- Email: [email protected]
MILITARISM AND MORTALITY
46 MILITARISM AND MORTALITY
SiR,—Dr Woolhandler and Dr Himmelstein (June 15, p 1375) suggest that "arms spending is causally related to infant mortality" and believe that it is "highly plausible that such a causal link does exist". This is absurd. Arms spending is no more a cause of infants dying than buying soap would be a cause of old pensioners living longer. "But give a man three weapons-correlation, regression, and a pen-and he will use all three".I In one sense the authors reason the obvious, and in another sense they obviate reason. Not surprisingly, their correlations "confirm what many have suspected"-ie, that the more money spent on arms, the less money available for health services. There is no need for correlation coefficients here. Also, if health expenditure is very low, infant mortality is high. To argue that infants die, because of arms spending, on the basis of a correlation between mortality rates and arms spending is an ecological fallacy.2In developed countries there is no correlation, or even inverse correlation, between the physician/population ratio and infant mortality rates. 1,1,4 On the logic of Woolhandler and Himmelstein, these countries could increase their military budgets even more, without adversely affecting their infant mortality rate. To claim that "military spending and access to clean water were statistical predictors of infant mortality rate" in developed and underdeveloped countries (though not in middle developed countries) raises two questions: how could two developed countries differ significantly in access to clean water, and why pick military spending as a predictor of infant mortality, with a correlation coefficient of mere 0 - 23 (the second lowest of 22 variables studied), while cigarette consumption per caput had the second highest negative coefficient (-0-75, p=0’0001)? Information on cigarette consumption would be at least more reliable than information on
military budgets. Woolhandler and Himmelstein then gradually dilute their claim by suggesting that unemployment is partly caused by military spending (which is later contradicted by "military projects provide
jobs") and that "a military establishment may create and maintain a high level of social inequality". No evidence, no raw data, only conjectures and correlation coefficients. Both unemployment and social inequality, they say, "may" increase infant mortality; in other words, infant mortality may be caused partly by unemployment and social inequality, which, in turn, may be caused partly by arms spending. The missing link in the causality sequence is what may partly be the cause of military spending. The matter is complicated by the admission that "per caput GNP did not seem important" and that "medical care resources" show "the apparent lack of effect... on infant mortality rate". That "bombs may kill before they explode" and Elsenhower’s pronunciamento are empty rhetoric. Before it is exploded this article may give a bad name to epidemiology. By all means, let us tell military juntas, mad generals, and all those politicians who are theologically adjusted to mass death that they are criminals, but let us not use pseudo-arguments which confuse mortality statistics with wishful morality. Department of Community Health, Trinity College, Dublin 1. Editorial. The 2. Robinson WS.
PETR SKRABANEK
anomaly that wouldn’t go away. Lancet 1978; ii: 978. Ecological correlations and the behaviour of individuals. Am Sociol Rev
1950; 15: 351-57. 3. Hart JT. A new type of general practitioner. Lancet 1983; ii: 27-29. 4. Chen MK, Lowenstein F. The physician/population ratio as a proxy adequacy of health care. IntJ Epidemiol 1985; 14: 300-03
national goal for the 1980s and that financial support for mothers and children be substantially increased. None of these measures were adopted and child poverty persists unabated. Innercity primary health care,2 the treatment of chronic renal failure,33 the provision of health care for the elderly,4 and the arrangements for cervical screeningare examples of other areas where improvements require not discoveries but concern and adequate funding. Those with a concern for health and welfare can no longer be ambivalent in their attitude to excesses of military spending. In Britain this should be reflected in outspoken medical opposition to Trident followed by pressure on our Government to begin serious negotiations for nuclear arms control with the Soviet Union. The needs of our patients will stand for no less. as a
measure
of the
SIR,-The finding of a correlation between arms spending and infant mortality, most marked in developed countries, is of immediate relevance to Britain as it moves towards the purchase of the Trident missile system. Quite apart from the fact that Trident will represent a dangerous escalation of the nuclear arms build-up and has no place in any rational scheme for the defence of Britain, it is appallingly expensive. And it is clear that Britain cannot safeguard the health and welfare of its people now, at a time when1 spending on Trident has hardly begun. The Black report demonstrated profound, correctable inequalities in health in the UK and recommended that the abolition of child poverty be adopted
Clifton Boulevard, Nottingham NG7 2UH
PETER H. WHINCUP
1. Townsend P, Davidson N, eds. Inequalities in health: the Black report. Harmondsworth: Penguin, 1982. 2. London Health Planning Consortium Study Group. Primary health care in inner London (Acheson report). London: LHPC, 1981. 3. Dowie R. Deployment of resources in treatment of end-stage renal failure in England and Wales. Br Med J 1984; 288: 988-91. 4. Andrews K. Demographic changes and resources for the elderly. Br Med J 1985; 290: 1023-24. 5. Chamberlain J. Failures of the cervical cytology screening programme. Br Med J 1984; 289: 853-54.
SiR.—Dr Woolhandler and Dr Himmelstein present a complex statistical analysis which, they suggest, reveals a correlation (they feel causal) between military spending and infant mortality. The correlation coefficient is lower than that for the other variables considered and may well be just an indirect association. This paper illustrates a problem in all scientific work-namely, the objectivity of the researchers. I suggest that Woolhandler and Himmelstein’s general beliefs would lead them to believe that military expenditure and infant mortality are correlated and they, therefore, place great emphasis on what others might well consider a less significant result. The example here is a political one, but similar examples can be found throughout medical research. Areas of knowledge are looked at or not looked at, results are believed or not believed, because of one’s own beliefs. Objectivity and rationality, the bases of modern science, are relative. We believe what we wish to believe, not what the facts show. Is this what clinical freedom is all about? I may say that my beliefs lead me to want to accept Woolhandler and Himmelstein’s findings, and probably in time I will quote their paper to support an argument. Before people berate me they should read Black’s invaluable paperl and some of the wide sociological and psychological material on knowledge. Department of Community Medicine, Sandwell Health Authority,
KEVIN KELLEHER
West Bromwich B70 9LD 1. Black N. Tales of the
unexpected:
a case
study in health service management. Soc Sci
Med 1982; 16: 1801-06.
DRUG POLICY IN THE THIRD WORLD
SIR,-Professor Islam (May 4, p 1044) reports that after the introduction of a national drug policy based on the "essential drug" concept of the World Health Organisation there is now no shortage of 150 essential drugs in Bangladesh. However, during my recent visit to eight primary health care centres in Bangladesh, I found gross shortages of many essential drugs, particularly antibiotics. The doctors told me that there were never enough drugs to cope with the ever-increasing number of patients attending the centres. Bangladesh seems to be some way from achieving a target of no shortage of essential drugs. Islam’s claim that multinational companies have not suffered losses, despite the ban on their profit-making drugs, is not supported by data or references. Nor is the claim that the drug policy has influenced prescribing patterns, and this may well be wishful thinking by the devisers of the policy. My impression was that, while prescription of "tonics" and "digestive enzymes" has fallen because of non-availability, the prescription of multiple antimicrobial agents without attempting a firm aetiological diagnosis remains common.
SiR,—Dr Woolhandler and Dr Himmelstein (June 15, p 1375) suggest that "arms spending is causally related to infant mortality" and believe that it is "highly plausible that such a causal link does exist". This is absurd. Arms spending is no more a cause of infants dying than buying soap would be a cause of old pensioners living longer. "But give a man three weapons-correlation, regression, and a pen-and he will use all three".I In one sense the authors reason the obvious, and in another sense they obviate reason. Not surprisingly, their correlations "confirm what many have suspected"-ie, that the more money spent on arms, the less money available for health services. There is no need for correlation coefficients here. Also, if health expenditure is very low, infant mortality is high. To argue that infants die, because of arms spending, on the basis of a correlation between mortality rates and arms spending is an ecological fallacy.2In developed countries there is no correlation, or even inverse correlation, between the physician/population ratio and infant mortality rates. 1,1,4 On the logic of Woolhandler and Himmelstein, these countries could increase their military budgets even more, without adversely affecting their infant mortality rate. To claim that "military spending and access to clean water were statistical predictors of infant mortality rate" in developed and underdeveloped countries (though not in middle developed countries) raises two questions: how could two developed countries differ significantly in access to clean water, and why pick military spending as a predictor of infant mortality, with a correlation coefficient of mere 0 - 23 (the second lowest of 22 variables studied), while cigarette consumption per caput had the second highest negative coefficient (-0-75, p=0’0001)? Information on cigarette consumption would be at least more reliable than information on
military budgets. Woolhandler and Himmelstein then gradually dilute their claim by suggesting that unemployment is partly caused by military spending (which is later contradicted by "military projects provide
jobs") and that "a military establishment may create and maintain a high level of social inequality". No evidence, no raw data, only conjectures and correlation coefficients. Both unemployment and social inequality, they say, "may" increase infant mortality; in other words, infant mortality may be caused partly by unemployment and social inequality, which, in turn, may be caused partly by arms spending. The missing link in the causality sequence is what may partly be the cause of military spending. The matter is complicated by the admission that "per caput GNP did not seem important" and that "medical care resources" show "the apparent lack of effect... on infant mortality rate". That "bombs may kill before they explode" and Elsenhower’s pronunciamento are empty rhetoric. Before it is exploded this article may give a bad name to epidemiology. By all means, let us tell military juntas, mad generals, and all those politicians who are theologically adjusted to mass death that they are criminals, but let us not use pseudo-arguments which confuse mortality statistics with wishful morality. Department of Community Health, Trinity College, Dublin 1. Editorial. The 2. Robinson WS.
PETR SKRABANEK
anomaly that wouldn’t go away. Lancet 1978; ii: 978. Ecological correlations and the behaviour of individuals. Am Sociol Rev
1950; 15: 351-57. 3. Hart JT. A new type of general practitioner. Lancet 1983; ii: 27-29. 4. Chen MK, Lowenstein F. The physician/population ratio as a proxy adequacy of health care. IntJ Epidemiol 1985; 14: 300-03
national goal for the 1980s and that financial support for mothers and children be substantially increased. None of these measures were adopted and child poverty persists unabated. Innercity primary health care,2 the treatment of chronic renal failure,33 the provision of health care for the elderly,4 and the arrangements for cervical screeningare examples of other areas where improvements require not discoveries but concern and adequate funding. Those with a concern for health and welfare can no longer be ambivalent in their attitude to excesses of military spending. In Britain this should be reflected in outspoken medical opposition to Trident followed by pressure on our Government to begin serious negotiations for nuclear arms control with the Soviet Union. The needs of our patients will stand for no less. as a
measure
of the
SIR,-The finding of a correlation between arms spending and infant mortality, most marked in developed countries, is of immediate relevance to Britain as it moves towards the purchase of the Trident missile system. Quite apart from the fact that Trident will represent a dangerous escalation of the nuclear arms build-up and has no place in any rational scheme for the defence of Britain, it is appallingly expensive. And it is clear that Britain cannot safeguard the health and welfare of its people now, at a time when1 spending on Trident has hardly begun. The Black report demonstrated profound, correctable inequalities in health in the UK and recommended that the abolition of child poverty be adopted
Clifton Boulevard, Nottingham NG7 2UH
PETER H. WHINCUP
1. Townsend P, Davidson N, eds. Inequalities in health: the Black report. Harmondsworth: Penguin, 1982. 2. London Health Planning Consortium Study Group. Primary health care in inner London (Acheson report). London: LHPC, 1981. 3. Dowie R. Deployment of resources in treatment of end-stage renal failure in England and Wales. Br Med J 1984; 288: 988-91. 4. Andrews K. Demographic changes and resources for the elderly. Br Med J 1985; 290: 1023-24. 5. Chamberlain J. Failures of the cervical cytology screening programme. Br Med J 1984; 289: 853-54.
SiR.—Dr Woolhandler and Dr Himmelstein present a complex statistical analysis which, they suggest, reveals a correlation (they feel causal) between military spending and infant mortality. The correlation coefficient is lower than that for the other variables considered and may well be just an indirect association. This paper illustrates a problem in all scientific work-namely, the objectivity of the researchers. I suggest that Woolhandler and Himmelstein’s general beliefs would lead them to believe that military expenditure and infant mortality are correlated and they, therefore, place great emphasis on what others might well consider a less significant result. The example here is a political one, but similar examples can be found throughout medical research. Areas of knowledge are looked at or not looked at, results are believed or not believed, because of one’s own beliefs. Objectivity and rationality, the bases of modern science, are relative. We believe what we wish to believe, not what the facts show. Is this what clinical freedom is all about? I may say that my beliefs lead me to want to accept Woolhandler and Himmelstein’s findings, and probably in time I will quote their paper to support an argument. Before people berate me they should read Black’s invaluable paperl and some of the wide sociological and psychological material on knowledge. Department of Community Medicine, Sandwell Health Authority,
KEVIN KELLEHER
West Bromwich B70 9LD 1. Black N. Tales of the
unexpected:
a case
study in health service management. Soc Sci
Med 1982; 16: 1801-06.
DRUG POLICY IN THE THIRD WORLD
SIR,-Professor Islam (May 4, p 1044) reports that after the introduction of a national drug policy based on the "essential drug" concept of the World Health Organisation there is now no shortage of 150 essential drugs in Bangladesh. However, during my recent visit to eight primary health care centres in Bangladesh, I found gross shortages of many essential drugs, particularly antibiotics. The doctors told me that there were never enough drugs to cope with the ever-increasing number of patients attending the centres. Bangladesh seems to be some way from achieving a target of no shortage of essential drugs. Islam’s claim that multinational companies have not suffered losses, despite the ban on their profit-making drugs, is not supported by data or references. Nor is the claim that the drug policy has influenced prescribing patterns, and this may well be wishful thinking by the devisers of the policy. My impression was that, while prescription of "tonics" and "digestive enzymes" has fallen because of non-availability, the prescription of multiple antimicrobial agents without attempting a firm aetiological diagnosis remains common.