Volume 73 Number 4, 1995
In This Issue:
Paul D. Cleary, Editor
Harold Edgar and David J. Rothman open this issue with "The Institutional Review Board and Beyond: Future Challenges to the Ethics of Human Experimentation." They describe the history and functioning of IRBs and offer several, probably controversial, suggestions for modifying the system. Over the past quarter century, institutional review boards (IRBs) have set and maintained admirable standards for the ethical conduct of research involving human subjects. IRB procedures probably are largely responsible for the fact that most clinical and health services researchers consider the research excesses of the past almost incomprehensible. Thus, researchers often consider the IRB at their institution a bureaucratic hurdle to get past, rather than an enforcer of standards.
The current system of IRB review was developed for an era different from our own. The types of medical and health care research that we do, the colleagues with whom we collaborate, and the sources of support for our research are changing quickly. Although IRB members are aware of, and sensitive to, changes in factors affecting the conduct of research involving human subjects, the current system may not be the best one for anticipating or preventing ethical problems in research. I invite readers to submit comments on the observations and suggestions put forth in this issue. I will publish the responses in a subsequent issue.
Child abuse, whether by individuals or as the result of the policies we choose, is appalling and unacceptable. The way in which we, as a nation, treat children reveals whether we are meeting our ethical and moral responsibilities toward this vulnerable population. In this issue of the Quarterly, we are pleased to have three outstanding articles on health care policy for children.
Many think that one of the more sensitive and meaningful indicators of the effectiveness of health care is the infant mortality rate. It is of enormous concern that we in the United States do so much less than many countries to help children survive their critical first year of life. In "A Strategic Framework for Infant Mortality Reduction: Implications for `Healthy Start'," Donna Strobino and her colleagues analyze the effectiveness of four strategies for reducing infant mortality; they conclude that the greatest potential impact would be achieved by improving the survival rates of low-birthweight infants. Their model provides a valuable framework for evaluating different approaches to fostering improved survival of infants in the United States.
One response to the high infant mortality rate in the United States was the expansion of the Medicaid program in the 1980s. In "Local Responses to Expanded Medicaid Coverage for Pregnant Women," Lisa C. Dubay and her colleagues describe their use of case studies, derived from four states in 1991, to evaluate how the expansion of Medicaid coverage affected access to prenatal care for low-income women. Unfortunately, they conclude that the impact was uneven, as improvement was recorded in only one state. Dubay et al. discuss policies other than Medicaid expansion that may be necessary to improve access to care and outcomes. A recently published pamphlet by Charles Bruner, a former state legislator, and James Perrin, a well-known expert on child health, described state initiatives to improve infant and child health. That pamphlet, "More than Health Insurance: State Initiatives to Improve Infant and Child Health," may be obtained from the Milbank Memorial Fund (645 Madison Avenue, 15th Floor, New York, NY 10022-1095) free of charge.
The policies and funding mechanisms affecting children are complex and fragmented. Holly Grason and Bernard Guyer analyze the differences between the organization and financing of programs for children and older persons in "Rethinking the Organization of Children's Programs: Lessons from the Elderly." They argue convincingly that the strategies used to develop a comprehensive system of services for elders are appropriate for children as well, but that legislation is needed to install and protect an integrated system. As this issue goes to press, the U.S. Congress is debating fundamental changes in federal policies affecting children. The articles published here illuminate several critical issues that should inform the national debate.
Two recent articles in the Quarterly have explored the relation between race and medical care. In "Differences in Treatment of Ischemic Heart Disease at a Public and a Voluntary Hospital" (MQ 72:2), Michael Yedidia reported observations about treatment differences between races in hospital care for heart disease. In the last issue (MQ 73:3), Ronnie D. Horner and colleagues reported, in "Theories Explaining Racial Differences in the Utilization of Diagnostic and Therapeutic Procedures for Cerebrovascular Disease," that, despite a higher rate of stroke, blacks undergo procedures like carotid endarterectomy less often than whites.
In this issue, Michael Greenberg and Dona Schneider, in "The Cancer Burden of Southern-Born African Americans: Analysis of a Social-Geographic Legacy," explore the possible reasons for the higher cancer rates experienced by Southern-born black Americans, especially those who migrated to the Northeast and Midwest, than by black Americans who were born, and who died, outside the South. They suggest that nutritional imbalances, cigarette smoking, high-risk jobs, limited access to medical screening and care, and other poverty-related factors may explain the discrepancy.
Another article on cancer by Graham A. Colditz and colleagues, "Cancer Prevention Strategies for the Future: Risk Identification and Preventive Intervention," suggests a strategy of primary prevention. Colditz et al. recommend that efforts to prevent tobacco-related cancers should focus on a variety of intervention strategies, ranging from counseling to higher taxes on tobacco products. Preventing breast and prostate cancer, however, will require identifying new, modifiable risk factors.
As regular readers of the Quarterly are aware, an ongoing series of articles, edited by Rosemary Stevens, has explored, from different perspectives, recent and anticipated changes in acute care hospitals (see James C. Robinson, "The Changing Boundaries of the American Hospital," MQ 72:2; John D. Stoeckle, "The Citadel Cannot Hold," MQ 73:1; Stephen M. Shortell and colleagues, "Reinventing the American Hospital," MQ 73:2; and Rudolf Klein, "Big Bang Health Care Reform," MQ 73:3). In this issue, Hugh L. Freeman, in "The General Hospital and Mental Health Care: A British Perspective," reviews the role of general acute care hospitals in providing psychiatric care in Great Britain. Historically, psychiatric care has taken place in specialty hospitals, often in public facilities. The establishment of the National Health Service in 1948 provided a system within which general hospitals were responsible for more of this care. Recent reforms, however, have created uncertainty about the provision of mental health services in Great Britain as they are shifted to settings outside of the general hospital.
