Editorial
edit Notes from the Field. You may contact these editors directly for further information. We have begun to computerize the reviewer data base in order to expedite the review process. This change is taking somewhat longer than anticipated which, coupled with changes in office personnel, resulted in delays in the processing of manuscripts. The reviewers' system is
mostly in place, and the staffing of the offices in Washington and Chapel Hill is almost complete; I anticipate no further delays in the Journal's business. Finally, this is a good time and place to thank our readers, authors, reviewers, and members of the Editorial Board for their continued interest in the Joumal. In the months and years ahead, I will be calling on you to review papers, write policy
pieces and editorials, and, of course, to solicit your opinion and counsel on important issues. The Journal can only function with the "labor of love" you so generously give. O Michel A. brohim, MD, PhD Edior Dr. Ibrahim is Dean, School of Public Health, University ofNorth Carolina, Chapel Hill, NC.
What Makes Infant Mortality Rates Fall in Developing Counties? "We have gathered at the World Summit for Children to undertake a joint commitment and to make an urgent universal appeal-to give every child a better future .... Child and infant mortality is unacceptably high in many parts of the world, but can be lowered dramatically with means that are already known and acceptable."'1 So declared the leaders of more than 70 nations at the recent World Summit for Children held in New York City. In this issue of the Journal, Peter Sandiford and his colleagues attempt to discover why infant mortality rates fall by examining the experience of Nicaragua from 1960 to 1986.2 Do their analyses and conclusions hold lessons forworld leaders as they prepare to discharge their commitment? The data which Sandiford, et all use in their analyses are all drawn from original sources and their limitations are assessed. Changes in income, nutrition, breast-feeding, maternal education, the modalities and infrastructures of the health services, and environmental sanitation are measured using available data. For public health workers, however, the most unusual data are the infant mortality estimates. Nicaragua has been a prime example of the inaccuracy of reported infant mortality rates in developing countries. For example, in 1964, Nicaragua's "reported" infant mortality rate was 49.7-twice as high as the United States rate of 24.8.3 However, Nicaragua's reported neonatal mortality rate was only 10.9, 39 percent lower than the United State's rate of 17.9 in that year.3 Wisely, Sandiford, et al, like the Pan American Health Organization in its most recent publication,4 have chosen to ignore "reported" infant mortality rates and rely upon calculations used by demographers and based on survey-derived ratios of sur-
12 American Journal of Public Health
viving to ever born children. The infant mortality rates resulting from these calculations are generally three to four times as high as the "reported" rates. These estimates may be too high, and do not take into account changes in the completeness of the death records during the 26 years covered. However, they show a continuing and consistent downward trend more marked after 1975, so that the estimated rate in 1986 is half what it was in 1960. The Somoza regime was not overthrown until 1979, by which time the estimated infant mortality had already begun its sharp decline. Although the 1-4 year mortality is now increasingly accepted as a more precise indicator of population health and socio-economic status,5 infant mortality has been considered as such an indicator for many years. There can be no doubt that Nicaragua's infant mortality fell during these 26 years, a phenomenon by no means unique to Nicaragua, but equally evident in many other Latin American countries.4 Sandiford, et al, although recognizing that "more than one factor may be involved," appear to ascnibe the declining rate in Nicaragua to improved access to health services. They believe that Somoza "sensing that the ground was slipping out from under him" invested heavily (with substantial United States aid) in social programs beginning in 197475, and that this accounts for the onset of the rapid decline at that time. There can be no doubt that health services access and health manpower resources improved after the Sandinistas came to power.6 The improvement is evident not only in manpower overall but in the shift of manpower from hospitals to primary care2 and in the expansion of social security coverage.7 The reduction in hospital beds per 1,000 population was not unique to Nicaragua, however, and has been noted in other Latin American coun-
tries.8 Nevertheless, the operation of other factors cannot easily be ignored. For example, although Sandiford, et at point out that the per capita Gross National Product (GNP) was stagnant during the 1970s and fell during the 1980s, the GNP measures overall national production rather than the distribution of resources within society and its social programs. There is little doubt that this distribution changed in the expected direction. Indeed, the authors themselves recognize that the nutritional status of children improved while food production was decreasing.2 Improved infant nutritional status probably contributed to the decline in the infant death rate. There is clear evidence that the level of maternal education is directly related to the infant mortality rate.9 The adult illiteracy rate of women in Nicaragua was 50 percent in 1963 and 26 percent in 19852 so that the influence of this factor on the infant death rate cannot be discounted. During the Sandinista regime, immunization coverage may have contnbuted slightly to declining infant deaths although it would tend to have a greater impact on the 1-4 year mortality. Oral rehydration units increased under the Sandinistas from 23 in 1979 to 334 in 1982, and in-hospital mortality from diarrhea had dropped from first to fifth place by 1983.10 However, reported infant deaths from diarrhea increased from 1,035 in 1985 to 1,285 in 1987,11 perhaps due to the increased ferocity of attacks against health facilities and personnel by the US-supported Contras.12 In short, one must agree with the Roemers that the declining infant mortality rates, not only in Latin America but also in South Asia, Africa, and Europe, "are not easy to interpret."'13 Yet one point stands out in this analysis of the Nicaraguan experience. The initiation of the rapid decline coincides
January 1991, Vol. 81, No. 1
Editorials
with a strengthening of the infrastructure designed to provide primary care including improved nutrition. Neither oral rehydration nor immunization coverage, two of the pillars of the current drive for "Health for all by the year 2,000," were operative in 1975, although they probably played a part in the latter years of the decline. Neither breastfeeding nor improved environmental sanitation contnbuted to the decline's initiation or continuum. There are two principal lessons to be learned from the Nicaraguan experience. First, the infrastructure to deliver primary care of any sort must be in place before the care can be delivered. Second, as the Roemers also point out,13 a government must be committed to health as one of its
priorities. In 1990, the Sandinista regime was replaced by a new government whose commitment to health will be watched with interest. As Sandiford, et al, noted, the infant mortality rate will continue to
monitor the effects of any policy change on child health and survival. [] Dieter Koch- Weser PhD, MD Alfiw Yankauer MD, MPH
References 1. Excerpts from the United Nations Declaration on Children. New York Times Oct 1 1990; A12 (col 1). 2. Sandiford P, Morales P, GarterA, Coyle E, Smith GD: Why do child mortality rates fall? An analysis of the Nicaraguan experience. Am J Public Health 1991; 81:30-37. 3. Pan American Health Organization: Health conditions in the Americas 1961-1964. Washington, DC: PAHO-WHO Scientific Pub. No. 138, 1966;38. 4. Pan American Health Organization: Health conditions in the Americas. 1990 edition. Washington, DC: PAHO-WHO Scientific Pub. No. 524, 1990; Vol. 1: 52-55. 5. Pan American Health Organization: Health conditions in the Americas, 1990 edition. (vol I) op. cit. p. 68. 6. Garfield RM, Taboado E: Health service reforms in revolutionary Nicaragua. Am J Public Health 1984; 74:1138-1144. 7. Pan American Health Organization: Health
8. 9. 10.
11. 12.
13.
conditions in the Americas, 1990 edition. (vol II) op. cit. p. 213. Pan American Health Organization: Health conditions in the Americas, 1990 edition. (vol I) op. cit., p 267. Pan American Health Organization: Health conditions in the Americas, 1990 edition. (vol I) op. cit. pp. 63-66. Tercero E: Oral Rehydration in Nicaragua. Three years of experience. Proceedings of the international conference on oral rehydration therapy, June 7-10,1983. Washington, DC Agency for International Development, 1984; 83-87. Pan American Health Organization: Health conditions in the Americas, 1990 edition. (vol I) op. cit., p. 217. Garfield R, Frieden T, Vermund SH: Health related outcomes of war in Nicaragua. Am J Public Health 1987; 77:615-618. Roemer MI, Roemer R: Global health and the role of government. Am J Public Health 1990; 80:1188-1192.
Address reprint requests to Dieter KochWeser, MD, PhD, Education Development Center, 55 Chapel Street, Newton, MA 02160. Dr. Yankauer is the former editor of this Journal.
Social Origins, Medical Education, and Medical Practice Education of health professionals is a high cost undertaking that society has learned to accept as essential, to some degree at least, because the need for health care is so pervasive and so urgent. Developing countries have an especially difficult time with these expenses because of the many other demands on public funds and the very high cost of medical education to the state, regardless of who pays the tuition fees. For all countries, moreover, the need to recoup the investment has put increasing emphasis on proper utilization of medical graduates. In this issue of the Journal, Julio Frenk and his colleagues have made an unusual contribution to international studies of health manpower development by analyzing the situation ofmedical employment and unemployment in Mexico today.' Their report is a fine example of the fact that international transfer of technology and information is a two-way street, a concept underlined in the recent shift in World Health Organization terminology from technical assistance, implying an hierarchical relationship, to technical cooperation, suggesting more of a partnership. The observations and conclusions of this study surely have relevance for many other countries, including those with socalled developed as well as developing
January 1991, Vol. 81, No. 1
economies. It is all too frequent to be faced with the paradox of "coexistence of underemployed physicians and underserved populations." Mexico has experienced a massive growth in medical schools and medical graduates since 1967. The growth was stimulated in part by two hardly unique factors-increased demand for higher education from the middle classes, and an enduring economic crisis that made university studies an attractive alternative to unemployment. As a result, a six-fold increase in the total number of physicians took place in Mexico in the quarter century between 1960 and 1985. Over the same period, there was a doubling of the population so that the proportion of available physicians reached 153 per 100,000 population. This is hardly an excessive number, yet the Frenk group, in a study based on Mexico's National Survey of Urban Employment-a well documented and regularly visited sample of 41,000 householdsfound that 22 percent of Mexican holders of a medical degree were either quantitatively or qualitatively underemployed and an additional 7 percent had no medical employment at all. Physicians were classified into those working at only one task (either independent practice or a single salaried job), those who had multiple employment
(which might be any combination of salaried and independent occupations), those who were qualitatively or quantitatively underemployed, and those not engaged in medicine. Thus, almost one-third of medical graduates were not properly utilizing their costly education; at the same time, nearly 10 million people, 11 percent of the Mexican population, had inadequate access to medical care. To look for policy implications that could lead to corrective action, the authors examined such factors as social origins, gender, caliber of medical school attended, year of entering medial practice, and specialization, if any. Among their many interesting findings was that a substantially higher proportion of recent graduates were un- or underemployed; this was true of 42 percent of those graduating after 1970 against 15 percent of older physicians. A similar observation was made for women, who have constituted a far higher proportion of medical students in recent years. Not surprisingly, an even higher proportion of those without a specialty and of those who were graduates of medical schools that were classified by independent observers as "inadequate" were not being properly used. Some ofthe most cogent observations made by Frenk and colleagues relate to so-
American Journal of Public Health 13
edit Notes from the Field. You may contact these editors directly for further information. We have begun to computerize the reviewer data base in order to expedite the review process. This change is taking somewhat longer than anticipated which, coupled with changes in office personnel, resulted in delays in the processing of manuscripts. The reviewers' system is
mostly in place, and the staffing of the offices in Washington and Chapel Hill is almost complete; I anticipate no further delays in the Journal's business. Finally, this is a good time and place to thank our readers, authors, reviewers, and members of the Editorial Board for their continued interest in the Joumal. In the months and years ahead, I will be calling on you to review papers, write policy
pieces and editorials, and, of course, to solicit your opinion and counsel on important issues. The Journal can only function with the "labor of love" you so generously give. O Michel A. brohim, MD, PhD Edior Dr. Ibrahim is Dean, School of Public Health, University ofNorth Carolina, Chapel Hill, NC.
What Makes Infant Mortality Rates Fall in Developing Counties? "We have gathered at the World Summit for Children to undertake a joint commitment and to make an urgent universal appeal-to give every child a better future .... Child and infant mortality is unacceptably high in many parts of the world, but can be lowered dramatically with means that are already known and acceptable."'1 So declared the leaders of more than 70 nations at the recent World Summit for Children held in New York City. In this issue of the Journal, Peter Sandiford and his colleagues attempt to discover why infant mortality rates fall by examining the experience of Nicaragua from 1960 to 1986.2 Do their analyses and conclusions hold lessons forworld leaders as they prepare to discharge their commitment? The data which Sandiford, et all use in their analyses are all drawn from original sources and their limitations are assessed. Changes in income, nutrition, breast-feeding, maternal education, the modalities and infrastructures of the health services, and environmental sanitation are measured using available data. For public health workers, however, the most unusual data are the infant mortality estimates. Nicaragua has been a prime example of the inaccuracy of reported infant mortality rates in developing countries. For example, in 1964, Nicaragua's "reported" infant mortality rate was 49.7-twice as high as the United States rate of 24.8.3 However, Nicaragua's reported neonatal mortality rate was only 10.9, 39 percent lower than the United State's rate of 17.9 in that year.3 Wisely, Sandiford, et al, like the Pan American Health Organization in its most recent publication,4 have chosen to ignore "reported" infant mortality rates and rely upon calculations used by demographers and based on survey-derived ratios of sur-
12 American Journal of Public Health
viving to ever born children. The infant mortality rates resulting from these calculations are generally three to four times as high as the "reported" rates. These estimates may be too high, and do not take into account changes in the completeness of the death records during the 26 years covered. However, they show a continuing and consistent downward trend more marked after 1975, so that the estimated rate in 1986 is half what it was in 1960. The Somoza regime was not overthrown until 1979, by which time the estimated infant mortality had already begun its sharp decline. Although the 1-4 year mortality is now increasingly accepted as a more precise indicator of population health and socio-economic status,5 infant mortality has been considered as such an indicator for many years. There can be no doubt that Nicaragua's infant mortality fell during these 26 years, a phenomenon by no means unique to Nicaragua, but equally evident in many other Latin American countries.4 Sandiford, et al, although recognizing that "more than one factor may be involved," appear to ascnibe the declining rate in Nicaragua to improved access to health services. They believe that Somoza "sensing that the ground was slipping out from under him" invested heavily (with substantial United States aid) in social programs beginning in 197475, and that this accounts for the onset of the rapid decline at that time. There can be no doubt that health services access and health manpower resources improved after the Sandinistas came to power.6 The improvement is evident not only in manpower overall but in the shift of manpower from hospitals to primary care2 and in the expansion of social security coverage.7 The reduction in hospital beds per 1,000 population was not unique to Nicaragua, however, and has been noted in other Latin American coun-
tries.8 Nevertheless, the operation of other factors cannot easily be ignored. For example, although Sandiford, et at point out that the per capita Gross National Product (GNP) was stagnant during the 1970s and fell during the 1980s, the GNP measures overall national production rather than the distribution of resources within society and its social programs. There is little doubt that this distribution changed in the expected direction. Indeed, the authors themselves recognize that the nutritional status of children improved while food production was decreasing.2 Improved infant nutritional status probably contributed to the decline in the infant death rate. There is clear evidence that the level of maternal education is directly related to the infant mortality rate.9 The adult illiteracy rate of women in Nicaragua was 50 percent in 1963 and 26 percent in 19852 so that the influence of this factor on the infant death rate cannot be discounted. During the Sandinista regime, immunization coverage may have contnbuted slightly to declining infant deaths although it would tend to have a greater impact on the 1-4 year mortality. Oral rehydration units increased under the Sandinistas from 23 in 1979 to 334 in 1982, and in-hospital mortality from diarrhea had dropped from first to fifth place by 1983.10 However, reported infant deaths from diarrhea increased from 1,035 in 1985 to 1,285 in 1987,11 perhaps due to the increased ferocity of attacks against health facilities and personnel by the US-supported Contras.12 In short, one must agree with the Roemers that the declining infant mortality rates, not only in Latin America but also in South Asia, Africa, and Europe, "are not easy to interpret."'13 Yet one point stands out in this analysis of the Nicaraguan experience. The initiation of the rapid decline coincides
January 1991, Vol. 81, No. 1
Editorials
with a strengthening of the infrastructure designed to provide primary care including improved nutrition. Neither oral rehydration nor immunization coverage, two of the pillars of the current drive for "Health for all by the year 2,000," were operative in 1975, although they probably played a part in the latter years of the decline. Neither breastfeeding nor improved environmental sanitation contnbuted to the decline's initiation or continuum. There are two principal lessons to be learned from the Nicaraguan experience. First, the infrastructure to deliver primary care of any sort must be in place before the care can be delivered. Second, as the Roemers also point out,13 a government must be committed to health as one of its
priorities. In 1990, the Sandinista regime was replaced by a new government whose commitment to health will be watched with interest. As Sandiford, et al, noted, the infant mortality rate will continue to
monitor the effects of any policy change on child health and survival. [] Dieter Koch- Weser PhD, MD Alfiw Yankauer MD, MPH
References 1. Excerpts from the United Nations Declaration on Children. New York Times Oct 1 1990; A12 (col 1). 2. Sandiford P, Morales P, GarterA, Coyle E, Smith GD: Why do child mortality rates fall? An analysis of the Nicaraguan experience. Am J Public Health 1991; 81:30-37. 3. Pan American Health Organization: Health conditions in the Americas 1961-1964. Washington, DC: PAHO-WHO Scientific Pub. No. 138, 1966;38. 4. Pan American Health Organization: Health conditions in the Americas. 1990 edition. Washington, DC: PAHO-WHO Scientific Pub. No. 524, 1990; Vol. 1: 52-55. 5. Pan American Health Organization: Health conditions in the Americas, 1990 edition. (vol I) op. cit. p. 68. 6. Garfield RM, Taboado E: Health service reforms in revolutionary Nicaragua. Am J Public Health 1984; 74:1138-1144. 7. Pan American Health Organization: Health
8. 9. 10.
11. 12.
13.
conditions in the Americas, 1990 edition. (vol II) op. cit. p. 213. Pan American Health Organization: Health conditions in the Americas, 1990 edition. (vol I) op. cit., p 267. Pan American Health Organization: Health conditions in the Americas, 1990 edition. (vol I) op. cit. pp. 63-66. Tercero E: Oral Rehydration in Nicaragua. Three years of experience. Proceedings of the international conference on oral rehydration therapy, June 7-10,1983. Washington, DC Agency for International Development, 1984; 83-87. Pan American Health Organization: Health conditions in the Americas, 1990 edition. (vol I) op. cit., p. 217. Garfield R, Frieden T, Vermund SH: Health related outcomes of war in Nicaragua. Am J Public Health 1987; 77:615-618. Roemer MI, Roemer R: Global health and the role of government. Am J Public Health 1990; 80:1188-1192.
Address reprint requests to Dieter KochWeser, MD, PhD, Education Development Center, 55 Chapel Street, Newton, MA 02160. Dr. Yankauer is the former editor of this Journal.
Social Origins, Medical Education, and Medical Practice Education of health professionals is a high cost undertaking that society has learned to accept as essential, to some degree at least, because the need for health care is so pervasive and so urgent. Developing countries have an especially difficult time with these expenses because of the many other demands on public funds and the very high cost of medical education to the state, regardless of who pays the tuition fees. For all countries, moreover, the need to recoup the investment has put increasing emphasis on proper utilization of medical graduates. In this issue of the Journal, Julio Frenk and his colleagues have made an unusual contribution to international studies of health manpower development by analyzing the situation ofmedical employment and unemployment in Mexico today.' Their report is a fine example of the fact that international transfer of technology and information is a two-way street, a concept underlined in the recent shift in World Health Organization terminology from technical assistance, implying an hierarchical relationship, to technical cooperation, suggesting more of a partnership. The observations and conclusions of this study surely have relevance for many other countries, including those with socalled developed as well as developing
January 1991, Vol. 81, No. 1
economies. It is all too frequent to be faced with the paradox of "coexistence of underemployed physicians and underserved populations." Mexico has experienced a massive growth in medical schools and medical graduates since 1967. The growth was stimulated in part by two hardly unique factors-increased demand for higher education from the middle classes, and an enduring economic crisis that made university studies an attractive alternative to unemployment. As a result, a six-fold increase in the total number of physicians took place in Mexico in the quarter century between 1960 and 1985. Over the same period, there was a doubling of the population so that the proportion of available physicians reached 153 per 100,000 population. This is hardly an excessive number, yet the Frenk group, in a study based on Mexico's National Survey of Urban Employment-a well documented and regularly visited sample of 41,000 householdsfound that 22 percent of Mexican holders of a medical degree were either quantitatively or qualitatively underemployed and an additional 7 percent had no medical employment at all. Physicians were classified into those working at only one task (either independent practice or a single salaried job), those who had multiple employment
(which might be any combination of salaried and independent occupations), those who were qualitatively or quantitatively underemployed, and those not engaged in medicine. Thus, almost one-third of medical graduates were not properly utilizing their costly education; at the same time, nearly 10 million people, 11 percent of the Mexican population, had inadequate access to medical care. To look for policy implications that could lead to corrective action, the authors examined such factors as social origins, gender, caliber of medical school attended, year of entering medial practice, and specialization, if any. Among their many interesting findings was that a substantially higher proportion of recent graduates were un- or underemployed; this was true of 42 percent of those graduating after 1970 against 15 percent of older physicians. A similar observation was made for women, who have constituted a far higher proportion of medical students in recent years. Not surprisingly, an even higher proportion of those without a specialty and of those who were graduates of medical schools that were classified by independent observers as "inadequate" were not being properly used. Some ofthe most cogent observations made by Frenk and colleagues relate to so-
American Journal of Public Health 13
