The Milbank Memorial Fund quarterly. Health and society最新文献

The impact upon health of changes in public policy regarding health services has not been systematically assessed. The long-term, and largely irreversible, effects of reduced support for health services to children present special challenges to collaborative research between clinical and public health approaches. Preliminary evidence from such a collaborative study of a variety of illnesses and interventions is persuasive of real benefit from prompt access to medical care.

Improvement in survival at advanced ages suggests that important changes in health and the natural history of disease processes may be occurring concurrently. a general model based upon cohort and life-course perspectives describes the changing relation of morbidity, disability, and mortality over time. Variability across different social and economic conditions is examined among institutionalized and non-institutionalized elderly, and between the United States and Japan. Future policy must take account of the qualitative, as well as the quantitative, changes in aging.

Improvements in the medical/technical ability to transplant human organs have led to similar--yet importantly different--societal and organizational responses among the nations of the "Atlantic Community." The highly decentralized system of organ procurement in the United States yields greater numbers; centrally directed European systems reflect lower wastage rates. An emerging convergence of the two approaches promises significant benefits and efficiencies in organ transplantation.

Questions surrounding withholding treatment from severely impaired newborns have elicited three significantly different substantive and procedural responses: from the Reagan administration's Department of Health and Human Services through the Carter President's Commission on Ethical Problems, and subsequent congressional legislation on child abuse. Movement from a rigid and simplistic application of medical imperatives to ambiguous and abstract criteria of the child's "best interest" represented limited progress. A new legislative compromise principle is an imperfect but practical accommodation to moral and medical realities.

Little is known about the health problems of the fastest-growing segment of the population. Three major community-based studies present prevalence information on physical and mental disabilities among the oldest old. These data also illustrate the limitations of interpretations in cross-sectional studies, and emphasize the value of prospective investigations of populations aged 85 and older. Although more costly and time-consuming, such prospective longitudinal studies are indispensable to sound policy planning.

The general public, physicians, and policy makers have all come to accept constraints on public expenditures for medical care as a reasonable means to redirect resources to competing sectors of national life, and to reflect changing political and social values. "Rationing" of facilities and services by explicit and implicit methods seems inevitable; the poor and disabled must not bear the brunt of stringency. The politics of competition and altered power relationships among providers offer new opportunities for system-wide reform.

A focus on persons aged 85 and over is a timely measure for better understanding the implications of population aging. Yet, it may generate inaccurate stereotypes that reinforce anxieties about conflicts between age groups in the allocation of health and social welfare resources. Alternative constructs enable consideration of a variety of options that differ from unnecessary extrapolations from existing public policies. These range from market initiatives, through state and local government actions, to federal intervention for meeting the challenges of becoming "an aging society."

Interactions of aging and disease are poorly understood by both clinicians and the aged themselves. The altered expressions of illness in the oldest old--in severity, presentation, and perception--provide a clinical challenge to treatment as well as to the formulation of health policy. A progressively diverse population, the oldest old will require new strategies for individualized care (acute and long-term), case-finding, research and training, and health promotion.