EDITORIALS

attack on professionalism, including the right of health experts to make decisions on behalf of the public, weakened the position of the central office specialists. Undoubtedly, the growing efforts of hospitals, medical schools, and other health institutions to respond to community needs also increased the pressure on the health department. And, as Mustalish reports, another influential factor was the Mayor's emphasis on better management of public services. The champions of decentralization should not rest on their laurels, however. Whether the present distribution of authority between bureau specialists and districts is stable, and whether services have been improved by the reorganization, can only be answered with time. The district health directors now have authority over budget and supervision of district personnel. Policy relating to changes in service programs, such as the start of new programs or the discontinuation of old ones, clearly remains a central office function. Management systems have been introduced to aid the district directors. These also enable the central office to compare the expenditures and productivity of the districts, which improves the central office capacity to make policy changes and supervise the districts. Societal changes suggest that the New York City story presages a change in the balance of power between specialists and generalists in health organizations generally. But the future holds no easy resolution in health affairs of the confficting values of centralization and decentralization and the associated conflict between generalists and specialists. The challenge to specialization implicit in the planning and management of health services can be expected to intensify the conflict. Because of the dominant position of specialization and the anti-administrative values inherent in the idea of the autonomous expert, the pains of finding the right balance will be acute and probably chronic as well. Most of the participants in the drama are ill prepared to face the issues in-

volved, for the vast majority are specialists who have received little training in the organizational dynamics involved and the inexorable societal forces bringing about the integration of health services through planning and management. Mustalish and his colleagues have performed a valuable service in updating the story of the decentralization of the New York City Health Department. Though the events may be unique to New York City, the issues involved will have to be confronted in most, if not all, organized health settings. To quote a distinguished former New York City Health Commissioner, Dr. Leona Baumgartner, "Health is a many splintered thing." In bringing together the pieces, or in managing, with a proper regard for public interest, the emerging interdependencies among the elements of the health field, it is our own ambivalence that we must face. We cannot have coherent health policies and coordinated services without some sacrifice of the professional freedoms deriving from technical expertise.

BASIL J. F. MoTT, PHD Address reprint requests to Basil J. F. Mott, Dean, School of Health Studies, Hewitt Hall, University of New Hampshire, Durham, NH 03824.

REFERENCES 1. Mustalish, A. C., et al. Decentralization in the New York City department of health: Reorganization of a public health agency. Am. J. Public Health 66:1149-1154, 1976. 2. Kaufman, H. The New York City Health Centers, ICP Case Series, No. 9, published for the Inter-University Case Program by the Bobbs-Merrill Company, Inc., Rev. Ed., 1959. 3. Thomas, W. C. Jr., and Hilleboe, H. E. Administrative centralization vs decentralization and the role of journalists and specialists. Am. J. Public Health, 58:1620-1632, 1968. 4. Ibid, pp. 621-622.

Current Fertility and Public Health Policy During the past 15 years, the birth rate in the United States has plummeted from 23.7 per thousand in 1960 to 18.4 in 1970 and 14.8 in 1975; it is now, in 1976, well below the "birth dearth" level of 16.6 in 1933. Does the change in birth rate, a crude description of overall changes, represent change for everyone in this country? For an answer, we have to turn to the less-than-current information that comes from the decennial censuses or from national surveys. Although these data do not cover the most recent years, 1970-1975, when the pace of fertility decline quickened, they do reveal a pattern of changing fertility even more striking than the overall decline in birth rates. A remarkable convergence in fertility patterns has been taking place among the whole range of social, economic, racial, and religious groups whose differential fertility had previously been so marked in the U.S. Sweet' found that the fertility of married urban white females dropped by about one-quarter AJPH December, 1976, Vol. 66, No. 12

in the intercensal decade between 1960 and 1970. More importantly, many major racial and ethnic groups experienced declines in the fertility of married women even greater than that of married urban whites: nearly 35 per cent for blacks, over 40 per cent for American Indians, close to 30 per cent for women identified in the censuses as having Spanish surnames and living in the Southwest or identified as MexicanAmericans. Thus, by 1970, it was clear that the fertility of each of these groups was drawing closer to the low levels recorded for the urban white married population. The gap is larger for some groups than for others: fertility of the married Mexican-American and Spanish surname population was still about 40 per cent higher than the fertility of married urban whites; black marital fertility was only 10 per cent higher than that of whites. Johnson,2 in this issue of the Journal, analyzes the 1970 census data still further to show that both education and la1145

EDITORIALS

bor force participation are associated with substantially lowered fertility among married women with Spanish surnames living in the Southwest, especially among younger women. Her findings are significant, since a similar pattern typified the white population in the earlier stage of the long downward trend in fertility; it seems likely that the fertility rate differential between this (and other minority groups) and urban whites has continued to narrow over the past six years, leading us further toward a common national pattern of fertility among married women. What went on to produce these dramatic changes? Analysis of survey data3 obtained in the same year as the census shows that the fertility declines among married women may be almost entirely attributed to declines in unwanted fertility-declines achieved through increases in contraceptive use (particularly of the most effective methods and of voluntary sterilization) so widesweeping that they have been termed a "contraceptive revolution." When these survey data were analyzed by intention and by contraceptive use, there was little doubt that the majority of women are now able to have the children they intend to have, and to avoid having children they don't want to have. During this period, we have reached a consensus that means of fertility control should be available to all who need and want them. This consensus is voiced repeatedly in Congressional legislation* which makes family planning a "universal" service, subject to no income ceiling or patient fee requirements.4 However, this is not a time for complacency in spite of the fact that the ability to control fertility according to an individual's or couple's own desires for children seems to be both widespread and backed by public health policy and programs. Attacks on liberal abortion policy continue: they threaten to block access to legal abortion for many whose contraceptives, or memory, failed them and who wish to ter*Federal sources of support for family planning include the Family Planning Act, Title XX funds for social service programs, Medicaid, and others. In September, P.L. 94-401, an amendment to the Title XX funds, was passed.

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minate the pregnancy. The severe limitation of Medicaid support for abortion services (Hyde amendment to the LaborHEW Appropriations Bill, H.R. 14232) blocks effective access for many women. There are still too many women bearing children whose births they would have liked to postpone or prevent. For such women, adolescents in particular, we still need to implement family planning policies in ways that will overcome barriers and facilitate the use of existing family planning and services and counsel. There have been great changes in the childbearing and childrearing behavior of Americans. Johnson's data are further evidence that increasingly large proportions of all groups are sharing in the trends toward lowered fertility and increased labor force participation by mothers of young children; it is in this context that her findings have their broadest meaning. They indicate that for women with lowered fertility intentions the work place may be an effective locus for family planning education and service; they suggest an increased need for services to children of working mothers. Public health policy and programs should respond quickly and flexibly to the new demands created by social change. It is rare that we have such clear guides to the directions we should follow.

JANE MENKEN, PHD SUSAN WATKINS, BA REFERENCES

1. Sweet, J. A. Differentials in the rate of fertility decline. Family Planning Perspectives 6:103-107, 1974. 2. Johnson, C. A. Mexican-American women in the labor force and lowered fertility. Am. J. Public Health 66:1186-1188, 1976. 3. Westoff, C. F. and N. B. Ryder. The Contraceptive Revolution. Princeton: Princeton University Press, 1976. 4. Rosoff, J. I. Planned Parenthood-World Population Washington Memo, September 16, 1976.

Address reprint requests to Dr. Jane Menken, Research Demographer, Office of Population Research, Princeton University, 21 Prospect Avenue, Princeton, N.J. 08540. Ms. Watkins is a graduate student in sociology and demography at the University.

AJPH December, 1976, Vol. 66, No. 12

Current fertility and public health policy.

EDITORIALS attack on professionalism, including the right of health experts to make decisions on behalf of the public, weakened the position of the c...
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