etters to the Editor
Letters to the Editor wiU be reviewed and are published as space pennits. By submitting a Letter to the Editor, the authorgives pennission forits publication in the JournaL Lettets should not duipcate material being published or submitted elsewhere. Those referring to a recent Journal article should be received within 3 montws of the article's appearance. The Editors reserve the right to edit and abridge and to publish responses. Submit three copies. Both text and references must be ped double-spaced. Text is limited to 400 words. Reprnts can be ordered through the author whose address is listed at the end of the letter.
Eligibility for Indian Health Service Programs Revisited In 1988, the Indian Health Service
severely restricted the access of American Indians to health services by requiring that their tribal governments be "recognized" by the Bureau of Indian Affairs and that the individual reside within the Indian Health Service health-delivery area (42 CFR ch. 1, § 36.12). In spite of the multitude of objections, the Department of Health and Human Services instituted the eligibility criteria changes on October 15, 1988; however, Congress has continued to restrict the use of appropriated funds in the implementation of these regulations, pending further examination.' Prior to 1988, services under the Indian Health Service were for "persons of Indian descent belonging to the Indian community served by the local facilities program." In 1988, the Bureau of Indian Affairs informed the US Senate that over
1042 American Joumal of Public Health
230 non-federally recognized American Indian tnbes were known to exist, with a total membership size of approximately 242 000.2 The requiring of political recognition by the Bureau of Indian Affairs thus eliminates health service access for thousands of eastern US and California American Indians, as well as some isolated communities of Alaskan Natives and any nonrecognized western American Indian tnrbes, while the Indian Health Service Service-Delivery-Area residency requirement eliminates health access for transient and homeless American Indians.3 The Indian Health Service has taken the responsibility ofproviding health services to American Indians and linked it to political recognition by an arm of govemment traditionally inimical to American Indians. This linkage has effectively sentenced many Native American communities to a slow death by eliminating their access to health programs that have helped keep their population alive in the past and that are and will be of vital im-
portance. In a 1987 Amencan Journal of Public Health article, "On Changing Indian Eligibility for Health Care,"4 the authors outline the disastrous effects of the eligibility changes, including the fractionalizing of Indian families based on blood quantum and federal recognition, and the spill-over effect of disenfranchisement. The article identifies the linkage to Bureau of Indian Affairs recognition as "a process of ultimate termination ... of providing organized health benefits." Bashshur, Steeler, and Murphy call the eligibility criteria changes "yet another broken promise." The process used by the Bureau of Indian Affairs to determine which American Indian peoples exist and are recognized as "Indians"-as well as the very assumption that the bureau has the moral
or legal authority to do so-have been the subject of controversy since the bureau initiated its own set of rules (25 CFR part 83) on September 5, 1978. While a few tribal enrollment rosters are controlled by Congress or the Bureau of Indian Affairs through federal regulation, the majority are in the hands of the tnibal government. Tribal governments have always been scrupulous in recognizing Indian status, and so there is no compelling reason to deny them this right. To further complicate the process, the Bureau of Indian Affairs requires the possession of a bureau Certificate of Degree of Indian Blood as eligibility for its programs. The US Department ofEducation requires only tnbal membership. The disastrous 4-year regulatory experiment needs to end while the damage is not yet permanent; and the eligibility criteria used before 1988 need to be put back in place. The American Public Health Association and all health professionals need to publicly support the access of American Indians and Alaskan Natives to desperately needed health services, without political tests such as Bureau of Indian Affairs recognition. C] RidhwdA. Rose, AM Richard A. Rose, MA, who is of Cherokee Indian ancestry, is a health program administrator with the New York State Department of Health, Office of Public Health. The views expressed are the author's and do not represent those of the New York State Department of Health. Requests for reprints should be sent to Richard A. Rose, MA, 123 Elmer Avenue, Schenectady, NY 12308.
References 1. Delayig the Impementation of a Certabi RudleAffectingthePmvirion ofHealth Services by the Indian Health Service, Senate Report No. 100493, 100th Cong, 2nd sess (August 25, 1988). 2. Ov tonFdemlAcbkwwledfgent Pro-
July 1992, Vol. 82, No. 7
Letm to the Editor cess, Senate Hearing No. 100-823, 100th Cong, 2nd sess (May 26, 1988). 3. Indian Healh Care. Washington, DC: US Congress, Office of Technology Assessment; April 1986. 4. Bashshur R, Steeler W, Murphy T. On chaning Indian eligibility for health care. Am J Public Health 1987;77:690-693.
;~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ -~- -
M~~~~~~~1
5
Cocaine Use in Obstetxic Patients Underported It is generally held that pregnant women underreport cocaine use. Two studies provide estimates of underreporting among prenatal patients: in one, 24 to 45% failed to report use'; in another, urine toxicology identified 10 times as many users as did biopsychosocial evaluations.2 We report data from women who delivered at one inner New York City hospital in 1988 without having received prenatal care at that hospital or its affiliates. In this population, information about substance abuse can be elicited only at the time of delivery. Urine samples were screened for cocaine metabolites by Emit (Syva). The assay is sensitive and specific for cocaine use within 2 to 4 days of testing. A woman was defined as testing positive if she or her infant tested positive. Reported cocaine use was obtained by structured research interviews (conducted as part of a study of HIV infection) that asked about cocaine or crack use and the month and year of last use. Of 196 women tested, 153 (78%) were also interviewed at delivery; the remainder refused (6%) or were discharged before they could be interviewed (16%). The mean age of the 153 women was 24.8 years. Sixty percent were Americanbom Blacks and 26% were born in the Caribbean or Latin America. Forty-four percent had graduated from high school. Fifty percent had received prenatal care from physicians or clinics unaffiliated with the delivering hospital; 50%o had received no prenatal care at all. Urine toxicologies taken at delivery were positive for cocaine in 52% of the women; only 16% had reported cocaine or crack use in the month of delivery (Table 1). Among 80 women with positive tests, 28% reported use during the month of delivery and another 26% reported use during pregnancy but not in the delivery month; in total, 76% reported ever using cocaine.
July 1992, Vol. 82, No. 7
~~~
goashwNrY.,ka~~~~~~~~~~~~~~~~~~...........
Our data confirm that cocaine use during pregnancy is greatly underreported. One implication is that research based on report alone is liable to bias in measures of association between cocaine and various outcomes. Furthermore, effects due to cocaine may be attributed erroneously to exposures, such as cigarette smoking, that are correlated with cocaine use but measured with less error. Biologic indicators of exposure such as assays of urine, hair, or meconium3-5 provide a better basis for classification; the latter two are reported to tap exposure over a period of months. Another implication is that, in some populations, reported use at any time in the past may provide a reasonably sensitive and specific screen for identifying current users. If subsequent assessment confirms current drug use, women and infants can be referred to appropriate resources. O Judith Sac koff, MS Jennie lUfrne, PhD Ann Kinney, MS Amos GnneIawm, MD The authors are with the New York State Psychiatric Institute and St. Luke's/Roosevelt Hospital Center, New York, NY. Requests for reprints should be sent to J. Sackoff, MS, New York State Psychiatric Institute, Box 53, 722 West 168th Street, New York, NY 10032.
Acknowledment This project was supported in part by a grant from the US Public Health Service (NIMH/ NIDA MH43520).
References 1. Zuckerman B, Frank DA, Hingson R, et al. Effects of maternal marijuana and cocaine use on fetal growth. N Engi J MeL 1989; 320:762-768.
2. Lurio J, Younge R, Selwyn P. Underdetection of substance abuse. N Engi J Med. 1991;325:1045. Letter. 3. Baumgartner WA, Black CT, Jones PF, Blahd WH. Radioinmunoassay of cocaine in hair: concise communication. J Nucl Med. 1982;23:790-792. 4. HoldenC. Hairyproblemsfornewdrugtesting method. Science. 1990;249:1099-1100. 5. Rodriguez E, Vermund S. Maternal drug use and pediatric HIV infection: a methodologic review. Pediatr AIDS HIV Infect.
1991;2:107-122.
Hazards of Low-Level Lead Exposure Recognized In a letter published in the October 1991Ame,ican Joural ofPublc Heakhk I wrote that childhood lead poisoning was incorrectly defined in a previously published article.1 2 My letter-and another in the same issue3-cited the definition of childhood lead poisoning published by the Centers for Disease Control (CDC) in 1985: "an elevated blood lead (>25 ,ugl dL) with an ethrocyte protoporphyrin (EP) level in whole blood of 35 Pg/dL or greater."4 On October 7, 1991, Dr. Louis W. Sullivan, Secretary of Health and Human Services, announced that the CDC had released new guidelines on preventing childhood lead poisoning.5 Because of scientific evidence on the adverse effects of low-level lead exposure, the 1985 intervention level of 25 ug/dL has been revised downward to 10 ,g/dL. These new guidelines do not explicitly define childhood lead poisoning, since it was impossible to come up with a single definition to meet the needs of all the diverse groups that use the CDC statement. Instead, the new CDC guidelines call for a multi-tier approach to follow-up, with different actions to be taken at different blood
American Journal of Public Health 1043
Letters to the Editor wiU be reviewed and are published as space pennits. By submitting a Letter to the Editor, the authorgives pennission forits publication in the JournaL Lettets should not duipcate material being published or submitted elsewhere. Those referring to a recent Journal article should be received within 3 montws of the article's appearance. The Editors reserve the right to edit and abridge and to publish responses. Submit three copies. Both text and references must be ped double-spaced. Text is limited to 400 words. Reprnts can be ordered through the author whose address is listed at the end of the letter.
Eligibility for Indian Health Service Programs Revisited In 1988, the Indian Health Service
severely restricted the access of American Indians to health services by requiring that their tribal governments be "recognized" by the Bureau of Indian Affairs and that the individual reside within the Indian Health Service health-delivery area (42 CFR ch. 1, § 36.12). In spite of the multitude of objections, the Department of Health and Human Services instituted the eligibility criteria changes on October 15, 1988; however, Congress has continued to restrict the use of appropriated funds in the implementation of these regulations, pending further examination.' Prior to 1988, services under the Indian Health Service were for "persons of Indian descent belonging to the Indian community served by the local facilities program." In 1988, the Bureau of Indian Affairs informed the US Senate that over
1042 American Joumal of Public Health
230 non-federally recognized American Indian tnbes were known to exist, with a total membership size of approximately 242 000.2 The requiring of political recognition by the Bureau of Indian Affairs thus eliminates health service access for thousands of eastern US and California American Indians, as well as some isolated communities of Alaskan Natives and any nonrecognized western American Indian tnrbes, while the Indian Health Service Service-Delivery-Area residency requirement eliminates health access for transient and homeless American Indians.3 The Indian Health Service has taken the responsibility ofproviding health services to American Indians and linked it to political recognition by an arm of govemment traditionally inimical to American Indians. This linkage has effectively sentenced many Native American communities to a slow death by eliminating their access to health programs that have helped keep their population alive in the past and that are and will be of vital im-
portance. In a 1987 Amencan Journal of Public Health article, "On Changing Indian Eligibility for Health Care,"4 the authors outline the disastrous effects of the eligibility changes, including the fractionalizing of Indian families based on blood quantum and federal recognition, and the spill-over effect of disenfranchisement. The article identifies the linkage to Bureau of Indian Affairs recognition as "a process of ultimate termination ... of providing organized health benefits." Bashshur, Steeler, and Murphy call the eligibility criteria changes "yet another broken promise." The process used by the Bureau of Indian Affairs to determine which American Indian peoples exist and are recognized as "Indians"-as well as the very assumption that the bureau has the moral
or legal authority to do so-have been the subject of controversy since the bureau initiated its own set of rules (25 CFR part 83) on September 5, 1978. While a few tribal enrollment rosters are controlled by Congress or the Bureau of Indian Affairs through federal regulation, the majority are in the hands of the tnibal government. Tribal governments have always been scrupulous in recognizing Indian status, and so there is no compelling reason to deny them this right. To further complicate the process, the Bureau of Indian Affairs requires the possession of a bureau Certificate of Degree of Indian Blood as eligibility for its programs. The US Department ofEducation requires only tnbal membership. The disastrous 4-year regulatory experiment needs to end while the damage is not yet permanent; and the eligibility criteria used before 1988 need to be put back in place. The American Public Health Association and all health professionals need to publicly support the access of American Indians and Alaskan Natives to desperately needed health services, without political tests such as Bureau of Indian Affairs recognition. C] RidhwdA. Rose, AM Richard A. Rose, MA, who is of Cherokee Indian ancestry, is a health program administrator with the New York State Department of Health, Office of Public Health. The views expressed are the author's and do not represent those of the New York State Department of Health. Requests for reprints should be sent to Richard A. Rose, MA, 123 Elmer Avenue, Schenectady, NY 12308.
References 1. Delayig the Impementation of a Certabi RudleAffectingthePmvirion ofHealth Services by the Indian Health Service, Senate Report No. 100493, 100th Cong, 2nd sess (August 25, 1988). 2. Ov tonFdemlAcbkwwledfgent Pro-
July 1992, Vol. 82, No. 7
Letm to the Editor cess, Senate Hearing No. 100-823, 100th Cong, 2nd sess (May 26, 1988). 3. Indian Healh Care. Washington, DC: US Congress, Office of Technology Assessment; April 1986. 4. Bashshur R, Steeler W, Murphy T. On chaning Indian eligibility for health care. Am J Public Health 1987;77:690-693.
;~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ -~- -
M~~~~~~~1
5
Cocaine Use in Obstetxic Patients Underported It is generally held that pregnant women underreport cocaine use. Two studies provide estimates of underreporting among prenatal patients: in one, 24 to 45% failed to report use'; in another, urine toxicology identified 10 times as many users as did biopsychosocial evaluations.2 We report data from women who delivered at one inner New York City hospital in 1988 without having received prenatal care at that hospital or its affiliates. In this population, information about substance abuse can be elicited only at the time of delivery. Urine samples were screened for cocaine metabolites by Emit (Syva). The assay is sensitive and specific for cocaine use within 2 to 4 days of testing. A woman was defined as testing positive if she or her infant tested positive. Reported cocaine use was obtained by structured research interviews (conducted as part of a study of HIV infection) that asked about cocaine or crack use and the month and year of last use. Of 196 women tested, 153 (78%) were also interviewed at delivery; the remainder refused (6%) or were discharged before they could be interviewed (16%). The mean age of the 153 women was 24.8 years. Sixty percent were Americanbom Blacks and 26% were born in the Caribbean or Latin America. Forty-four percent had graduated from high school. Fifty percent had received prenatal care from physicians or clinics unaffiliated with the delivering hospital; 50%o had received no prenatal care at all. Urine toxicologies taken at delivery were positive for cocaine in 52% of the women; only 16% had reported cocaine or crack use in the month of delivery (Table 1). Among 80 women with positive tests, 28% reported use during the month of delivery and another 26% reported use during pregnancy but not in the delivery month; in total, 76% reported ever using cocaine.
July 1992, Vol. 82, No. 7
~~~
goashwNrY.,ka~~~~~~~~~~~~~~~~~~...........
Our data confirm that cocaine use during pregnancy is greatly underreported. One implication is that research based on report alone is liable to bias in measures of association between cocaine and various outcomes. Furthermore, effects due to cocaine may be attributed erroneously to exposures, such as cigarette smoking, that are correlated with cocaine use but measured with less error. Biologic indicators of exposure such as assays of urine, hair, or meconium3-5 provide a better basis for classification; the latter two are reported to tap exposure over a period of months. Another implication is that, in some populations, reported use at any time in the past may provide a reasonably sensitive and specific screen for identifying current users. If subsequent assessment confirms current drug use, women and infants can be referred to appropriate resources. O Judith Sac koff, MS Jennie lUfrne, PhD Ann Kinney, MS Amos GnneIawm, MD The authors are with the New York State Psychiatric Institute and St. Luke's/Roosevelt Hospital Center, New York, NY. Requests for reprints should be sent to J. Sackoff, MS, New York State Psychiatric Institute, Box 53, 722 West 168th Street, New York, NY 10032.
Acknowledment This project was supported in part by a grant from the US Public Health Service (NIMH/ NIDA MH43520).
References 1. Zuckerman B, Frank DA, Hingson R, et al. Effects of maternal marijuana and cocaine use on fetal growth. N Engi J MeL 1989; 320:762-768.
2. Lurio J, Younge R, Selwyn P. Underdetection of substance abuse. N Engi J Med. 1991;325:1045. Letter. 3. Baumgartner WA, Black CT, Jones PF, Blahd WH. Radioinmunoassay of cocaine in hair: concise communication. J Nucl Med. 1982;23:790-792. 4. HoldenC. Hairyproblemsfornewdrugtesting method. Science. 1990;249:1099-1100. 5. Rodriguez E, Vermund S. Maternal drug use and pediatric HIV infection: a methodologic review. Pediatr AIDS HIV Infect.
1991;2:107-122.
Hazards of Low-Level Lead Exposure Recognized In a letter published in the October 1991Ame,ican Joural ofPublc Heakhk I wrote that childhood lead poisoning was incorrectly defined in a previously published article.1 2 My letter-and another in the same issue3-cited the definition of childhood lead poisoning published by the Centers for Disease Control (CDC) in 1985: "an elevated blood lead (>25 ,ugl dL) with an ethrocyte protoporphyrin (EP) level in whole blood of 35 Pg/dL or greater."4 On October 7, 1991, Dr. Louis W. Sullivan, Secretary of Health and Human Services, announced that the CDC had released new guidelines on preventing childhood lead poisoning.5 Because of scientific evidence on the adverse effects of low-level lead exposure, the 1985 intervention level of 25 ug/dL has been revised downward to 10 ,g/dL. These new guidelines do not explicitly define childhood lead poisoning, since it was impossible to come up with a single definition to meet the needs of all the diverse groups that use the CDC statement. Instead, the new CDC guidelines call for a multi-tier approach to follow-up, with different actions to be taken at different blood
American Journal of Public Health 1043
