and provide a rationale and direction for therapy in heroin use, a behavioral model would appear to be distinctly superior to others, including the communicable disease or clinical model. References 1. Morton, F. L. A County Health Department's Role in Drug Programs. HSMHA Health Rep. 86:1069-1076, 1971. 2. Parsons, T. The Social System, pp. 436-439. The Free Press, New York, 1951. 3. Torrey, E. F. The Death of Psychiatry, pp. 148-150. Chilton Book Company, Radnor, PA, 1974. 4. Solomon, R. L. Punishment. Am. Psychol. 19:239-253, 1964. 5. Cautela, J. R. Covert Sensitization. Psychol. Rep. 74:459-468, 1967.
Frank L. Morton, MD, MPH Behavior Therapy Institute White Plains, NY
RESPONSE TO DR. MORTON'S LETTER I appreciate your taking the time to comment on my article. Let me respond with the following points: First, the article was intended as a discussion of one way of approaching research in the problem of drug abuse. It was not my intent to suggest that the epidemiologic model is the only model or even the best model. Nor was it the intent of the article to review all models of drug addiction. I believe the epidemiologic model is broad enough "to accommodate all aspects of a
social or health interest area." It has not contributed substantially to a better understanding of etiology because studies of that sort are very complex to design and expensive to fund. However, the ability of the epidemiologic approach to suggest the etiology of other diseases (smoking and lung cancer, for example) has been
shown repeatedly. The similarity between drug abuse and other phenomena which spread by "social diffusion" does not detract from the utility of this observation in studying drug abuse. It may limit the importance of such observations with
regard to elucidating etiology, but it does form the basis of an analytic approach to the problem which permits a quantitiative assessment of drug abuse trends. In this regard, other models of drug abuse (including the behavioral model) are relatively weak. Does that mean they should be characterized as "limited or half-models" and discarded as being deficient? I think not. In my opinion, the medical model does not demand relegation of the addict to a dependent role, nor does it require that the process under consideration have a single etiology or a single form of therapy. Medicine abounds with examples in which the patients take an active role in the treatment of their illnesses, in which diseases have multiple etiologies. Problems like drug abuse are quite complex, and not suited to overly simplistic analytic techniques. We must be flexible enough to approach the problem from many different points of view, incorporating the strengths of different models and different methodologies, if we are to reach a better understanding of drug abuse. Mark H. Greene, MD Washington, DC
IN THE MEDICAL SERVICES MARKETPLACE Dr. M. E. Schaefer's article, in Public Health Briefs of your March, 1975, issue (65:293, 1975), strikes me as a very interesting and thoughtful treatment of "the concepts of demand, want, and need in the market for medical services." I do not remember the original article by Jeffers et al. (61:46, 1971), which Schaefer cites as his springboard, but I'm sure that together they cover a large assortment of implications and ramifications that should stimulate further reaction and discussion among readers. Particularly noteworthy are Schaefer's allusions to a variety of "externalities" in consumption and production. I would go further, to urge that these be regarded not as tangential considerations but as possibly sur-
passing in value the strictly economic or dollar-measured factors. Just as econometric market analyses on food would prompt me to contend for externalities that precede and transcend the values of a market-focused economy. And who, in that case, would resolve the problem of costing out the pleasure benefits (pain-avoidance, gourmandry, cuisinery) versus the survival benefits (life, vigor, creativity)? Beyond this, what are Schaefer's grounds for assuming that the choice of the patient (as user or consumer) is properly and necessarily overridden by the opinion of either the medical expert or the central planner?! My gestalt of the citizen in a free society provides him with the sovereign right of choice-in the exercise of which he will weigh (as he sees fit) the expert advice of the provider, the planner, and others. And, incidentally, why is economics constrained to deal with only the first of the three goal conceptions (demand, want, and need)? Is there no way to break out of the market frame of reference to conceive a Humanist Economics? Particularly when there is so much underutilization of our industrial resource, and so much slack in our development of the human resource! Finally, I perceive that Schaefer and Jeffers might not actually be so far apart as the technical argument suggests. When Schaefer acknowledges (at the end of p. 294) that "a positive consumption externality may occur if individual A's satisfaction is increased merely by knowing that individual B received some medical care," he has perhaps identified the very factor that underlies, sustains, and validates the Jeffers position favoring all the health care that is useful. Herman S. Solomon Associate Research Analyst New York State Department of Labor
OCCUPATIONAL HEALTH AND SAFETY The
articles
on occupational
safety and health in the January, LETTERS TO THE EDITOR
647
1975, edition were very good. They are particularly noteworthy given the editorial by Henry Howe. Dr. Howe points to the challenge facing those working in the field of occupational safety and health in bringing the full range of health care workers into the field. In viewing this as, at least, an immediate goal, the article by Mssrs. Wegman, Boden, and Levenstein was particularly note-
worthy. The Urban Planning Aid occupational safety and health program developed a fully comprehensive occupational safety and health service to workers and their unions which combined the screening of workers with the treatment and possible prevention of such exposures in the future. The key aspect of both Dr. Howe's editorial and the program developed by UPA was the central role that workers and their representatives play in a program involving their occupational safety and health problems.
Alexander Adler,t special assistant to the assistant administrator for Extramural Affairs, Health Resources Administration, DHEW, has been elected president of the Manpower, Analysis and Planning Society. MAP is composed of professional people in government, industry, universities, and other organizations with major interests in manpower analysis, surveys, projections, and issues with major manpower implications. Tom D. Y. Chin, MD, MPH,t has been appointed chairman of the department of human ecology and community health, University of Kansas Medical Center, Kansas City. Chin has been acting chairman of the department since last summer. * Fellow. t Member.
648
AJPH JUNE, 1975, Vol. 65, No. 6
This participation is missing in the program described by Dr. Cimino, but knowing of Dr. Cimino's efforts and the sanitation union in NYC there was probably some worker involvement. Its a shame it wasn't spelled out in the article. The article which would seem to give the most problem to someone trying to implement a program in occupational safety and health would be the one by Dr. Samuel Webb, "Objective Criteria for Evaluating Occupational Health Programs." While appearing to be quite objective, it is really quite out from the spirit of the Occupational Safety and Health Act of 1970. That Act quite specifically stated that the involvement of workers and their representatives is key to the success of making the workplace a safe and healthful place to work. It would appear that Dr. Webb is still laboring under the old style industrial medical approach which makes employers solely responsible and singularly in
Richard Feinberg, PhD,* has been reelected president of the Mid-Atlantic Chapter, American Medical Writers Association. Feinberg is a research psychologist and professional staff consultant on Visual Abnormalities, Collaborative Perinatal Program, National Institute of Neurological Diseases and Stroke, NIH. Arthur E. Helfand, DPM,* was recently presented with the Distinguished Service Award by St. Luke's & Children's Medical Center, Philadelphia, for promoting continuing education, outstanding leadership, and untiring dedication. Helfand is co-chief of the department of podiatry and director of podiatric education at St. Luke's. Rebecca S. Parkinson, MSPH,t has been appointed to the staff of the College of Medicine and Dentistry of New Jersey's Office of Consumer Health Education. Parkinson is the program associate of a
control of all occupational health programs which reach their employees. I would advise readers of the Journal that in order to conduct a successful occupational safety and health program they should follow the guidelines set down by UPA, in its efforts. The programs which we conducted at Cornell University's Industrial Labor and Relations Schools were also modeled after the combined efforts of workers and their unions and health and scientific professionals. We felt that whatever success we had in our program was in large part due to the equal respect and sets of activities that these experts conducted together in attempting to make the workplace a little safer for workers. The APHA Convention in November, 1975, will be a good place to discuss the different approaches in making the workplace safer and healthier for workers.
Frank Goldsmith, Secretary-Elect Occupational Health Section, APHA
pilot program to train patient and community health education coordinators. Elsie M. Tytla, MD,t has been appointed medical advisor to the Medical Services Administration of HEW's Social and Rehabilitation Service. Tytla has been a pediatrician in New London, CT, for more than 17 years.
Binnie L. Manges,* assistant director of the St. Louis County (MO) department of community health and medical care (Health Education and Information Center) on March 25 (Public Health Educa-
tion). Orianna McDaniel, MD,t retired, of Minneapolis, MN (Laboratory).
Frank L. Morton, MD, MPH Behavior Therapy Institute White Plains, NY
RESPONSE TO DR. MORTON'S LETTER I appreciate your taking the time to comment on my article. Let me respond with the following points: First, the article was intended as a discussion of one way of approaching research in the problem of drug abuse. It was not my intent to suggest that the epidemiologic model is the only model or even the best model. Nor was it the intent of the article to review all models of drug addiction. I believe the epidemiologic model is broad enough "to accommodate all aspects of a
social or health interest area." It has not contributed substantially to a better understanding of etiology because studies of that sort are very complex to design and expensive to fund. However, the ability of the epidemiologic approach to suggest the etiology of other diseases (smoking and lung cancer, for example) has been
shown repeatedly. The similarity between drug abuse and other phenomena which spread by "social diffusion" does not detract from the utility of this observation in studying drug abuse. It may limit the importance of such observations with
regard to elucidating etiology, but it does form the basis of an analytic approach to the problem which permits a quantitiative assessment of drug abuse trends. In this regard, other models of drug abuse (including the behavioral model) are relatively weak. Does that mean they should be characterized as "limited or half-models" and discarded as being deficient? I think not. In my opinion, the medical model does not demand relegation of the addict to a dependent role, nor does it require that the process under consideration have a single etiology or a single form of therapy. Medicine abounds with examples in which the patients take an active role in the treatment of their illnesses, in which diseases have multiple etiologies. Problems like drug abuse are quite complex, and not suited to overly simplistic analytic techniques. We must be flexible enough to approach the problem from many different points of view, incorporating the strengths of different models and different methodologies, if we are to reach a better understanding of drug abuse. Mark H. Greene, MD Washington, DC
IN THE MEDICAL SERVICES MARKETPLACE Dr. M. E. Schaefer's article, in Public Health Briefs of your March, 1975, issue (65:293, 1975), strikes me as a very interesting and thoughtful treatment of "the concepts of demand, want, and need in the market for medical services." I do not remember the original article by Jeffers et al. (61:46, 1971), which Schaefer cites as his springboard, but I'm sure that together they cover a large assortment of implications and ramifications that should stimulate further reaction and discussion among readers. Particularly noteworthy are Schaefer's allusions to a variety of "externalities" in consumption and production. I would go further, to urge that these be regarded not as tangential considerations but as possibly sur-
passing in value the strictly economic or dollar-measured factors. Just as econometric market analyses on food would prompt me to contend for externalities that precede and transcend the values of a market-focused economy. And who, in that case, would resolve the problem of costing out the pleasure benefits (pain-avoidance, gourmandry, cuisinery) versus the survival benefits (life, vigor, creativity)? Beyond this, what are Schaefer's grounds for assuming that the choice of the patient (as user or consumer) is properly and necessarily overridden by the opinion of either the medical expert or the central planner?! My gestalt of the citizen in a free society provides him with the sovereign right of choice-in the exercise of which he will weigh (as he sees fit) the expert advice of the provider, the planner, and others. And, incidentally, why is economics constrained to deal with only the first of the three goal conceptions (demand, want, and need)? Is there no way to break out of the market frame of reference to conceive a Humanist Economics? Particularly when there is so much underutilization of our industrial resource, and so much slack in our development of the human resource! Finally, I perceive that Schaefer and Jeffers might not actually be so far apart as the technical argument suggests. When Schaefer acknowledges (at the end of p. 294) that "a positive consumption externality may occur if individual A's satisfaction is increased merely by knowing that individual B received some medical care," he has perhaps identified the very factor that underlies, sustains, and validates the Jeffers position favoring all the health care that is useful. Herman S. Solomon Associate Research Analyst New York State Department of Labor
OCCUPATIONAL HEALTH AND SAFETY The
articles
on occupational
safety and health in the January, LETTERS TO THE EDITOR
647
1975, edition were very good. They are particularly noteworthy given the editorial by Henry Howe. Dr. Howe points to the challenge facing those working in the field of occupational safety and health in bringing the full range of health care workers into the field. In viewing this as, at least, an immediate goal, the article by Mssrs. Wegman, Boden, and Levenstein was particularly note-
worthy. The Urban Planning Aid occupational safety and health program developed a fully comprehensive occupational safety and health service to workers and their unions which combined the screening of workers with the treatment and possible prevention of such exposures in the future. The key aspect of both Dr. Howe's editorial and the program developed by UPA was the central role that workers and their representatives play in a program involving their occupational safety and health problems.
Alexander Adler,t special assistant to the assistant administrator for Extramural Affairs, Health Resources Administration, DHEW, has been elected president of the Manpower, Analysis and Planning Society. MAP is composed of professional people in government, industry, universities, and other organizations with major interests in manpower analysis, surveys, projections, and issues with major manpower implications. Tom D. Y. Chin, MD, MPH,t has been appointed chairman of the department of human ecology and community health, University of Kansas Medical Center, Kansas City. Chin has been acting chairman of the department since last summer. * Fellow. t Member.
648
AJPH JUNE, 1975, Vol. 65, No. 6
This participation is missing in the program described by Dr. Cimino, but knowing of Dr. Cimino's efforts and the sanitation union in NYC there was probably some worker involvement. Its a shame it wasn't spelled out in the article. The article which would seem to give the most problem to someone trying to implement a program in occupational safety and health would be the one by Dr. Samuel Webb, "Objective Criteria for Evaluating Occupational Health Programs." While appearing to be quite objective, it is really quite out from the spirit of the Occupational Safety and Health Act of 1970. That Act quite specifically stated that the involvement of workers and their representatives is key to the success of making the workplace a safe and healthful place to work. It would appear that Dr. Webb is still laboring under the old style industrial medical approach which makes employers solely responsible and singularly in
Richard Feinberg, PhD,* has been reelected president of the Mid-Atlantic Chapter, American Medical Writers Association. Feinberg is a research psychologist and professional staff consultant on Visual Abnormalities, Collaborative Perinatal Program, National Institute of Neurological Diseases and Stroke, NIH. Arthur E. Helfand, DPM,* was recently presented with the Distinguished Service Award by St. Luke's & Children's Medical Center, Philadelphia, for promoting continuing education, outstanding leadership, and untiring dedication. Helfand is co-chief of the department of podiatry and director of podiatric education at St. Luke's. Rebecca S. Parkinson, MSPH,t has been appointed to the staff of the College of Medicine and Dentistry of New Jersey's Office of Consumer Health Education. Parkinson is the program associate of a
control of all occupational health programs which reach their employees. I would advise readers of the Journal that in order to conduct a successful occupational safety and health program they should follow the guidelines set down by UPA, in its efforts. The programs which we conducted at Cornell University's Industrial Labor and Relations Schools were also modeled after the combined efforts of workers and their unions and health and scientific professionals. We felt that whatever success we had in our program was in large part due to the equal respect and sets of activities that these experts conducted together in attempting to make the workplace a little safer for workers. The APHA Convention in November, 1975, will be a good place to discuss the different approaches in making the workplace safer and healthier for workers.
Frank Goldsmith, Secretary-Elect Occupational Health Section, APHA
pilot program to train patient and community health education coordinators. Elsie M. Tytla, MD,t has been appointed medical advisor to the Medical Services Administration of HEW's Social and Rehabilitation Service. Tytla has been a pediatrician in New London, CT, for more than 17 years.
Binnie L. Manges,* assistant director of the St. Louis County (MO) department of community health and medical care (Health Education and Information Center) on March 25 (Public Health Educa-
tion). Orianna McDaniel, MD,t retired, of Minneapolis, MN (Laboratory).
