Escaping Policy Traps: Strategic Options for Overcoming Entrenchment.

Policy entrenchment per se is a neutral concept; both good and bad policies may become entrenched. A policy trap, however, is entrenchment's pathological form: a self-reinforcing array of policies that simultaneously creates (1) well-established, often widely recognized failures in society, and (2) high barriers to change. A familiar type of policy trap arises when the benefits of a policy are concentrated while the costs, albeit greater, are widely diffused, opaque to many who bear them, or seemingly remote. But policy traps are not necessarily permanent; they may persist only as long as reformers are unable to identify their vulnerabilities and seize moments of political opportunity. Reconstituting a domain of policy ultimately requires formulating an alternative. Without presuming to be exhaustive, this article outlines four general strategies for overcoming policy entrenchment: Schumpeterian innovation, globally oriented innovation, institutional conversion, and social creativity (the nonmarket analog to Schumpeterian change). Focusing on three areas, the article examines how policy traps have arisen and might be overcome in fossil fuels, the internet economy, and the US health care system.

Professionalization and public health: historical legacies, continuing dilemmas.

Professionalization in public health reflects wider institutional and political forces. Depending on the historical context in different countries, public health has developed as a medical specialty or as an independent field, entirely within the state or in mixed public-private institutions, closely or weakly tied to social movements, and in varying relations to fields such as engineering, nursing, environmental science, and the military. In early 20th-century America, the rise of the medical profession and the biomedical model of disease had a formative influence on public health, leading to a different institutional pattern from Britain. Public health in the United States emerged (1) largely outside the medical profession, but under the sway of the biomedical model; (2) without medicine's command of an exclusive jurisdiction and high status; and (3) with a limited role in healthcare organization and planning. Professionalism in public health continues to be subjected to contradictory pressures and uncertainties. Healthcare reform, bioterrorism, and environmental crises could expand its mandate and access to resources, but conflicts with other institutions are likely to result in limits on the capacity of public health professionals to assert an exclusive jurisdiction.

Incidence and onset of delayed seizures after overdoses of extended-release bupropion.

BACKGROUND: Delayed seizures have been reported with overdoses of bupropion extended-release (XL). This study systematically evaluates the frequency and timing of seizures and an association between other toxic effects (ie, agitation, tremors, and hallucinations) and seizures. METHODS: A 3-year multi-poison center observational study of hospitalized patients with ingestion of bupropion XL >or=600 mg in adults and >or=4 mg/kg in children was performed. Patients with coingestants or a medical history that could affect seizure occurrence were excluded. Data collection forms captured onset time of seizure(s), other symptoms, and treatment. RESULTS: One hundred seventeen patients met inclusion criteria: median age of 22 years (range, 1.3-65 years) with 16 children 8 hours. Subsequent seizures occurred in 49%. Children ages 1.3, 3, and 7 years, developed seizures. In patients >or= 13 years of age, median dose with seizures was 4350 mg (range, 600-54 000) compared to 2400 mg (range, 600-9000) in patients without seizures. Agitation, tremors, and hallucinations occurred in 29.7%, 40.5%, and 18.9% of patients with seizures, respectively, compared with 12.5 %, 17.5%, and 10% in patients without seizures. The neurologic effects agitation (P = .045) and tremors (P = .005) occurred more frequently. CONCLUSION: Delayed seizure onset suggests a minimum observation period of 24 hours after bupropion XL overdose. Although patients experiencing agitation or tremors may be at greater risk, seizures can occur without preceding central nervous system toxicity.

Précis of Paul Starr's The Social Transformation of American Medicine. 1982.

The following is a presentation of selected passages from The Social Transformation of American Medicine (original pages numbers enclosed in parentheses) in tandem with the names of the authors in this retrospective issue and the various themes and issues they address.