Developing economics expertise for the evaluation of primary health care

Given that government budgets are increasingly stretched in the face of competing demands, there is a pressing need for evidence on the costs and benefits of public sector investments. Nowhere is this need greater than in the health field, where the benefits of programmes are typically difficult to measure. Within the health sector a key area of interest is primary health care, which is generally regarded as a central function and the most important means by which the health of the population can be improved. This paper reports the results of a recent survey of Commonwealth countries which sought to establish the extent of economic evaluation of PHC programmes, the impact on decision-making and the level of health economics expertise available in Third World countries. Based on the results of the survey, suggestions are made for improving the commissioning and conduct of economic evaluations, for interpreting and implementing evaluation results, and for developing government expertise in economic evaluation.     

State Lotteries for Public Revenue

Lotteries, the state fiscal gimmick of the eighties, operate in jurisdictions encompassing substantially more than half the nation's population and enjoy considerable public acceptance. The revenue they generate is small, rarely more than two percent of state general revenue, it is subject to major year-to-year swings, and it is very expensive to generate, particularly when vendor commissions are recognized as part of cost. Furthermore, lotteries bear a high implicit excise tax rate and, because of the pattern of play across income classes, appears to worsen the overall equity of the revenue system. Their economic impact appears to be that of an internal transfer, although states with major lottery equipment suppliers have most to gain, particularly if they do not operate their own lottery. Lotteries are not destined to become mainstays of government finance, although their spread is likely, even with the fiscal questions they raise.     

Sudden death in an infant resulting from torsion of the uterine adnexa

A 2-month-old infant girl died suddenly as a result of torsion of the uterine adnexa. The infant was found unresponsive in bed and was pronounced dead shortly after her arrival at a hospital. There were no antecedent signs of illness. At autopsy, the right ovary and right fallopian tube were twisted and were dark purple, swollen, and necrotic. The right ovary was enlarged by a follicle cyst 4 cm in diameter, which likely precipitated the torsion. The mechanism of death was unclear but may have resulted from the release of cytokines produced in response to necrotic adnexal tissue. Fatal uterine adnexal torsion has been reported rarely in infants; in all those cases there were antecedent symptoms. Torsion of the uterine adnexa should be included in the differential diagnosis of sudden death in infancy.     

Utilizing the urinary 5-HTOL/5-HIAA ratio to determine ethanol origin in civil aviation accident victims

Specimens from fatal aviation accident victims are submitted to the FAA Civil Aerospace Medical Institute for toxicological analysis. During toxicological evaluations, ethanol analysis is performed on all cases. Care must be taken when interpreting a positive ethanol result due to the potential for postmortem ethanol formation. Several indicators of postmortem ethanol formation exist; however, none are completely reliable. The consumption of ethanol has been shown to alter the concentration of two major serotonin metabolites, 5-hydroxytryptophol (5-HTOL) and 5-hydroxyindole-3-acetic acid (5-HIAA). While the 5-HTOL/5-HIAA ratio is normally very low, previous studies using living subjects have demonstrated that the urinary 5-HTOL/5-HIAA ratio is significantly elevated for 11-19 h after acute ethanol ingestion. Recently, our laboratory developed and validated an analytical method for the simultaneous determination of both 5-HTOL and 5-HIAA in forensic urine samples using a simple liquid/liquid extraction and LC/MS/MS and LC/MS/MS/MS. In this previous work a 15 pmol/nmol serotonin metabolite ratio cutoff was established in postmortem urine, below which it could be conclusively determined that no recent antemortem ethanol consumption had occurred. In the current study this newly validated analytical method was applied to five ethanol-positive aviation fatalities where the origin of the ethanol present could not previously be conclusively determined. In four of the five cases examined the detected ethanol was demonstrated to be present due to postmortem microbial formation, and not consumption, even though some indication of ethanol consumption may have been present.     

A coffee can, factor analysis, and prediction of antisocial behavior: the structure of criminal risk

The predictive accuracy of the Psychopathy Checklist-Revised, Level of Service Inventory-Revised, Violence Risk Appraisal Guide, and the General Statistical Information on Recidivism were compared to four instruments randomly generated from the total pool of original items. None of the four original instruments better predicted post-release failure than the four randomly generated instruments. These results suggest two conclusions: (a) the instruments are only measuring criminal risk, and (b) no single instrument has captured sufficient risk assessment theory to result in better prediction than randomly derived instruments measuring criminal risk. A two-stage factor analysis was completed on 1614 cases. This analysis of the risk items indicated a 4-factor solution and all 4 factors were equal to the original instruments in predicting post-release failure. Thus, the original instruments did not improve prediction over randomly structured scales, nor did the restructuring of items improve risk assessment, suggesting substantial deficiencies in the conceptualization of risk assessment and instrumentation. We argue that developing a risk-based construct, which involves hypothesis testing and an explanation of behavior, is the optimal method to advance risk assessment within the criminal justice and mental health systems. Such an approach would provide targeted areas for clinical intervention that are salient to risk.     

STR genotyping and mtDNA sequencing of latent fingerprint on paper

A systematic study was conducted to investigate whether DNA can be successfully extracted from latent fingerprints deposited on ordinary paper and analysed using short tandem repeat profiling and mitochondrial DNA sequencing. In order to evaluate the performance of latent fingerprint analysis in a criminal case, experiments with varying conditions were carried out to improve our understanding of low copy number (LCN) DNA typing. After optimising the extraction methods to achieve increased sensitivity, the examination of touched paper can routinely yield the STR profile of the individual who has touched it. A fingerprint can therefore be considered as a potential source of DNA for genetic identification. Nevertheless, the findings of our "after enhancement experiment" (using chemically or physically pre-treated fingerprints), and our "mixture experiment" (using fingerprints from three to four people on the same sheet of paper) help to define the limitations of the low copy number PCR technique in forensic casework.     

The Political Fate of Market Reform in Latin America, Africa, and Eastern Europe

Why did political leaders adopt drastic, costly neoliberal policies in a number of countries, but not in others? Why did these painful measures elicit popular support in some nations, while triggering rejection and protest elsewhere? To complement extant explanations for these puzzling developments, the article draws on the core finding of prospect theory, a psychological theory of decision making under risk: people tend toward bold, risky choices when facing prospects of losses, but opt for caution when anticipating gains. Accordingly, leaders enact and citizens support drastic reforms only when they face deep crises, such as hyperinflation. This argument yields predictions about the different stages of the reform process, which the article assesses through a wide-ranging examination of reform politics in Latin America, Africa, and Eastern Europe. Boolean analysis corroborates most of the predictions derived from prospect theory, but also suggests the importance of economic andpolitical-institutional context factors.     

Public attitudes towards the death penalty

Responses to a general question regarding the use of the death penalty were compared with the sentences that respondents chose in a set of scenarios describing homicide cases. The percentage of respondents who assigned the death sentence in one or more of the following scenarios was higher than those who favored the death penalty in the abstract question, but there were inconsistencies in the answers. A majority assigned the death penalty only for the most heinous offender described, and the figures were lower for other crimes, even clear cases of first degree murder. At the same time, a manipulation involving information about methods of execution did not affect answers. These results strongly suggest that the abstract questions typically used in public opinion polls do not accurately reflect the public's feelings about use of the death penalty in specific cases. More generally, research on public opinion regarding criminal justice policies should survey a variety of specific circumstances.