Love Canal, the slow restitution to victims; the use of Superfund money to clean up only six toxic dumps out of. 22,000; the refusal to regulate cancer- causing ...
LETTERS TO THE EDITOR
health costs and service utilization, particularly within federally qualified HMOs, or possibly in conjunction with one of the current national surveys conducted by the US Department of Health and Human Services. One should remember that mental health problems have existed throughout history and presently represent the most complex and least understood of all public health problems.6 While the federal government has virtually ignored the collection of mental health costs and service utilization, annual reports to Congress (through 1981) were submitted summarizing the data concerning federally qualified HMOs.78 An initial attempt to standardize financial and utilization data included the measures of total annual ambulatory encounters per member and total annual ambulatory physician encounter per member. In collecting the information in our national survey, we avoided presenting subjective estimates (as provided by HMO personnel) reported as objective statistical data. The major problems of referral rates and referral pathways to mental health care reinforce the need for reliable reporting systems which, in our judgment, currently do not exist within HMOs, and particularly within non-hospital based, non-multi-system based HMOs, as well as individual practice association (IPA) model HMOs. Such a data base would provide the foundation for more detailed evaluation of the interactions of HMO physical and mental health service utilization, in general, and would perhaps allow a more detailed analysis of the effects of HMO organizational structure and referral behavior upon mental health costs and service utilization. REFERENCES 1. Levin BL, Glasser JH, Roberts RE: Changing patterns in mental health service coverage within health maintenance organizations. Am J Public Health 1984;74:453-458. 2. Cheifetz DI, Salloway JC: Patterns of mental health services provided by HMOs. Am Psychol 1984;39:495-502. 3. Levin BL, Glasser JH: A survey of mental health service coverage within health maintenance organizations. Am J Public Health 1979;
69:1120-1125. 4. Levin BL, Glasser JH: Mental health coverage within prepaid health plans. Adm Ment Health
1980;7:271-28 1. 5. Levin BL, Glasser JH: A national survey of prepaid mental health services. Hosp Comm Psychiatry 1984;35:350-355. 6. President's Commission on Mental Health: Report to the President. Washington, DC: Govt Printing Office, Vol 1, 1978. 7. Seventh Annual Report to Congress: Health Maintenance Organizations. DHHS Pub. No.
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(PHS) 82-50192. Washington, DC: Govt Printing Office, 1982. 8. Third Annual Report to Congress: Health Maintenance Organizations. DHEW Pub. No. (PHS) 78-13058. Washington, DC: Govt Printing Office, 1978. Bruce Lubotsky Levin, DrPH Assistant Professor of Epidemiologic Studies and Policy Analysis, University of South Florida, The Florida Mental Institute; Robert E. Roberts, PhD Professor of Epidemiology and Sociology, University of Texas Medical School; Jay H. Glasser, PhD Associate Professor of Biometry, University of Texas School of Public Health
The Mix of FMGs and USFMGs The article Foreign Medical Graduates in the 1980s: Trends in Specialization,' would have been more incisive had it compared the geographic and specialty distributions of USFMGs and FMGs. As the article contends, "FMGs have not disappeared and are not likely to do so." The solution is obvious. Individuals with the fortitude and drive that make them leave their own country (USFMG) and often learn medicine in other languages must have an overwhelming ambition to be physicians. They are willing and able to overcome the many obstacles leading to US licensure that are put in their paths. Many foreign schools have agreements with US hospitals in which their students do their clinical training. These hospitals are few and far between. Why not make hospital clerkship programs more available to them and give them the best possible clinical training? In return, have USFMGs serve for a given number of years in certain areas of our country that have a shortage of physicians. If the real reasons for trying to exclude FMGs from the US are actually to uphold the "quality of care," then why not see to it that clinical opportunities for FMGs are increased and improved? State, federal, and medical policy makers need to sit down together and agree upon an across-the-boards legislation for the FMG to replace the ambiguous or non-existent policies of each individual state. REFERENCE 1. Mick SS, Worobey JL: Foreign medical graduates in the 1980s: trends in specialization. Am J Public Health 1984; 74:698-703. Charles Wright APDO Postal 31-765, Guadalajara, Jalisco, Mexico
Mick and Worobey Respond We share Mr. Wright's desire to see comparisons of foreign national medical graduates (FMGs) and US citizen foreign medical graduates (USFMGs) by specialty selection and geographical location. Unfortunately, we know of no published or unpublished national data which permit such analyses. This is an indication of the inadequate information base which is available to those interested in physician manpower issues. It may even be one of the reasons why a rational, comprehensive, and equitable policy at the national level on the desirable mix of US-educated and foreign-educated US physicians is difficult to achieve. However, from our recently completed studies based on limited samples, we do know that among older cohorts of USFMGs, i.e., those who graduated from medical school before 1974, the current location of over half was in the states of Florida, New Jersey, and New York.' Furthermore, these individuals tended to locate in larger urban centers in proportions equal to those of both foreign national FMGs and US medical graduates. USFMGs' proportionate representation in rural areas was smaller than either of these two latter groups. Although these data do not necessarily represent more recent cohorts of USFMGs, they also do not support Mr. Wright's implication that USFMGs have served or will serve in rural communities. There is no doubt that USFMGs have demonstrated unusual courage and ambition in pursuing their medical educations.2 McGuinness and Mason demonstrated that 25 per cent of USFMGs who attended medical school in the 1960s and 1970s never qualified as licensed US physicians.3 Clearly the risks are high, and one must admire those who pursue this perilous route. The studies which have assessed the results of remedial clinical training for USFMGs have been uniformly positive.7 These programs help, and they could well be expanded. Mr. Wright's suggestion that USFMGs agree to practice in underserved areas in return for such extra clinical training in the US is an interesting idea that deserves consideration. However, it should be considered only in a larger policy context of overall physician manpower requirements; hence, we agree with Mr. Wright's conclusion 1421
that "State, federal, and medical policy makers need to sit down together and agree upon an across-the-board legislation for the FMG to replace the ambiguous or non-existent policies of each individual state." REFERENCES 1. Mich SS, Worobey JL: Foreign and US medical graduates: a decade later. Oklahoma City: University of Oklahoma, Unpublished Report, 1984. 2. Mick SS, Stevens RA, Goodman LW: United States foreign medical graduates in Connecticut: how they compare with foreign medical graduates. Med Care 1976; 14:489-501. 3. McGuinness AC, Mason HR: Career destiny of 550 Americans several years after graduating from a foreign medical school. J Med Educ 1982; 57:581-585. 4. Stillman PL, Ruggill JS, Rutala PJ, et al: Students transferring into an American medical school: remediating their deficiences. JAMA 1980; 243:129-133. 5. Stimmel B, Benenson TF, Tedeschi J, Smith H: Clinical performance and specialty choice of COTRANS students. JAMA 1979; 241:139142. 6. Richert JA, Shimpfhauser F, Papp K: Prescription-based educational training: program for US students returning from foreign medical schools. NY State Med J 1980; 811-815. 7. Rosner F, Mulvilhill JE: American foreign medical graduates performance after a year of supervised clinical clerkships (fifth pathyway). JAMA 1979; 241:714-716. Stephen S. Mick, PhD Jacqueline Lowe Worobey, MA Department of Health Administration, College of Public Health, University of Oklahoma, Health Sciences Center, Oklahoma City, OK 73190
Comments Received on Environmental and Policy Concerns I. An Infamous State of Affairs? I am disturbed to notice something new creeping into the Journal which I never noticed before. Especially in the lead article on the Health Department: Enemy or Champion of the People?' and the one on Citizen Action for Environmental Health,2 I get an implication that the average citizen is used to "neatly packaged TV dramas like Quincy", suffers from scientific illiteracy, and cannot understand some of the more complex environmental issues. Also that the public is not always entitled to preliminary data since it may confuse them into hasty condemnation. Dr. David Harris further implies in his concluding statement that health officials must not allow themselves to be too vulnerable to citizen criticism and 1422
must find strength to be "the voice of reason." This unfortunate wording is further corroborated by Dr. Freudenberg who refers to the environmental groups as "perceiving" presumably incorrectly that government agencies are blocking their information, though I see he somewhat mitigates this harsh statement by later adding that motivated citizens can master technical knowledge quickly. But at the same time he comments that whether citizen criticism of evasive government officials' reluctance to give information is true or not, is only a consequence of the perceptions! He deplores environmentalist adversarial attitude as being less willing to use conventional channels to redress grievances, while giving no attention at all to the well known fact that we have constantly tried conventional channels to no avail. Perhaps we environmental and population and animal rights activists are in ignorance of the genesis of these articles. Perhaps many people are unaware that APHA is a non-governmental organization (NGO) nevertheless committed (we hope) to print both sides. Or perhaps you are now more committed to assuage governmental agencies? Perhaps you have failed to point out what is well known across the country: that neither EPA, FDA, or OSHA have lately been doing what they are supposed to do, and that the Reagan Administration has specifically ordered them to drag their feet. Where in the pages of your magazine can I see that you would be willing to refer, perhaps, to some of the better known and specific foot-dragging gambits: the slow cleanup at Three Mile Island and Love Canal, the slow restitution to victims; the use of Superfund money to clean up only six toxic dumps out of 22,000; the refusal to regulate cancercausing substances, notably EDB, diesel emissions, ethylene oxide, benzene, etc., from the workplace. For comments on many others I might, as one example, refer you to the Spring 1984 issue of Public Citizen and/or of the Reagan philosophy of non-protection of public health in favor of coddling corporate America. Are you, in fact, verging towards making justifications of this infamous state of affairs? In a word, I feel a certain sadness at such seeming justification, and would like to be reassured that APHA is truly an NGO and that my interpretation of these articles is incorrect. Elaine Stansfield 20081/2 Preuss Rd., Los Angeles, CA 90034
II. Stonewalling by Health Officials and Industry? Public health officials can become "champions of the public interest" by listening to the people in communities affected by environmental dangers as Nicholas Freudenberg eloquently points out in his article, "Citizen Action for Environmental Health .. (AJPH May 1984). Unfortunately Dr. David Harris in his editorial in the same issue chooses not to listen to this "new environmental movement." Instead Dr. Harris looks for excuses for public health officials who withhold information from the public and who compromise with industry. There is the excuse the public is "scientifically illiterate", there is the excuse that this is a complex issue. Of course environmental issues are complex but Dr. Harris should follow his own advice, "the historical record shows that public health's finest hours often occurred when vigorous preventive action preceded the crossing of every scientific 't' and the dotting of every epidemiological 'i' ". So called "housewife data" such as the study by Lois Gibbs, the housewife leader of the Love Canal Homeowners Association, often produce the most important data for an honest health official. I am a leader of a community environmental group in the Ironbound section of Newark, NJ. The highest levels of dioxin in the United States have been recorded in our neighborhood. Yet over a year after dioxin was discovered, no scientific health survey of the residents has been conducted, no health testing of the residents has been done, and no health testing of the workers who produced the dioxin has been conducted. This is the type of behavior by public officials that community groups label "covering up." Our health depends on public health officials who are not afraid to stand up to the adversaries (as Dr. Harris outlines them) of "ignorance and apathy, businessmen who put their profits above the general welfare, uncaring or corrupt politicians, even organized medicine itself." Arnold Cohen
Responds I agree with Arnold Cohen and Elaine Stansfield that governmental regulations have often failed to protect AJPH December 1984, Vol. 74, No. 12