space, nuclear energy, interest on debt, and veterans' benefits, not to mention subsidies on military grounds for the merchant marine and air transport industries. Health costs deserve an appraisal more rational than these crude budgetary comparisons. In Annals of Internal Medicine (80:645, 1974), Dr. Edward Burger, Jr., of the National Science Foundation's policy office, cites several studies which demonstrate that, while health charges have increased both relatively and absolutely since 1950, life expectancy in the U.S. has not. Health charges have soared at a rate far beyond that of the consumer price index, but average life expectancy after the age of 10 in the U.S. since 1954 has been fairly flat: among males, it has even declined. In contrast, virtually all countries with vital records comparable to ours report longer average lives and a more rapid rate of increase in life expectancy since 1950. Granting that longevity is a flawed index of health status (it matters no less how much we live than how long), these data earn no laurels for the U.S. health system. One factor in the relatively high U.S. death rate is that mortality has been increasing in eight specific categories associated, respectively, with environmental stresses, notably those from air pollution, and with personal habits, i.e., excessive speeding, addiction to drugs or alcohol, overeating, and obsession with hand guns. These causes of death are not attacked by conventional clinical services. The rise in health expenditures, on the other hand, may mean that under social insurance many more patients receive care which makes their life more tolerable even if survival is not prolonged.

Unfortunately, until the facts can be examined extensively and objectively, we cannot know actually what the data mean. It might be assumed, from personal observation, that many clinical and hospital services are extravagant, ineffective, misplaced, or unnecessarily expensive. Such assumptions can be tested only to a degree by professional consensus or careful administrative review. When possible, it is preferable that the test 526

AJPH MAY, 1975, Vol. 65, No. 5

be a well controlled clinical trial, comparable to the Fisher study of breast cancer surgery, to check the economy, validity, or merit of prevailing or innovative practices such as prescriptions of medication or diet, diagnostic procedures, methods of hospital management, or other aspects of health service. It is true that for many health services a rational cost-benefit ratio is not calculable. Presumably such services and others will continue through respect for tradition or in blind faith. In fact, some practices persist which were found to be worthless, obsolete, or even harmful more than 30 years ago. In view of past errors, one wonders whether it is within a nation's capability to be eternally vigilant toward all health services, including the well established and scientifically supported. Still, there seems to be no other way to improve health status at a reasonable cost without constant evaluation and reevaluation of health practices and doctrines. Such evaluation also implies a definition of health goals, one more pragmatic than that approved by the World Health Organization. For example, will we choose to allot priorities, after humanitarian considerations, for the young, the gifted, and the achievers, including mothers, as those most likely to yield social benefits for the costs of the health system? Or shall we provide health services without regard to individual merit but according to the category of eligibility, personal wealth, or social misfortune, i.e., to the wealthy, the insured, the aged, the indigent, the handicapped, the retarded, the physically or mentally defective, the addicted, and those periodically traumatized by their own taste for violence? Shall we favor creative productivity or blind euphoria? Whatever course is followed, all those employed in health services must acknowledge that, for the indefinite future, every time they collect a fee, a wage, or a profit, someone from the Office of Management and Budget in the Executive Office of the President will be looking at the amount and asking, "Is this money necessary?" Marcus Rosenblum, FAPHA

ON DEVELOPMENT OPERATIONS IN MENTAL HEALTH DELIVERY SYSTEMS Dr. May's (AJPH 65:156, February, 1975) conceptualization of the need for the translation of research findings into effective clinical action in mental health services is laudable. Countless efforts have been applied to criticizing and critiquing the state of the art in mental health evaluation and research. Concurrently insufficient attention has been given to the fact that despite available scientific evidence, research findings have not been implemented. Dr. May gives recognition to this predicament and proposes one seemingly plausible solution, the "mental health engineer." However, his suppositions appear overly simplistic. An abundance of empirical research exists amidst a high degree of theoretical incoherence in mental health investigations. The application of isolated methodological findings in the absence of theoretical construct is nonsensical. The grounding of theory seems more exigent than the birth of the new mental health professional. Given a cogent theory, the translation of research findings into program change and the definition of clinical areas for research should not be relegated to an "engineer." Professionals in mental health planning, evaluation, and administration consider the above role as partially descriptive of their endeavors. The addition of a "mental health engineer" only affords one more direction to pass the buck. Finally, I would respond to Dr. May's search for mental health engineers and his question "Does such a man exist?" Given his determination to utilize this new professional, the probabilities of finding an individual with such faultless characteristics would be greatly increased by also considering women in the quest for a

"'superman." Linda J. Webb, MPH Texas Research Institute of Mental Sciences

Letter: On development operations in mental health delivery systems.

space, nuclear energy, interest on debt, and veterans' benefits, not to mention subsidies on military grounds for the merchant marine and air transpor...
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