The mandate for investigational cancer therapies

The heated national health care reform debate of the summer of 1993 has now simmered down, but pieces of the debate are still percolating along at the state level. Within the past year, numerous states have introduced bills that would mandate insurance coverage for investigational cancer therapies--in particular high-dose chemotherapy and bone marrow transplant for breast cancer. The problem with these initiatives, well-intended though they may be, is that they threaten to spread unproven technologies at a rapid rate and at the same time miss the opportunity to collect data that would prove the safety and effectiveness of the methods. The author explores these issues and suggests how managed care companies can play a more aggressive role in parrying the threat.     

Lifestyle Options and Economic Strategies: Subsistence Activities in the Mississippi Delta1

Abstract "Subsistence" and "informal economy" are contrasted in their utility as sociological concepts and their ability to explain a variety of activities in two rural Mississippi Delta communities. Literature on subsistence stresses that the desired outcome of participation is not an increase in income but the social rewards of participation itself. Two underlying dimensions of participation in these activities are documented through the literature and through a confirmatory factor analysis of empirical data: life-style choice and economic strategy. These were constructed into indexes and examined individually and in combination as dependent variables using regressors at the community, household, and individual levels. Community ties were weakly associated with participation in such activities. Whites and those with higher incomes participated more in lifestyle choice oriented activities. Participation in general was statistically related to households needing less weekly income and being of larger size. Potential connections with persistent rural poverty are discussed.     

A Multivariate Model for Repeated Failure Time Measurements

A parametric multivariate failure time distribution is derived from a frailty-type model with a particular frailty distribution. It covers as special cases certain distributions which have been used for multivariate survival data in recent years. Some properties of the distribution are derived: its marginal and conditional distributions lie within the parametric family, and association between the component variates can be positive or, to a limited extent, negative. The simple closed form of the survivor function is useful for right-censored data, as occur commonly in survival analysis, and for calculating uniform residuals. Also featured is the distribution of ratios of paired failure times. The model is applied to data from the literature     

Health care 2015: flight of the butterfly

Projecting out to the year 2015 sounds presumptuous. Who can predict that far ahead? Perhaps no one can. Social and organizational arrangements come slowly. It takes five years or so to implement simple concepts, sometimes decades for more radical changes. Once you have the ideas in tangible form, it can take another five years to get it working right. Early adopters bring others into the movement and, over 15-25 years, new directions dominate. It takes at least a generation of new practitioners to take on the new values and methods so what is likely to dominate in 2015 is beginning to be taken somewhat seriously as the successor movement to our current fad with externally imposed managed care. Put another way, entire generations of people will resist new ideas, making implementation unlikely until their control fades and a new generation takes the helm. The exciting challenge for the observer is to address the issue of where health is and should be going. Both are difficult challenges. Agreeing on what is important and what is not represents a competitive challenge. How do we perceive the world? Surely our value sets will color what we see. Who is not predisposed to select a future where they fit and their pet theories are likely to become reality. For these and other reasons, it is probably easier to agree on what we would like to see happen in the future than on what is happening. Unfortunately, unless we see the world as it is, we are less likely to be able to shift it in a direction we would like to see.     

Going to Pieces: Paul Monette and the Fragments of the Tribe

Author of the highly acclaimed Borrowed Time: An AIDS Memoir (1988) and winner of the 1992 National Book Award for his autobiography Becoming a Man: Half a Life Story, Paul Monette died of complications from AIDS in Los Angeles on February 12, 1995. His most recent work, Last Watch of the Night: Essays Too Personal and Otherwise (1994), is his third volume in a trilogy of autobiographical writing on growing up gay, coming-out, and living with AIDS. A graduate of Phillips Academy and Yale University, Monette received a number of awards for his writing and his work as an outspoken voice in the battle against AIDS, including the National Book Award, three Lambda Literary awards, the PEN Center West Freedom to Write Award, and three honorary doctorate degrees, from Wesleyan University, the City University of New York, and the State University of New York at Oswego. A memorial service was held for Monette on Sunday, February 19, 1995, at the Directors Guild of America on Sunset Boulevard in Los Angeles. Paul Monette was 49.     

The missing bridge: How immigrant networks keep Americans out of dirty jobs

Immigrants are over half of the new entrants in occupations in southwestern labor markets that range from farmworker to janitor to engineering professor. This paper explains how the availability of immigrant workers changes employment practices in ways that push and pull Americans out of jobs which remain "dirty" or unattractive to U.S. workers. An immigrant network that eventually takes over an enterprise's jobs can begin by accident or design. Accidental immigrant takeovers begin with pioneer workers who persist in high turnover jobs such as seasonal farmworker. These workers offer to bring their friends and relatives to fill vacancies as they occur. Takeovers by design sometimes follow a strike in which immigrants are recruited to be strikebreakers. After immigrants dominate the workforce, the language and culture of the workplace change in ways that make American workers feel out-of-place. Employers feel under no compulsion to upgrade dirty jobs as long as immigrant workers are available, so the technology and productivity of immigrant-enclave jobs tend to be frozen, guaranteeing that dirty jobs get less and less attractive to Americans. Indeed, industries dependent on immigrant workers often turn protectionist when they realize that even low immigrant wages are not sufficient to ensure their survival in the global marketplace. In this way, Americans lose out in several ways: They must compete directly with immigrant workers in the labor market, and then pay higher prices for the goods produced by immigrant workers because the industries preserved by them demand protection from imports. This paper will explore the manner in which immigrant networks displace Americans from dirty jobs and how the availability of immigrant workers can preserve sunset industries which turn protectionist. Examples from fruit and vegetable agriculture, garments, and shoes will be discussed.     

An extension of ebloc to valued graphs

In this paper we show how the algorithm EBLOC can be extended to deal with valued data directly. The technique is then applied to Sampson's (1969) monastery data and comparisons are made with the original EBLOC algorithm.     

An innovative approach to selecting an executive director

As a guide for how to select a new executive director, a family agency adopted the search committee process from higher education. The approach included clarifying agency goals and the director's qualifications, a board-staff screening, and interviews held jointly with public representatives before final board selection.