Tension, compression, and shear: directions, stresses, and outcomes of health care cost control

"Control" of health care costs is often portrayed as a struggle between external, "natural" forces pushing costs up and individuals, groups, and societies trying to resist the inevitable. This picture is false. Control includes strenuous efforts by some to raise costs, and by others to resist those increases, and/or to transfer costs to someone else. But all such forces originate in the purposes and interests of individuals and groups. Health care cost control is a struggle among conflicting interests over the priorities of a society, and claims of "inevitability" are simply part of the political rhetoric of that struggle. International experience supports certain conclusions. First, there is no basis for the claim that limits on expenditure growth must threaten the health of (some members of) a society. Second, there is a substantial variety of experience with cost control. Failure in the United States is often presented as evidence of the impossibility of control, but most other countries have succeeded. Finally, control requires the direct confrontation of interests, with substantial build-up of stress. Advocates of expansion are more successful if they can transform compressive forces into efforts to shift the burden onto someone else. Pressures from providers in every country for "privatization" and/or payment by users reflect this recognition of economic interest.     

Euthanasia: a challenge for the forensic toxicologist

People die daily in the hospital. Mostly, they die because their illnesses were no longer treatable (natural death). Unfortunately, some people die an unnatural death, in particular, as the result of euthanasia. In contrast to the situation in most countries, in the Netherlands euthanasia is accepted by the courts under strict conditions. It can be very difficult for the legal authorities to establish whether a person has died from natural causes or from suicide, euthanasia, or murder. In addition to the pathologist and the lawyer, the toxicologist also has a number of problems in showing whether euthanasia has been carried out. These can consist of the following analytical problems: (a) interactions--the patients involved have frequently been receiving a large number of toxic and nontoxic drugs simultaneously; (b) identification--not all drugs administered are included in general screening procedures; (c) metabolites--a large number of metabolites may have accumulated toward the end of a long therapeutic regimen; and (d) determination--determination of quaternary muscle relaxants and their various metabolites, as well as other drugs, can be problematic. There are also toxicokinetic problems; because of poor kidney and liver function, low serum albumen, general malaise, and interactions between these factors and other drugs, the kinetics of a given drug can differ from normal. This makes it all the more difficult to determine whether the patient died from an accumulation of medication or from a so-called "euthanetic" drug mixture.(ABSTRACT TRUNCATED AT 250 WORDS)     

A risk marker analysis of assaulted wives

In the wife assault literature, a number of risk markers have been identified. Using the data of the female respondents to the National Family Violence Survey (n = 699), a multivariate analysis was performed to examine which risk factors best differentiated between women involved in nonviolent relationships, verbally aggressive relationships, relationships exhibiting minor physical aggression and severely violent relationships. High levels of marital conflict and lower socioeconomic status emerged as the primary predictors of an increased likelihood of wife assault. Research implications are discussed.     

Work,fertility, and the status of women in Mexico

Among the major transformations affecting Mexican women in recent decades were their growing participation in the labor market and the fertility decline that began in the 1970s with widespread access to contraception. Data from 3 major Mexican fertility surveys, employment surveys, and censuses are used to analyze changes in female employment and their determinants during the years of economic recession in the 1980s. The main characteristics of the Mexican fertility decline are described, and the relationship between fertility and female employment before and during the economic recession is scrutinized for different social sectors. Suggestions for research on the affects of these changes on the social condition of Mexican women are then presented. The proportions of Mexican women over 12 years old who declared themselves economically active increased from 16% in 1970 to 21% in 1979 and 32% in 1987. Until the 1970s the majority of employed women were young and single or childless. But a clear increase occurred between 1976-87 in the economic participation of older women in union. Economic participation of low income and less educated women increased as they sought work or created their own in response to deteriorating living conditions during the recession. Young women with intermediate or higher educational levels did not increase their relative presence in the labor market in the same period. The marked increase in economic participation of less educated women in union with small children was accompanied by a significant increase in manual occupations. Between 1982-87, the proportion of women aged 20-49 in nonsalaried manual occupations rose from 7.6% to 18.5%. Mexico's fertility decline has been well documented. The total fertility rate declined from 6.3 in 1973 to 3.8 in 1986, while the percentage of women in union using a contraceptive method increased from 30.2 in 1976 to 52.7 in 1987. Fertility differentials have been declining but are still considerable. The inhibitory influence of children on female labor force participation in Mexico is clear, but in the years of economic recession the most notable increase in female workers was in women with 3 or more children of whom the youngest was under 3. It appears that the influence of children on women's employment depends on the socioeconomic status of the woman as well as on the dynamism or sluggishness of the labor market. Research is needed on the significance of changes in fertility and female employment for women's status in Mexico. Several recent works have presented results of microsocial analyses of the ways in which women experience changes in their lives resulting from fertility and employment decisions. A methodological strategy for studying these changes and their influence on women's status should focus on comparisons between different generations and birth cohorts, different types of employment, and different socioeconomic statuses. Both macrosocial and microsocial forms of analysis are needed to provide a full picture.     

The metropolitan character of urbanization in Mexico, 1900-1988

The author analyzes trends in urbanization in Mexico during the twentieth century, with a focus on the impact of rapid industrialization since 1982. Sections are included on the interrelations among economic development, industrialization, and urbanization; stages, levels, and measures of urbanization; the development of the city system in Mexico; and stages in the growth of Mexico City. (SUMMARY IN ENG)