ffVback Health Services and Health Status As one of the participants in the conference on social sciences in health at APHA (Briefings, Health Services Research, Winter 1974), I wish to object to the conclusions drawn by Prof. Jack Elinson. His first conclusion was that "perhaps the traditional measures of health status should be changed to reflect more sensitively the services provided by the health delivery system." This persistent but logically and empirically erroneous position has enjoyed too great a longevity (and even increasing popularity in some quarters) to allow its restatement without challenge. From a logical point of view, the proposal that health status be measured by provided health service contains the implicit assumption that health services are positively related to health status. Furthermore, since most health service is aimed not at the primary prevention of disease but at treatment of existing disease, rehabilitation, or care of the untreatable, illness must be a prerequisite for most health services. Thus, if the position restated by Elinson assumes that (1) health service is a direct index of health status and (2) we know that illness is a prerequisite for most health service, then we are led to the paradoxical deduction that illness is directly related to health status. In practical terms, such logic would lead life insurance companies to the absurd conclusion that applicants who frequently use health services (e.g., those hospitalized often) are those at the lowest risk of dying. I doubt that even the strongest advocates of this position would wish to invest their money in a company that predicated its rate schedule on such a conclusion. Empirically, the suggestion that services delivered be used as an index of health status amounts to the displacement of the manifest goal of health service-the enhancement of health-by the delivery of service for service's sake-what has been aptly called "wing-flapping." Changing measures of health status to reflect delivered services is tantamount to making treatment the touchstone of health. Even a cursory examination of the history of public health will reveal that the impact of health services on the health status of populations has been negligible in comparison to the unintended benefits

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of a rising standard of living and the intended benefits of mass application of primary prevention measures. Hence, while it may be self-serving, the proposition that service be used as an index of health status is both logically and empirically fallacious. One can see that Elinson himself is uneasy with this conclusion and feels it needs buttressing, but he augments it with an equally erroneous second conclusion, that "perhaps unmet health care needs (rather than health status) should be the criterion by which we judge a society's ability to discharge its responsibility to meet the needs of its people." There are at least two ways of interpreting this second conclusion from the conference, neither of which is tenable. First, one may interpret it literally to mean that unmet needs are an index of need-meeting on the part of society. This is clearly a meaningless tautology. An alternative, if freer, interpretation translates "unmet health care needs" as unmet health care demands. This interpretation views unmet needs as an index of unmet egalitarian demands for service-the idea that service should be distributed equally throughout the population. This interpretation is consistent with the position taken in the first conclusion since service again becomes an end in itself. Advocates of this view would argue that if health care demands are met equally in all segments of society, all is right with the world-regardless of the impact these equally distributed services have on health status. The error in this position is simply explained. Since illness in general, as well as those diseases for which we have effective preventive and curative measures, are not equally distributed throughout society, the egalitarian delivery of health care will produce gross overtreatment and undertreatment of those segments of society in which particular diseases are respectively less and more prevalent. In addition, attention only to service demands would produce the wholesale delivery of services of unproven effectiveness and poor efficiency, justified solely on the basis that they were demanded. It is most unfortunate that Prof. Elinson chose to utilize his psychologically potent position as final discussant to reiterate this view, thereby implying that the conference as a whole endorsed his conclusions. These ideas would have policy makers and researchers relinquish their interest in the health of populations in favor of easily measured and administratively manipulatable indexes of service that have doubtful relationships to health status and only serve the political and pecuniary ends of service providers. We cannot pattern our behavior after the drunk who, having lost his keys down a dark alley, searches under a lamppost a block away because that is where the light is. The fact that health status may be hard to define operationally is no excuse to retrogressively define it as health service simply because process variables are more easily quantified than outcome variables. MAURICE S. SATIN

Psychiatric Epidemiology Unit Hudson River Psychiatric Center Poughkeepsie, NY 210

Health Services Research

Health services and health status.

ffVback Health Services and Health Status As one of the participants in the conference on social sciences in health at APHA (Briefings, Health Service...
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