PREPARED STATEMENT OF JAMES G. HAUGHTON, M.D., M.P.H., FAPHA, FIRST DEPUTY ADMINISTRATOR, HEALTH SERVICES ADMINISTRATION, CITY OF NEW YORK The Irony It is indeed ironic that the major problems which we face in addressing ourselves to the health needs of our over 65 population have been created by the major public health victories of the last hundred years. At the turn of the century the leading causes of death were infectious diseases: influenza-pneumonia, diarrhea and enteritis, diphtheria and tuberculosis. At that time 4 out of 10 deaths (40%) were caused by infectious diseases.1 In addition to the leading causes of death there were such scourges as smallpox, typhoid, malaria, and venereal diseases. Major Public Health Victories But by the early 1950's vaccines had been developed and major eradication programs had been mounted; penicillin, sulfa and other antibiotics had been discovered and deaths from infectious diseases had been reduced to 1 out of 13 (7.7%). Even in the area of chronic disease there have been some break-throughs which have reduced mortality and disability. Examples of these are the discovery of insulin for diabetes and cortisone for arthritis and other disabling collogen diseases. Positive Results These victories have indeed had many positive results for our populace particularly when one looks at our generally accepted measures of the health status of the nation. In 1915, 100 of every 1000 children born alive in the United States died before their first birthday; in 1965 the rate was 24/1000.2 In 1900 the death rate from all causes was 17.2 per 1000 population while in 1965 it was 9.4almost a 50% improvement. As a result of all this, while the life span has not changed, the life expectancy has improved so that, whereas in 1900 the average American born could expect to live 47 years, the American born in 1964 can expect to reach 70 years of age. The Price of Progress But as always we have paid a price for this progress, and what is the price? Our birth rate is twice our death rate; therefore, there is rapid population growth placing considerable strain on our resources especially in the crowded Metropolitan complexes where housing, water pollution and air pollution are among our major problems. In addition we have a rapidly growing aging population now estimated at 19 million and projected to reach 24.5 million before the end of this century. With the burgeoning of this segment of the population has come a shift in the major causes of death. Instead of the acute infectious diseases previously mentioned, the major killers are now heart disease, cancer, stroke and diabetes. But what is perhaps worse is that these killers do not act quickly; instead they are a major drain upon the economy because of the prolonged disability which they cause. Our public health progress has also brought us face to face with some of the social problems of the aging. The American worker who retires at age 65 can reasonably look forward to about 20 years of retired life. He is therefore faced with the need to fill 20 years of leisure time. He must also learn to cope with the need to be a contributing, useful member of society at a time when his usefulness seems to have come to an end. He must adjust to the isolation resulting from the maturing and scattering of his family. He must adapt to his diminishing physical capabilities even if he is not disabled by a chronic disease. Health Needs Having pointed out the irony in our unprecedented public health progress, let us look at the challenges it presents us. Because the major causes of morbidity 1 Encyclopaedia Britannica, Vol. 18. p. 739 "Public Health in the U.S." 2 Encyclopaedia Britannica, Book of the Year-1966, p. 802. 3 Encyclopaedia Britannica, Book of the Year-1966, p. 803. in this population are the chronic diseases which we have not yet learned to prevent, we must make major efforts to detect them as early as possible so that we can hopefully delay or limit the disability they cause. Fortunately the means for early detection are at our command. For more than a decade we have been investing major portions of our effort into the early detection of chronic diseases, but we have been doing it in a vacuum because we have persisted in defining public health in its narrowest terms. As a result we have reached only a fraction of those who need our services. The mental health of this population should be one of our major concerns. Here again prevention is of major significance, and again the means are at our disposal. I read recently that David Dubinsky, retired president of the International Ladies Garment Workers Union would devote his retirement years to a program for preparing prospective retirees of his industry for retirement. Other unions have also taken steps in that direction. Public Health agencies must also address themselves to this problem for this is an important part of preventive medicine. There are approximately 50,000 persons in New York City over the age of 80. Many of them are isolated because of disability and become disoriented and senile because of their isolation. Public Health programs must also address themselves to this aspect of preventive care either by direct intervention by offi cial health agencies or by the stimulation and leadership which such agencies can provide to the private and voluntary sectors. One of the major causes of death which merits mention is accidents. Many of these accidents occur in the over 65 population because they live in inadequate housing. Hardly a week passes without local press reports of deaths of elderly persons from fires in New York City. I wonder how many of these deaths could have been prevented. I wonder how many hip fractures could be prevented by housing designed specifically for the aged with all the known safety features. I suspect that in terms of cost benefit the investment would be well worthwhile in pure dollars and cents without even considering the saving in human suffering. Treatment Services Treatment services are, of course, an important part of planning for any segment of the population, but it may well have less significance for this population than for a younger one. Obviously, early detection is useless unless it is followed up by immediate and vigorous treatment. But in the later phases of the natural history of these chronic ailments it has become increasingly clear to me that some of the social considerations are of much greater import than the actual medical services. Five years ago we began an experiment to provide private group practice medical care to a dependent over 65 population. We assumed that these persons would welcome the opportunity to leave what we considered the impersonal, demeaning atmosphere of hospital out-patient clinics and have access to a private physician by appointment in comfortable surroundings. Instead we found to our surprise that many of them refused to leave the familiarity of the clinics, not only because the surroundings were familiar but also because the visit to the clinic was a social affair-a chance to visit with friends, to get away from the isolation of a small apartment or a small room, a chance to be the center of attraction while an interesting disease was being described to a group of residents by the head of the department. We further found that of those who did accept care from the group practice program we received fewer complaints from those who were enrolled in a group whose physicians were older and therefore apparently more in empathy with this elderly population even though this medical group was not considered one of the medically strong groups in the program. We are convinced that these patients were more impressed with the social aspects of the care received than with the efficacy of the medication prescribed. The Future Much has been learned about the care of the aged from our own experience in New York City' and the experience of others in other parts of the country. 4 Haughton, J. G.-"The Organization of Medical Services in a Private Nursing Home: Three New Approaches". New England Journal of Medicine, May 13, 1965, p. 996-1003. We must take advantage of this experience and enlarge upon it. We must redefine Public Health in much broader terms and address ourselves not only to the control of disease but to the physical, mental and social well being of this population. Health Care cannot exist in a vaccum. A dollar spent in better and safer housing for the elderly may well be more productive in terms of cost effectiveness than the same dollar spent in health services for the same population and may well have greater impact upon the health status of the elderly. I believe that this may well be true because during the period July 1959 to June 1961, 66.8% of all persons 65 and over who were injured in their homes in the United States received medical attention for the injury and 72.4% of these had one or more days of restricted activity as a result. In addition, fractures and dislocations in persons 65 and over accounted for 4,228,000 hospital days during the period 1963-1965 for an average length of stay of 24.2 days. The annual cost of accidents in the home for all ages is estimated at $1,300,000,000, and since we know that the accident rate per 100 population for those 65 and over is higher than for every other age group except children under 10 we can readily judge the cost to the economy. Activities in concert with social service and other service agencies aimed at ameliorating the isolation, depression and disorientation of the aged may well do more to promote the mental health of this group than all our mental health facilities and treatment modalities. Recent health legislation creating the Medicare and Medicaid programs is providing new health funds and thereby relieving some of the demand for local funding of treatment services. This should make it possible to address ourselves to some of the socio-medical aspects of the problem. Whether this happens will depend upon the leadership Public Health and Social Service professionals provide. Public Health officials must take their places among those who plan for our communities. They must show them that they do not wear blinders and that they are not health chauvinists who ignore other needs of the community in their quest for health dollars. They must convince them that they see health within the broader context of the total well-being of the community and that they recognize the impact of other services upon the total health of the community. Then and only then will they become effective members of the political structure of our society. COMPREHENSIVE HEALTH PLANNING This approach to health planning may seem like rank heresy to some, but I submit that this must be the approach if P.L. 89-749 is to be effective as an instrument for rational comprehensive health planning. Planning which addresses itself to the real health needs of a community cannot be carried out in splendid isolation. Urban Renewal, Model Cities, OEO programs, all these must include health concerns and Public Health officials must therefore take an active part in these developments. It is because of our commitment to this point of view that the New York City Health Services Administration has developed and maintains a close working relationship with the City Planning Commission and Human Resources Association. The fact is that some of the emerging nations which we like to call the underdeveloped nations have already been forced to do that kind of planning. When resources are limited, rationality demands that planning be carried out in terms of what is in the broadest public interest and how the greatest cost benefit can be derived. It is in this context that health and welfare services tend to be funded in terms of their contribution to the total well-being of the community rather than because health is presumably intrinsically good. Some nations have for example had to decide to reduce a malaria eradication program to a malaria control program in order to expend more funds for agricultural development because it didn't make sense to save people from malaria so they could die of malnutrition. The funds spent in agricultural development contributed more to the growth of the economy and hence to the total well-being U.S. National Health Survey (Injured Persons)-Serles B-16 (1960), B-37 (1962), B-39 (1963). Accident Facts-1966 Edition, National Safety Council, Chicago. of the nation. The net-cost benefit was therefore greater and more in the public interest. We may perhaps never be forced to make such choices, but we must certainly be prepared to justify our health activities on better grounds than the intrinsic goodness of health services both for our aged population and those who are younger. In a city as large as New York it will not be a simple matter to provide health services to the aging with all the social concerns which we all agree are necessary. But I believe that this goal can at least be approached if we abandon the rigidities of the past and become more flexible about the way in which services are provided. There is a growing literature on the use of subprofessional personnel with appropriate training and supervision. This literature seems to indicate that we have been caught in a trap based upon a confusion of objectives.' Let me give an example. There are in the United States approximately 400 public health educators at the Master's degree level. Even with the most optimistic statistical projection is it conceivable that we could even produce enough health educators at that level to make them the only source of health education to the public? Obviously this is not feasible. Should our objective therefore be to alleviate the shortage of public health educators or rather to attack the inadequacy of community health education? If the latter is our objective, we can begin rationally to explore other more realistic means of solving the problem. We can draw the same analogies in public health nursing and in social work. This approach has already begun to bear fruit in New York City. Public Health Assistants are already expanding the productivity of the public health nurse, dental hygienists are already expanding the capabilities of the dentists and in addition providing more dental health education than public health educators. More recently social health technicians and social work case aides have begun through some of our antipoverty and manpower development programs to provide some of the social service outreach and supportive services which are expanding the capabilities of the limited number of professional social workers available to us. It is only through such innovation that large Metropolitan enclaves will be able to effectively combine health and social services for large numbers of people. OEO NEIGHBORHOOD FAMILY CARE CENTERS Recently we have received 5 grants from OEO for the establishment of Neighborhood Family Care Centers where we will not only deliver comprehensive health care but will also train subprofessional workers to perform relevant health and social service functions as part of the socio-medical team. In addition there are currently in our capital budget funds for 17 New Neighborhood Family Care Centers and funds for the renovation and conversion of several existing Public Health centers to family health care. All of these resources will be equally available to the elderly among us. The effects of Medicare and Medicaid upon health care of the aging is a subject about which we have great concern. Attached to this statement is a paper which I have prepared for delivery at a session of the 95th annual meeting of the APHA in Miami Beach Fla. on October 26, 1967. I have labeled it Appendix A. It deals with some of the issues related to the effects of this legislation on health care for the elderly.8 Domiciliary facilities for the aging who cannot live alone but who do not require institutionalization is another matter to which we have given some attention. Appendix B attached is a report of our findings in a study made in 1964 and our resulting recommendations." These have been submitted to the New York State Department of Social Services which has jurisdiction over such facilities and some of our recommendations have recently been implemented. With a rapidly growing aging population we will be continually faced with the need to anticipate and deal with new problems. The extent to which we deal successfully with these problems will be determined by our ability to be innovative and flexible in the application of our resources to the problems. This committee 7 Bellin, L. E.; Killeen, Mary; Mazerka. J. J.—“Preparing Public Health Subprofessionals Recruited From the Poverty Group-Lessons From an OEO Work Study Program." American Journal of P.H. Vol 57, No. 2, February, 1967. 8 See p. 506. 9 In subcommittee files. can play an important role in creating a public awareness of the problems and in providing the leadership in the Congress which will be necessary to generate the resources required for the accomplishment of our tasks. (The chairman addressed the following questions to Dr. Haughton in a letter written after the hearings:) а 1. Your statement (p. 7) says that P.L. 89-749, if it is to be effective, must be implemented in conjunction with other federal programs. We would appreciate additional discussion of this point, with any suggestions you may wish to give on possible changes in federal law or policy in order to facilitate such a broadbased approach. 2. On page 5, you described the reluctance of many elderly individuals to leave their familiar clinics when you implemented a group practice medical care program for them. Was this a serious problem that should be considered in plans for establishment of such group health practice programs in the future? 3. Your address on the future of public general hospitals makes the case for transforming such hospitals into centers of high-quality care for all income groups. Have you any suggestions for federal action that would accelerate this process? 4. Your working paper on medicare and medicaid protests against the "prohibition of routine physical examinations under medicare". How would you implement such checkups? Do you now have the screening facilities that would be required? (The following reply was received :) Question 1, with regard to Public Law 89-749, is a most important one. If comprehensive health planning is to be meaningful and really comprehensive it must be responsible for all health planning in a region, in this case the region being New York City. In the past, urban renewal programs, slum clearance programs, and even OEO programs have been planned without any real concern for the health facilities which must accompany such planning. As a matter of fact, members of the health agencies have not been involved in this community planning. In some instances, OEO programs are planned for health services without involving local health authorities. This has not happened in New York City simply because we have taken a very firm position against it and, in some instances, have even threatened not to accept any OEO funds if the priorities and concerns of the local health authorities were not taken into consideration. The time has long passed when health planners can isolate themselves from the agencies who plan for the total community. Health planning must of necessity become a part of total community planning, and this is possible and should be vigorously implemented under Public Law 89-749. As I read the present law, it is clear the intent is that the comprehensive health planning agency at the State level be a public or governmental agency. At the local level, however, it apparently provides that the agency may be a voluntary agency. This is, to my mind, a weakness, since a voluntary agency can never be as publicly accountable as is a public agency. While it is true that in some localities the local health authority may not have the competence or expertise to carry out such planning, I believe that these agencies should be encouraged to develop such expertise and that, in the interim, a State planning agency carry out the functions for those localities which do not have the talent. Because of this permissiveness in the law with regard to what agency may do the planning at the local community level, we are now faced in New York City with a rivalry between the local regional health and hospital planning council and a proposed public agency. This kind of rivalry can be eliminated or avoided if an amendment to the law should provide that, clearly, the planning agency must be based in government. Question 2 is a sociological one, and one that is difficult to deal with, since there is no way to create an aura of familiarity in a new setting. Those persons over 65 who have been going to out-patient clinics for many years will want to continue to attend them in some cases. Our aim, therefore, should be to up-grade the outpatient clinics and to convert them to group practice organizations so that we may improve the quality of the services and the amenities related to them while, at the same time, maintaining these older persons in the familiar surroundings to which they are accustomed. Our aim in New York City is to reorganize the |