Economic boundaries of health policy: factors influencing 1993-1994 reform proposals.

This article offers a theoretical framework for understanding the crisis of U.S. health care system and the mainstream debate on restructuring health care financing and delivery subsystems. The author argues that the crisis of the health care system is a cause and a consequence of the long cycle of structural changes in the U.S. economy since World War II. The article distinguishes between the level and the rate of growth of health care expenditures. It is possible to moderate the level of health care expenditure by adopting measures in the direction indicated by the historical experience of other advanced capitalist economies. However, in the long term the rate of growth of health care costs will exceed the rate of growth of gross domestic product, thus any attempt to limit it will result in deterioration in the quantity and quality of health care services. The 1993-1994 mainstream debate is revisited to show how these proposals were a part of the overall effort to resolve the long-term problems of the U.S. economy. The defeat of the Clinton plan was due to its concerns with efficiency of the health care system in the face of the demand by a majority of the U.S. capitalist class to cut costs.

The Cuban health care system and factors currently undermining it.

This paper explores the dynamics of health and health care in Cuba during a period of severe crisis by placing it within its economic, social, and political context using a comparative historical approach. It outlines Cuban achievements in health care as a consequence of the socialist transformations since 1959, noting the full commitment by the Cuban state, the planned economy, mass participation, and a self-critical, working class perspective as crucial factors. The roles of two external factors, the U.S. economic embargo and the Council of Mutual Economic Cooperation (CMEA), are explored in shaping the Cuban society and economy, including its health care system. It is argued that the former has hindered health efforts in Cuba. The role of the latter is more complex. While the CMEA was an important source for economic growth, Cuban relations with the Soviet bloc had a damaging effect on the development of socialism in Cuba. The adoption of the Soviet model of economic development fostered bureaucracy and demoralization of Cuban workers. As such, it contributed to two internal factors that have undermined further social progress including in health care: low productivity of labor and the growth of bureaucracy. While the health care system is still consistently supported by public policy and its structure is sound, economic crisis undermines its material and moral foundations and threatens its achievements. The future of the current Cuban health care system is intertwined with the potentials for its socialist development.

PIP: The dynamics of health care in Cuba during a period of severe crisis was explored within an economic, social, and political context. Cuban achievements in health care since 1959 were a consequence of the full commitment to health care by the state, the planned economy, and mass participation. In 1959 the infant mortality rate was 60/1000 live births and life expectancy was 65.1 years. By the period of 1983-88 Cuba had attained an infant mortality rate of 15/1000 and female life expectancy of 76 years compared to the figures of 27/1000 and 73 years, respectively, in South Korea. In response to problems that arose in the 1960s an improved health care model stressing the involvement of health care workers in the community was proposed in 1974. In the early 1980s 20,000 family physicians were trained to provide primary care services in the communities. Two external factors, the US economic embargo and the Council of Mutual Economic Cooperation (CMEA), shaped the Cuban society and economy, including its health care system. The U.S. embargo forced Cuba to pay higher transportation costs to import medical supplies from Soviet-bloc countries. Once the Soviet bloc collapsed, Washington further tightened the embargo through the Torricelli Bill of 1992, which bars U.S. subsidiaries in other countries from trading with Cuba and forbids US portage for 6 months to any ship that has docked in Cuba. As a result, in 1993 Cuba's imports for public health cost an extra $45 million. The CMEA was an important source for economic growth; however, the adoption of the Soviet model of economic development contributed to two internal factors that have undermined health care: low productivity of labor and the growth of bureaucracy. Social expenditures declined from 70% of the GNP in 1970 to 36% in 1995. Meanwhile, administrative personnel grew from 90,000 persons in 1973 to 240,000 persons in 1984. In 1995 some 50,000 physicians were serving a population of 11 million. Since 1986 a total of 1042 individuals have been found to be HIV positive. The policy of forced isolation of HIV-positive persons and AIDS patients was relaxed recently. While the health care system and its structure is sound, the economic crisis undermines its material and moral foundations and threatens its achievements.

Steroid hormone receptor immunohistochemistry and amplification of c-myc protooncogene. Relationship to disease-free survival in breast cancer.

BACKGROUND: It is important to develop parameters that aid in prognosticating which patients with breast cancer are more likely to have a rapid disease course and therefore might benefit from early aggressive therapies. METHODS: Specimens from two groups of women, deliberately selected because their clinical courses differed greatly, were studied to detect amplification of the protooncogenes c-myc, int-2, and C-erbB-2/neu by slot-blot assay, the estrogen receptor (ER), and the progesterone receptor (PR) by both biochemical and immunohistochemical procedures (ERICA and PRICA). One group of 50 patients had a prolonged disease-free interval after initial surgery (mean, 6.4 years); the other group of 52 women had had rapid disease recurrence (mean, 1.4 years) or progression (5 patients died of disease within 1 year of diagnosis). The patients were selected from 1700 consecutively accessioned cases if they fit the study criteria and sufficient tissue was available for oncogene hybridization studies. RESULTS: The two groups differed statistically by stage, number of involved axillary lymph nodes, ERICA and PRICA results (P = 0.001), and amplification of c-myc (P = 0.003). The percentage of patients with rapid disease recurrence and progression increased from 0-93% when risk factors changed from best case (ERICA and PRICA results, positive; c-myc, not amplified; and axillary nodes, not involved) to worst case (ERICA and PRICA findings, negative; c-myc, amplified; and axillary nodes, involved). CONCLUSIONS: Women with these worst-case parameters were more likely to have a recurrence sooner and rapidly progressive disease. They might benefit from early aggressive therapeutic measures.

Marital status and stage at diagnosis in cancer.

The association of marital status and stage of diagnosis in cancer was examined for seven common disease sites. Data were drawn from the New York State Cancer Registry for Brooklyn residents diagnosed between 1978 and 1982. Married persons were found to have a better chance of early diagnosis only for cancers of the breast and prostate. When the analysis was stratified for race, this advantage was limited to whites. Married whites were 1.8 times more likely to be diagnosed with early prostatic cancer (p less than 0.01) and 1.2 times more likely to be diagnosed with early breast cancer (p less than 0.05). The earlier stage of diagnosis may be due to differences in a complex of social, economic, behavioral, and biological factors. These results suggest the need for additional educational and screening programs for the unmarried.

First year medical student experiences with being discouraged from entering medical school.

Three hundred and fourteen first year medical students from two consecutive classes were surveyed for their experiences with being discouraged from entering medical school. Sixty-eight percent (215) had been discouraged from becoming physicians. The sources of discouragement were varied, with 43% citing physician acquaintances and 40% friends and neighbors. Parents were the principal source of encouragement (58%) followed by friends and neighbors (47%). More students (34%) were encouraged by undergraduate professors and advisors than by their family doctor (23%), a physician relative (18%), or a physician acquaintance (31%). Discouragement centered on three broad areas: diminished financial rewards, increased financial costs, and quality of life.

Cervix and breast cancer incidence in immigrant Caribbean women.

Cervix and breast cancer incidence in 1978-82 was computed for immigrant and United States-born Black women in Brooklyn, New York. Compared to the national SEER (Surveillance, Epidemiology and End Results) rates, US-born and Haitian women had high rates of invasive cervical cancer, while English-speaking Caribbean immigrants had an average rate. However, while US-born women had an average rate of carcinoma in situ of the cervix, both immigrant groups had low rates. Both immigrant groups had low rates of breast cancer, whereas US-born Black women had an average rate.

Second year medical student opinion about public health and a second year course in preventive medicine and community health.

The results of five annual surveys of second year medical students over an eight year period of time (1978-1985) concerning perceptions and attitudes toward public health and a course in preventive medicine and community health are presented. The questionnaire format was a combined fixed alternate and free response type and was structured to require only ten to 15 minutes for its completion. Participation rates were generally high varying from 60.2% (1980) to 93.8% (1985). The majority of students in all years favorably evaluated most components of structure, content and presentation of the course. It was found that opinions about the course can be modified by the introduction of variables that are unrelated to the scope of the quality of the course as occurred in 1979, with a difficult midterm examination. Student anger over this examination was translated and expressed as negative opinion about many other aspects of the course which in other years were highly rated. This finding underscores the vulnerability of surveys of subjective opinion and demonstrates that course evaluations must include other objective aspects in addition to student perceptions.