index. By way of contrast, the more widely applied Standard Mortality Ratio (SMR) is heavily influenced by differences in mortality at the older ages and this is seen as a disadvantage since "death rates among the elderly are probably least amenable to health planning intervention." Actually, no index that is designed to reflect general mortality can show an impressive effect of such interventions within a reasonable period of time except under exceptional conditions. A major decrease in the death rate in a specific age group, e.g., infant mortality, or in the cause of death categories reflecting mortality related to hypertension would reduce both the YLL and SMR only slightly. The point is that even when planning is directed at improving the general availability and accessibility of health services in disadvantaged areas, effectiveness measures linked to mortality rates need to be particularized to age and cause of death subgroups. These considerations apply with equal force to the application of a mortality index to rank order areas for special attention. The index has the properties of all summary measures, i.e., convenience and an apparent capability of communicating a message that is uncomplicated by a large array of statistics. Also, sampling variability is lower than in agespecific comparisons. But, the summary index cannot usually stand isolated from more detailed mortality measures as

aids in identifying areas or population subgroups where more intensive studies of health issues and programs should be concentrated. Whether the YLL index by itself can serve as such a "preliminary screening measure" is susceptible to testing by examining specific goals of HSAs and the extent to which the YLL identifies the same local areas to be given high priority as disaggregated mortality measures. The result would be a more precise understanding of the utility of the YLL for planning agencies. The presentation in this issue of the Journal and the related treatment in the Statistical Notes for Health Planners should stimulate such explorations. SAM SHAPIRO Address reprint requests to Sam Shapiro, Professor of Health Services Administration, Department of Health Care Organization, and Director, Health Services Research and Development Center, Johns Hopkins School of Hygiene and Public Health, 624 N. Wolfe St., Baltimore, MD 21205. Mr. Shapiro is a member of the Journal Editorial Board.

REFERENCES 1. Kleinman, J.C. Age-adjusted mortality indexes for small areas: Applications to health planning. Am. J. Public Health 67:834-840, 1977. 2. Kleinman, J.C. Mortality. Statistical Notes for Health Planners, National Center for Health Statistics, Health Resources Administration, Dept. HEW, No. 3, February, 1977.

Abortions and Public Policy, 11 Pages 860-862 of the current issue of the Journal contain an estimate of the number of deaths of women of childbearing age to be expected as the result of cutting off Medicaid funds for abortion.1 We regret that this Public Health Brief could not have been published in July and covered by our editorial that month.2 Unfortunately we cannot function as a newspaper does; we have a minimum 2½// month lag time between delivery to the printer and publication of a manuscript, as do most professional journals. It is only on rare and fortuitous occasions that our pages reflect what is "front page news" in the rapidly changing world of the mass media. In this case, all we can say is that the abortion issue was hot in the summer solstice when the U.S. House of Representatives appropriated Medicaid funds with the stipulation that they could not be used to pay for abortions, and the U.S. Supreme Court handed down its decision allowing states to decide whether or not to use public funds to pay for abortions. The Congressional stipulation, in contrast to the Supreme Court's decision, forbids the use of federal funds to pay for abortions even if the mother's life is endangered. Petitti and Cates' estimates do not take into account the effect of canceling out abortions that are deemed medically necessary in order to protect a mother's life. Their calculations are AJPH September, 1977, Vol. 67, No. 9

based on the differentials in risk between abortions and term pregnancies, the substitution of illegal for legal abortions, and the added risk to the mother of delay in obtaining an abortion. As they point out, the exact combination of these effects that will ensue are impossible to predict but, regardless of the combination, the lives lost will be appreciable. Should abortions be denied even to protect a mother's life, the exact effect is also unpredictable, but surely additive. There are, of course, many other costs associated with the withdrawal of Medicaid funds for abortion. Some of them are cited by Petitti and Cates in an older study based on New York City data.3 Although not projected nationally, these social costs were of substantial magnitude. Still further costs could be projected by calculating the calamities avoided by abortions undertaken as a result of an amniocentesis diagnosis, or the predictable effects of a teratogenic agent. These costs can be expressed in terms of women's lives lost and the misery of unwanted and unwelcome children or in the dollars and cents figures of medical and social care and loss of productivity. In any case, one can predict with confidence that confusion and distortion of the health care system will follow in the wake of the variations in state laws that the Court and House actions portend. These are additional, though bitter, reasons for continuing to retain maternal mor817


tality committees whose values are discussed in a neighboring editorial.4 It seems unfortunate that this side of the ledger has not been spelled out for the public to ponder. The formalization of social controls is a proper function of the laws of a society. However, laws should reflect an ample consensus derived through a rational process that has considered their effects in practical terms. Laws that do not reflect this process can lead only to inequity and abuse.



REFERENCES 1. Petitti, D.B. and Cates, W. Jr. Restricting Medicaid funds for abortions: Projections of excess mortality for women of childbearing age. Am. J. Public Health: 67:860-862, 1977. 2. Yankauer, A. Editorial: Abortions and public policy. Am. J. Public Health 67:604-605, 1977 3. Robinson, M., Pakter, J. and Svigir, M. Medicaid Coverage of Abortions in New York City: Costs and Benefits. Fam. Plan. Perspect.: 6:202-208, 1974. 4. Pearse, W. H. Editorial: Maternal Mortality Studies-Time to Stop? Am. J. Pub. Health: 67:815-816, 1977.

Nathalie Masse Memorial Committee Established

At the request and with the help of many of Dr. Masse's* friends, a Memorial Committee to perpetuate her memory has been established. This Committee has decided to create an international prize and a research fellowship.

Prize Award

This prize of 10,000 francs, to be known as the "International Nathalie Masse Prize," will be awarded for the first time in 1979. Subsequently it will be offered at two year intervals. It will reward an original work relating to children, resulting from research done by an institution, or an individual under 40 years of age, in order to promote young professional workers and investigators. The award winner will be chosen, without regard to nationality, by an international jury. Fellowship Research Grant

This grant, to be known as the "Nathalie Masse Research Grant" will be awarded for the first time in 1978, and subsequently every two years. Intended for young research workers, its aim is to assist them in studies which are directed towards social and preventive pediatrics. The regulations concerning the grant and the application forms may be obtained by writing to Nathalie Masse Memorial Committee, International Children's Centre, Chateai' de Longchamp, Bois de Boulogne, 75016, Paris. *Dr. Nathalie Masse, who died in 1975, was Director of Teaching at the International Children's Centre for 18 years. She made major contributions to the improvement of child health and welfare.


AJPH September, 1977, Vol. 67, No. 9

Abortions and public policy, II.

Laws must be made through a rational process which takes into account the public consensus. The practical effect of laws must also be considered. The ...
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