The resistible rise of preventive medicine

The politics of preventive health care have changed dramatically in the last fifteen years. In the late 1960s and early 1970s, prevention was the motherhood issue of health care reform. With only the slightest glimmer of controversy, vaccination, promotion of lifestyle changes, mass screening, and safety regulation all became widely accepted strategies for improving health and reducing medical expenditures. By the mid-1980s, the dark side of each strategy became visible. Vaccinations can cause serious and permanent injuries; lifestyle factors are being used to raise insurance premiums, to deny eligibility for disability insurance benefits, and to deny employment. Screening is similarly used to deny employment, and new technologies for prenatal screening have raised fears of stigma and selective abortion among racial, handicapped, and antiabortion groups. Occupational safety regulation is increasingly focused on excluding the "high-risk" individual from jobs. In the absence of social protections from these economic and social harms, citizens have used tort and civil rights litigation to resist preventive health measures.     

Is Activity-Based Costing Up to the Challenge When It Comes to Privatization of Local Government Services?

After its initial success in the private sector, activity-based costing (ABC) has been embraced by the public sector as an analytical tool that can be used to improve the efficiency of government operations, especially in the area of the privatization of operations. Despite claims that ABC can greatly enhance the evaluation of how to most efficiently deliver services, there are significant obstacles that must be overcome before ABC can be effectively implemented. In order to underscore the challenges facing successful ABC execution in the public sector, the use of activity-based cost accounting by the City of Indianapolis for its privatization initiatives is discussed. Generally ABC is not up to challenge of providing local governments with the tool necessary to comprehensively evaluate direct services and determine which are candidates for contracting out or privatization.     

Learning Lessons and Transferring Policy across Time, Space and Disciplines

An area of recent interest in the International Relations and Comparative Politics literature concerns 'policy transfer'. This is a dynamic whereby knowledge about policies, administrative arrangements or institutions is used across time or space in the development of policies, administrative arrangements and institutions elsewhere. Policy transfer is deemed to be on the increase in an era of globalisation. Indeed, some governments and international organisations are proactive in promoting harmonisation and convergence or exporting policy lessons. This paper surveys the state of the burgeoning literature, identifies some methodological issues in studying policy transfer, and outlines some additional routes of research.     

Characteristics of firearms and gunshot wounds as markers of suicide.

Data from a total of 1,200 cases that the Medical Examiner of Dallas County, Texas, ruled as suicide with a firearm have been compared with the results of forensic laboratory examinations and tests; 75% are with handguns and 25% are with long guns. The incidence of suicides by gender yields 82% males and 18% females, with the most common entrance site being the head. With regard to racial distribution of persons committing suicide, > 88% are white in the study population group, which is 76% white. Data are presented for the incidence of blood detected inside and on the muzzle end of the barrel of the firearm, and for the persistence of blood inside the barrel even after the weapon was discharged to obtain test bullets. The analysis of handwipings for primer residues shows that "positive" results are obtained for approximately 50% of the revolvers and approximately 32% of the pistols when the caliber is > 22. Other projects such as transfer of gunshot residues to the hand by simply handling the weapon, the incidence of single-contact wounds in homicide versus suicide cases, and the percent of positive identification of bullets with weapons submitted are described.     

Physicians as gatekeepers: illness certification as a rationing device

Illness or disability is often used as an eligibility criterion by public programs that distribute money, services, privileges, and exemptions. Physicians then play a central role in the allocation process. But physicians are caught between a large pool of applicants who want some benefit, on the one hand, and an organization with limited resources to distribute, on the other hand. Three conflicts are engendered in this gatekeeping role: the tension between trusting and mistrusting information provided by the patient, the tension between erring on the false positive side and the false negative side in diagnostic decision-making, and the tension between doing everything possible for each patient and allocating limited resources among several needy clients. Several non-medical factors influence the ultimate outcome of this allocation process, which, in theory, rests on clinical decision-making: the specificity and restrictiveness of the formal definitions of illness and disability used by a program; the structure of the determination process; the overall policy of the organization on distribution of benefits; and the ability of the organization to use administrative review, direct incentives, and written standards to control the certifying behavior of physicians.     

Diversifying Local Government Revenue in Bosnia-Herzegovina Through an Area-Based Property Tax

After a bitter and devastating war, Bosnia and Herzegovina is making slow but steady progress rebuilding its economy and government structure. As normalcy returns, the demand for government services invariably will continue to increase, especially at the sub-entity levels of government. Unfortunately, the current fiscal structure severely restricts the resources available to local governments. This article suggests that Bosnia and Herzegovina consider adopting a property tax as a means to provide much- needed revenue. After describing the current governmental and fiscal system that has evolved since the signing of the Dayton Accords, the authors discuss why an area-based property tax, rather than a more traditional property tax based on capital value or market prices, makes sense for this country in transition.