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Home , Health economics

are concerned with the organization of the for health services and the yield of in people for health. The "optimum" use of resources for the care of the sick and the pro- motion of health defines the special field of inquiry.

Toward a Definition of Health Eeonomies

SELMA J. MUSHKIN, Ph.D.

T WO RECENT dev-elopments, each trace- services ancd altered metlhods of paying for able to scientific advances in , have hiealtlh care. They comprise one set of eco- focused attention onilealtlh economics. nomic issues. First, new therapeutic products lhave pro- A second set of issues arises from another vided specifics for maany infectious diseases thlat, development in medical science: the possibility less than 20 yeairs ago, were importanit causes of of iniereasing life expectancy. Average life ex- death in the United States anid other industrial pectancy at birth in many of the nations of Asia nlatioIns. These changes in medical teclhniques, ancd Africa-nations which include almost wlichl lhave in-creased the plhysiciani's capacity to two-tlhirds of the world populationiwas until deal effectively with (liseases, lhave altered pat- recently about 30 years. This imay be coni- ternis ii the organi%zationi of lhealtlh services. tralsted witlh almost T0 years of life expectanicy Concomito'antly, probleimis associated witlh the aclhieved in the United States. The potential costs of medical care have been intensified an(d increase in life expectancy shlarply focuses lhave stimulated prepayment arrangements for problems of balance between population meetinig these costs. anid resources, between work forces and out- These chaniges lhave also giveni rise to mnany put, in the industrially underdeveloped but questionis about thle natuire of the "miiarket" for denisely populated nations of the world. Scien- lhealth services; about the relation of planit "ca- tific advances inl medicine anid public healtlh can pacity' ( facilities, for example) .to be applied quickly and witlh nminimulm expenidi- use of health services; and about variationis in tures to reduce death and morbidity rates in "demiand" attributable to prepayment. Espe- these nations. Spraying witlh DDT, immuniza- cially urgent are questions about slhifts in "de- tion-witlh BCG, and treatment with penicillin mand" due to third party payments for limited have yielded dramatic results in ireduced mor- types of medical care anud about effects o- alter- tality from nmalaria, tuberculosis, syplhilis, and native methods of paynmeiit and comipeflsatioln yaws. oln the "" of healtlh servic'es. These ques- Reduced deatlh rate lhas intensified a searchl tionls are illustrative of the many raised by for answers to specific economic questions so altered patterns in the organization of health that the achievements in lhealth will not be dis- sipated by the pressures of increased popula- Dr. Mushkin is an in the Division of Public tion on low food supplies, wvith the consequent Health Methods, , and research intensification of poverty. Some of these ques- associate, Johns Hopkins University School of Hy- tions are related to the mean-s by wlhich the net giene and Public Health. yield of investmenit in peol)le for health may

Vol. 73, No. 9, September 1958 785 be measured, the relative amounts of comple- riodical in 1944 published news items on gov- mentary and supporting capital investment and ernmental health programs, views of the health capital growth required, and the effects of professions on the organization and financing changes in health status on . At of health services, medical , hospital the same time, the changing monetary of organization and services, dental health needs man, in his productive capacities, effects an and services, voluntary plans, impact on . and public . In the foreword These two sets of issues in common require, to the first issues, Dr. Sinai stated, ". . . this among other things, an analysis of the optimum publication is a tangible tribute to . . . con- use of resources for maintaining and improv- tributions toward the development of a new ing the people's health and the quality of the and vital blending of the medical and the so- population. Both sets of issues have been cial sciences. The blend is public health pressed by the requirements for policy formula- economics." tion-public for health issues facing less de- Thus "health economics" has been both veloped nations, and largely private for health broadly conceived to encompass the range of issues arising out of the medical market, at social sciences, including public administration, least within the United States. and narrowly conceived to deal with business methods of organization and of payment. Administrative Definition What then is health economics? Generally, Economic Propositions "health economics" has been used by health ad- What has the professional economist had to ministrators to refer to any investigation that say about health economics? Until fairly re- deals with in its relationship to health. cently, economists have given little thought to The two medical journals with economics in the market organization of health services or their titles perhaps give a clue to what those to the net economic yield of investment in the in the health professions consider to be encom- health of people. This lack of attention to the passed within the scope of a health economics medical market may be traced to the special inquiry. One of these journals, Medical Eco- characteristics of medicine that mark it as an nomics, is essentially a business journal for exception to economic propositions that explain , and regularly features articles on the mechanisms of the market generally. physicians' office methods and finances. Special There are several important characteristics feature articles in 1957, for example, deal with of the medical market that differentiate it from the physicians' income, hours of practice, spe- the market of . First, the cialties, fee determination, voluntary health in- profit motive is not adequate as an explanation surance developments as they bear on the phy- of the activity in the medical "market." Hos- sicians' practice and finances, cost of practice pitAl care throughout the centuries has been including malpractice insurance, taxation prob- either primarily public or under the auspices of lems such as definitions of business expense, and nonprofit . While services of physi- problems of estate planning. cians in the United States are organized on as The second periodical, Public Health Eco- individualistic basis as any profession or enter- nomics, published by the Bureau of Public prise (and it is fair to say, even more so), physi- Health Economics of the University of Michi- cians have accepted their social role in the gan's School of Public Health, abridges arti- community and have often cared for the sick cles and news items. Materials abridged are and promoted health without remuneration for classified currently in the following manner: their time and skill. Also, professional motiva- legislation, governmental programs in opera- tion in pursuing the medically interesting case tion (Federal and State), prepayment plans, often causes the medical practitioner to evaluate health personnel, hospital and other health fa- his leisure, income, and work differently from, cilities, receipt of care, and developments in say, skilled operatives in industry. other countries. The first issues of this pe- Second, in medicine, price is not the sole

786 Public Health Reports means by which and of medical ices are for the,cure and diagnosis of disease and health services may be equated. As a so- (2). Moreover, data on expenditures and on cial responsibility, private associations, non- the relation of expenditure to income suggest profit in form, and private practitioners have that the familial patterns of are provided necessary services for those unable to distorted when illness strikes. pay. And fees for services have been graded Efficient organization of economic resources in accord with rough evaluations of ability to for health, guided by the consumer's prefer- pay. In the generally, however, the ence, depends upon the consumer's knowledge price system is the instrument for the alloca- and the extent of his education. Despite per- tion of among consumers and their com- sistent efforts to educate consumers they re- peting . Government traditionally veal considerable absence of accurate knowl- has been looked upon as an instrument to cor- edge about the quantity and quality of health rect the market mechanism where it fails mark- services required. The nature of the medical edly to satisfy the wants of individuals. In service itself and its intangible character rein- the sphere of medical care, however, individual force the- consumer's- lack of knowledge about needs have been met historically, at least in his purcshase s,eand impede a rational choice part, by nonprofit organizations and by the that could guide the allocation of resources. practitioner guided by the code of Hippocrates. Furthermore, in an individual's purchase of Moreover, a competitive price has been gen- many medical services, there is a social . erally absent from the medical market, at least Purchase of health services for the prevention until recently. In part, this is attributable to of contagious and infectious diseases, such as the absence of a homogeneous commodity. Skill smallpox, poliomyelitis, and whooping cough, and capacity vary with the individual abilities provides a utility, or a benefit, for the com- of health personnel, and needs of patients dif- munity as a whole. Even curative health serv- fer, too. ices, such as those for the treatment of tubercu- Third, medical services are personal services; losis or syphilis, help to prevent the spread of money cannot veil the transaction. The cold the diseases; thus an individual's purchase of impersonality of money, so much a part of all services for his own cure benefits his neighbor. other "business" transactions, is largely absent These important "extra-buyer benefits," or "ex- from medical exchanges between those who ternal " in the prevention of disease, give services and those who receive them. For are instances in which individual demand and a part of what one buys in medical services is market price underestimate the marginal and a personal relationship. total benefits provided. Preventive health serv- Fourth, consumers do not choose between ices would be undervalued, underpriced, and health services and other underproduced, unless administrative agencies by means of a simple rational weighing of (government or nonprofit) entered the market. choices, for (taking consumer health expendi- tures as a guide) the consumer prefers to avoid, or remove the circumstances that compel, using Population and Resources resources for health purposes. In every in- While economists have devoted little attention come group there is a heavy concentration of to the medical market they have long dealt with expenditures for medical care among those fam- population growth in relation to limited physi- ilies who suffer illness. This concentration cal resources. Malthus' Essay on the Principle suggests that consumer outlays are undertaken of Population, first published in 1798, triggered primarily to cure or provide services for the a series of economic postulates giving a man- sick. This pattern of consumer preferences against-nature view which earned economics its may be illustrated in other ways. For ex- designation as the dismal science. Most im- ample, in any year, only about one-third of the portant of these postulates for health program- population purchases dental services (1). ing was the iron law of . About one-fifth of services are for , whose Principles (written preventive health services; the remaining serv- in the decade 1881 to 1890) represents a transi-

Vol. 73, No. 9, September 1958 787 tion from classical to modern economics, wrote: Marshall, , and others. Subse- ". . .- earlier economists argued as though man's quent studies of special importance to this par- character and efficiency were to be regarded as ticular analysis are those made by Wolfbein a fixed quantity.... [Economics] is getting to and Wool for the U. S. Department of Labor on pay every year a greater attention to the plia- the measurement of a working life (6, 7). bility of human nature, and to the way in which The third facet is the application of cost- the character of man affects and is affected by benefit ratios to health programs. Work in the prevalent methods of the production, dis- this area has been traced to the 16th century tribution and consumption of wealth" (3a). study of Jean Bodin, to Richard Cantillion's Marshall, dealing with the agents of produc- essay on The Nature of Commerce in General tion in book 4 of his Principles, considers not published in 1755, 'and to Quetelet, a social only the growth of the population but the health statistician, who wrote in i835: "In his early and strength of the population. Marshall years, man lives at the expense of society; he opened a chapter of this book with, "We have contracts a debt which he must one day dis- next to consider the conditions on which de- charge; and if he dies before he has succeeded pend health and strength, physical, mental and in doing so, his life will have been a burden moral. They are the basis of industrial effi- rather than a benefit to his fellow citizens . . ." ciency, on which the production of material (8). Economic studies of cost-benefit ratios wealth depends; while conversely the chief im- of health programs have been carried out portance of material wealth lies in the fact that, largely by health administrators and others in when wisely used, it increases the health and the health professions rather than by econo- strength, physical, mental and moral of the mists. Hermann M. Biggs expressed the health human race" (3b). administrator's concern in his slogan coined While some few economists have recognized more than three and a half decades ago for the the concept of "personal capital," of personal New York City Health Department: "Public hazards to workers in industry as "social health is purchasable; within natural limita- costs," and of health (physical and mental) as tions a community can determine its own death a component of workers' efficiency, by and rate." large these concepts have been qualifications rather than integral parts of their economic Winslow-Myrdal Exchange propositions. Three interrelated facets of analysis are es- Health cost-benefit analysis has gained new on significance since World War II, especially in sentially involved. Population pressures international or- resources, constituting one facet, have been dealt the studies and activities of ganizations. Major contributions to t h i s with in economic discussions of underdeveloped A. in his areas the world (4). The Malthusian analysis were made by C.-E. Winslow of 1951 volume on The Cost of Sickness and the theory has gained new importance in this con- Price of Health, by the exchange of views be- text. before the value of man. tween Winslow and The second facet is the capital Fifth World Health Assembly of the World Dublin and Lotka, demographers and 'actuaries in the sub- have contributed the Health Organization in 1952, and rather than economists, on Economic major work on the methodology of evalu- sequent volume by Myrdal ating the capital represented by man (5). For Theory and Underdeveloped Regions published their purpose they define capital value as the in 1957. present and discounted value of future earn- Differences between Winslow's views and ing power of the earner, reduced by the those of Myrdal are largely differences in em- costs of birth, upbringing, and maintenance phasis. Winslow argued that investment in during a working life. In their study they health promised large dividends in life capital. traced the thinking on man's capital value For in the less-developed areas of the world through the works of Sir , Adam where there was no surplus to invest in the Smith, William Farr, Frederick Engel, Alfred profitable enterprise of health, the vicious cycle

788 Public Health Reports of poverty and disease pursued its course un- variable first affected, and so on" (12). Myrdal checked. "Men and women were sick because notes that if his theory of cumulative causation they were poor; they became poorer because is valid, an upward movement of the entire they were sick, and sicker because they were system could be caused by pressures applied to poorer" (9a). The doctrine that successful one or several points in the system. However, health programs will increase the sum of human in agreement with Winslow, he argues that ra- misery, Winslow said, is founded-on the falla- tional policy should not induce a change in only cious assumption that there is some basic law one factor, especially with sudden or great limiting to that which force. has at the moment been realized. He pointed Drawing on his theory of cumulative causa- to improvements in agricultural production in tion, Myrdal argues that it is far from a simple the less developed areas of the world, to the de- matter to define or to measure the economic velopment of mineral resources, to other social value of programs directed to the promotion of as well as economic measures improving the a population's health. well-being of the population, and to the supple- Costs and benefi'ts are likely to be different in mentation of these measures by efforts in some the short run from what they would be other- countries to limit excessive rates of population wise and to be different in different environ- increases. He emphasized that the public ments. Long-run values depend on the interre- health programs cannot be planned in a vacuum, lationship of factors in any given society. but only as a vital part of a broader program Myrdal emphasized that the success of of social improvement (9b, 10). He urged health programs will depend entirely on health leaders to "keep careful records of the cost whether they are appropriately integrated in a of their health programmes and of the actual program of general economic development. He results attained, and make estimates of the eco- thus agreed with Winslow that health pro- nomic gains corresponding to the decreases re- grams should "be a vital part of a broader pro- corded in mortality and morbidity" (11). gram of social reconstruction." Myrdal, starting from Winslow's thesis Qf a Myrdal also agreed with Winslow that a "vicious cycle," elaborates a theory of circular health program could increase the num- causation. In brief the Myrdal theory is that ber of persons in the productive age groups and at one point of time there is accommodation in their productivity. But, he emphasized, "the society between opposing forces. If either of economic value of preventing premature two opposing forces changes, Myrdal writes, a death . . . depends entirely upon whether such change is bound to occur in the other force, "and an economic development is under way which start a cumulative process of mutual interaction ensure,s productive work for the greater number in which the change in one factor would continu- of people we thus keep alive" (13). If death ously be supported by the reaction of the other rates are reduced in areas in which there is al- factor and so on in a circular way. . . . The ready substantial , poverty could point is not simply that many forces are work- be aggravated. While Myrdal, in common with ing in the same direction. They are, in fact, not Winslow, questioned the static notion of a doing so. In general there are periods when "population optimum," in view of the expanda- opposing forces balance one another so that the bility of production resources, he laid far system remains in rest until a push or a pull is greater emphasis than Winslow on the need for applied at one point or another. When the capital investment in production facilities. whole system starts moving after such a shock The amount of planned capacity required to the changes in the forces work in the same di- prevent economic stagnation and increased dis- rection, which is something different. And this tress would be enlarged by a truly successful is so because the variables are so interlocked health program. in circular causation that a change in any one Myrdal suggested that calculations on the induces the others to change in such a way that price of health and the cost of illness should be these secondary changes support the first based on something other than a dollar value change, with similar tertiary effects upon the of people.

Vol. 73, No. 9, September 1958 789 Success of a program, for example,, might be But there are a number of reasons why these calculated on in life and abilities rather preferences are not a wholly reliable guide to than dollars. Costs of alternative programs, or optimum use of health resources, even when of their administration alone, might also be the word optimum is used in this special sense. compared without reference to the dollar value First, the consumer would prefer to avoid of people. illness and the purchase of health services. The Winslow-Myrdal exchange has served to And, as has already 'been indicated, there are point up three needs: (a) greater precision in sizable "extra-buyer benefits" in an individual's defining measurements of the cost of sickness, purchase of medical services. Others in the (b) more careful distribution between primary community benefit from his purchase. Pur- and secondary impacts and effects of health pro- chases by some consumers, for example, of grams, and (c) a more careful formulation of influenza during the recent-"epi- assumptions that underlie alternative economic demic prevented further spread of the disease. models (static or dynamic) used in estimating The value of the medical services to each con- the costs of sickness. The exchange, moreover, sumer did not depend upon his consumption has served to provide a broad perspective from of medical services alone but upon decisions of which to explore the subject matter of health his neighbors as well. Those who made no economics. purchases of influenza vaccine also benefited. Thus, the social value of medical services is far Health Economics Defined larger than the private marginal value. In- Tentatively defined, health economics is a dividual decisions of a consumer are therefore field of inquiry whose subject matter is the inadequate as an efficient guide to the optimum optimum use of resources for the care of the sick allocation of resources for health purposes. and the promotion of health. Its task is to For these individual decisions undervalue appraise the efficiency of the organization of health services, which results in an under- health services, and to suggest ways of improv- production of these services. ing this organization. Second, some health services do not lend Promotion of health patently involves more themselves to pricing on the market so that than services of the health professions. It in- society's preference for them cannot be ade- cludes food, housing, recreation, and clothing, quately valued on the market. Air and water but, although they contribute importantly to control measures, fluoridation of health and wellness, they must be excluded water supplies, and mosquito control are ex- from the scope of health economic studies. amples of these services. Furthermore, the Unless they are excluded, the scope of these price system for individual services is not studies would encompass all economic activities applied in all cases: (a) the medically indigent and the special problems of health economics are not excluded from care when they are sick, would receive inadequate treatment. While the and (b) public safety and health sometimes scope of health economics may be delimited in require direct provision of health services and this way, account must be taken of the compet- the removal of the individual from the com- ing uses of scarce resources, the impact of eco- munity. Public hospital services for the nomic levels and economic growth on the status mentally ill and for those with tuberculosis of health, and the need for health services. are illustrative of services placed outside the The allocation of economic resources is price-market system. generally determined in the market by the Third, the allocation of health resources is preference of consumers for different types of determined by a mixture of private market de- consumer goods and by the preference of cisions and administrative decisions. "Admfin- workers for different types of work, leisure, istrative decisions" include those decisions made and income. Welfare economists have taken by the government, private nonprofit agencies, these preferences, as expressed in the market, and professional organizations. Decisions con- as the guide to optimum use of resources (14- cerning some health facilities (the building and 16). size of a general hospital, for example) are

790 Public Health Reports made by voluntary agencies. The Visiting methods of measurement require extensive fur- Nurse Association determines the availability ther study. Not potential but actual increases of part-time care in many communities. in production under prevailing conditions of In some places the content and quality of rural must be measured against the cost health services are determined by the regional of health services in order to determine their organizations associated with medical schools. relationship to the economic optimum. The principles underlying these administrative One additional aspect of the problem may be decisions and the way in which they influence mentioned. The economic optimum bears some the allocation of health resources need to be relation to the amount of health resources re- explored. quired to provide care for all the illnesses in the It may be that the principles underlying population. The optimum may be below or public budget decisions are applicable to ad- above the amount of health services suggested ministrative decisions of voluntary health agen- by professional standards. Standards of health cies as well as public agencies. While econo- resource requirements are familiar to the health mists have largely neglected theories of public practitioners. Professional planning for health expenditure in favor of theories of taxation and services and setting standards are characteris- policy, analysis of governmental budgeting has tics of the health field. Standards of profes- begun. The Joint Economic Committee of sional education, requirements for entrance into Congress, by its 1957 study of Federal expendi- the health professions, hospital standards,' and ture policy for economic growth and stability, even in some instances standards of care are de- has stimulated the development of principles termined by professional groups. Moreover, for determining public budget (17, 18). Re- government, by compulsory measures, has en- view of the work is needed to assess its con- forced standards of public health. For exam- tribution to our understanding of the optimum ple, vaccination is required as a condition for allocation of economic resources for health. admission to school, and standards are set for Consumer preferences as expressed in the the distribution of milk, for food handlers, and- market are one guide to optimum use, even for water supplies. though an incomplete guide. Another thing to The National Health Survey is designed to look at is the effect of health programs on provide data on sickness in the population. In labor resources and production. Gains in out- discussing the potential uses of data from such put as a consequence of health services may a survey the U. S. National Committee on Vital equal or exceed (in a given period of time) the and Health Statistics indicated that quantita- resources used for health. The number and tive information would provide a basis for quality of new manpower resources must be sound evaluations of health facilities, personnel, compared with the health manpower used in the and programs as well as for a determination of provision of services. For example, it would how available resources should be divided be possible to compare the amount of manpower among programs (20). In an earlier study, Lee used in providing health services in the United and Jones related sickness in the population to States with gains in labor force participation the needed volume of health services and resulting from reduced death rates. Reduced manpower requirements (21). death rates in the United States have resulted The subject matter of health economics in- in a decline in separations from the labor force cludes factors that determine price patterns for at all ages up to age 65. Despite the marked health services, ways in which the materials, delay in entry into the labor force by young goods, health manpower, and facilities are people, and the earlier exit from the labor force brought together at the right time and place and by those in the older age groups, the nmale in the right proportions to provide health serv- worker today puts in many more years of work ices, and ways in which the different health than did his counterpart 50 years ago (19). goods and services are coordinated. The mech- The problems of cost-benefit measurement have anisms by which goods and services are coordi- been mentioned in the discussion of the Wins- nated are "trade" in the market by the consum- low-Myrdal exchange. The concepts and er's purchases of health goods and services,

Vol. 73, No. 9, September 1958 791 professional codes of performance, and govern- sick and the promotion of health, taking into mental and voluntary agency planning and account competing uses of these resources. budget decisions. The basic problems are of two kinds: the or- Health economics also includes in its subject ganizatio)a of the medical market, and the net matter the effects of health services on the size, yield of investment in people for health. character, and efficiency of the work force and Consumer preferences are not an adequate population. It seeks to gain an understanding guide to the optimum allocation of resources of the interaction of levels of living, production, for health.- There are a number of reasons and physical and mental wellness. The health why this is so. For one thing, a consumer factors which make for work absence, for re- would prefer to avoid the illnesses which re- tirement from work, for labor turnover, for the quire use of resources for health purposes. quality of performance on the job, and for job For another, his neighbors benefit from the satisfaction fall within the scope and concern medical services he purchases, for example, of health economics. The general topics which "flu shots" during the recent influenza epi- need to be considered in a comprehensive treat- demic. Individual decisions undervalue health ment of the economics of health include the services, and would result in underproduction interaction of health services and gross national of these services unless supplemented by actions , population growth and economic devel- of private voluntary agencies and government. opment, and productivity of labor forces; health problems associated with industrial develop- ment; the supply of health services; utilization REFERENCES of services and their pricing; and financing of (1) U. S. National Health Survey: Health statistics. public and nonprofit agency programs. Preliminary report on volume of dental care, United States, July-September 1957. Public The scope of inquiry included in the tenta- Health Service Pub. No. 584-B2. Washington, tive definition of health economics is by no D. C., U. S. Government Printing Office, 1958. fneans novel. It is suggested by the work that p. 7. is going forward in the bureau of medical (2) U. S. National Health Survey: Health statistics. economics of the American Medical Associa- Preliminary report on volume of physician visits, United States, July-Septemnber 1957. tion, and the bureau of economic research Public Health Service Puib. No. 584-Bi. Wash- and statistics of the American Dental Associa- ington, D. C., U. S. Government Printing Of- tion. These organizations have explored the fice, 1958. p. 13. interaction of use and price of health services, (3) Marshall, A.: Principles of economics. Ed. 8. health manpower, and facilities and consumer London, Macmillan and Co., 1938. (a) p. 764; demand. The studies of Eli Herbert (b) p. 193. Ginzberg, (I4) Leibenstein, H.: Economic backwardness and Klarman, and others have increased our under- economic development. New York, John Wiley standing of the economics of the hospital sys- & Sons, Inc., 1957, ch. 10. tem (22). Ginzberg's work has also included an (5) Dublin, L. I., and Lotka, A. J.: The money value examination of the economic of a man. Rev. ed. New York, Ronald Press special problems Co., 1946. of health manpower and methods of providing (6) U. S. Department of Labor, Bureau of Labor care (23, 24). And an increasing number of Statistics: Tables of working life for women. doctoral dissertations in economics have been Bull. 1204. Washington, D. C., U. S. Govern- concerned with these, or similar problems. ment Printing Office, 1957. (7) U. S. Department of Labor, Bureau of Labor Statistics: Tables of working life; length of Summary working life for men. Bull. 1001. Washington, D. C., U. S. Government Printing Office, 1950. The health administrator has usually equated (8) Quetelet, quoted in Rene Sand: The advance to "health economics" with "money questions in . London, Staples Press, 1952, the field of health." But, money is not the p. 584. central problem of health economics. Health (9) Winslow, C.-E. A.: The cost of sickness and the price of health. Monogr. Series No. 7. Geneva, economics is concerned with the optimum use World Health Organization, 1951. (a) p. 9: of scarce economic resources for the care of the (b) p. 80.

792 Public Health Reports (10) Health is wealth [An abridged version of refer- and stability. Joint committee print. 85th ence 9]. Geneva, World Health Organization Cong., 1st sess. Washington, D. C., U. S. Gov- [1952?] ernment Printing Office, 1957. (11) Winslow, C.-E. A.: The economic values of pre- (19) Wolfbein, S. L.: The length of working life. ventive medicine. Chron. World Health Org. Paper presented at Fourth International 6: 196, August 1952. Gerontological Congress, Merano, Italy, July (12) Myrdal, G.: Economic theory and underdeveloped 1957. Washington, D. C., U. S. Bureau of regions. London, Gerald Duckworth and Co., Labor Statistics, 1957. 1957, pp. 16, 17. (20) U. S. National Committee on Vital and Health (13) Myrdal, G.: Economic aspects of health. Chron. Statistics: Proposal for collection of data on World Health Org. 6: 211, August 1952. illness and impairments in the United States; (14) Baumol, W. J.: and the theory a report of the subcommitee on national mor- of the State. Cambridge, Harvard University bidity survey. PHS Pub. No. 333. Washington, Press, 1952. D. C., U. S. Government Printing Office, 1953. (15) Macfie, A. L.: Economic efficiency and social wel- (21) Lee, R. I., and Jones, L. W.: The fundamentals of fare. New York, Oxford University Press, good medical care. Chicago, University of Chi- 1943. cago Press, 1933. (16) Scitovsky, T.: Welfare and . Chi- (22) National Planning Association: Good health is cago, Richard D. Irwin, Inc., 1951. good business; a summary of a technical study. (P17) U. S. Congress, Joint Economic Committee: Hear- Planning Pamphlets No. 62. Washington, D. C., 1948. ings . . . Federal expenditure policy for eco- (23) Ginzberg, E.: What every economist should and stability. 85th Cong., 1st nomic growth know about health and medicine. Am. Ec. sess. Washington, D. C., U. S. Government Rev. 44: 104-119, March 1954. Printing Office, 1958. (24) Ginzberg, E.: Health, medicine, and economic wel- (18) U. S. Congress, Joint Economic Committee: Fed- fare. J. Mount Sinai Hospital 19: 734-743, eral expenditure policy for economic growth March-April 1953.

Report of International Association of Gerontology A conference of the European section of the Social Science Research Committee, International Association of Gerontology, held in Copen- hagen, Denmark, in October 1956, discussed pensions, assistance, and levels of living, work and retirement, and family and institutional care. The conference recommended that, for purposes of comparison, data be collected in various countries on old people living alone or with relatives, thcose living in institutions and nonprivate such as hotels, those who have surviving children, and those who are bedridden, housebound, or limited in movement. Speakers from the United Kingdom, Italy, Denmark, and the Neth- erlands described and discussed surveys of income, budgets, living con- ditions, family relationships, pensions and retirement, research on employment, causes of institutionalization, costs of institutional versus home care, and sociomedical surveys. The proceedings, entitled "The Need for Cross-National Surveys of Old Age," are available from the Division of Gerontology, Univer- sity of Michigan, 1510 Rackham Building, Ann Arbor, Mich.

Vol. 73, No. 9, September 1958 793; ...... the noteworthy aspects of the pa- igns per; and the conclusions of the au- ...... * .-.*-@-...... -.-.@-**.*...... S thor and reviewer, if any. The pa- ...... per itself is not read to the staff as a rule: the purpose of the review is simply to inform the staff and to got encourage reading in pertinent ...... fields. Reviews ordinarily are lim- ited to 5-10 minutes. Time is also

...... we@-*.*@--.@...... allowed for questions and dis- this a new cussions. With issue, department, Signs and Symptoms, is opened. Periodicals, bulletins, and maga- Its main purpose is to provide a setting for what Dr. Joseph W. Moun- zines are assigned on a 6-month or tin once called gems of public health practice. In addition to rare yearly basis. gems, it will give brief notice to other events or activities presumably Staff members are encouraged to of to readers. The doings of local and State health organiza- read in detail the papers they re- tions will be the prime, but not the exclusive, focus of this department, view, to mark important points, and to read them a second time before especially if they indicate an important trend or some outstanding offering their review. development or achievement. Contributions are welcomed. Home Safety Directory of Services tion with them has resulted in the The final report of the California A describing all services training of visiting nurses in reha- directory Home Safety Project covering the in Greater Cleveland, Ohio, for bilitation and the enlistment of help years 1953-57 has been issued by the care of the chronically ill has been from social workers, nutritionists, California Department of Public published recently by the Cleveland and others. By the beginning of June 1958, Health. The 165-page report re- Academy of Medicine and the Wel- views the home accident problem fare Federation of Cleveland. nearly 100 patients had been visited and 38 cases had been closed. in California and outlines a pro- Intended as a reference for doc- gram of State and local health de- tors and staff members of health partment activities. It emphasizes and welfare agencies, the 118-page Pay for Patients the epidemiological approach to ac- book lists about 200 different agen- cident prevention. Distribution of cies. In a pilot program 25 mental pa- the report is limited. In addition to medical facilities, tients have been working for pay at the services described include nurs- the New York State hospital in ing and rehabilitative, educational, Central Islip. Hearing Tests financial, and casework assistance. Patients work at small handerafts Audiometric tests for parents help Special sections deal with the treat- or such simple tasks as sewing but- them to understand corrective ther- ment of chronically ill children, tons on cards. apy and sound range limitations of older persons, and veterans. Dr. Francis J. O'Neill, director of children with hearing losses, the Information about each agency the hospital, reports that the pa- Alaska Department of Health re- includes: services, eligibility re- tients are not approaching financial ports. quirements, area served, fees, hours, independence, but he feel's the work The tests, offered during National and referral procedures. advances rehabilitation. in The directory has been distrib- Hearing Month May 1958, were uted to some 2,800 doctors in the available to 5 communities; 196 Cleveland area. Keeping Current adults were tested. Responsibility for keeping current Glaucoma Traveling with public health literature is managed by the Saanich and South In the summer of 1957 funds from Rural arthritic victims in West- Vancouver Island Health Unit, Vic- the Public Health Service enabled chester N. British County, Y., are being toria, Columbia, by giving the District of Columbia to begin ex- treated in their homes by therapists. each staff member an opportunity over 40 for The New York State Chapter of the to report at a regular meeting on amining residents age Arthritis and Rheumatism Founda- reading he has done. glaucoma provided they were not tion sends therapists to patients un- H. George Henderson-Watts, sen- under care of an eye doctor. By the able to leave their homes or unable ior sanitary inspector, reports that end of May 1958, 3,866 patients had to travel to distant . staff members give the title, author, been examined and 27 cases of glau- The patients' private physicians and source; a brief statement of coma verified. An additional 238 approved the program and consulta- the author's purpose; a comment on patients were under observation.

794 Public Health Reports