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pro-choice sensibility, yet are unable to solve the problem of boycotts and religious issues leading to the unwillingness of the pharmaceutical industry to supply a product for which there is a legitimate demand?

Abortion in US Courts currently undergoes the influence of restrictions, limitations and conditions about the procedure. Opinions in the group were divided as to whether we must expect that Roe v. Wade (stating that the right of personal privacy includes the abortion decision, but subject to certain limitations) will be overturned. The future of RU-486 would certainly follow suit. An important point, it was thought might be the definition of pregnancy as ‘after the moment of implantation until the moment of birth’. The medical profession, in general, is on record for this definition. This definition should avoid the debate about the unsolvable question of when life begins. Since RU-486 acts right at the moment when implanta- tion begins, it should also protect some contraceptives from legal action. Its ambiguity-is it a contracep- tive or an abortifacient? - would remain, an ambiguity which accomodates the ambivalence that many Americans feel about having an abortion. Still, it is expected that in the near future the focus will be= on legislative action and on how the Courts go.

For the near future two scanarios have been suggested. One, rather than introducing RU-486 on the basis of its ambiguity, it should be presented as an abortifacient, even if mainly at an early stage. People should be further educated about what antiprogestin drugs are. Two, the most realistic scenario has sug- gested that the American Company gives its okay for RU-486. But then, nothing may ever convince them to go against the pressure of the right-to-life community.

As an effort at understanding the games people play around RU-486, the proceedings of this conference are of some interest. However, little new material is being offered. On the other hand, the truly inter- disciplinary approach remains and is worthwhile reading. One major inconsistency between the group’s understanding of the present situation and its many suggestions to change is the following. The group, rightly so it seems, criticizes those who appropriate scientific data for political reasons. Yet, many par- ticipants were themselves not averse to the strategy that would exploit the ambiguity of RU-486 in order to accomodate the moral ambivalence many Americans feel about having an abortion. Despite the single opinion voiced in the above-mentioned scenario, this seems to be an inconsistency that worries the ethicist.

Dr. M. De Wachter Director Institute for Bioethics

Maastricht The Netherlands

Health Care for the Poor and Uninsured: Strategies that Work

Edited by N. Tate and K. Kavanagh The Haworth Press, Inc., New York, 1992 98 pp., ISBN I-56024-315-5

This is a compilation of papers delivered at the Second Annual Conference on Health Care for the Poor and Uninsured sponsored by several universities and health organizations in Tennessee, USA. The papers included in this monograph have been published also as a special issue of the Journal of Health and Social Policy (Vol. 3, No. 4, 1992).

The monograph consists of eight papers and the focus on the US. The papers are highly variable in quality, the worst being the live page Introduction by the co-editors. It not only does not say very much but what it says is either grossly inaccurate or misleading. Examples: On page I they assert that ‘..._ in the Mid-South region (Arkansas, Mississippi, Tennessee) and other southern states, 25% of all children die in the first year of life.’ This amounts to an infant mortality rate of 250 per IOOO! It is surprising that the publishers would fail to catch such a glaring misstatement of facts, and that a professional journal would publish it with its eyes closed. Another example on page 5: . . . ‘less than 1% of the health care dollar is spent on prevention while 90% is spent in the last few months of life’. Nowhere do they give their delini- tion of ‘prevention’, therefore we do not know whether they include investment in research and develop-

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ment, education and training of health professionals, expenditures on licensing, accreditation, quality assurance, health manpower distribution and similar other categories are under this heading. Further, irrespective of factual accuracy of their assertion that 90% of medical expenditures are incurred in the last few months of life, it needed to be stated that the end-of-life medical expenditures include services to not only the aged but also to children and youth who are victims of accidents, crime, drugs and suicide related acts.

(Prevention efforts in these areas require investments in road and automobile design enforcement and similar other related activities. Are these expenditures included under ‘Prevention’?) Of the remaining seven papers, two are very worthwhile because of their scientifically rigorous design and high quality analysis, and therefore soundness of their findings. These are S.L. Baker and J.J. Kronenfeld ‘High Risk Channeling to Improve Medicaid Maternal and Infant Care’, and M.A. Kelley et al. ‘The Role of Per- ceived Barriers in the Use of Comprehensive Prenatal Care Program’. The Kelley et al. paper was also presented at the Annual Meeting of the American Public Health Association in October 1990.

Two other papers also merit attention: Saundra Wheeler et al. ‘Gift of Life: Enhancing the Availability of Obstetrical Care in Alabama’ and O.R. Butler, ‘The Reduction of Black Infant Mortality: An Eighteen Month Evaluation of Three Tennessee Black Health Care Task Forces’ Demonstration Projects’. These papers illustrate the need for a high level of commitment, competence and coordination for providing the historically have-nots with effective access to health services.

The remaining three papers are space tillers: K.B. Davis, ‘A New Defense: The Maternity Waiver Program’ is sophomoric both in concept and analysis; D.R. Bender, ‘Avoiding the Cost Burden of Newborn Screening for the Poor and Uninsured: Mississippi Model’ seems pointless, for it presents no useful information; and Dale Anglund, ‘The Caregiver Is the Key to the Long-Term Care Issue’ could have been a worthwhile contribution if he had not focused on himself and used this forum for a commer- cial on his enterprise.

This poorly edited collection is a disappointment. If the initiatives reported here paints a representative picture of all that is going on in the US to give the poor and uninsured effective access to health care, then one could come to a conclusion that these experiments are a few and too far between bright lights in the vast dark landscape.

Let us hope that the picture is a bit more hopeful on the assumption that the Annual Conference on Health Care for the Poor and Uninsured is an activity not intended to represent the nationwide efforts in this regard, but instead it aims to highlight the contributions of selected individuals and organizations in the southern part of the country.

Professor Dr. Jain Sagar Department of Health Policy and Administration

School of Public Health The University of North Carolina at Chapel Hill

Chapel Hill, USA

Economics and Mental Health

Edited by R. Frank and W. Manning Jr. The John Hopkins University Press, Baltimore, 1992 351 pp., Paperback USS22.50, Hardcover USS60.00, ISBN 0-8018-4429-O

Despite the enormous amount of money spent on care for mental illnesses, economic analyses of this sector are relatively scarce, so any substantial contribution to a better understanding of the economic aspects has to be welcomed.

Economics and Mental Health was compiled in honour of Carl A. Taube, and pays attention to various topics under four major headings: the supply-side, the economic cost, the demand and experimentation. These four domains are preceded by a chapter containing a thorough overview of the impact of economic studies in the field of mental health care.