LETTERS TO THE EDITOR
incidence of sudden infant death syndrome (SIDS) in North Carolina, there is a methodological error. One concern in the study is the relationship between SIDS rate and the total infant mortality rate. He (correctly) notes that since SIDS cases represent approximately 10 per cent of total infant mortality, some positive correlation between the two measures would be expected. More precisely, one would expect a correlation of approximately 0.32 since 10 per cent of the variance in the general infant mortality is attributable to SIDS cases and the proportion of shared variance is r2 (r2 = 0.10, r = 0.32). Thus, under the null hypothesis that SIDS incidence rate is independent of the rate of all other (non-SIDS) causes of infant mortality, r = 0.32 should serve as the null hypothesis rather than the null hypothesis tested by Blok that r = 0. Another more direct means of overcoming this difficulty would be to calculate the rate of "non-SIDS infant mortality" for each city and county and then determine the correlation with SIDS rates. When Blok states that "'the existence of a higher than average general infant mortality rate may likely be taken as an indication that a higher than average SIDS rate is also present" (p. 372), he is, in effect, elaborately restating the fact that 10 per cent of infant mortality is due to SIDS. What is of interest to this reader (and presumably to Blok as well) is whether or not the rate of SIDS correlates with other causes of infant mortality. David A. Savitz Departinent of Preventive Medicine Ohio State Universitv Columbus, OH43210
REFERENCE 1. Blok JH: The incidence of sudden infant death syndrome in North Carolina's cities and counties: 1972-1974. Am J Public Health 68:367-372, 1978.
Comment on Jonas Editorial on Consumer Involvement We read with interest the editorial by Steven Jonas' which is apparently a comment on Paap's article on consumer control of health centers.2 Jonas AJPH February 1979, Vol. 69, No. 2
seems to suggest that because the basic "building blocks" of the health care system are controlled by physicians, we must be "realistic" about the limits of consumer control. He then offers guidelines for "'effective" consumer involvement, to three of which we will respond: The first has to do with the role of the consumer in health care services. Jonas repeats the frequently made point about the necessity of clarifying the objectives of consumer input, and suggests that consumers should be primarily concerned with the evaluation of programs. Later, however, he adds that the role of a board is to set policy and select administrators, so his position leaves the appropriate role for consumers unclear. In our opinion, if consumers focus on the task of evaluation, the important question of "'Who's in charge here?" will not be raised, and provider dominance will be continued despite consumer majorities on boards. Secondly, Jonas sees the separation of responsibility and authority as a source of problems in many organizations, not just those with consumerbased boards of directors. This view denies the uniqueness of consumer involvement and perpetuates provider dominance, in that the special problems of consumers will not be recognized or dealt with. Finally, while calling for a majority of consumers on policy-making boards, Jonas thinks we also should play down the distinction between consumers and professionals. To the contrary, we think the consumer-professional distinction should be maintained so that consumer needs will be considered, thus balancing the traditional professional dominance on boards. Indeed, the concept of consumer-based boards is founded on the view that consumers and professionals have different interests. Much of the "'new" potential for consumer control is founded in the fact that consumer perspectives can be formally considered at all levels of the health care system, not just the local level. Following Jonas' suggestions would result in no change in the present system and could lead to reduced and token consumer participation. This would further legitimatize the domi-
nance of professionals since it could be claimed that consumers are participating in the decision-making. Hopefully, recognition of the major factors inhibiting effective consumer control which are discussed by Paap will not be used to discourage consumers and consumer advocates from realizing their political influence, but rather to encourage them to work to increase consumer power at all the "building block" levels. Warren R. Paap Associate Professor of Sociology Bill Hanson Associate Professor of Sociology Dept. of SociologylAnthropology California State College-Bakersfield 9001 Stockdale Highway Bakersfield, CA 93309
REFERENCES 1. Jonas, S: Limitations of community control of health facilities andservices, Am J Public Health, 68:541-543, 1978. 2. Paap,WR.: Consumer-based boards of health centers; Structural problems in achieving effective control. Am J Public Health, 68:578-582, 1978.
Dr. Jonas Responds Hanson and Paap mis-read my editorial. I did not say that physicians control the building blocks of the health care delivery system. Rather, clearly referring to an earlier paper of mine,' I said that the ruling class and its political apparatus control the building blocks. I did say that because of the licensing and fee-for-service private practice systems, physicians make the majority of medical program decisions, and make them quite independently in most instances. Second, to make my position on the role of consumers perfectly clear, I will quote from the last paragraph of my editorial: "Policy-making boards should have consumer majorities . .. Boards should make policy; professionals should administer programs. Boards should set and monitor performance in terms of program results and hold the professionals responsible for their work. ... Whether professional or consumer, board members should be chosen to work in the health 179
incidence of sudden infant death syndrome (SIDS) in North Carolina, there is a methodological error. One concern in the study is the relationship between SIDS rate and the total infant mortality rate. He (correctly) notes that since SIDS cases represent approximately 10 per cent of total infant mortality, some positive correlation between the two measures would be expected. More precisely, one would expect a correlation of approximately 0.32 since 10 per cent of the variance in the general infant mortality is attributable to SIDS cases and the proportion of shared variance is r2 (r2 = 0.10, r = 0.32). Thus, under the null hypothesis that SIDS incidence rate is independent of the rate of all other (non-SIDS) causes of infant mortality, r = 0.32 should serve as the null hypothesis rather than the null hypothesis tested by Blok that r = 0. Another more direct means of overcoming this difficulty would be to calculate the rate of "non-SIDS infant mortality" for each city and county and then determine the correlation with SIDS rates. When Blok states that "'the existence of a higher than average general infant mortality rate may likely be taken as an indication that a higher than average SIDS rate is also present" (p. 372), he is, in effect, elaborately restating the fact that 10 per cent of infant mortality is due to SIDS. What is of interest to this reader (and presumably to Blok as well) is whether or not the rate of SIDS correlates with other causes of infant mortality. David A. Savitz Departinent of Preventive Medicine Ohio State Universitv Columbus, OH43210
REFERENCE 1. Blok JH: The incidence of sudden infant death syndrome in North Carolina's cities and counties: 1972-1974. Am J Public Health 68:367-372, 1978.
Comment on Jonas Editorial on Consumer Involvement We read with interest the editorial by Steven Jonas' which is apparently a comment on Paap's article on consumer control of health centers.2 Jonas AJPH February 1979, Vol. 69, No. 2
seems to suggest that because the basic "building blocks" of the health care system are controlled by physicians, we must be "realistic" about the limits of consumer control. He then offers guidelines for "'effective" consumer involvement, to three of which we will respond: The first has to do with the role of the consumer in health care services. Jonas repeats the frequently made point about the necessity of clarifying the objectives of consumer input, and suggests that consumers should be primarily concerned with the evaluation of programs. Later, however, he adds that the role of a board is to set policy and select administrators, so his position leaves the appropriate role for consumers unclear. In our opinion, if consumers focus on the task of evaluation, the important question of "'Who's in charge here?" will not be raised, and provider dominance will be continued despite consumer majorities on boards. Secondly, Jonas sees the separation of responsibility and authority as a source of problems in many organizations, not just those with consumerbased boards of directors. This view denies the uniqueness of consumer involvement and perpetuates provider dominance, in that the special problems of consumers will not be recognized or dealt with. Finally, while calling for a majority of consumers on policy-making boards, Jonas thinks we also should play down the distinction between consumers and professionals. To the contrary, we think the consumer-professional distinction should be maintained so that consumer needs will be considered, thus balancing the traditional professional dominance on boards. Indeed, the concept of consumer-based boards is founded on the view that consumers and professionals have different interests. Much of the "'new" potential for consumer control is founded in the fact that consumer perspectives can be formally considered at all levels of the health care system, not just the local level. Following Jonas' suggestions would result in no change in the present system and could lead to reduced and token consumer participation. This would further legitimatize the domi-
nance of professionals since it could be claimed that consumers are participating in the decision-making. Hopefully, recognition of the major factors inhibiting effective consumer control which are discussed by Paap will not be used to discourage consumers and consumer advocates from realizing their political influence, but rather to encourage them to work to increase consumer power at all the "building block" levels. Warren R. Paap Associate Professor of Sociology Bill Hanson Associate Professor of Sociology Dept. of SociologylAnthropology California State College-Bakersfield 9001 Stockdale Highway Bakersfield, CA 93309
REFERENCES 1. Jonas, S: Limitations of community control of health facilities andservices, Am J Public Health, 68:541-543, 1978. 2. Paap,WR.: Consumer-based boards of health centers; Structural problems in achieving effective control. Am J Public Health, 68:578-582, 1978.
Dr. Jonas Responds Hanson and Paap mis-read my editorial. I did not say that physicians control the building blocks of the health care delivery system. Rather, clearly referring to an earlier paper of mine,' I said that the ruling class and its political apparatus control the building blocks. I did say that because of the licensing and fee-for-service private practice systems, physicians make the majority of medical program decisions, and make them quite independently in most instances. Second, to make my position on the role of consumers perfectly clear, I will quote from the last paragraph of my editorial: "Policy-making boards should have consumer majorities . .. Boards should make policy; professionals should administer programs. Boards should set and monitor performance in terms of program results and hold the professionals responsible for their work. ... Whether professional or consumer, board members should be chosen to work in the health 179
