LETTERS TO THE EDITOR
must be fought vigorously in the interest of justice to the medical profession. William J. Curran, JD, LLM, SM Hyg Frances Glessner Lee Professor of Legal Medicine Harvard School ofPublic Health Boston, MA
On Health Services in Day Care Centers The recent AJPH article by Chang, et all on health services in day care centers, while timely, is regrettably limited to the licensed day care centers. Although most educators and public health officials place a high value on the need for the services of health coor-
dinators, speech therapists, social workers, dentists, etc., in day care centers, it is becoming more difficult to persuade the cost-conscious legislators at the state or national level that these services are essential. They criticize the cost of licensed day care centers, estimated at + $2,000 annually, and urge, instead, more use of family day care or baby sitting which can be secured for $300-$500 less by foregoing staff training, health services, lower staff-child ratios, hot meals, and the like. Family day care, currently the hottest item in the bureaucrat's bag of budgetary tricks to lower the cost of social services, is defined as in-home care, given usually by a mother of one or two small children to two to six other children. These mothers are seldom trained or supervised, let alone equipped to diagnose health problems or refer parents to proper specialists. More worrisome is the unknown quality of the baby sitters being used by working mothers of small children. The number of mothers leaving children to go to work has increased dramatically in recent years and many are single parents with lowest incomes. In 1975, seven million children under six years of age had mothers in the working force.2 How many of these children are adequately cared for, to say nothing of having their health needs met, is the critical question and there is very little hard data.3 Today's priority, then, is not to address the health services in organized AJPH October, 1978, Vol. 68, No. 10
day care centers, but to identify those children in family day care and unsupervised baby sitting situations and look closely at their health needs. This can be done by seeking out the mothers where they work to ascertain where and how their children are being cared for. I submit we will find some serious health problems in a population that has not yet been fully covered despite the combined efforts of EPSDT, CHAP, research such as that of Chang's, etc. Helen R. Patterson Field Consultant National Action for Foster Children (of Milwaukee) 80 Beckwith Terrace Rochester, NY 14610
REFERENCES 1. Chang A. Zukerman S and Wallace H: Health services needs of children in day care centers, Am J Public Health 68: 373-377, 1978. 2. Toward a National Policy for Children and Families, National Academy of Sciences, Washington, DC, 1976, p. 73. 3. op. cit. pp. 67-69.
Dr. Chang's Response Ms. Patterson certainly is correct in directing our attention to the health services needs of the large and growing number of children cared for in licensed (the minority) and unlicensed (the majority) family day care homes. One could dispute her implication, however, that family day care per se precludes "staff training, health services, lower staff-child ratios, hot meals, and the like."'1 2 It can be conceded that very little is known about the health and health services needs of children cared for in this setting. Since the majority of these children come from families with economic hardships it would not come as a surprise that these children are in need not only of additional health services but also social and financial services. We have surveyed the licensed family day care homes in Berkeley and have also documented needs in adequacy of health records, availability of health policies and guidelines, care for sick children, management of behavioral problems, etc.3 We need such documentation in order to propose alterna-
tives to meeting these unmet needs. However, this should not mean that there is no value in research that looks at children in all care settings. Albert Chang, MD, MPH Assistant Professor School of Public Health University of California Berkeley
REFERENCES 1. Sale JS: Family day care-Potential child development service. Am J Public Health 62:668-70, 1972. 2. Rauch MD and Crowell DC: Toward High Quality Family Day Care for Infants and Toddlers, Final Report of the Infant Satellite Nurseries Project-Department of Human Development, University of Hawaii, Honolulu, Hawaii, 1974. 3. Chang A: Health Services Needs in Licensed Family Day Care Homes (Submitted for Publication).
Comment on 'Health Status Indices and Access to Medical Care' In his paper1 published in the May 1978 issue of the American Journal of Public Health, Andersen presented two indices purporting to measure access to medical care. It is argued here that major flaws with the indices tend to lessen their utility. The use-disability ratio is the mean number of physician visits as a fraction of the mean number of disability days in a population times 100. This formulation suggests that the worst possible situation is reflected in a ratio value of zero and the best possible situation in a ratio value of 100. Herein lies the problem. Should the best possible situation be represented by a ratio value of 100? This value implies that for one day of disability there should be one physician visit. For a self-limiting condition, such as influenza, a physician usually advises his patients to stay home unless complications arise. Does it mean that these patients have an access problem just because their days of disability do not match their physician visits? After all, there is such a thing as over-utilization of health services. The symptom-response ratio is 1027
must be fought vigorously in the interest of justice to the medical profession. William J. Curran, JD, LLM, SM Hyg Frances Glessner Lee Professor of Legal Medicine Harvard School ofPublic Health Boston, MA
On Health Services in Day Care Centers The recent AJPH article by Chang, et all on health services in day care centers, while timely, is regrettably limited to the licensed day care centers. Although most educators and public health officials place a high value on the need for the services of health coor-
dinators, speech therapists, social workers, dentists, etc., in day care centers, it is becoming more difficult to persuade the cost-conscious legislators at the state or national level that these services are essential. They criticize the cost of licensed day care centers, estimated at + $2,000 annually, and urge, instead, more use of family day care or baby sitting which can be secured for $300-$500 less by foregoing staff training, health services, lower staff-child ratios, hot meals, and the like. Family day care, currently the hottest item in the bureaucrat's bag of budgetary tricks to lower the cost of social services, is defined as in-home care, given usually by a mother of one or two small children to two to six other children. These mothers are seldom trained or supervised, let alone equipped to diagnose health problems or refer parents to proper specialists. More worrisome is the unknown quality of the baby sitters being used by working mothers of small children. The number of mothers leaving children to go to work has increased dramatically in recent years and many are single parents with lowest incomes. In 1975, seven million children under six years of age had mothers in the working force.2 How many of these children are adequately cared for, to say nothing of having their health needs met, is the critical question and there is very little hard data.3 Today's priority, then, is not to address the health services in organized AJPH October, 1978, Vol. 68, No. 10
day care centers, but to identify those children in family day care and unsupervised baby sitting situations and look closely at their health needs. This can be done by seeking out the mothers where they work to ascertain where and how their children are being cared for. I submit we will find some serious health problems in a population that has not yet been fully covered despite the combined efforts of EPSDT, CHAP, research such as that of Chang's, etc. Helen R. Patterson Field Consultant National Action for Foster Children (of Milwaukee) 80 Beckwith Terrace Rochester, NY 14610
REFERENCES 1. Chang A. Zukerman S and Wallace H: Health services needs of children in day care centers, Am J Public Health 68: 373-377, 1978. 2. Toward a National Policy for Children and Families, National Academy of Sciences, Washington, DC, 1976, p. 73. 3. op. cit. pp. 67-69.
Dr. Chang's Response Ms. Patterson certainly is correct in directing our attention to the health services needs of the large and growing number of children cared for in licensed (the minority) and unlicensed (the majority) family day care homes. One could dispute her implication, however, that family day care per se precludes "staff training, health services, lower staff-child ratios, hot meals, and the like."'1 2 It can be conceded that very little is known about the health and health services needs of children cared for in this setting. Since the majority of these children come from families with economic hardships it would not come as a surprise that these children are in need not only of additional health services but also social and financial services. We have surveyed the licensed family day care homes in Berkeley and have also documented needs in adequacy of health records, availability of health policies and guidelines, care for sick children, management of behavioral problems, etc.3 We need such documentation in order to propose alterna-
tives to meeting these unmet needs. However, this should not mean that there is no value in research that looks at children in all care settings. Albert Chang, MD, MPH Assistant Professor School of Public Health University of California Berkeley
REFERENCES 1. Sale JS: Family day care-Potential child development service. Am J Public Health 62:668-70, 1972. 2. Rauch MD and Crowell DC: Toward High Quality Family Day Care for Infants and Toddlers, Final Report of the Infant Satellite Nurseries Project-Department of Human Development, University of Hawaii, Honolulu, Hawaii, 1974. 3. Chang A: Health Services Needs in Licensed Family Day Care Homes (Submitted for Publication).
Comment on 'Health Status Indices and Access to Medical Care' In his paper1 published in the May 1978 issue of the American Journal of Public Health, Andersen presented two indices purporting to measure access to medical care. It is argued here that major flaws with the indices tend to lessen their utility. The use-disability ratio is the mean number of physician visits as a fraction of the mean number of disability days in a population times 100. This formulation suggests that the worst possible situation is reflected in a ratio value of zero and the best possible situation in a ratio value of 100. Herein lies the problem. Should the best possible situation be represented by a ratio value of 100? This value implies that for one day of disability there should be one physician visit. For a self-limiting condition, such as influenza, a physician usually advises his patients to stay home unless complications arise. Does it mean that these patients have an access problem just because their days of disability do not match their physician visits? After all, there is such a thing as over-utilization of health services. The symptom-response ratio is 1027
