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Critically Ill: The Family and Health Care

Reprinted from The Family in America, a publication of The Rockford Institute Center on the Family in America, May, 1992, Vol. 6, No. 5, by permission. The Family in America is published monthly by The Rockford Institute, 934 North Main St, Rockford, IL 61103-7061.

Health care has pushed itself to the top of the national agenda in recent months. In January of this year, Democratic leaders convened a "Town Meeting" on health care in 285 sites around the country. At these town meetings, voters saw a specially prepared video depicting current provisions as wholly inadequate. "We need change, dramatic change," House Speaker Thomas S. Foley (D-WA) says in the tape. Sponsors of the meetings presented three different plans for guaranteeing health care to all Americans. In one option, Medicare would expand to cover all citizens; in a second plan, health care for all Americans would be covered under a new nationalized system, comparable to that found in Canada and many European countries; in a third option (called "play or pay"), the federal government would require all employers either to offer health insurance to their employees or to pay into a national government system for caring for uninsured Americans. Proponents of these systems seek not only to provide all Americans with health care, but also to impose some restraint on runaway health care costs. Total national health expenditures rose from $74 billion in 1970 to $604 billion in 1989. Real per capita spending on health care has climbed more than five times faster than productivity over the past two decades. The rise in health-care costs paid by government has been even steeper, from $28 billion in 1970 to $190 billion in 1986. The expenses of a single government program -- Medicare -- have risen from just $7.6 billion in 1970 to $102 billion in 1989. To date, policymakers have achieved only meager success in their efforts to contain costs through price controls, health maintenance organizations, and physician review. National health-care costs are projected to rise to $1.5 trillion by the year 2000 and to a staggering $2 trillion by the year 2030.

As pressures grow for a political resolution to the crisis in medical spending, some analysts now believe that the problem cannot be properly understood without considering significant changes in American family life. Although only individual Americans can decide how to order their family lives, a growing body of research reveals that such decisions profoundly affect how much of the nation's wealth must be spent on medical care.

Evidence linking health and family life is not hard to find. Writing recently in Social Science and Medicine, Catherine K. Riessman and Naomi Gerstel observed that "one of the most consistent observations in health research is that married [people] enjoy better health than those of other marital statuses." Riessman and Gerstel noted that "this pattern has been found for every age group (20 years and over), for both men and women, and for both whites and nonwhites."

In a paper presented to the American Public Health Association, Charlotte A. Schoenborn and Barbara F. Wilson reported in 1988 that in a national survey "married persons had fewer health problems than unmarried persons." The researchers further suggested that the "surge in divorces" in recent decades has imposed "hidden health costs on the American population."

"A Healthy Estate"

Nor is there anything peculiar to this century or this country about the link between marriage and health. In a genealogical study of upper-class Europeans during the 16th, 17th, 18th, and 19th centuries, Sigismund Peller established that "mortality of married men always has been more favorable -- especially in the age below 50 -- than that of bachelors." Although Peller found relatively high morality rates among married women during the 16th and 17th centuries (due in large part to deaths in childbirth), he found that mortality rates improved dramatically for married women over the centuries while mortality rates for unmarried women under age 50 improved more slowly. William Farr noted a fairly consistent link between marriage and mortality in a study focused on mid-19th century France. Probably because of deaths in childbirth, Farr did find higher death rates among married women than among unmarried women aged 20-25. Among women over age 30 and among men over age 20, Farr documented a significantly lower mortality rate among the married than among the unmarried. "Marriage is a healthy estate," Farr concluded. "The single individual is more likely to be wrecked on his voyage than the lives joined together in matrimony."

In much more recent studies published in 1987 and 1990, demographers at Princeton University have documented the same pattern. In the 1987 study, the researchers analyzed "a range of cultures (Sweden, Japan, England, and Wales, and the United States whites)" and found that "in all cases, despite any differences in marriage behavior that may exist, married persons experience lower mortality rates" than single, divorced, and widowed peers. The Princeton team then broadened their survey to 26 developed countries ranging from Austria to New Zealand to Singapore. Across all of those cultures, the results were similar: "It is clear that in developed countries married persons of both sexes experience a marked mortality advantage relative to single individuals." In the 1990 study, Princeton investigators established that in 16 industrialized countries, unmarried men and women suffered from higher death rates than married men and women. The researcher concluded that their findings "strengthen previous speculations about the importance of marriage in maintaining health and the increased stresses associated with both the single and the formerly married states." These findings may be of growing relevance in the years ahead because "for the majority of countries [studied] ... as well as for both genders, the excess mortality of each unmarried state (relative to married persons) has increased over the past two to three decades."

Poor health among the unmarried often translates into huge hospital bills, since the unmarried do not have spouses to care for them at home. In a two-year study at the University of Michigan, researchers monitored the health of 165 men and women all aged 55 and over, after their hospitalization for various chronic conditions. The investigators observed that the unmarried men and women suffered from "worse health overall" than the married and spent "far larger fractions of time in the hospital (34.1 percent vs. 16.0 percent.)"

And although studies usually find that marriage confers a greater health benefit upon men than upon women, wedlock clearly fosters good health among women, too. In a 1990 study supported by the National Institutes of Aging and the National Institute of Mental Health, researchers found that among women ages 40-64, those who were married enjoyed a significant health advantages over those who were unmarried and that those who were mothers were healthier than those without children.

Researchers are still trying to clarify the reasons for the linkage between marriage and good health. In a study published in 1962, Joseph Berkson admitted that "powers of explanation seem to fail" when trying to account for the fact that death rates run consistently higher for singles than for marrieds and higher for the divorced than for singles, not only overall but for "such diverse disease groups as heart disease and cancer, arteriosclerosis and benign neoplasms, suicide and appendicitis, peptic ulcers and tuberculosis, nephritis, accidents, and bronchitis."

Debra Umberson shed more light on the subject in a study published in 1987. She found that mortality rates ran consistently lower for parents than for adults who are not parents and for the married than for the unmarried because marriage and parenthood both exert a "deterrent effect on health-compromising behaviors" such as excessive drinking, drug use, risk-taking, and disorderly living. By providing a system of "meaning, obligation, [and] constraint." family relationships markedly reduce the likelihood of unhealthy practices.

Further evidence of the relationship between divorce and poor health habits comes from John Clauson of the University of California at Berkeley. Clauson's research leads him to believe that both divorce and smoking may be traced to a common personality profile. According to Clauson, young people with "planful competence" (people who are "thoughtful, self-confident, and responsible") tend to avoid both divorce and smoking, while young people evincing little planful competence tend to become heavy smokers early in life and to divorce in subsequent years."

Yet health habits alone cannot fully account for the health-enhancing effects of marriage. In a study recently completed at Ohio State University, researchers compared the health of separated or divorced men with that of married men who were carefully matched in economic and occupational circumstances. Nor were the two groups distinguishable by "even marginal differences in health-related behaviors." Yet the researchers found that the divorced and separated suffered poorer health and had "poorer cellular immune system control" than their married peers.

Living Longer

Researchers in Sweden have reported similar findings. Looking at the health statistics for about 8,000 middle-aged Swedish men, the researchers found a mortality rate of 9 percent among married men over a period of approximately ten years compared with a mortality rate of 20 percent among single men during the same period. Even after taking health habits and occupational class into account, the researchers established that "death from causes other than cancer and cardiovascular disease was strongly associated with marital status." These findings deserve particular scrutiny because the Swedish marriage rate is now the lowest in the industrialized world, while the Swedish rate of family dissolution is perhaps the hightest.

In a study in 1982, Jukka T. Salonen found the same pattern among Finnish men. Even after results were statistically adjusted to account for tobacco use, cholesterol levels, and blood pressure, this study showed that an unmarried middle-aged man was more than twice as likely as a married man to die from various diseases, including ischaemic heart disease, and cerebrovascular disease.

Clearly, the effects of marriage upon health are not limited to any changes that wedlock may cause in health habits. (Harold Morowitz of Yale University concludes that "being divorced and a non-smoker is slightly less dangerous than smoking a pack or more a day and staying married." adding facetiously that "if a man's marriage is driving him to heavy smoking, he has a delicate statistical decision to make." Many researchers now explain the health benefits of marriage as a consequence of social support. Evidence from a longitudinal study in Alameda County, California, suggests that marriage is one type -- albeit a particularly important type -- of "social network tie" affecting health. In their analysis of the Alameda County data, researchers for the National Institute of Aging find that marital status assumes "primary importance" in determining mortality rates among those less than 60 years old.

In 1989, Swedish epidemiologists corroborated the insights gained in Alameda County Study, by finding "an independent association between marital status and all-cause mortality" among Swedish adults.

Social ties also apparently account for the pattern identified by Ofra Anson in a recent analysis of data collected in the National Health Interview Survey. Anson found that single women living alone spend more days sick in bed and suffer more chronic conditions than do women living with husbands. Single women living with unrelated persons likewise suffer worse health than married women, but not as bad as that of singles living alone. But those women reporting the worst health are unmarried mothers: compared to other groups of women, unmarried mothers visit doctors more often, spend more days sick in bed, and are hospitalized more often.

In 1989, researchers at Columbia University classified almost two million deaths occurring in 1986 according to the cause of death and according to the likelihood that such deaths might have been prevented or delayed by "formal" care (the kind of care received by physicians or other professionals), "informal" care (the kind of care received from family members or friends), or some combination of formal and informal care. The results revealed that for both men and women, for both blacks and whites, for almost every age group, marriage provides protection against early death. The protective effect of marriage appeared most pronounced for types of death that can be delayed or prevented chiefly through informal care. Most of the causes of death included in this category were chronic diseases such as diabetes, cirrhosis, asthma, and hypertensive heart disease. For this category, the mortality rate of unmarried white males aged 35-54 ran an astounding 390 percent higher than for their married peers. Among white females, the mortality rate for this type of death ran 200 percent higher for unmarrieds aged 35-44 and 120 percent higher for unmarrieds 45-54, compared to married women of the same ages. A parallel but less dramatic pattern appeared among blacks.

In a recent examination of the relationship between marriage and cancer -- the nation's second leading cause of death -- epidemiologists at the Michigan Cancer Foundation could find no consistent relationship between cancer and marital status (although a statistical relationship between marriage and lower cancer rates could be discerned for a few specific types of cancer such as cancer of the buccal cavity among black and white males and among black females; lung cancer among blacks of both sexes; and cervical and ovarian cancer for females of both races). However, the authors of this study did note evidence that "marriage influences survivorship among cancer patients," even if it does not prevent its occurrence. Indeed, in a study conducted in 1987 in New Mexico, researchers found that unmarried victims of cancer are more likely to go untreated for cancer than married victims and even if treated are still less likely to survive than married victims. "The decreases in survival [among cancer victims] associated with being unmarried are not trivial," the researchers noted.

Stressing that "married people live longer and generally are more emotionally and physically healthy than the unmarried," Robert H. Coombs of the UCLA School of Medicine laments that "the therapeutic benefit of marriage remains relatively unrecognized."

Most of the research on the physical health effects of divorce has focused on adults, not children. But parental divorce does appear to put children's health at risk. In The Broken Heart: The Medical Consequences of Loneliness (1979), James Lynch of the University of Maryland cited evidence that parental divorce not only causes mental neurosis, but also helps foster "various physical diseases, including cardiac disorders" later in their lives. In a national study in 1985, researchers found that, children of divorced parents suffered significantly worse health than the children of intact marriages. The authors of the study concluded that "marital status is related to health status of all the family members, including both parents and children."

Sick Children

In 1988, researchers examined two health surveys conducted by the National Center for Health Statistics, finding that "single mothers report poorer overall physical health for their children." The authors of the study explain their findings by noting that many unmarried mothers live in poverty, so exposing their children to greater health risks, and that a disproportionate number of single mothers are young and therefore more likely to bear an illness-prone premature infant. The Rutgers researchers also uncovered evidence that unmarried mothers are more likely than married mothers to exaggerate the health problems of their children. Indeed, Finnish health authorities at the University of Tampere find that children from broken homes are significantly more likely to require medical attention from psychosomatic symptoms than children from intact families. But most health problems among children in single-parent households are not psychosomatic. In a paper presented in 1990 before the Population Association of America, Deborah Dawson reported that in a nati0nal survey, "the overall health vulnerability score was elevated by 20 to 40 percent" among children living with never-married, divorced, and remarried mothers, compared to children living with both biological parents.

Like divorce, illegitimacy appears linked to harmful -- often fatal -- health problems for children. In a study completed in 1987, researchers at the National Center for Health Statistics found that compared with married mothers, unmarried women run "a substantially higher risk of having infants with very low or moderately low birth weights." Low birth weight defines one of the best predictors of infant mortality. The NCHS researchers believe that marriage exerts no "direct causal influence on the outcome of pregnancy," but argue that a life course that includes marriage is likely to be healthier than one that does not. (Unmarried mothers, are, for example, more likely to smoke than married mothers.)

Divorce and illegitimacy also affect the future health of children by increasing the likelihood that they will engage in premarital sex or that they will use tobacco, alcohol, or illegal drugs. In recent studies in the United States and Canada, researchers have shown that, compared to teens from intact homes, adolescents from nonintact families are more likely to engage in premarital sex and to use tobacco, alcohol, and illicit drugs. Such teens appear especially vulnerable to diseases (including AIDS) caused by tobacco, by sexual contact, and by dirty drug needles.

In another recent study highlighting the importance of family life on children's health, researchers at Stanford Center for Chicano Research discovered that Mexican-American children are remarkably healthy, significantly more healthy than Puerto-Rican children, even though Mexican-Americans are just as impoverished as Puerto Ricans and have much less access to medical care than Puerto Ricans. In trying to explain this "unexpected" pattern, the researchers rate a significant difference in family life: "Puerto-Rican families are ... more likely to be headed by a single parent than Mexican-American families, who have a percentage of two-parent families similar to that of non-Hispanic whites.

American policymakers and concerned citizens can hardly ignore the apparent linkage between family dissolution and poor health at a time of high divorce and illegitimacy rates and of low and falling marriage rates. The American divorce rate has risen more than 40 percent since 1970, by almost 250 percent since 1940. Perhaps 40 percent of marriages formed in the 1980's are headed for divorce. On the other hand, the rate for first marriages among women ages 15-44 has dropped more than 35 percent since 1970; one American in eight now remains unmarried for life. Partly because of a sharp drop in marital fertility, the proportion of the nation's children born out of wedlock has soared. In 1960, only one birth in twenty was illegitimate. In 1985, over one-fourth of all births were out of wedlock.

The health costs associated with this national retreat from family life are not only the burden of individual households, but of the taxpayers. Largely because of the rise in illegitimacy, taxpayers now pay the birth costs for one infant in seven. Because of illegitimate children are born prematurely with alarming frequency, they often require special surgery, mechanical respirators, isolation incubators, and other costly medical care paid for out of general hospital funds and the public purse. In a 1984 study at the National Center for Health Services, analysts found that divorced women were not only less healthy than married women (despite the fact that "the divorced population is somewhat younger than the married"), but that divorced women are more likely than married women to rely on public assistance for health care. Likewise, in their study in 1988 on single motherhood and children's health, researchers at Rutgers commented that unmarried mothers and their children "disproportionately constitute a population which is chronically dependent on the state for basic necessities, including health care."

The erosion of family life not only drives up the nation's future medical bills, it also reduces the number of future taxpayers who can pay those bills. Policy analyst Ben Wattenberg identifies the trend toward fewer, later, and less stable marriages as a primary reason for a national fertility rate which has languished below replacement levels for more than a decade. Wattenberg indeed believes that the "birth dearth" could cause Social Security system to fail early in the next century if -- as many predict -- the Social Security trust fund is combined with the Medicare trust fund.

Family disruption and depressed fertility not only erode the tax base, these developments also create higher public costs for the institutional care of the sick and elderly. In 1977, Lynch reported that Americans were paying "uncounted billions of dollars" to care for divorced and single people who stay in hospitals longer than do married people suffering from the same illnesses. American taxpayers also face rising costs of insitutionalizing elderly persons because of childlessness and family dissolution. In RAND Corporation studies published in 1988 and 1990, Peter Morrison warned that trends in American family life may make it difficult to care for the rising number of elderly Americans. He noted that because of high divorce rates, "the care spouses traditionally have provided each other in old age will be far less available" in the decades ahead. The birth dearth will further exacerbate the difficulty of caring for the elderly. "Early next century when baby boomers grow old," Morrison writes, "they will have few adult children to fill the role of caregiver, because they produced so few offspring." And while the working woman's need for paid child care has received a great deal of attention, the plight of the working woman's elderly parents has received less consideration. Pointing out that "by tradition, adult daughters have provided elderly parents with home care," Morrison anticipates a "demographic scenario" in which "elderly Americans long on life expectancy may find themselves short on care where it matters most -- at home." Researchers from Vanderbilt University anticipated "intergenerational conflict" provoked by the increasing costs of providing nursing-home care for aging Americans without children able or willing to care for them in their homes. In 1989, annual public expenditures for nursing-home care already stood at over $25 billion. Because of the profound effects of marriage and family life upon health-care costs, the public debate over how to meet those costs cannot proceed very far without addressing these issues. That debate is already heating up.

Writing recently in The New Republic, Phillip Longman argued that "medicare is going broke" because of the aging of the population and the declining American birth rate. "Without fundamental changes, Medicare won't be able to meet the needs of today's middle-aged Americans and their children," Longman reasons, warning that under current policies "the trade-off between health care for the young and the old will become increasingly stark and unavoidable." Formerly chief of staff at the White House under President Lyndon Johnson, James R. Jones predicts that unless current trends can be checked, federal spending on health care could consume 20 percent of every American worker's taxable income by the year 2009. Under such a crushing tax burden, younger Americans would find it hard to avoid "a sizable decline in their future standard of living." Jones, therefore, calls for "no less than rethinking our notion of health care entitlement from the bottom up." Fundamental rethinking may account for the rediscovery of family responsibilities by some public-health officials. Richard Morse of Kansas State University sees "some movement, at present, to deny welfare or Medicaid to those individuals whose families cannot prove they are unable to perform that responsibility." Alexa K. Stuifbergen of the University of Texas at Austin likewise believes that "policymakers are increasingly looking to the family as a hedge against the rising cost of health care services."

This rediscovery of family responsibility for health care raises vexing questions, however, in our era of "no fault" divorce and stigma-free illegitimacy. If (as many Americans believe) the government should not "impose values" by promoting any particular lifestyles, it is then just to impose the collectivized costs of repudiating values undergirding marriage and child rearing? If the relationship between family life and public health-care costs is acknowledged, how can a modern welfare state avoid political warfare between lifestyles?

The Family vs. the State

Further, Americans need to ask whether personal freedom or family integrity can survive a statist assault on illness. From Plato to B.F. Skinner, utopians have regarded the family as a regressive social unit and therefore an obstacle to the creation of the ideal state. In one of the great anti-utopian novels of this century, Brave New World (1932), Aldous Huxley depicted a regime of hedonistic totalitarianism in which the state has conquered sickness - and destroyed the family. In the climactic episode, a "Savage" who has not been programmed by state psychologists protests against a world in which marriage and disease have disappeared together. Dismayed that he cannot marry because marriage has disappeared as an institution, the Savage protests also against the engineered healthiness of the world. "I don't want comfort," the Savage insists. Claiming "the right to be unhappy," the Savage also affirms "the right to grow old and ugly and impotent; the right to have syphilis and cancer; the right to have too little to eat; the right to be lousy; the right to live in constant apprehension of what may happen tomorrow; the right to catch typhoid; the right to be tortured by unspeakable pain."

Some Americans may regard the Savage's tirade against an imaginary utopia as irrelevant to circumstances in the United States. Others will point to evidence that even in its limited attempts to mitigate uncertainty and suffering, the welfare state has weakened family life. A former Fulbright scholar in Sweden, a country with an exceptionally well-developed welfare system, David Popenoe has gone so far as to suggest that "the inherent character of the welfare state by its very existence help[s] to undermine family values or familism -- the belief in a strong sense of family identification and loyalty, mutual assistance among family members, and a concern for the perpetuation of the family unit." Popenoe points out that although many of Sweden's welfare programs "began with the goal of helping families to function better," over time "the very acceleration of welfare-state power weakened the family still further."

To the degree that American policymakers do expand the health services available from the welfare state, they likewise run the risk of weakening the family. Anthropologists Glynn Custred and Andrei Simic note the "circular relationships ... in which the state is increasingly called upon to fill the void created by the erosion of the family's primary functions, and in so doing further aggravates the situation." In pointing to what might be taken as an example of this "circular relationship," Stephen Crystal documents the difficulty federal officials have encountered in trying to reverse a previous policy of paying the nursing-home costs of elderly parents with adult children. Though financially able children once covered such costs, many affluent Americans now resist the notion that they are responsible for their aging parents. "It's hard," observes Crystal, "to unscramble an omelet."

No easy resolution to the health care crisis appears possible. Marriage and family life foster good health; yet, Americans are in retreat from family life. In any case, Americans rarely chose to accept or avoid the commitments of marriage and family in order to control their health-care costs. If Aldous Huxley saw clearly, then the capacity to make family ties actually requires a willingness to accept risks, including health risks. Even the development of private, non-government forms of health insurance may signal a movement away from reliance upon the family.

Aside from the cultural effects of the welfare state and health insurance, contemporary observers have another reason not to dismiss too hastily the protest of Huxley's Savage against a world devoid of disease and marriage. More than a few scholars have traced the current decline of family life to changes in religious and moral attitudes. These changes themselves may be partly attributable to the greater power of and greater reliance upon modern medical technology. For centuries, Christians and Stoics regarded the contemplation of death as an important moral and spiritual exercise. Relatively few Americans now engage in this exercise. "Everything ... goes on," writes French historian Philippe Aries, "as if neither I nor those who are dear to me are any longer mortal. Technically, we might admit that we might die .... But really, at heart, we feel we are nonmortals." "Death," writes Aries elsewhere, "has become a taboo, an unnameable thing .... In the 20th century, death has replaced sex as the principal prohibition." Aries further believes that "advancements in therapeutics and surgery" have fostered death denial: "Everyone acts as though medicine is the answer to everything .... Caesar must die one day, [but] there is absolutely no reason for oneself to die."

It is beyond the scope of this essay to assess fully the causes and consequences of the invisibility and denial of death -- except as a histrionic spectacle in violent movies and television shows. However, the pervasive shift in attitudes toward death does signal a cultural shift of more than trivial importance to anyone trying to understand contemporary family life and medical care.

America's retreat from family life is the consequence of many diverse cultural trends, most of them beyond the direct control of policymakers in a liberal democracy. American government officials are now asked to cope with the rising medical costs created by family dissolution; yet, by collectivizing those costs, these officials help cause further erosion of family ties. It is a dilemma sure to unsettle the nation in the decades ahead.

Endnotes

1. Clifford Kraus, "Democrats Begin Health Offensive," New York Times, 5, January, 1992, p. A8.

2. Bureau of the Census, Statistical Abstract of the United States: 1991, 11th ed. (Washington: U.S. Government Printing Office, 1991_§_, table 136.

3. James R. Jones, "Aging and Generational Equity: When Past, Present and Future Converge," The Internist, January 1989, p. 6.

4. Bureau of the Census, Statistical Abstract of the United States: 1991, table 136.

5. Jones, "Aging and Generational Equity," (see note 3), 7.

6. Catherine K. Riessman and Naomi Gerstel, "Marital Dissolution and Health: Do Males or Females Have Greater Risk?" Social Science and Medicine 20 (1985): 627.

7. Charlotte A. Schoenborn and Barbara F. Wilson, "Are Married People Healthier? Health Characteristics of Married and Unmarried U.S. Men and Women," paper presented at American Public Health Association, Boston, Massachusetts, 15 November 1988, pp. 3,4,9,15.

8. Sigismund Peller, "Studies on Mortality Since the Renaissance," Bulletin of the History of Medicine 13 (1943): 435 - 441 and 21 (1947): 73 - 99.

9. William Farr, "Marriage and Mortality," in Vital Statistics: A Memorial Volume of Selections from the Reports and Writings of William Farr (London, 1885; rpt. Metuchen, NJ: The Library of the New York Academy of Medicine/ The Scarecrow Press, 1975), 438 - 441.

10. Ellen S. Kisker and Noreen Goldman, "Perils of Single Life and Benefits of Marriage," Social biology 34 (1987): 135 - 140.

11. Yuaureng Hu and Noreen Goldman, "Mortality Differentials by Marital Status: An International Comparison," Demography 27 (1990): 233 - 250.

12. Lois M. Verbruggs and Donald J. Balaban, "Patterns of Change in Disability and Well-Being," Medical Care 27 Supplement (1989); S138-S147.

13. Pamela K. Adelmann, "A Causal Analysis of Employment and Health in Midlife Women," Women and Health 16 (1990): 5 - 17.

14. Joseph Berkson, "Mortality and Marital Status: Reflections on the Derivation of Etiology from Statistics," American Journal of Public Health 52 (1962): 1318 - 1329.

15. Debra Umberson, "Family Status and Health Behaviors: Social Control as a Dimension of Social Integration," Journal of Health and Social Behavior 28 (1987): 309 - 316.

16. John A. Clausen, "Health and the Life Course: Some Personal Observations," Journal of Health and Social Behavior 28 (1987): 337 - 344.

17. Janice K. Kiecolt-Glaser, et al., "Marital Discord and Immunity in Males," Psychosomatic Medicine 50 (1988): 213 - 229.

18. Annika Rosengren, Hans Wedel, and Lars Wilhelmsen, "Marital Status and Mortality in Middle-Aged Swedish Men, "American Journal of Epidemiology 129 (1989): 54 - 63.

19. See David Popenoe, "What Is Happening to the Family in Sweden?" Social Change in Sweden, No. 36, Swedish Information Service, December 1986, pp. 1 - 7.

20. Jukka T. Salonen, "Socioeconomic status and risk of cancer, cerebral stroke, and death due to coronary disease and any disease: a longitudinal study in eastern Finland, "Journal of Epidemiology and Community Health 36 (1987): 294 - 297.

21. Morowitz quoted by James L. Lynch in _The Broken Heart: The Medical Consequences of Loneliness_ (New York: Basic Books, 1977), 45 - 46.

22. Teresa E. Seeman et al., "Social Network Ties and Mortality Among the Elderly in the Alameda County Study," American Journal of Epidemiology 126 (1987): 714 - 721.

23. Bertil S. Hanson et al., "Social Network and Social Support Influence Mortality in Elderly Men," American Journal of Epidemiology 130 (1989): 100 - 111.

24. Ofra Anson, "Living Arrangements and Women's Health," Social Science and Medicine 26 (1988): 201 - 208.

25. Eugene Litwak et al., "Organizational Theory, Social Supports, and Mortality Rates: A Theoretical Convergence," American Sociological Review 54 (1989): 49 - 66.

26. G. Marie Swanson, Steven H. Belle, and William A. Satariano, "Marital Status and Cancer Incidence: Differences in the Black and White Populations," Cancer Research 45 (1985): 5883 - 5889.

27. James S. Goodwin, et al., The Effects of Marital Status on Stage, Treatment, and Survival of Cancer Patients," Journal of the American Medical Association 258 (1987): 3125 - 3130.

28. Robert H. Coombs, "Marital Status and Personal Well-Being: A Literature Review," Family Relations 40 (1991): 97 - 102.

29. Lynch, _The Broken Heart_ (see note 21), 78 - 80.

30. John Guidubaldi and Helen Cleminshaw, "Divorce, Family Health, and Child Adjustment," Family Relations 34 (1985): 35 - 41.

31. Ronald Angel and Jacqueline L. Worobey, "Single Motherhood and Children's Health," Journal of Health and Social Behavior 29 (1985): 38 - 52.

32. Hilleui Aro, et al., "Psychosomatic Symptoms Among 14 - 16 Year Old Finnish Adolescents," Social Psychiatry 22 (1987): 171 - 176.

33. Deborah A. Dawson, "Family Structure and Children's Health and Well-Being: Data From the 1988 National Health Interview Survey on Child Health," paper presented at the annual meeting of the Population Association of America, Toronto, May, 1990.

34. Joel C. Kleinman and Samuel S. Kessel, "Racial Differences in Low Birth Weight," New England Journal of Medicine 317 (1987): 749 - 753.

35. See Susan Newcomer and J. Richard Udry, "Parental Marital Status Effects on Adolescent Sexual Behavior," Journal of Marriage and the Family 49 (1987): 235 - 340; Rhys B. Jones and D. Paul Moberg, "Correlates of Smokeless Tobacco Use in a Male Adolescent Population," American Journal of Public Health 78 (1988): 61 - 63; Jean-Francois Saucier and Ann-Marie Ambert, "Parental Marital Status and Adolescents' Health-Risk Behavior," Adolescence 18 (1983): 403 - 411; William J. Doherty and Richard H. Needle, "Psychological Adjustment and Substance Use Among Adolescents Before and After a Parental Divorce," Child Development 62 (1991): 328 - 327; Richard H. Needle, S. Susan Su and William J. Doherty, "Divorce, Remarriage, and Adolescent Substance Use: A Prospective Longitudinal Study," Journal of Marriage and the Family 52 (1990): 157 - 159; Denise Kandel and Emily Rosenbaum, "Early Onset of Adolescent Sexual Behavior and Drug Involvement," Journal of Marriage and the Family 52 (1990): 783 - 798.

36. Fernando S. Mendoza et al., "Selected Measures of Health Status for Mexican-American, Mainland Puerto-Rican, and Cuban-American Children," Journal of the American Medical Association 265 (1991): 227 - 232.

37. Bureau of the Census, Statistical Abstract of the United States: 1989, p. 85; Bureau of the Census, Historical Statistics of the United States: Colonial Times to 1970 (Washington: U.S. Government Printing Office, 1976), 1:64.

38. Arthur J. Norton and Louisa F. Miller, "Marriage, Divorce, and Remarriage in the 1990's" paper presented at the annual meetings of the American Public Health Association, Atlanta, Georgia, November 1991; Bureau of the Census, Statistical Abstract of the United States: 1991, table 128.

39. Bureau of the Census, Statistical Abstract of the United States: 1991, table 93.

40. Marc L. Berk and Amy K. Taylor, "Women and Divorce: Health Insurance Coverage, Utilization, and Health Care Expenditures," American Journal of Public Health 74 (1984): 1276 - 1279.

41. Angel and Worobey, "Single Motherhood and Children's Health" (see note 31), 49.

42. Ben J. Wattenberg, _The Birth Dearth _(New York: Pharos, 1987), 124 - 126.

43. Wattenberg, _The Birth Dearth_ (see note 42), 68 - 70.

44. Lynch, _The Broken Heart_ (see note 21), 209.

45. Peter A. Morrison, "The Current Demographic Context of Federal Social Programs," N-2785-HHS/NICHD, The RAND Corporation, September 1988, pp. 9 - 12; Peter A. Morrison, "Demographic Factors Reshaping Ties to Family and Place," The RAND Corporation, June 1990, P-7650.

46. Wayne A. Ray, et al., "Impact of Growing Numbers of the Very Old on Medicaid Expenditures for Nursing Homes: A Multi-State Population-Based Analysis," American Journal of Public Health 77 (1987): 699 - 703.

47. Bureau of the Census, Statistical Abstract of the United States: 1991, table 142.

48. Phillip Longman, "Deathbed Politics," The New Republic, 30 March 1987, pp. 18 - 20.

49. Jones, "Aging and Generational Equity," (see note 3), p. 8.

50. "Interviews: Richard L.D. Morse, Ph.D.," Family and Community Health 9 (February 1987): 85.

51. Alexa K. Stuifbergen, "The Impact of Chronic Illness on Families," Family and Community Health 9 (February 1987): 50.

52. Aldous Huxley, _Brave New World_ (1932; rpt. New York: Harper & Row, 1969), 160 - 163.

53. David Popenoe, _Disturbing the Nest: Family Change and Decline in Modern Societies_ (New York: Aldine de Gruyter, 1988), 237 - 239.

54. Glynn Custred and Andrei Simic, "Modernity and the American Family: A Cultural Dilemma," International Journal of the Sociology of the Family 12 (1982): 163.

55. Stephen Crystal, _America's Old Age Crisis: Public Policy and the Two Worlds of Aging_, (New York: Basic, 1982), 13.

56. See Pitirim Sorokin, _Social and Cultural Dynamics: A Study of Change in Major Systems of Art, Truth, Ethics, Law, and Social Relationships_, rev. and abridged ed., (1957; reprint, New Brunswick, NJ: Transaction, 1985), 700 - 702.

57. Philippe Aries, _Western Attitudes Toward Death_ (Baltimore: Johns Hopkins University Press, 1974), 106.

58. Philippe Aries, "The Reversal of Death: Changes in Attitudes Toward Death in Western Societies," in _Death in America_, ed. Philippe Aries, et al., (Philadelphia: University of Pennsylvania, 1975), 140.

59. Aries, The Reversal of Death" (see note 56), 140.

[ JBEM Index / Volume 6 / Number 3 ]

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