EDITORIALS
pends on recognition of the economic value of childrenmore specifically the family's perception of such value to them. Studies by Nag and his co-workers3 and by others in different cultures of developing countries show that, after the earliest years, children do have material economic value which continues into adult life and gives parents old age security in the absence of an organized social security system. We are too ready to attribute fatalism rather than realism to the poorest segments of populations. In parts of Haiti, a father who works gathering sugar cane and is paid according to the amount gathered, finds it useful to have a son picking up cane stalks. His wife is helped if she has a daughter with her when she squats on the sidewalk in the city peddling her.wares and a daughter at home to cook meals and care for the house. Given the existing mortality risk, it is not unreasonable to want four or five children. Haitians are realists, not fatalists.4 The economic value of children is defined some years after birth, continues for years thereafter, and attains greatest meaning when sons reach adulthood. It follows that incentives to reduce fertility need to be characterized by long continuation and lifelong guarantees. Such is seldom the case. In any event, willingness to relinquish the security of having children in return for a government guarantee exists only where there is high level of faith that the long term commitment will be kept. In most developing countries there has not been enough government stability to warrant such confidence. In general, it becomes clear that the size of an incentive must be appreciable to have significant effect. Granting appreciable incentive to a large portion of the population is, in effect, a redistribution of wealth. The leaders of very few non-socialist poor countries have serious interest in such redistribution. Hence, incentives in most countries remain inconsequential token payments with little if any effectiveness. Disincentives, on the other hand, are inconsistent with the aim of providing a better life for all if they deprive some children of better schooling or housing because they happen to have too many siblings. Incentives are proposed for social objectives. It may be unrealistic to expect a social objective to be attained until a social consensus has been reached. Social censure already exists as a cogent determinant of fertility behavior in all societies. In Pakistan five children is seen as a small family; in Japan three is considered as a large one. In all groups, there is a tight consistent family norm, a norm which can change surprisingly from one decade to another. The morality of incentives is subject to individual interpretation. Persons who consider themselves enlightened are wont to say, "People should have the freedom to produce as
many children as they can rear properly and the means to restrict the number to as few as they wish." That is another way of saying "The rich may have more children than the poor." I cannot agree with this. I do not believe that selective deprivation of the personal, psychological and emotional elements of parenthood (whatever the number of children) should be added to the material insults of poverty. The wealthy should share equal responsibility for population reduction in both affluent and poor nations, just as affluent nations should (but do not) reduce their disproportionate raid on the earth's resources. All species have an innate drive to have offspring. When the numbers of offspring exceed the environmental capacity, man, like animals, should seek ways to achieve balance by reducing the numbers and improving the environment. I think it is legitimate to consider incentives but only after social consensus has been achieved and family planning services, including abortion and sterilization, are fully available and readily accessible to all persons who want them. Parenthood is a personal privilege involving a responsibility to society; and this should apply equally to all persons regardless of economic status or other considerations. An ethical application of this principle would result in a simple model of redistribution of wealth, modified for fertility conformance, so that: those who subscribe to fertility standards, if rich, would pay the usual graduated income tax, if poor, would have their basic needs met and receive added premium benefits; while those who exceed fertility standards, if rich, would pay severe graduated penalties on top of the income tax, if poor, would continue to have basic needs met. These are my personal opinions about what ought to be.
SAMUEL M. WISHIK, MD, MPH Address reprint requests to Center for Population and Family Health, Columbia University, 60 Haven Avenue, New York, NY 10032. Dr. Wishik is Emeritus Professor and Senior Consultant to the Center for Population and Family Health.
REFERENCES
1. Tan, S. A., Lee, J. and Ratham, J. S. Effects of social disincentive policies on fertility behavior in Singapore. Am. J. Public Health 68:119-124, 1978. 2. Enke, S. and Hickman, B. D. Offering bonuses for reduced fertility. J. Biosoc. Sci. 5:329-346, 1973. 3. Nag, M. Economic cost and value of children in Japanese, Nepalese and Peruvian villages. International Institute of the Study of Human Reproduction, Columbia University, 1975 (unpublished). 4. Murray, G. F. The Evaluation of Haitian Peasant Land Tenure: A Case Study in Agrarian Adaption to Population Growth. Vol. I and II. PhD Dissertation, Columbia University, 1977.
The Case for Cervical Cancer Screening It may be useful to review our position on the question of the efficacy of screening for cervical cancer in the light of the article on this procedure which appears in this issue of the Journal.' Determination of the efficacy of screening large population groups could come from only well-designed random114
ized controlled trials. Since ethical and technical reasons presently prohibit the performance of such trials, we have no alternative but to draw conclusions from the evidence currently available from observational studies. In spite of considerable controversy, most scientists would agree to demonstrable benefits-identification of women at risk and the
AJPH February 1978, Vol. 68, No. 2
EDITORIALS
reduction of morbidity and mortality from invasive carcinoma-even though benefits may be difficult to quantitate precisely. If we were to agree to the fact that screening has value, we could then legitimately address the question of cost-effectiveness-that is, what does it cost society at large to save the lives of a few? Although the overall value of lives saved can be converted in dollars as an economic exercise, it is impossible to translate to dollars the value of years added to a specific individual's life. Research in this area is continuing. Nevertheless, putting aside the value to society of lives saved, the dollar cost of screening should be contrasted with the dollar cost of managing the later stages of cervical cancer. The accountability of certain costs by a society is determined largely by its economic capacity and its cultural and attitudinal values. A developing country with severely limited resources may wish to focus on the more pressing health problems. By contrast, an affluent society possessing vast, but not limitless, resources may accede to its obligations to respond to more of its health problems. Doctors or nurses perform cervical cancer screening in primary care settings with minimal inconvenience to women. The screening is usually well-integrated with the health care delivery system. In short, given that cervical cancer screening is a widely accepted procedure of demonstrable benefit to that population which is able to bear the cost, it is only prudent to recommend this type of screening as a valuable preventive measure and to urge its coverage by health insurance plans.
This recommendation should be accompanied by vigorous monitoring, surveillance and collection of pertinent data to produce answers to three fundamental questions: 1. How often should the screening be performed-once every six months, year, two years, or longer? It is here, perhaps, that we can perform randomized controlled trials. The frequency of cervical cancer screening has important implications, not only on cost, but on manpower and facility utilization as well. 2. What is the actual cost-effectiveness of this procedure? Sooner or later we must come to grips with some order of priorities for public health programs. Information on costeffectiveness will be crucial in determining which programs receive funds. 3. What are the adverse physical and psychological effects of the procedure? With this knowledge, efforts can be directed to their prevention, or at least to their minimization or treatment.
MICHEL A. IBRAHIM, MD, PHD Dr. Ibrahim, Chairman of the Journal's Editorial Board, is Professor of Epidemiology, School of Public Health, University of North Carolina, Chapel Hill 27514.
REFERENCE 1. Guzick, D. S. The efficacy of screening for cervical cancer: A review. Am. J. Public Health 68:125-134, 1978.
Oral History of Dr. Abel Wolman Request for Assistance I am recording an oral history of DR. ABEL WOLMAN. Many readers of this Journal have had first-hand experiences with Dr. Wolman at different times and in various situations throughout his long career. Knowledge of these could help me considerably in framing questions that are likely to elucidate significant aspects of Dr. Wolman's activities that might otherwise be overlooked. Whether or not you send such recollections, please suggest specific questions along with the reasons for thinking that Dr. Wolman's responses to them would be of importance or particular interest. Letters and clippings might also be helpful-send copies, if possible, but originals can be copied and returned on request. Your assistance is really needed-particularly because my own long and close relationship with Dr. Wolman has been personal rather than professional-and because without it there are likely to be unfortunate gaps in the final result some years hence. In writing, please indicate whether I may use your name when asking Dr. Wolman questions you have proposed or that are based primarily on information you have supplied. I should add that Dr. Wolman has approved my placing requests of this type in this and other appropriate publications. Please contact me at the following address:
Walter Hollander, Jr., MD Professor Emeritus of Medicine University of North Carolina 531 Dogwood Drive Chapel Hill, NC 27514 Phone: (919) 942-2957
AJPH February 1978, Vol. 68, No. 2
115
pends on recognition of the economic value of childrenmore specifically the family's perception of such value to them. Studies by Nag and his co-workers3 and by others in different cultures of developing countries show that, after the earliest years, children do have material economic value which continues into adult life and gives parents old age security in the absence of an organized social security system. We are too ready to attribute fatalism rather than realism to the poorest segments of populations. In parts of Haiti, a father who works gathering sugar cane and is paid according to the amount gathered, finds it useful to have a son picking up cane stalks. His wife is helped if she has a daughter with her when she squats on the sidewalk in the city peddling her.wares and a daughter at home to cook meals and care for the house. Given the existing mortality risk, it is not unreasonable to want four or five children. Haitians are realists, not fatalists.4 The economic value of children is defined some years after birth, continues for years thereafter, and attains greatest meaning when sons reach adulthood. It follows that incentives to reduce fertility need to be characterized by long continuation and lifelong guarantees. Such is seldom the case. In any event, willingness to relinquish the security of having children in return for a government guarantee exists only where there is high level of faith that the long term commitment will be kept. In most developing countries there has not been enough government stability to warrant such confidence. In general, it becomes clear that the size of an incentive must be appreciable to have significant effect. Granting appreciable incentive to a large portion of the population is, in effect, a redistribution of wealth. The leaders of very few non-socialist poor countries have serious interest in such redistribution. Hence, incentives in most countries remain inconsequential token payments with little if any effectiveness. Disincentives, on the other hand, are inconsistent with the aim of providing a better life for all if they deprive some children of better schooling or housing because they happen to have too many siblings. Incentives are proposed for social objectives. It may be unrealistic to expect a social objective to be attained until a social consensus has been reached. Social censure already exists as a cogent determinant of fertility behavior in all societies. In Pakistan five children is seen as a small family; in Japan three is considered as a large one. In all groups, there is a tight consistent family norm, a norm which can change surprisingly from one decade to another. The morality of incentives is subject to individual interpretation. Persons who consider themselves enlightened are wont to say, "People should have the freedom to produce as
many children as they can rear properly and the means to restrict the number to as few as they wish." That is another way of saying "The rich may have more children than the poor." I cannot agree with this. I do not believe that selective deprivation of the personal, psychological and emotional elements of parenthood (whatever the number of children) should be added to the material insults of poverty. The wealthy should share equal responsibility for population reduction in both affluent and poor nations, just as affluent nations should (but do not) reduce their disproportionate raid on the earth's resources. All species have an innate drive to have offspring. When the numbers of offspring exceed the environmental capacity, man, like animals, should seek ways to achieve balance by reducing the numbers and improving the environment. I think it is legitimate to consider incentives but only after social consensus has been achieved and family planning services, including abortion and sterilization, are fully available and readily accessible to all persons who want them. Parenthood is a personal privilege involving a responsibility to society; and this should apply equally to all persons regardless of economic status or other considerations. An ethical application of this principle would result in a simple model of redistribution of wealth, modified for fertility conformance, so that: those who subscribe to fertility standards, if rich, would pay the usual graduated income tax, if poor, would have their basic needs met and receive added premium benefits; while those who exceed fertility standards, if rich, would pay severe graduated penalties on top of the income tax, if poor, would continue to have basic needs met. These are my personal opinions about what ought to be.
SAMUEL M. WISHIK, MD, MPH Address reprint requests to Center for Population and Family Health, Columbia University, 60 Haven Avenue, New York, NY 10032. Dr. Wishik is Emeritus Professor and Senior Consultant to the Center for Population and Family Health.
REFERENCES
1. Tan, S. A., Lee, J. and Ratham, J. S. Effects of social disincentive policies on fertility behavior in Singapore. Am. J. Public Health 68:119-124, 1978. 2. Enke, S. and Hickman, B. D. Offering bonuses for reduced fertility. J. Biosoc. Sci. 5:329-346, 1973. 3. Nag, M. Economic cost and value of children in Japanese, Nepalese and Peruvian villages. International Institute of the Study of Human Reproduction, Columbia University, 1975 (unpublished). 4. Murray, G. F. The Evaluation of Haitian Peasant Land Tenure: A Case Study in Agrarian Adaption to Population Growth. Vol. I and II. PhD Dissertation, Columbia University, 1977.
The Case for Cervical Cancer Screening It may be useful to review our position on the question of the efficacy of screening for cervical cancer in the light of the article on this procedure which appears in this issue of the Journal.' Determination of the efficacy of screening large population groups could come from only well-designed random114
ized controlled trials. Since ethical and technical reasons presently prohibit the performance of such trials, we have no alternative but to draw conclusions from the evidence currently available from observational studies. In spite of considerable controversy, most scientists would agree to demonstrable benefits-identification of women at risk and the
AJPH February 1978, Vol. 68, No. 2
EDITORIALS
reduction of morbidity and mortality from invasive carcinoma-even though benefits may be difficult to quantitate precisely. If we were to agree to the fact that screening has value, we could then legitimately address the question of cost-effectiveness-that is, what does it cost society at large to save the lives of a few? Although the overall value of lives saved can be converted in dollars as an economic exercise, it is impossible to translate to dollars the value of years added to a specific individual's life. Research in this area is continuing. Nevertheless, putting aside the value to society of lives saved, the dollar cost of screening should be contrasted with the dollar cost of managing the later stages of cervical cancer. The accountability of certain costs by a society is determined largely by its economic capacity and its cultural and attitudinal values. A developing country with severely limited resources may wish to focus on the more pressing health problems. By contrast, an affluent society possessing vast, but not limitless, resources may accede to its obligations to respond to more of its health problems. Doctors or nurses perform cervical cancer screening in primary care settings with minimal inconvenience to women. The screening is usually well-integrated with the health care delivery system. In short, given that cervical cancer screening is a widely accepted procedure of demonstrable benefit to that population which is able to bear the cost, it is only prudent to recommend this type of screening as a valuable preventive measure and to urge its coverage by health insurance plans.
This recommendation should be accompanied by vigorous monitoring, surveillance and collection of pertinent data to produce answers to three fundamental questions: 1. How often should the screening be performed-once every six months, year, two years, or longer? It is here, perhaps, that we can perform randomized controlled trials. The frequency of cervical cancer screening has important implications, not only on cost, but on manpower and facility utilization as well. 2. What is the actual cost-effectiveness of this procedure? Sooner or later we must come to grips with some order of priorities for public health programs. Information on costeffectiveness will be crucial in determining which programs receive funds. 3. What are the adverse physical and psychological effects of the procedure? With this knowledge, efforts can be directed to their prevention, or at least to their minimization or treatment.
MICHEL A. IBRAHIM, MD, PHD Dr. Ibrahim, Chairman of the Journal's Editorial Board, is Professor of Epidemiology, School of Public Health, University of North Carolina, Chapel Hill 27514.
REFERENCE 1. Guzick, D. S. The efficacy of screening for cervical cancer: A review. Am. J. Public Health 68:125-134, 1978.
Oral History of Dr. Abel Wolman Request for Assistance I am recording an oral history of DR. ABEL WOLMAN. Many readers of this Journal have had first-hand experiences with Dr. Wolman at different times and in various situations throughout his long career. Knowledge of these could help me considerably in framing questions that are likely to elucidate significant aspects of Dr. Wolman's activities that might otherwise be overlooked. Whether or not you send such recollections, please suggest specific questions along with the reasons for thinking that Dr. Wolman's responses to them would be of importance or particular interest. Letters and clippings might also be helpful-send copies, if possible, but originals can be copied and returned on request. Your assistance is really needed-particularly because my own long and close relationship with Dr. Wolman has been personal rather than professional-and because without it there are likely to be unfortunate gaps in the final result some years hence. In writing, please indicate whether I may use your name when asking Dr. Wolman questions you have proposed or that are based primarily on information you have supplied. I should add that Dr. Wolman has approved my placing requests of this type in this and other appropriate publications. Please contact me at the following address:
Walter Hollander, Jr., MD Professor Emeritus of Medicine University of North Carolina 531 Dogwood Drive Chapel Hill, NC 27514 Phone: (919) 942-2957
AJPH February 1978, Vol. 68, No. 2
115
