Cost and value in medical education--what we can learn from the past.

What lessons can be learned from the history of cost and value in medical education? First, the issue of cost and value in medical education has been around for a long time. Rising costs and an economic recession have made us focus on the subject more, but the issue has been just below the surface for over 200 years. A problem like this will not go away by itself - we must tackle it now. Second, the history of cost and value in medical education makes us look critically at who should pay. Should it be students, institutions or governments? We can see from the past that several different models have been tried; that all have their advantages and disadvantages; and that none are perfect. Third, looking at the past should make us realise that the issue of cost in medical education cannot be viewed in isolation. Medical educators throughout history have looked at how cost can affect selection for medical school, how costs can be related to benefits, and the effect of rising costs on career choices. Cost in medical education has always had far reaching consequences and implications. It probably always will. Looking at issues in medical education from the perspective of cost often makes them more stark and explicit - this in turn may help us to start to find solutions. In the future our solutions must be evidence based and must take account of cost.

O Tratamento dos doentes insanos de Vila Viçosa no hospital de Rilhafoles (segunda metade do século XIX) / The treatment of the insane patients at the hospital in Vila Viçosa rilhafoles (second half of the nineteenth century)

Neste trabalho analisamos os trâmites processuais respeitantes ao envio de doentes insanos de Vila Viçosa para o hospital de Rilhafoles, na segunda metade do século XIX, e as relações estabelecidas com o hospital desta vila alentejana relativamente ao pagamento do tratamento. A braços com uma grave crise financeira, o hospital de Vila Viçosa recusava sistematicamente a responsabilidade de enviar os alienados para Rilhafoles, numa tentativa de passar esse ónus para a administração do concelho, mostrando-se muito renitente no pagamento das faturas que lhe chegavam do hospital de São José. O conflito entre as duas instituições chegou ao monarca e sem outra alternativa que a do pagamento, o hospital da vila alentejana procedeu ao envio de parcelas de dinheiro, ainda que de forma muito atrasada. Para a realização deste trabalho servimo-nos dos livros de atas da Misericórdia e do fundo do Governo Civil de Évora, custodiadas pelo Arquivo Distrital da mesma cidade. Estas fontes resultam essencialmente da correspondência estabelecida entre a Misericórdia de Vila Viçosa, o administrador do concelho e o governador civil de Évora (AU)

In this work we examined the procedural requirements related to the sending of insane patients of Vila Viçosa to the hospital of Rilhafoles, in the second half of the 19th century, and the relationships established with the hospital of this Alentejo town relating to the payment of treatment. Faced with a severe financial crisis, the hospital of Vila Viçosa systematically refused the responsibility to send the insane patients to the Rilhafoles hospital in an attempt to pass this burden on the administration of the county, being very reluctant to pay the bills that came to him from the hospital of São José. The conflict between the two institutions came to the monarch with no other alternative than the payment, the hospital of village of the Alentejo region proceeded to sending parcels of money, albeit way too late. For the realization of this work we use the books of the Misericórdia and the documents of the Civil Governor found of the city of Évora under the custody of the Distrital Archive of the same city. This documents results, basically, from the correspondence between the Misericórdia of Vila Viçosa, the council administrator and the civil governor of Évora (AU)

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Land rent and housing policy: a case study of the San Francisco Bay area rental housing market.

In the San Francisco Bay Area, where residential rent is among the highest in the United States, an analysis of data from several sources demonstrates that high rent cannot be accounted for by higher quality, higher operating costs, or higher construction costs. At least one-third of the total rent paid is land rent. Despite increases in real incomes, very-low-income tenants in the Bay Area today have less income remaining after payment of rent than tenants did in 1960. High land rent is a long-term feature of the Bay Area rental market that results mostly from its geography, the density of its urban centers, and a strong economy, rather than from regulatory barriers to new multifamily construction. Deregulation is not a sufficient response to the effects of land rent on low-income tenants. Government should subsidize non-profit housing organizations, particularly land trusts that remove residential land from the market. Taxes on land rent would be a particularly appropriate funding source.

A silver lining? The connection between gasoline prices and obesity.

I find evidence of a negative association between gasoline prices and body weight using a fixed effects model with several robustness checks. I also show that increases in gas prices are associated with additional walking and a reduction in the frequency with which people eat at restaurants, explaining their effect on weight. My estimates imply that 8% of the rise in obesity between 1979 and 2004 can be attributed to the concurrent drop in real gas prices, and that a permanent $1 increase in gasoline prices would reduce overweight and obesity in the United States by 7% and 10%.

The impact of transit-oriented development on housing prices in San Diego, CA.

This research measures the influence of transit-oriented development (TOD) on the San Diego, CA, condominium market. Many view TOD as a key element in creating a less auto dependent and more sustainable transport system. Price premiums indicate a potential for a market-driven expansion of TOD inventory. A hedonic price model is estimated to isolate statistically the effect of TOD. This includes interaction terms between station distance and various measures of pedestrian orientation. The resulting model shows that station proximity has a significantly stronger impact when coupled with a pedestrian-oriented environment. Conversely, station area condominiums in more auto-oriented environments may sell at a discount. This indicates that TOD has a synergistic value greater than the sum of its parts. It also implies a healthy demand for more TOD housing in San Diego.

National Rural Employment Guarantee Scheme, poverty and prices in rural India.

The objective of this analysis is mainly to construct an intuitive measure of the performance of the National Rural Employment Guarantee Scheme (NREGS) in India. The focus is on divergence between demand and supply at the district level. Some related issues addressed are: (i) whether the gap between demand and supply responds to poverty; and (ii) whether recent hikes in NREGS wages are inflationary. Our analysis confirms responsiveness of the positive gap between demand and supply to poverty. Also, apprehensions expressed about the inflationary potential of recent hikes in NREGS wages have been confirmed. More importantly, higher NREGS wages are likely to undermine self-selection of the poor in it.

Similar problems, different solutions: comparing refuse collection in the Netherlands and Spain.

Because of differences in institutional arrangements, public service markets, and national traditions regarding government intervention, local public service provision can vary greatly. In this paper we compare the procedures adopted by the local governments of The Netherlands and Spain in arranging for the provision of solid waste collection. We find that Spain faces a problem of consolidation, opting more frequently to implement policies of privatization and cooperation, at the expense of competition. By contrast, The Netherlands, which has larger municipalities on average, resorts somewhat less to privatization and cooperation, and more to competition. Both options-cooperation and competition-have their merits when striving to strike a balance between transaction costs and scale economies. The choices made in organizational reform seem to be related to several factors, among which the nature of the political system and the size of municipalities appear to be relevant.

What goes around, comes around: a history of medical tuition.

In this article the actual and relative costs of tuition at 3 Ontario medical schools are traced over the past 150 years. In addition, the factors that led to Ontario's nearly 4-decade experiment in private medical education (and to its eventual demise) are presented. In relative terms, tuition was stable for over a century, then declined (after 1960) as government support rose. Access to medical training for students from middle-income families may also have improved steadily until the late 1980s. Because there is no shortage of people wanting to become doctors, there seems to be no limit to the price that could be set for a medical education. The recent hikes in tuition have outstripped inflation and may be reducing accessibility to restrictive levels, similar to those that prevailed in the 19th century. The author invites readers to question current trends.

Profit is a dirty word: the development of the public baths and wash-houses in Britain 1847-1915.

Researh on sanitary reform in nineteenth-century Britain has focused mainly on the introduction of large-sanitary infrastructure, especially waterworks and sewage systems. Other sanitary measures such as the provision of public baths and wash-houses have been ignored, or discussed in the limited context of working-class responses to middle-class sanitarianism. Yet by 1915 public baths and wash-houses were to be found in nearly every British town and city. A detailed analysis of these 'enterprises' can provide a useful way of understanding the changing priorities of public health professionals and urban authorities as well as the changing attitudes of the working classes. Connections between personal cleanliness and disease evolved during the century, particularly after the formation of germ theory in the 1880s. This paper demonstrates how the introduction of public baths and wash-houses in Liverpool, Belfast, and Glasgow was initially a direct response to sanitary reform campaigns. It also shows that the explicit public health ideology of these developments was constantly compromised by implicit concerns about municipal finance and the potential profit that such enterprises could generate. This city-based analysis shows that this conflict hindered the full sanitary benefit which these schemes potentially offered.

Panis populi--bread and public health in Australia.

The 'standard loaf, 680 gm, white, supermarket-purchased' as expressed in the Consumer Price Index, is but the basic form of bread sold to the Australian public. In the public health context, three themes have been intimately associated with bread--quality control, price control and bread used as a vehicle for supplementary nutritive agents important in preventive medicine. Price control, through assizing, has been a feature of bread marketing in western communities for seven centuries; and bread remains the last item on which price control (although seldom enforced) exists in Australia. Quality control, for public health, is determined both by regulation and by the force of increasingly literate consumers, of whom women occupy the most important determinant. From the preventive medicine point of view, important themes in bread quality, such as its use to reduce laxative sales on the one hand and to reduce the demographic incidence of colonic cancer on the other, remains outside formal regulation. Australia is a relatively conservative nation in the context of nutritional additives. It was not until 1953 that the National Health and Medical Research Council approved the addition of extra B vitamins to bread. Currently, folic acid is added as a discretion to selected high-premium breakfast cereals in Australia in one attempt to reduce the incidence to neural tube defects. The addition of such ingredients to bread remains an unrealised, but potentially important aspect of preventive medicine in Australia.

Economic evaluation in healthcare. A brief history and future directions.

Over the last decade there has been tremendous interest in economic evaluations of healthcare programmes, especially in the pharmaceutical field. Economic evaluations started about 30 years ago as rather crude analyses, in which the value of improved health was measured in terms of increased labour production. Now, more refined methods are available to measure health changes in terms of quality-adjusted life-years gained or willingness to pay. It is important to continue this development, and major fields for future work include the incorporation of quality-of-life measurements into economic evaluations and the linking of cost-effectiveness and cost-benefit analyses into a unified framework of economic evaluation. How to incorporate distributional issues is another important area. Finally, it seems crucial to further explore the link between economic evaluation and decision making, since the purpose of economic evaluations is to affect decision making.

[The delirious complaint presented to the King and to the deputies of the Assembly of 1614 by the fellows apothecaries from Paris]. / La délirante remontrance présentée au roi et aux députés des Etats-généraux de 1614, par les compagnons apothicaires de Paris.

In this document, the fellows apothecaries complain of the burdonsome costs imposed upon them by the community masters in order for them to be granted their own masterships.