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U
Letters to the Editor
Letters are welcomed and will be published, iffound suitable, as space permits. The editors reserve the right to edit and abridge letters, to publish replies, and to solicit responses from authors and others. Letters should be submitted in duplicate, double-spaced (including references), and generally should not exceed 400 words.
Let's Clean up Our Own Shop In discussing the general health of the public, more specifically maternal and infant well-being, health providers accept the fact that breast-feeding of infants is superior to bottle (formula) feeding. The reasons include psychological, nutritional, immunological, dental, orthodontic, infectious, and developmental benefits for the child; with bonding, psychological, parenting, contraception control, and monetary benefits for the mother. These issues pertain to populations of maternal-infant dyads, and not necessarily to particular individuals. The group of infants most at risk for organic and psychological pathology are often from the least educated and/or poorest families. The purpose of this letter is to plead with the American Journal of Public Health and the American Public Health Association to help support overtly the beneficial spectrum of breast-feeding. In the published book "Official Programs and Abstracts" provided to each of the 11,500 participants at the [1977] APHA Annual Meeting in Washington, DC, (the largest public health meeting in the history of the United States) everyone held upright the meeting book with the title "Toward a National Health Policy" on the cover, and a full-page infant formula advertisement on the back page. The advertisement implied that the product advertised was "the best" for the child. Thus 11,500 well-meaning health professionals carried blatant for782
mula publicity for all to see. This type of covert publicity represents the antithesis of "Toward a National Health Policy" to me. A whole hour of the Food and Nutrition Section [business meeting] at the October, 1977 convention dealt with the lack of control over television advertising (especially sweetened cereals) and its effects on children's eating habits. Before we chide others in our "free enterprise system" to be more sensitive to our children's needs, let us first "clean up our own shop." We should form a united front to promulgate the benefits of human lactation and not have to deal with subliminal, shrewd, Madison Avenue techniques. If we are going to move "Toward a National Health Policy." we must present only what we know to be beneficial to our future children, especially if we are truly "serving society and protecting health" (motto on all AJPH covers). Our newer outreach ideas of community health educators will not affect infant nutrition if we can't extirpate those influences that are contrary to our own beliefs. Although marasmic illness and diarrheal disease due to bottle feeding are much less common in the USA, we know that human milk can help prevent organic pathology. Our country is replete with problems arising from a dearth of knowledge about parenting and infant nutrition. Breast-feeding is not the panacea, but its widened adoption, when circumstances permit, would help solve them. Why should we be party to those manifestations of the free enterprise system which, regardless of their motivation, would work against such a solution? Peter D. Magnus, MD, MPH County of Los Angeles Dept. ofHealth Services 1106 S. Crenshaw Blvd. Los Angeles, CA 90019
On Suicide and the Aging I found the article Problems in Suicide Statistics for Whites and Blacks' by Warshauer and Monk to be lacking in explanation for the difficulties in the reporting of suicide for the 55-plus age group. Wolff speaks about the high suicide rate in the elderly.2 Resnick and Cantor stated that even though persons over the age of 65 make up 9 per cent of the population, they account for 25 per cent of all suicides. Also, white males over 65 have a suicide rate four times the national average.3 Burston noted that self poisoning with medications, a serious problem with many elderly, usually involved depression and loneliness.4 Suicide is currently listed among the ten leading causes of death, but more careful and realistic recording might show it to be even more common. Certainly, in most age groups (including the aged), many suicides are concealed in the data for accidents and natural deaths. Perhaps we should look in retrospect at "accidental" deaths in the elderly. Death comes most often to persons who are malignantly depressed, to the point of being unresponsive to any treatment intervention. Nevertheless, the medical records indicate that the demise was sometimes unexpected. Karl Menninger has stated that unlike the suicidal person, the accident prone individual is not in touch with his self-destructive qualities because conscious awareness of these tendencies is intolerable.5 Thus there is significant concern with the problem of reporting suicides in the elderly population. The results of future research on the certification of suicide should develop uniform methods of recording the modes of death and prior indicators of suicidal potential, i.e., prior suicidal behavior, bereavement and loss, serious physical AJPH August, 1978, Vol. 68, No. 8
LETTERS TO THE EDITOR
illness, etc., so that the reported data will be reliable and valid. Since the act of suicide can be taken as a social index of rejection by a member of the community, suicide rates are an indicator of poor mental health among our elderly population. Greater accuracy in suicide data will permit a better understanding of suicide in the elderly, and will permit us to develop more effective ways of therapeutic intervention in preventing suicide. Rein Tideiksaar R.P.A.-C. Jewish Institute for Geriatric Care New Hyde Pk, NY S.U.N.Y. Stony Brook, NY
REFERENCES 1. Warshauer MA and Monk M: Problems in suicide statistics for whites and blacks. Am J Public Health 68:383-388, 1978. 2. Wolff K: Depression and suicide in the geriatric patient, J. Am Geriatrics Soc. 17:668, 1969 3. Resnick H and Cantor J: Suicide and aging, J Am Geriatrics Soc. 18:152, 1970 4. Burston GR: Self poisoning in elderly patients, Geront Clin 11: 279, 1969 5. Menninger K: Purposive Accidents as an Expression of Self-Destructive Tendencies, International Journal of Psychoanalyis, 17:8, 1936
Article on Excess Maternal Deaths Challenged The September issue of the Journal carried a paper by Petitti & Cates' on possible consequences of cutting funds for Medicaid abortions. The paper had an error. In compilation of data for the excess number of maternal deaths which would occur if all babies were born instead of being aborted the authors did not subtract the deaths which would occur due to legal abortions (1l),2 they only counted the probable non-abortion related maternal deaths. Also at the time of submission of that paper to the Journal the Vital Statistics data for 1975 had already been available for two months. If 1975 data were substituted for 1974 data there would be a further reduction of 7 deaths. AJPH August 1978, Vol. 68, No. 8
The paper also carried a lot of wrong assumptions. Tietze3 considers that two abortions are needed to avert one birth. I think this to be a conservative figure, but even taking this figure into account the number of maternal deaths would go down considerably. However, there are other wrong assumptions too. The white mortality rates should not be taken for the white poor, while non-white rates were taken for black poor. I doubt that there is any considerable difference between the mortality rates of the poor of both both races. The most strained calculations appear in the table containing two weeks delay. It is logical to think that a woman would need two weeks to find the money for early abortion, but I doubt that two weeks would be sufficient for her to find the money for the expensive late abortion. More likely she would forego the idea of abortion. Since late abortions are many times more dangerous than birth, then even if some of the late abortions in the table 3 were changed to birth, there would be some saving of maternal lives, not a loss of five. However, with the assumption taken by the authors there was no justification for the assumption that abortions done at present at 21 weeks or more would not take place. Those abortions would still be legal. It is a pity that a paper with an error and some weak assumptions appeared in the Journal, since it is already widely quoted. It degrades science when it is used for political reasons. Barbara J. Syska
Research Analyst Natl. Right to Life Committee 341 National Press Bldg. Washington, DC 20045
REFERENCES 1. Petitti DB and Cates W: Restricting medicaid funds for abortions: Projections of excess mortality for women of childbearing age. AJPH, 67:860-862, 1977. 2. Cates W, Grimes DA, Smith JC, and Tyler CW: Legal abortion mortality in the United States, JAMA 237: 452-455, 1977. 3. Tietze C: Hearing before the Subcommittee on Constitutional Amendments of the Committee on the Judiciary, United States Senate, Ninety-third Congress, second session on SJ 119 & SJ 130,
Abortion-Part 2, p. 52; U.S. Govt. Printing Office, 1976.
The Authors' Response We appreciate the opportunity to respond to Ms. Syska. Unfortunately, most of her points focus down on the absolute number of projected excess deaths, rather than on the broader public health implications of our model. As we clearly stated in our paper,' pregnancy, whether carried to term or not, increases the risk of death. Legal abortion before 16 weeks' gestation is safer than any other alternative.outcome available to pregnant women. Obviously only those women whose pregnancies were unwanted would opt for legal abortion. Any public policy which tends to restrict this choice entails a small, but measurable, increased risk to pregnant women whose options have been denied. The first point made by Ms. Syska was initially raised by Dr. Sylvan Wallenstein.2 In our answer to him,3 we implied that to do as he had suggested would subtract the risks of the abortion procedure twice. However, because we were projecting excess mortality, we now realize that his approach was correct, by taking into account the competing mortality risk of legal abortion. The corrected estimate lowers the projected number of deaths from the
term-birth alternative by approximately 20 per cent.2 Using 1975 data, as Ms. Syska prefers, would also reduce the projected number of deaths from the term-birth alternative. We used 1974 data because the 1975 data were not available at the time the manuscript was prepared in early 1977. Ms. Syska's assumption that two abortions are needed to avert one birth is based on a population that does not use contraception; several studies have recently shown that women who obtain abortions are more likely to use contraception after their pregnancy termination than prior to becoming pregnant.4 5 The mortality risks associated with contraception could be added to the model, but we do not feel the small increment in accuracy would warrant greater model sophistication. 783
U
Letters to the Editor
Letters are welcomed and will be published, iffound suitable, as space permits. The editors reserve the right to edit and abridge letters, to publish replies, and to solicit responses from authors and others. Letters should be submitted in duplicate, double-spaced (including references), and generally should not exceed 400 words.
Let's Clean up Our Own Shop In discussing the general health of the public, more specifically maternal and infant well-being, health providers accept the fact that breast-feeding of infants is superior to bottle (formula) feeding. The reasons include psychological, nutritional, immunological, dental, orthodontic, infectious, and developmental benefits for the child; with bonding, psychological, parenting, contraception control, and monetary benefits for the mother. These issues pertain to populations of maternal-infant dyads, and not necessarily to particular individuals. The group of infants most at risk for organic and psychological pathology are often from the least educated and/or poorest families. The purpose of this letter is to plead with the American Journal of Public Health and the American Public Health Association to help support overtly the beneficial spectrum of breast-feeding. In the published book "Official Programs and Abstracts" provided to each of the 11,500 participants at the [1977] APHA Annual Meeting in Washington, DC, (the largest public health meeting in the history of the United States) everyone held upright the meeting book with the title "Toward a National Health Policy" on the cover, and a full-page infant formula advertisement on the back page. The advertisement implied that the product advertised was "the best" for the child. Thus 11,500 well-meaning health professionals carried blatant for782
mula publicity for all to see. This type of covert publicity represents the antithesis of "Toward a National Health Policy" to me. A whole hour of the Food and Nutrition Section [business meeting] at the October, 1977 convention dealt with the lack of control over television advertising (especially sweetened cereals) and its effects on children's eating habits. Before we chide others in our "free enterprise system" to be more sensitive to our children's needs, let us first "clean up our own shop." We should form a united front to promulgate the benefits of human lactation and not have to deal with subliminal, shrewd, Madison Avenue techniques. If we are going to move "Toward a National Health Policy." we must present only what we know to be beneficial to our future children, especially if we are truly "serving society and protecting health" (motto on all AJPH covers). Our newer outreach ideas of community health educators will not affect infant nutrition if we can't extirpate those influences that are contrary to our own beliefs. Although marasmic illness and diarrheal disease due to bottle feeding are much less common in the USA, we know that human milk can help prevent organic pathology. Our country is replete with problems arising from a dearth of knowledge about parenting and infant nutrition. Breast-feeding is not the panacea, but its widened adoption, when circumstances permit, would help solve them. Why should we be party to those manifestations of the free enterprise system which, regardless of their motivation, would work against such a solution? Peter D. Magnus, MD, MPH County of Los Angeles Dept. ofHealth Services 1106 S. Crenshaw Blvd. Los Angeles, CA 90019
On Suicide and the Aging I found the article Problems in Suicide Statistics for Whites and Blacks' by Warshauer and Monk to be lacking in explanation for the difficulties in the reporting of suicide for the 55-plus age group. Wolff speaks about the high suicide rate in the elderly.2 Resnick and Cantor stated that even though persons over the age of 65 make up 9 per cent of the population, they account for 25 per cent of all suicides. Also, white males over 65 have a suicide rate four times the national average.3 Burston noted that self poisoning with medications, a serious problem with many elderly, usually involved depression and loneliness.4 Suicide is currently listed among the ten leading causes of death, but more careful and realistic recording might show it to be even more common. Certainly, in most age groups (including the aged), many suicides are concealed in the data for accidents and natural deaths. Perhaps we should look in retrospect at "accidental" deaths in the elderly. Death comes most often to persons who are malignantly depressed, to the point of being unresponsive to any treatment intervention. Nevertheless, the medical records indicate that the demise was sometimes unexpected. Karl Menninger has stated that unlike the suicidal person, the accident prone individual is not in touch with his self-destructive qualities because conscious awareness of these tendencies is intolerable.5 Thus there is significant concern with the problem of reporting suicides in the elderly population. The results of future research on the certification of suicide should develop uniform methods of recording the modes of death and prior indicators of suicidal potential, i.e., prior suicidal behavior, bereavement and loss, serious physical AJPH August, 1978, Vol. 68, No. 8
LETTERS TO THE EDITOR
illness, etc., so that the reported data will be reliable and valid. Since the act of suicide can be taken as a social index of rejection by a member of the community, suicide rates are an indicator of poor mental health among our elderly population. Greater accuracy in suicide data will permit a better understanding of suicide in the elderly, and will permit us to develop more effective ways of therapeutic intervention in preventing suicide. Rein Tideiksaar R.P.A.-C. Jewish Institute for Geriatric Care New Hyde Pk, NY S.U.N.Y. Stony Brook, NY
REFERENCES 1. Warshauer MA and Monk M: Problems in suicide statistics for whites and blacks. Am J Public Health 68:383-388, 1978. 2. Wolff K: Depression and suicide in the geriatric patient, J. Am Geriatrics Soc. 17:668, 1969 3. Resnick H and Cantor J: Suicide and aging, J Am Geriatrics Soc. 18:152, 1970 4. Burston GR: Self poisoning in elderly patients, Geront Clin 11: 279, 1969 5. Menninger K: Purposive Accidents as an Expression of Self-Destructive Tendencies, International Journal of Psychoanalyis, 17:8, 1936
Article on Excess Maternal Deaths Challenged The September issue of the Journal carried a paper by Petitti & Cates' on possible consequences of cutting funds for Medicaid abortions. The paper had an error. In compilation of data for the excess number of maternal deaths which would occur if all babies were born instead of being aborted the authors did not subtract the deaths which would occur due to legal abortions (1l),2 they only counted the probable non-abortion related maternal deaths. Also at the time of submission of that paper to the Journal the Vital Statistics data for 1975 had already been available for two months. If 1975 data were substituted for 1974 data there would be a further reduction of 7 deaths. AJPH August 1978, Vol. 68, No. 8
The paper also carried a lot of wrong assumptions. Tietze3 considers that two abortions are needed to avert one birth. I think this to be a conservative figure, but even taking this figure into account the number of maternal deaths would go down considerably. However, there are other wrong assumptions too. The white mortality rates should not be taken for the white poor, while non-white rates were taken for black poor. I doubt that there is any considerable difference between the mortality rates of the poor of both both races. The most strained calculations appear in the table containing two weeks delay. It is logical to think that a woman would need two weeks to find the money for early abortion, but I doubt that two weeks would be sufficient for her to find the money for the expensive late abortion. More likely she would forego the idea of abortion. Since late abortions are many times more dangerous than birth, then even if some of the late abortions in the table 3 were changed to birth, there would be some saving of maternal lives, not a loss of five. However, with the assumption taken by the authors there was no justification for the assumption that abortions done at present at 21 weeks or more would not take place. Those abortions would still be legal. It is a pity that a paper with an error and some weak assumptions appeared in the Journal, since it is already widely quoted. It degrades science when it is used for political reasons. Barbara J. Syska
Research Analyst Natl. Right to Life Committee 341 National Press Bldg. Washington, DC 20045
REFERENCES 1. Petitti DB and Cates W: Restricting medicaid funds for abortions: Projections of excess mortality for women of childbearing age. AJPH, 67:860-862, 1977. 2. Cates W, Grimes DA, Smith JC, and Tyler CW: Legal abortion mortality in the United States, JAMA 237: 452-455, 1977. 3. Tietze C: Hearing before the Subcommittee on Constitutional Amendments of the Committee on the Judiciary, United States Senate, Ninety-third Congress, second session on SJ 119 & SJ 130,
Abortion-Part 2, p. 52; U.S. Govt. Printing Office, 1976.
The Authors' Response We appreciate the opportunity to respond to Ms. Syska. Unfortunately, most of her points focus down on the absolute number of projected excess deaths, rather than on the broader public health implications of our model. As we clearly stated in our paper,' pregnancy, whether carried to term or not, increases the risk of death. Legal abortion before 16 weeks' gestation is safer than any other alternative.outcome available to pregnant women. Obviously only those women whose pregnancies were unwanted would opt for legal abortion. Any public policy which tends to restrict this choice entails a small, but measurable, increased risk to pregnant women whose options have been denied. The first point made by Ms. Syska was initially raised by Dr. Sylvan Wallenstein.2 In our answer to him,3 we implied that to do as he had suggested would subtract the risks of the abortion procedure twice. However, because we were projecting excess mortality, we now realize that his approach was correct, by taking into account the competing mortality risk of legal abortion. The corrected estimate lowers the projected number of deaths from the
term-birth alternative by approximately 20 per cent.2 Using 1975 data, as Ms. Syska prefers, would also reduce the projected number of deaths from the term-birth alternative. We used 1974 data because the 1975 data were not available at the time the manuscript was prepared in early 1977. Ms. Syska's assumption that two abortions are needed to avert one birth is based on a population that does not use contraception; several studies have recently shown that women who obtain abortions are more likely to use contraception after their pregnancy termination than prior to becoming pregnant.4 5 The mortality risks associated with contraception could be added to the model, but we do not feel the small increment in accuracy would warrant greater model sophistication. 783
