Letters to the Editor
evidence was oversimplified, the data were misinterpreted, and the body of work in this area in the scientific literature was ignored (for example, see Foster's review'). Also, the validity of citations of Brodeur's articles in the medical and scientific literature has been questioned.2 Several additional misconceptions have been presented in two more recent articles by Brodeur in The New Yorker. Most of the evidence Brodeur cited for the alleged association comes from epidemiologic studies. In "Annals of Radiation: Calamity on Meadow Street,"3 Brodeur cited a 1979 study containing numerous flaws that he chose to ignore. Michaelson4 and Poole and Trichopoulos5 have presented detailed analyses of some of these flaws. Brodeur also wrote that data from one study6 showed "four times the expected rate of brain cancer in children whose mothers used electric blankets." Brodeur had selected the subgroup with the highest odds ratio in the study, one that represented only 9% of the total population studied for prenatal electric blanket exposure. The odds ratio for association of all prenatal electric blanket exposures with the incidence of childhood cancer was only 1.3. In one study,7 according to Brodeur, "children whose fathers were electricians ran three and a half times the risk of developing tumors of the central nervous system than other children ran." Brodeur insinuated that this finding related to EMF exposure. In that article, however, the ratio was related not to fathers with jobs involving potential EMF exposure, but rather to "fathers who were electricians." This is an important distinction. The odds ratio for jobs in industries involving potential EMF exposure was only 1.6. The authors stated, "the highest risk estimate in our analysis was the odds ratio of 10.0 for construction electricians . . . (who) work largely with unenergized wiring, implying that they have a limited exposure to electromagnetic fields." Brodeur's reference to a cancer cluster in association with EMF exposure lacked a cause-and-effect relationship. An epidemiologist from a state health department has stated that "our investigation of a cluster of brain cancer cases ... was severely hampered by local reaction to the inaccuracies and misconceptions in The New Yorker article."8 Others have expressed similar complaints.8 In "Deartment of Arnpklfcation,"9 Brodeur stated that "eye melanoma .. has been found to be 'notably high for electrical and electronics workers,' who 898 American Journal of Public Health
are known to be exposed to strong magnetic fields." Yet the cited study10 did not mention exposure to EME. Brodeur also stated that "melanoma of the skin is ... prevalent amongworkers in electrical and electronic occupations, and thus associated with exposure to magnetic fields." Occupational titles, however, are a poor means of assessing potential EMF exposure. Brodeur called for several departments of health to conduct full-scale investigations of alleged EMF hazards. Yet it is questionablewhether the money spent on such investigations would be justified. As Weisburger11 has explained, "with limited funds available for serious research efforts, a program on electromagnetic fields and cancer could be counterproductive by diverting effort and money from more relevant research and public information activities." In contrast to Brodeur's claims, the majority of epidemiologic studies do not support the contention that there is an association between EMF exposure and cancer.12 His highly speculative and unsubstantiated claims should not be accepted as representing the scientific literature dealing with EMFs. Public health experts should be aware of these misconceptions and must challenge the appearance of such accounts in both the popular press and in medical and scientific journals. [1 James R. Jauche, PhD Requests for reprints should be sent to James R. Jauchem, Directed Energy Division, Occupational and Environmental Health Directorate, Armstrong Laboratory, Brooks Air Force Base, TX 78235. The opinions are those of the author and do not necessarily state or reflect those of the US government.)
References 1. Foster KR. Book review-Currents of death: Power lines, computer terminals, and the attempt to cover up their threat to your health. IEEE Eng Med Biol Mag.
1990;9(1):89.
2. Jauchem JR. Electromagnetic fields: Is there really a danger? Lancet 1990;336:884. Letter. 3. 7he New Yorker. July 9, 1990. 4. Michaelson SM. Household magnetic fields and childhood leukemia: a critical
analYsis. Pedatrics. 1991;88:630-635.
5. Poole C, Trichopoulos D. Extremely lowfrequency electric and magnetic fields and cancer. Cancer Causes ControL 1991;2: 267-276. 6. Savitz DA, John EM, Kleckner RC. Magnetic field exposure from electric appli-
ances and childhood cancer. Am JEpide-
miot 1990;131:763-773.
7. Johnson CC, Spitz MR. Childhood nervous system tumours: an assessment of
risk associated with paternal occupations involving use, repair or manufacture of electrical and electronic equipment. Int J EpidemnioL 1990;18:756-762. 8. Newman ME. Electromagnetic fields and cancer-Media and public attention affect research.JNatlCancerInst. 1991;83:164166. 9. 7he New Yorker. November 8, 1990. 10. Swerdlow AJ. Epidemiology of eye cancer in adults in England and Wales, 1962-1977. Am JEpideniology. 1983;118:294-300. 11. Weisburger JH. Cancer and electromagnetic fields. Lancet. 1990;336:1259. Letter. 12. JauchemJR, MerrittJH. The epidemiology of exposure to electromagnetic fields: an overview of the recent literature.JClin EpidemioL 1991;44:895-906.
The Correct Use of Growth Charts It is with great interest that I read the article by M. T. Ruel, D. L. Pelletier, J.-P. Habicht, et al., "Comparison between two growth charts in Lesotho" (Am J Public Health. 1991;81:610-615). I was surprised to see that both emphasize percentage deficit, which is taken as a percentage of the median of the reference population. My experience in different places (most recently in Indonesia) is that health workers feel that, on a Road-toHealth (RHT) chart that carries the top of the "green" at the male median W/Age, anyone who falls beyond the top line (i.e., in the white part) is "abnormal." I am very glad that at least the RHT was chosen as the more effective chart and that both mothers and health workers had a better understanding of the process indicated on the card. As it is, teaching is usually done the wrong way round: the chart should not be an initial indicator but a tool for the evaluation of growth; the advice given is the most important. The Guideline should come first, with the feeding advice, then the weighing to see if the mother's efforts have bome fruit-this is the original process of child health care. The interview with the mother-not the chart-gives the answers regarding good or indifferent care. Many children bom at or above the chart median can stay there without any problem, but health workers are quite happy if they "flatten off" into the "green" until they approach the 80%o line, and in some countries supplementary feeding may start only at the 60%o line. I wonder why the Catholic Relief Service Food and Nutrition Programme still uses the GS card with its unphysiologic implications? Especially in Africa, one would not expect the well fed to deviate too farfrm the National Center for Health Statistics distribution-
June 1992, Vol. 82, No. 6
Lettm to the Editor one would like to see about 50%o above the top line on the chart, where there is no space at all. O Coei J. Gejhuysen, DCH (Londn), FRCP(E), MPH Requests for reprints should be sent to Coeli J. Geefhuysen, DCH, FRCP(E), MPH, Tropical Health Education Program, University of Queensland Medical School, Herston Road, Brisbane, Queensland, 4006, Austalia.
Ruel and Habicht Respond Dr. Geefhuysen makes some important points. The growth chart is an educational tool to be used in conjunction with counseling of mothers, and it is not an end in itself. Dr. Geefhuysen argues that growth charts should not be used as an indicator (in other words, a screening tool), but rather as an instrument to educate mothers and to evaluate the impact of their efforts and good practices on their children's growth. This use of growth charts for monitoring and evaluating the effects of interventions is important and was not mentioned in our article. However, it need not be the only one in any given primary health care program. We discuss in a review article the advantages and limitations of the use of growth charts for distinct purposes that include education, screening, monitoring, evaluation, and as an integrating strategy.1 We agree with Dr. Geefhuysen that growth charts are almost universally used as if only the latest measurement was relevant. Decisions are usually based upon whether the measured child's weight falls within the safe or alarm zone. Our findings from Lesotho indicate that both health workers and mothers can understand the notion of growth rate ("direction of growth"), in spite ofthe fact that foryears, emphasis had been put on the child's weight relative to standards.2 We are grateful for this opportunity to comment on one of the "Guidelines for Action" presented in our article (appendix IIB)3 that stated that mothers should be advised to introduce liquids into the child's diet in the first 3 months of life. These guidelines represented the consensus of the organizations delivering primary health care in Lesotho at the beginning of the study (1985). This recommendation is no longer valid in view of the findings from recent studies done in Brazil,4 Peru,5 and the Philippines,6 which show that the introduction of water, teas, and other nonnutritive liquids before the age of 3 months was associated with increased morbidity
June 1992, Vol. 82, No. 6
and mortality. Educational efforts should thus emphasize exclusive breastfeeding and discourage the introduction of other liquids before the age of 3 months. ] Marie T. Ruel4 PhD Jean-Pierre Habichi, PhD Requests for reprints should be sent to Marie T. Ruel, PhD, Institute of Nutrition of Central America and Panama (INCAP), Calzada Roosevelt, Zone 11, Apartado 1188, Guatemala, Guatemala, Central America.
References 1. Ruel MT. Growth monitoring as an educational tool, an integrating strategy and a source of information: a review of experience. In: Pinstrup-Andersen P, Pelietier D, Alderman H, eds. Beyond Chid SwvivaL Enhancing Chid Growth and Nutition in Developing Countries. Ithaca, NY: Cornell University Press; in press. 2. Ruel MT, Pelletier DL, Habicht JP, Mason JB, Chobokoane CS, Maruping AP. A comparison of mothers' understanding of two growth charts in Lesotho. WHO Bull.
1990;68:483-491.
3. Ruel MT, Pelletier DL, Habicht J-P, Mason JB, Chobokoane CS, Maruping AP. Comparison of two grwth charts in Lesotho: health workers' ability to understand and use them for action. Am J Publc Health.
1991;81:610-616.
4. Victora CG, Smith PG, Vaughan JP, Nobre LC, Lombardi C, Teixeira AMB, Fuchs SC, Moreira LB, Gigante LP, Barros FC. Infant feeding and deaths due to diarrhea. Am J
EpidemioL 1989;129:1032-1041.
5. Brown KH, Black RE, Lopez de Romafia G, Creed de Kanashiro H. Infant-feeding practices and their relationship with diarrheal and other diseases in Huascar (Lima), Peru. Pediat,ics. 1989;83:31-40. 6. Popkin BM, Adair L, Aldn JS, Black R, Briscoe J, Flieger W. Breast-feeding and diarrheal morbidity. Pediatrics. 1990;86:874882.
Arficle on HBV in Cuba Criticized Dr. Pfrez-Stablel misrepresents the Cuban H1V program, misquoting relevant data, describing the program without having visited treatment facilities or interviewed seropositive persons, their friends, their families, or the staff who treated them, as others have done.2-5 Although only two of his cited sources contain quantitative data regarding HIV in Cuba (one World Health Organization report listing AIDS cases only6 and an article in a weekly news magazine7), essential figures quoted-HIVpositive persons (434), persons tested (5, 117, 250), numbers of positive gay/ bisexual males (105), sex distriution (315 men, 119 women), among others-appear in none of his references and are neither 1988 nor 1989 data (for example, by De-
cember 31, 1989, 388, not 434, persons in Cuba had been identified as HIV positive.3 Perez-Stable misuses references in other respects. He claims no legal bases for the program even though it emanated from Cuba's constitution and statutes.8-10 He cites a survey among US Latinos (largely Mexicans and Central Americans)," but not Cuban studies2.12"13 to support his opinions regarding condom purchase and use. He dates public education to 1987 although articles in the Cuban press and health education first appeared in mid-1986. He asserts, without evidence, that HIV seropositivity among certain groups in Cuba was comparable to 0.4%, which is 9 to 14 times greater than any HIV seropositivity reported except for hemophiliacs. He divides numerators by denominators of discordant years and equates number of tests with individuals tested. He copies text and ideas without acknowledgment. Only one example shall be cited here. Compare the extract Awith extracts B & C: A. The programs have varied from innovative pilot projects to Spanish translations of inappropriate European film clips. Nationally televised two-hour programs have featured bland panel formats with experts from the MINSAP. ... Physicians and public health experts wearing their white coats responded to questions using predominantly technical terminology and few graphics to illustrate concepts.', P 565 B. Programs on television have been few ... mostly boring, using Spanish translations of totally inappropriate American or European film clips and panel formats where whitecoated MINSAP physicians answer questions posed by either callers or journalist.14. p 16 C. They have been few and the majority consist of MINSAP functionaries, often dressed in white coats answering questions from the population or journalists, in a monotonous manner, many times in language full of medical terms. 15 p 42
D. Many of the television programs use Spanish translations of totally inappropriate American or European film clips or panel formats in which physicians answer questions posed by either callers or journalists.3. P 531 (This text was written and circulated in 1990, the year before publication.)
Information, apparently from Santana et al.3 is not footnoted. In fact, an omission in that article led Perez-Stable to erroneously date educational broadcasts, thus revealing his uncited source. Public health workers are entitled to informed, detailed discussions of the Cu-
American Journal of Public Health 899
evidence was oversimplified, the data were misinterpreted, and the body of work in this area in the scientific literature was ignored (for example, see Foster's review'). Also, the validity of citations of Brodeur's articles in the medical and scientific literature has been questioned.2 Several additional misconceptions have been presented in two more recent articles by Brodeur in The New Yorker. Most of the evidence Brodeur cited for the alleged association comes from epidemiologic studies. In "Annals of Radiation: Calamity on Meadow Street,"3 Brodeur cited a 1979 study containing numerous flaws that he chose to ignore. Michaelson4 and Poole and Trichopoulos5 have presented detailed analyses of some of these flaws. Brodeur also wrote that data from one study6 showed "four times the expected rate of brain cancer in children whose mothers used electric blankets." Brodeur had selected the subgroup with the highest odds ratio in the study, one that represented only 9% of the total population studied for prenatal electric blanket exposure. The odds ratio for association of all prenatal electric blanket exposures with the incidence of childhood cancer was only 1.3. In one study,7 according to Brodeur, "children whose fathers were electricians ran three and a half times the risk of developing tumors of the central nervous system than other children ran." Brodeur insinuated that this finding related to EMF exposure. In that article, however, the ratio was related not to fathers with jobs involving potential EMF exposure, but rather to "fathers who were electricians." This is an important distinction. The odds ratio for jobs in industries involving potential EMF exposure was only 1.6. The authors stated, "the highest risk estimate in our analysis was the odds ratio of 10.0 for construction electricians . . . (who) work largely with unenergized wiring, implying that they have a limited exposure to electromagnetic fields." Brodeur's reference to a cancer cluster in association with EMF exposure lacked a cause-and-effect relationship. An epidemiologist from a state health department has stated that "our investigation of a cluster of brain cancer cases ... was severely hampered by local reaction to the inaccuracies and misconceptions in The New Yorker article."8 Others have expressed similar complaints.8 In "Deartment of Arnpklfcation,"9 Brodeur stated that "eye melanoma .. has been found to be 'notably high for electrical and electronics workers,' who 898 American Journal of Public Health
are known to be exposed to strong magnetic fields." Yet the cited study10 did not mention exposure to EME. Brodeur also stated that "melanoma of the skin is ... prevalent amongworkers in electrical and electronic occupations, and thus associated with exposure to magnetic fields." Occupational titles, however, are a poor means of assessing potential EMF exposure. Brodeur called for several departments of health to conduct full-scale investigations of alleged EMF hazards. Yet it is questionablewhether the money spent on such investigations would be justified. As Weisburger11 has explained, "with limited funds available for serious research efforts, a program on electromagnetic fields and cancer could be counterproductive by diverting effort and money from more relevant research and public information activities." In contrast to Brodeur's claims, the majority of epidemiologic studies do not support the contention that there is an association between EMF exposure and cancer.12 His highly speculative and unsubstantiated claims should not be accepted as representing the scientific literature dealing with EMFs. Public health experts should be aware of these misconceptions and must challenge the appearance of such accounts in both the popular press and in medical and scientific journals. [1 James R. Jauche, PhD Requests for reprints should be sent to James R. Jauchem, Directed Energy Division, Occupational and Environmental Health Directorate, Armstrong Laboratory, Brooks Air Force Base, TX 78235. The opinions are those of the author and do not necessarily state or reflect those of the US government.)
References 1. Foster KR. Book review-Currents of death: Power lines, computer terminals, and the attempt to cover up their threat to your health. IEEE Eng Med Biol Mag.
1990;9(1):89.
2. Jauchem JR. Electromagnetic fields: Is there really a danger? Lancet 1990;336:884. Letter. 3. 7he New Yorker. July 9, 1990. 4. Michaelson SM. Household magnetic fields and childhood leukemia: a critical
analYsis. Pedatrics. 1991;88:630-635.
5. Poole C, Trichopoulos D. Extremely lowfrequency electric and magnetic fields and cancer. Cancer Causes ControL 1991;2: 267-276. 6. Savitz DA, John EM, Kleckner RC. Magnetic field exposure from electric appli-
ances and childhood cancer. Am JEpide-
miot 1990;131:763-773.
7. Johnson CC, Spitz MR. Childhood nervous system tumours: an assessment of
risk associated with paternal occupations involving use, repair or manufacture of electrical and electronic equipment. Int J EpidemnioL 1990;18:756-762. 8. Newman ME. Electromagnetic fields and cancer-Media and public attention affect research.JNatlCancerInst. 1991;83:164166. 9. 7he New Yorker. November 8, 1990. 10. Swerdlow AJ. Epidemiology of eye cancer in adults in England and Wales, 1962-1977. Am JEpideniology. 1983;118:294-300. 11. Weisburger JH. Cancer and electromagnetic fields. Lancet. 1990;336:1259. Letter. 12. JauchemJR, MerrittJH. The epidemiology of exposure to electromagnetic fields: an overview of the recent literature.JClin EpidemioL 1991;44:895-906.
The Correct Use of Growth Charts It is with great interest that I read the article by M. T. Ruel, D. L. Pelletier, J.-P. Habicht, et al., "Comparison between two growth charts in Lesotho" (Am J Public Health. 1991;81:610-615). I was surprised to see that both emphasize percentage deficit, which is taken as a percentage of the median of the reference population. My experience in different places (most recently in Indonesia) is that health workers feel that, on a Road-toHealth (RHT) chart that carries the top of the "green" at the male median W/Age, anyone who falls beyond the top line (i.e., in the white part) is "abnormal." I am very glad that at least the RHT was chosen as the more effective chart and that both mothers and health workers had a better understanding of the process indicated on the card. As it is, teaching is usually done the wrong way round: the chart should not be an initial indicator but a tool for the evaluation of growth; the advice given is the most important. The Guideline should come first, with the feeding advice, then the weighing to see if the mother's efforts have bome fruit-this is the original process of child health care. The interview with the mother-not the chart-gives the answers regarding good or indifferent care. Many children bom at or above the chart median can stay there without any problem, but health workers are quite happy if they "flatten off" into the "green" until they approach the 80%o line, and in some countries supplementary feeding may start only at the 60%o line. I wonder why the Catholic Relief Service Food and Nutrition Programme still uses the GS card with its unphysiologic implications? Especially in Africa, one would not expect the well fed to deviate too farfrm the National Center for Health Statistics distribution-
June 1992, Vol. 82, No. 6
Lettm to the Editor one would like to see about 50%o above the top line on the chart, where there is no space at all. O Coei J. Gejhuysen, DCH (Londn), FRCP(E), MPH Requests for reprints should be sent to Coeli J. Geefhuysen, DCH, FRCP(E), MPH, Tropical Health Education Program, University of Queensland Medical School, Herston Road, Brisbane, Queensland, 4006, Austalia.
Ruel and Habicht Respond Dr. Geefhuysen makes some important points. The growth chart is an educational tool to be used in conjunction with counseling of mothers, and it is not an end in itself. Dr. Geefhuysen argues that growth charts should not be used as an indicator (in other words, a screening tool), but rather as an instrument to educate mothers and to evaluate the impact of their efforts and good practices on their children's growth. This use of growth charts for monitoring and evaluating the effects of interventions is important and was not mentioned in our article. However, it need not be the only one in any given primary health care program. We discuss in a review article the advantages and limitations of the use of growth charts for distinct purposes that include education, screening, monitoring, evaluation, and as an integrating strategy.1 We agree with Dr. Geefhuysen that growth charts are almost universally used as if only the latest measurement was relevant. Decisions are usually based upon whether the measured child's weight falls within the safe or alarm zone. Our findings from Lesotho indicate that both health workers and mothers can understand the notion of growth rate ("direction of growth"), in spite ofthe fact that foryears, emphasis had been put on the child's weight relative to standards.2 We are grateful for this opportunity to comment on one of the "Guidelines for Action" presented in our article (appendix IIB)3 that stated that mothers should be advised to introduce liquids into the child's diet in the first 3 months of life. These guidelines represented the consensus of the organizations delivering primary health care in Lesotho at the beginning of the study (1985). This recommendation is no longer valid in view of the findings from recent studies done in Brazil,4 Peru,5 and the Philippines,6 which show that the introduction of water, teas, and other nonnutritive liquids before the age of 3 months was associated with increased morbidity
June 1992, Vol. 82, No. 6
and mortality. Educational efforts should thus emphasize exclusive breastfeeding and discourage the introduction of other liquids before the age of 3 months. ] Marie T. Ruel4 PhD Jean-Pierre Habichi, PhD Requests for reprints should be sent to Marie T. Ruel, PhD, Institute of Nutrition of Central America and Panama (INCAP), Calzada Roosevelt, Zone 11, Apartado 1188, Guatemala, Guatemala, Central America.
References 1. Ruel MT. Growth monitoring as an educational tool, an integrating strategy and a source of information: a review of experience. In: Pinstrup-Andersen P, Pelietier D, Alderman H, eds. Beyond Chid SwvivaL Enhancing Chid Growth and Nutition in Developing Countries. Ithaca, NY: Cornell University Press; in press. 2. Ruel MT, Pelletier DL, Habicht JP, Mason JB, Chobokoane CS, Maruping AP. A comparison of mothers' understanding of two growth charts in Lesotho. WHO Bull.
1990;68:483-491.
3. Ruel MT, Pelletier DL, Habicht J-P, Mason JB, Chobokoane CS, Maruping AP. Comparison of two grwth charts in Lesotho: health workers' ability to understand and use them for action. Am J Publc Health.
1991;81:610-616.
4. Victora CG, Smith PG, Vaughan JP, Nobre LC, Lombardi C, Teixeira AMB, Fuchs SC, Moreira LB, Gigante LP, Barros FC. Infant feeding and deaths due to diarrhea. Am J
EpidemioL 1989;129:1032-1041.
5. Brown KH, Black RE, Lopez de Romafia G, Creed de Kanashiro H. Infant-feeding practices and their relationship with diarrheal and other diseases in Huascar (Lima), Peru. Pediat,ics. 1989;83:31-40. 6. Popkin BM, Adair L, Aldn JS, Black R, Briscoe J, Flieger W. Breast-feeding and diarrheal morbidity. Pediatrics. 1990;86:874882.
Arficle on HBV in Cuba Criticized Dr. Pfrez-Stablel misrepresents the Cuban H1V program, misquoting relevant data, describing the program without having visited treatment facilities or interviewed seropositive persons, their friends, their families, or the staff who treated them, as others have done.2-5 Although only two of his cited sources contain quantitative data regarding HIV in Cuba (one World Health Organization report listing AIDS cases only6 and an article in a weekly news magazine7), essential figures quoted-HIVpositive persons (434), persons tested (5, 117, 250), numbers of positive gay/ bisexual males (105), sex distriution (315 men, 119 women), among others-appear in none of his references and are neither 1988 nor 1989 data (for example, by De-
cember 31, 1989, 388, not 434, persons in Cuba had been identified as HIV positive.3 Perez-Stable misuses references in other respects. He claims no legal bases for the program even though it emanated from Cuba's constitution and statutes.8-10 He cites a survey among US Latinos (largely Mexicans and Central Americans)," but not Cuban studies2.12"13 to support his opinions regarding condom purchase and use. He dates public education to 1987 although articles in the Cuban press and health education first appeared in mid-1986. He asserts, without evidence, that HIV seropositivity among certain groups in Cuba was comparable to 0.4%, which is 9 to 14 times greater than any HIV seropositivity reported except for hemophiliacs. He divides numerators by denominators of discordant years and equates number of tests with individuals tested. He copies text and ideas without acknowledgment. Only one example shall be cited here. Compare the extract Awith extracts B & C: A. The programs have varied from innovative pilot projects to Spanish translations of inappropriate European film clips. Nationally televised two-hour programs have featured bland panel formats with experts from the MINSAP. ... Physicians and public health experts wearing their white coats responded to questions using predominantly technical terminology and few graphics to illustrate concepts.', P 565 B. Programs on television have been few ... mostly boring, using Spanish translations of totally inappropriate American or European film clips and panel formats where whitecoated MINSAP physicians answer questions posed by either callers or journalist.14. p 16 C. They have been few and the majority consist of MINSAP functionaries, often dressed in white coats answering questions from the population or journalists, in a monotonous manner, many times in language full of medical terms. 15 p 42
D. Many of the television programs use Spanish translations of totally inappropriate American or European film clips or panel formats in which physicians answer questions posed by either callers or journalists.3. P 531 (This text was written and circulated in 1990, the year before publication.)
Information, apparently from Santana et al.3 is not footnoted. In fact, an omission in that article led Perez-Stable to erroneously date educational broadcasts, thus revealing his uncited source. Public health workers are entitled to informed, detailed discussions of the Cu-
American Journal of Public Health 899
