l.fnm lo Ibt EiSMr 



557 



6. CnrryjenAo EstadLrnco I96S-/974, M«r>- 

 a|rua. Nicangua Banco CeninJ de Nxa- 

 rapii. 19^5. 



7 Mimeo repon Managua. Ncaragua: Oft- 

 ana Ejccuirvi d< Encucstas y Censoa; 

 1977 



8. Stcaragtitt 10 Anas en Ctfras Managua, 

 Ntcaragua tr»tiiuio Naoonate de Esiadis- 

 icn y Censns; l****- 



9 Anuano EsiadiKnco de ^'icarvgno- Marv 

 agua. Noragua: Co%<mmcni of Nicara- 

 gua. 1 976. 

 10. %r^ntnano Sobrv Erodicacion de la Mo- 

 Itina Washmgion. DC Pan American 

 Ilcallh Organizalpoo. l<Wi5 PAHO PuNi- 

 caorwi Oenirfka # 1 18. 

 11 Crowe RN ImerrebiKw hetwetn health 

 and population- nt-servaimn^ dcrrved from 

 ficW expcnences Soc Sa Med IWChl4c: 

 «-I20. 

 11 See Wolfe 8l_ Behrman I Deierminants 

 of child monaItr\ . health, and nuiriiion in a 

 developing counirv- y />^ Econ. 1982:1 1: 



13- SecCaWwellJC Rnuie^todccieawd mor- 

 t.iliiv tn poor cmintrics. Pnpul Dcy- Re\\ 

 tW^;i:(2) 171-219 



14. Drll D. Reich M. ed. Health. S'umnnn. 

 anH Ecnttmnic Crves. Dover, Ma:«: Au- 

 hum Hou^. I98fi 



15, C"hcn LC Coping *iih ecooomic crisis: 

 pi»lic\' developmeni in China and Indis- 

 Hrallh Pnlin rUinn. I9fr'::(:):i.Vl-)49 



Smidiford and Colleagues 

 Respond 



It IS under«;iandaMc thai Richard 

 G.irficld IS skeptical of our snggciUKm that 

 impff^cd access w* hollh care was ihc 

 f.icitif most likely to have hroughl ahoul 

 the sharp fnlt in child moilality that began 

 in Nicaragua in the mtd-l970s. It has 

 pro\cn remarkably difTicull lo demon- 

 siraie such an impact in m<Kt parts of the 

 workJ' (although Costa Rtca may be an 

 cxception-K and despite massive assis- 

 tance from the United States Agency for 

 Iniemaiional Development, it is generally 

 fcltihat one of the reasons for the downfall 

 of Somoza's regime was its lack of invest- 

 ment m social programs. Indeed, thc5;e 

 were our own prejudices at ihe tirpc thai 

 we embarked upon ihts work. In fad. it 

 was only after carefully eliminating alter- 

 native hypotheses (including most of 

 those put forward by GarficW) that we fi- 

 nally accepted ihc concept that improve- 

 ments in child health, at least in recent 

 decades, arc not inevitably the outcome of 

 interventions or developments external to 

 the health scaor. 



Of courv. Garfield's problem, like 

 fMjrs mtttally, is to find a more plausible 

 explanatton for Nicaragua's breakthrough 

 in child mortality. He starts by suggesting 

 (hat It may be a delayed efTeci of economic 

 growth in the ]%05. TTic trouble with such 

 exphnations is that, unless there is a lag 



period that can be justif)ed a prion, it is not 

 possible to explain any change on thLs h»- 

 sts. Nicaragua's last period of rapid eco- 

 fKxnic growth ended in 1965.* ^"hWc it b 

 true that the impact of income growth on 

 health status may be delayed, it is difTicull 

 to see how the boom of the earK 19641k 

 was still improving infant mortality 1? or 

 M years later. The same is true of trans- 

 port, convnunicatHDns. electnaty. and po- 

 table water supplies, whose growth and 

 decline in supply closely matched that of 

 the overall gross domestic product/* Nor 

 does urbanization account for tKc phe- 

 nomenon. As our original arttcle showed, 

 the fall m mortality N^as apparently as 

 rapid in rural as in urban areas and com- 

 menced at approximate!)' the same time. 



In contrast lo the supply of energy, 

 water, transport, and communicatKWis. 

 the supply of government soaal services 

 rose steeply m the 197fKand I98f>s This is 

 in accord with nur impresston that the re- 

 sources available to primary health care 

 were increasing. That this spending was 

 not entirely s^iakcd up by expansion of 

 hospital-based care is clear fnjm the si- 

 multaneous increase in the number of 

 health centers and decrease in the number 

 of hospuai beds per capita. 



Some of Garfield's data should be 

 viewed with caution. Particularly suspect 

 are the data for Ihe mimhcr nf medical 

 visiis per capita. Not only arc iIk Hgurcs 

 difTcrcnl from those that wc obtained from 

 original sources in Nicaragua, but they 

 alsti imply that each doctor in Nicaragua 

 was seeing only about six patients per d-ny. 

 It is difficult lo sec how the number of 

 visits almost tripled between 1978 and 

 1980 while the number of doctors in the 

 country fell by almost 10%. Because all of 

 these data depended upon the aggregation 

 of statistics between difTercnt institutioos, 

 there was obviously plenty of scope for 

 omission and overlap. In faa, the number 

 of patients seen by doctors is probably not 

 the nxjst valid indicator of health care de- 

 livery, because it neglects the wort of 

 nurses and auxiliary nurses who were 

 siafTing most of the ambulatory care units 

 in the country. 



Regarding Garfield's assertion that 

 only a quarter of the population had ac- 

 cess to health care by the end of ihe 197[>i. 

 it should be pointed out thai a single esti- 

 mate gives no indication of whether cov- 

 erage was improving or not. Using 

 Garfield's own figures, the number of 

 births in health institutions (in our opinion 

 one of the belter indicators of health ser- 

 vice coverage) grew by an average of 6.0% 



per year from 1974 m 197R hm "nnh" K 

 4.2^ per year frimi lOWi m 1«IK. •'■**» 



Grvcn Ihc limitations in tlic »v.itl:il»K- 

 information, any cxplaruilion far Nx-irt 

 gua's inlcresiinp trcrxl in chid nwtnititx 

 must relv to some dcprcc on spcoil.ii***^. 

 based hop>efiiIly on s**iiihI ihrnry II"** 

 ever, our sind\ nnd GnrlicW's rr<p«»ttsr ••• 

 It do illusiraie l^>ih the poienitJin ,intl rh.- 

 pitfalls of annl\7iiip and inlerfrrlinc i"ti 

 tincly atllcctcH hrnllh infurmzii*!! '^^ 

 refer Snndip^nf. htmiiR. WV. UUr/#^.i 

 Gcnrge Dmey Stnrth, Mfi ItChr, Mi. M^r 

 r/t^nrri Ctnk. MUfhn 



Requests fi»r rcpiriii<; ^iMntld tx <rni i" IVi.-? 

 Sandifnrd. MIJOiH. MV. MMrJxn. I-vo. 

 porA Sch«*il 'if Tropicjl Mcdionc PnnlMfVr 

 Place. LKery^wl I .^ M)A nnptir^l 



References 



I DepinpKni nMiiirfn.iiK*rul rr^iiwtiH' i*-l 

 Social AfT.nrs Mtminhn nml limllh /'-■/:.■»■ 

 r^rtcrrthttf^ 'ij tlic E\]>en C-~>tp "" "^t-' 

 tahryand Ucnhh Piitirw Rimtr. VJ M.n t.- - 

 June 1^}*^ NiAx >(mV.NV Lf«dN-i»«»^: 

 I9R4 t>iciin>(:nl Sll SA,'SrR_\«l 



2. Roxeio-Bixin I Int.inl nxrtljfcv tii ( *-ii 



Rica: exptiuiinp ihe rcecnt vctin*- ^' -' 

 Fnm rinnn. I'r^, ps? r.l 

 ■^ Sf*X»r M. lhtti>\ lint* tf-ri '•'ni'-^ '" rtr \ - 



l>cp3rl.n!icnit« .[<■ t'L-i<niiiiin VshiJi. ' '"• 

 vcrsid;>d N;icn'it.il Auinnoiiu-i deNirni:-?"** 

 1987. 

 4 GnrfieM R. \V.I1i.iim C IhnF- .in.! T. . ■• 

 UilHtn. lltr Sh iiiitxputii r.^prr^-tH • ( '•. 

 fnril. HnphiMl: tlMAM; !«» 



Intimidation of 

 CTR-FiHuletl Scientisls 

 Claimed 



The July I'NI Jottnial cnrrof .i Pi'Ik-v 

 Fonim disoi*isioo by Warner' and t p:'|v 

 by Cumniings cl al.^ bcratm| scicniiM* 

 whose work is supported by the Cn^indl f'n 

 Tohacai Research (CTR) f(T onspctifKil 

 ethicnl fniliircs .hkJ daimiiig thai ihc -Atnl <*l 

 those socntisis (>nly serves lo rcinforir 

 doubts in the public miTxl aNxji the so. criu 

 of ha7<irds of smoking. 



Like mnm otl>ers, my .is^snonic^nn'n 

 accept rcscnrdi gmnis fnim envcn>nKP'. 

 unions. .itkI industry, irxiiHlii^ C*1"R \V'- 

 reported rcsiilis. with ackn(TwtttgnK*niv i** 

 speoal grnnisfrnmCrR when:ifpn«pn4''-. 

 in nrKirc Ihnn ? d<i7cn ki-Tdinp ps^k: hr iMh. 

 statislkrs. cpnkrmK>logy. and rthcr j<<«ini.iK 

 well krKiwn Uv iltc Ihorrxighncss of ilirn 

 reviews. inHiiffiiigihc,^"imcwTyor'"i''''»' 

 Pubbc Hciifth. f)lni(vsjy. »e h.-xl sr'»i»r 

 ihinglos-iv that tlic reviewers and C(Iii<ms of 

 these jotininK fcMirxl w(>nh\ ri p(ibli<;l*tr>r 

 de^te scircc jcHimal sp.Tcc and dcsi-nic .ic 

 knowledgmcnt to the source d himls. 



1 197 Ajncncan iounuJ of PuWic Heahh 



September 1991 Vo* ?:. N- 



