Believing is seeing

Useful, well-demonstrated, well-vetted ideas in clinical practice, disease management, health care management, ideas that would save lives, save money, and make life better for the patient, are sometimes simply ignored, dismissed as radical, as completely unfounded, dangerous, and without merit. Why are new ideas so slow to spread in medicine and health care? Because believing is seeing. We do not look for something we don't believe in. In fact, we do not even see a thing if we don't believe in it. We have dedicated ourselves so powerfully to medicine, to health care as we know it, that we often do not even see any alternatives. A combination of factors makes it likely that, in the coming decade or two, we will change almost everything that is fundamental about health care and medicine. In a time of such rapid change, we desperately need to root out and question our deep assumptions and beliefs, to get off the tracks laid down by training and experience and ask questions we have never asked before.     

IntroductionExposing Misinformation Concerning Child Sexual Abuse and Adult Survivors

This article introduces a special volume on misinformation about child sexual abuse. Despite extensive research findings on the long-term effects and consequences of child sexual abuse, misinformation on this topic is widespread. Several forces have worked to support and disseminate this erroneous information. Because it is difficult to comprehend the horror of sexual crimes against children, society's denial and disbelief have often unwittingly supported the agendas of those who want to discount or minimize the impact of these crimes. The media has also contributed to the aura of skepticism surrounding claims of sexual abuse and its mental health impact, and has reported favorably on controversial and unproven claims such as the “false memory syndrome.” In the hope of countering misinformation and thus raising the level of discourse to the engagement of real scientific issues, a number of well known and respected researchers and clinicians examine various facets of the problem.     

Nonparametric Tests for Stratum Effects in the Cox Model

Thispaper considers the stratified proportional hazards model witha focus on the assessment of stratum effects. The assessmentof such effects is often of interest, for example, in clinicaltrials. In this case, two relevant tests are the test of stratuminteraction with covariates and the test of stratum interactionwith baseline hazard functions. For the test of stratum interactionwith covariates, one can use the partial likelihood method (Kalbfleischand Prentice, 1980; Lin, 1994). For the test of stratum interactionwith baseline hazard functions, however, there seems to be noformal test available. We consider this problem and propose aclass of nonparametric tests. The asymptotic distributions ofthe tests are derived using the martingale theory. The proposedtests can also be used for survival comparisons which need tobe adjusted for covariate effects. The method is illustratedwith data from a lung cancer clinical trial.     

Dependence Estimation Over a Finite Bivariate Failure Time Region

This articleconcerns nonparametric estimation of association between bivariatefailure times. In the presence of independent right censoring,the support for failure time variates may be restricted and measuresof dependence over a finite failure time region may be of particularinterest. To this end, the reciprocal cross ratio function, weightedby the bivariate failure time density, is proposed as a summarymeasure of dependence over a failure time region. This `relativerisk' estimator is shown to be consistent and asymptoticallynormally distributed, with consistent bootstrap variance estimator.A finite-region version of Kendall's tau, which is suitable forcensored failure time data, is also proposed, and correspondingasymptotic distribution theory is noted. The accuracy of theseasymptotic approximations is studied in simulations and an illustrationis provided.     

"At my age I should be sitting under that tree": the impact of AIDS on Tanzanian lakeshore communities

In 1992, the author led a participatory rural appraisal (PRA) exercise for a community fisheries project in Kagera region, on the western side of Lake Victoria, Tanzania. The PRA team visited four settlements: the prime harbor settlement on Kerebe Island; N'toro beach, in Bukoba district, near the Ugandan border; Chamkwikwi landing site in Muleba district; and Buzirayombo bay settlement in Biharamulo district in the south. This article draws on that research, to give an outsider's analysis of the ways in which AIDS was changing livelihoods in poor fishing and farming communities. On the lakeshore and islands, adults were falling ill and dying. This loss of men and women in their prime was causing major economic and social stresses for the single parents, grandparents, and orphans whom the authors met. They showed resilience and adaptability in the face of this threat to their already precarious livelihoods. The article ends by suggesting ways in which development policy makers and practitioners should support livelihoods in the era of AIDS.     

Work rehabilitation programs: a 1997 survey

By adapting to the changing health care environment, legislative reforms, and consumer needs, work rehabilitation programs have experienced a metamorphosis. This study surveyed occupational therapists currently employed in work programs to ascertain a current demographic profile of work rehabilitation programs. Respondents indicated the delivery of services in the areas of prevention, assessment and rehabilitation. The majority of work rehabilitation programs in this study provide services in the form of ergonomics, education and training, and job analyses at the worksite. The area of work injury prevention services is forecasted for increased growth among work rehabilitation programs.     

Gender and income in pharmacy: human capital and gender stratification theories revisited

This is a case study of gender and earnings in pharmacy--a profession characterized by its rapid recruitment of female practitioners. We try to account for disparities in earnings between male and female pharmacists in Ontario with the aid of human capital theory and gender stratification theory. Data is drawn from a random sample of 463 Ontario pharmacists. We find a consistent sex gap in earnings regardless of occupational level of practitioners (i.e. owner, manager or employee) and net of such factors as hours worked, commitment to work, hours devoted to childcare, absences from the labour market, and years since graduation. Instead, the main reason why women in pharmacy earn less than males is because they remain employees throughout their careers. However, we are less successful at identifying the additional factors responsible for the depressed earnings of female practitioners. We discuss our findings in light of the claims of gender stratification and human capital theory.     

Commitment to care: managed care and child incarceration

Downsizing and managed care in the 1990s followed the psychiatric hospital scandals and closures of the 1980s. Many families are now unable to provide care for their troubled children. Childhood emotional or behavioral disorders have rapidly spread beyond the confines of the home into a community that has adopted a "zero tolerance" for crime. Intolerance for childhood criminal behavior has resulted in an explosion of children's prisons where, in the name of rehabilitation, many are finally receiving psychological help. This article discusses the decreased treatment of childhood psychiatric disorders and the increased admissions to children's prison facilities.