cancers for those ages 45 to 65. Men ages 55 to 84 have experienced major increases in mortality for certain cancers plausibly associated with occupational exposures, including cancers of the brain, lung, and multiple myeloma. These older age groups have potentially sustained longer workplace exposures to carcinogens, some of which have 25-year or greater latencies. Changes in infectious diseases, workplace exposures, diagnostic trends, environment, and nutrition require further study.

The relationship between ambulatory physician use and hospitalization was studied using aggregate data in the Province of Quebec, Canada. The analysis showed that the introduction of health insurance covering physician services had a negligible influence on hospitalization. The average length of short-term hospital stays was determined by the proportion of aged population, the proportion of English speaking persons, and the prior level of hospitalization in the medical market areas. Overall, hospital discharge rates remained very constant during the period of six years (1970-1975). There were, however, reductions in hospitalization for infectious diseases, diseases of the blood and blood-forming organs, respiratory diseases, and diseases of the skin and subcutaneous tissue, and increases in the hospitalization rates for neoplasms, circulatory system disorders, musculoskeletal conditions, congenital anomalies, and perinatal morbidity and mortality.

The roles of education and income as determinants for utilization of ambulatory services in the U.S. are investigated by the application of path analysis to a subsample of the 1970 National Health Interview Survey. The methodology permits the identification of both the direct and indirect effects of each independent variable on utilization within a model that views need as the major determinant of care. Previous findings that income has no direct effect on utilization, while education does, are reaffirmed. Contrary to previous analyses, however, it is shown that income does have a strong indirect effect on utilization via its impact on need arising from chronic conditions, measured as limitation of activity. Individuals in the highest income category have a mean annual visit rate of 4.13, while the rate for those in the lowest is 5.43. Most of the differential, 1.3, is attributable to the lower prevalence of chronic conditions in the highest income bracket. The total effect of education, on the other hand, is only 60% of its direct effect since higher educational attainment is associated with lower levels of chronicity. Disaggregation of direct and indirect effects through the need variables shows that income has a greater effect on utilization than does education.

The intent of this essay is to highlight the global reorganization of the asbestos industry over the period 1970-2007. Descriptive analysis illustrates that asbestos consumption in the industrialized countries declined precipitously over this period, in juxtaposition to a notable increase in consumption in the developing countries. In 2007, asbestos consumption in the developing countries was more than two million metric tons but negligible elsewhere in the world economy. The author argues that as asbestos increasingly became the focus of government oversight in the industrialized countries, continued capital accumulation efforts necessitated displacement of risk to the developing countries. The global revitalization of asbestos production and consumption over the period 1970-2007 presents numerous challenges in terms of occupational and environmental health hazards in the developing countries. It has the potential, moreover, to prefigure a significant expansion of asbestos-related disease into the 21st century, absent a global ban on asbestos use.

By most measures, the United States is the most unequal of the world's advanced capitalist economies, and inequality has increased substantially over the past 30 years. This article documents trends in the inequality of three key economic distributions--hourly earnings, annual incomes, and net wealth--and relates these developments to changes in economic and social policy over the past three decades. The primary cause of high and rising inequality is the systematic erosion of the bargaining power of lower- and middle-income workers relative to their employers, reflected in the erosion of the real value of the minimum wage, the decline in unions, widescale deregulation of industries such as airlines and trucking, the privatization and outsourcing of many state and local government activities, increasing international competition, and periods of restrictive macroeconomic policy.

PIP The 2 themes of this century, increasing environmental fragility and increasing human demands on government, are underlined by the failure of government to effectively govern, and the complex technology and modern communication systems which further divide the developing nations from the developed ones. Population stabilization may help relieve the tension between increasing expectation from government and the fiscal bind in 3 ways: 1)a higher per capita income would increase per capita government revenue which would have a better chance of meeting citizen expectations, 2)a moderately redistributive effect on personal income might occur by decreasing unwanted fertility through the dynamics of economics and increasing the role of government in elevating living standards, and 3)with reduction of government expenditure per capita, the cost of providing any given level of service would decrease. The nuclear age has altered the concept of what constitutes national security. Rapid population growth in the developing countries is also significant, and the United States economy depends on overseas investment. A constructive foreign policy, as opposed to neoimperialism or isolationism, is recommended to help influence world population growth.

This article analyzes labor policy, especially that of occupational health and safety, initiated by the Saskatchewan New Democratic Party (NDP) from 1971 to 1982. The NDP was perceived by Canadian provincial labor federations and the Canadian Labour Congress as the government most approximating a European labor party. The provincial labor legislation was seen as exemplary, and the occupational health and safety legislation as a "beacon" for the rest of Canada. This article suggests that the advances in occupational health and safety statute and regulations were a direct response to the government's policy to develop uranium mining. In order to pursue a vigorous renewable and nonrenewable resource policy, the government maintained that uranium could be mined "safely." This resulted in "progressive" health and safety legislation and the reinforcement of the colonial status of people of Indian ancestry. This policy of growth and development also resulted in joint venture relationships with multinational corporations and increasing investments in the north for nonrenewable resource development. Prior to the landslide defeat of the NDP in 1982 by the Conservative Party, the richest 5 percent of Saskatchewan people earned as much, in total, as the poorest 50 percent. Meanwhile, ordinary workers experienced declining real wages and increased employment insecurity.

This paper describes the experience of Sri Lanka in reforming the structure of production, importation, and distribution of pharmaceuticals in the period 1972-1976. It highlights the actions and reactions of transnational pharmaceutical corporations to these reforms, and traces the achievements and problems of the State Pharmaceuticals Corporation which was set up to implement the reforms. The roles of political leadership in regulating the power of drug transnationals, and of the medical profession in resisting reform, seem to be of crucial significance. Developing countries wishing to lower the present high cost of drug delivery must proceed with great care and immense caution, since complex problems of quality control, bioequivalence, medical acceptance, and consumer reeducation are involved.

Living and working through the period since the British National Health Service began in 1947, the author describes his experiences as a family and general practitioner and in particular notes the effects and non-effects of the reorganization that took place in the National Health Service in 1974.

Taking the case of Chile in the period 1974-85, this article examines the impact of economic conditions and social policies on poor households, and especially on children. The study starts with an analysis of the nature of the economic policies implemented in Chile during 1974-85 and their effects on income distribution and on the material living conditions of poor households. It then looks into the social policies, government expenditure, and the main programs directed toward poor households and children, as well as at the changes in child welfare that followed. From this macrosocial level the study diverts to the household level and describes, based on several in-depth studies of small samples of households in the Santiago metropolitan area during the years 1982-85, the daily experiences of poor households--their deteriorating economic conditions and the behaviors adopted to stretch scarce resources to satisfy basic needs. The final part draws some lessons from the Chilean case.

PIP In the past, delegates to the population conferences held under the auspices of the United Nations were specialists who attended in their private capacities or as representatives of private organizations and the academic community. At the 1974 World Population Conference the delegates will speak for their governments and not as individuals. It will be a political conference and its subject matter will be population in a broad sense. The tentative agenda of the conference includes: 1) recent population trends future prospects, 2) relations between population change and economic and social development, 3) relations between population, resources, and environment, 4) population and the family, and 5) a World Population Plan of Action. It is anticipated that certain parallel activities will be carried out simultaneously with the conference. The conference should succeed in focusing attention on population matters in national and universal perspectives. It should also advance the definition of national population policies and, from the totality of those, an international policy may emerge and find expression in the World Population Plan of Action.

This paper argues that the bleak budgetary outlook in the United States is not unexpected and will be difficult to change. Present conservative fiscal policy has substantial economic merit and widespread political support. The President has presented a reasonably consistent political and economic philosophy to which viable alternatives have yet to be offered. Backing up his budget with threats of vetoes and impoundments, the President is polarizing a power struggle with Congress which overshadows substantive issues. The nearly $4 billion increase in federal health outlays, in conjunction with major cuts in hospital construction, mental health, research, manpower, and health services planning and delivery, highlights the mortgaging of the budget by uncontrollable expenditures for pensions, Medicare, interest, etc. Acceptance of a crisis in health care is no longer a basis for developing federal health policy, which now contemplates a limited federal role and reliance upon states and the marketplace. But the federal budgetary situation will worsen as Medicare and Medicaid contribute to a situation of ever rising prices unconstrained by rational organization.

This paper continues to spin the thread of previous analyses of the bleakness of the budgetary outlook in the United States and the difficulty of change. The budget remains mortgaged by actions in previous years, and the economic outlook is uncertain. "The politics of frugality" has come to dominate the American political scene, but the President's choices to reduce spending on human resource programs by $18 billion are more apparent than real. The new Congressional review procedures, a reaction to the Watergate years, interrelate budget with health policy and highlight the necessity for action to control medical care prices if any new federal initiatives, e.g. national health insurances, are to be budgetarily feasible.

For the 1978 legislative elections, all French political parties have, for the first time, a relatively detailed health policy. The right-wing parties of the present government concentrate on the reduction of medical expenditure and the maintenance of the free enterprise tradition of French medicine. The left-wing parties concentrate more on the development of public health institutions and suggest nationalization of the pharmaceutical industry. Within the Left, there is, however, a difference of emphasis: the Socialists propose the setting up of medicosocial centers and abolition of the fee-for-service system; the Communists concentrate rather on industrial health and believe that an improved health service can only come from changes in overall social economic policy. None of these policies is particularly adventurous but their mere existence shows that health is now a major political preoccupation in France. Some of these policies are mainly concerned with individual and public welfare and others with the necessity of maintaining a certain social order. The debate surrounding health policy usually turns around these two issues.

This study investigates trends and clustering of gender policy in 22 OECD (Organization for Economic Cooperation and Development) countries during 1979-2008. The starting point was Sainsbury's gender policy regime framework, and the study included indicators reflecting the male bread-winner, individual earner-carer, and separate gender roles regimes. The indicators were followed over seven time points for mean, range, and distribution. Cluster analyses were performed for the years 1979, 1989, 1999, and 2004. In accordance with previous studies, the authors found a Nordic cluster of earner-carer countries, while several Southern European countries and the United States were marked by their low generosity and high pension requirements. Though aspects of the separate gender roles regime have become more widespread, no country could be classified as fully belonging to this regime type. The two aspects of the model--compensatory measures in the pension system, and benefits for caring activities--were never present simultaneously.

For the past 13 years there has been an aggressive anti-union government in the United Kingdom. Yet despite this fact, very real advances have been made in the area of working-class activity over the issue of workplace hazards. Trade unions, because of membership concern and activity, have been forced to keep this topic on their agenda. The European Community has been a big factor in these advances. This article describes some of the issues and elements of the fightback. In the 1990s, with the rediscovery of environmental issues, the hazards movement of the United Kingdom, and elsewhere, is here to stay and set to expand.

In July 1979, a coalition of social forces in Nicaragua, under the leadership of the Sandinistas, toppled the discredited 43-year Somoza dictatorship. In addition to revolutionary Nicaragua's own substantial efforts, since 1979 international forces and developments have had profound impacts on the nation's ambitious social programs. This article investigates the impact of foreign nations and international organizations on Nicaragua's health conditions since 1979. Given or pledged assistance, for health and other social needs, has been forthcoming, for example, from Latin America, Western Europe, socialist countries, the United Nations, the Organization of American States, and the European Economic Community. International forces, however, have also had a negative impact on Nicaragua's health conditions. Since 1981, counter-revolutionary guerilla forces, known as contras, have fought the Nicaraguan government troops in a disastrous conflict, involving substantial international assistance for each side. The United States and several other nations have provided some form of aid to the contras. The war in Nicaragua has resulted in enormous human and material losses, and, of course, has adversely affected health conditions.

This article draws on the vast evidence that suggests, on one hand, that socioeconomic inequalities in health are present in every society in which they have been measured and, on the other hand, that the size of inequalities varies substantially across societies. We conduct a comparative case study of the United States and Canada to explore the role of neoliberalism as a force that has created inequalities in socioeconomic resources (and thus in health) in both societies and the roles of other societal forces (political, economic, and social) that have provided a buffer, thereby lessening socioeconomic inequalities or their effects on health. Our findings suggest that, from 1980 to 2008, while both the United States and Canada underwent significant neoliberal reforms, Canada showed more resilience in terms of health inequalities as a result of differences in: (a) the degree of income inequality, itself resulting from differences in features of the labor market and tax and transfer policies, (b) equality in the provision of social goods such as health care and education, and (c) the extent of social cohesiveness across race/ethnic- and class-based groups. Our study suggests that further attention must be given to both causes and buffers of health inequalities.

This article has three sections. The first discusses the hegemonic interpretations of the 1980 and 1984 U.S. elections that are being reproduced on both sides of the political spectrum and that are presented as justification of current federal health and social policies. This section presents evidence that questions those hegemonic interpretations. Section II presents an alternative explanation of current political realities rooted in the class practices of the current federal administration and the Republican Party and in the abandonment by the opposition party--the Democratic Party--of the class practices of the New Deal. It discusses the reasons for that situation and analyzes its consequence for social policy. Section III presents evidence that questions the ideological arguments that are put forward by the Right (and are uncritically accepted by large sectors of the Left) and that sustain current federal economic and social policies. This section concludes with a discussion of alternative policies, stressing the need to rediscover class practices and its implication in health and social policy.