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assuming an overlap of approximately 25%, we would come to a figure of about 8,500 days of restricted activity in the United States per 1,000 persons per year with respect to chronic disease. This is undoubtedly an understatement, since it does not include the institutional population. Another problem, of which the National Health Survey staff is very much aware, is the number of these who have died within the past year. There are also major omissions in the field of mental disorders. But even with this conservative estimate, at a figure of 8,500 days of restricted activity per 1,000 persons per year, the problem of chronic illness exceeds that of the aggregate of all acute illness.
As for the mortality as a measure of the extent of the problem, the chronic disease issue is far greater. Among the leading 20 causes of death, illness which during life was chronic accounts for something like 18 or 19 of the causes, depending upon how we classify a condition like pneumonia, which is often a terminal event in a chronic disorder. Accidents are almost the only cause of death of any significant proportions in the United States today which are not a chronic disorder, and in old people even accidents are often indirectly related to chronic illness.
The social problem of chronic illness is compounded by the fact that it not only affects many people and makes their lives difficult and creates burdens for those around them, but it constitutes a problem of high costs. The mere duration of the illness means long-term medical care. And so, largely because of its economic impacts, chronic illness has become a major medical-political issue of the day. Every significant political group in the country is debating ways of coping with the economic problem.
Much progress has already been made in coping with these economic aspects of chronic illness, through the extension of various programs of governmental or public medical care. The municipal hispital, the programs for crippled children, the Veterans Administration Service, the mental and tuberculosis hospitals, the vocational rehabilitation program, a major share of the medical service provided under public assistance, the largest sector of which is the old-age group these programs are all largely oriented to meeting the economic costs of chronic illness. Primary Prevention
From the public health point of view, we conventionally speak of various levels of prevention. One level is primary prevention. This means, in its original sense, doing somthing before the person has signs of illness. A tremendous amount reasearch is being done today on the ultimate instrument of prevention, the determination of etiology Epidemiological studies, both in the field and in laboratory investigations, are being purused rapidly with respect to heart disease, cancer, arthritis and other major chronic diseases.
In actual operation, there have been many accomplishments. The development of immunization against poliomyelitis has been a major success in the reduction, through primary prevention of paralytic polio, formerly a major chronic illness. The tuberculosis control program has likewise been largely successful in the primary prevention of this chronic disease, mainly through elimination of infectious cases by institutionalization. The same is true of venereal disease. For the last 6 or 8 years there has been a rise in venereal disease again, a relatively small rise if you take as your bench mark the situation 30 years ago. However, the general trend has certainly been a long-term reduction in acute cases and particularly the chronic sequelae of syphilis and gonorrhea.
With respect to cancer, we have learned an enormous fact in the association of tobacco and cancer of the lung, now the major cause of cancer in males. Far less has been done with this knowledge than many of us would like to see, but we have an instrument for primary prevention of cancer of the lung which can be more fully exploited in the years ahead. Some of the rarer cancers relating to occupation, in the dye industry and in other industries dealing with various hydrocarbons, have been successfully reduced by occupational hygiene. In the field of arteriosclerosis, we are on the verge of some type of consensus on etiology. The new knowledge about fat consumption and exercise may provide clues to measures for primary prevention of the major cause of death in the United States today, arteriosclerotic heart disease. There is certainly a tremendous amount of presumptive evidence that points to a combination of culprits: the fatty composition of the diet, the extent of exercise that a person engages in, the element of stress. With respect to congenital defects, another major type of chronic illness, our knowledge of the problem of radiation has grown rapidly. We are certainly far
more cautious than in the past about use of man-produced radiation because of its possible effects in leading to congenital disorders the next generation.
As for chronic bronchial disease, bronchitis and emphysema, we certainly have accumulated evidence on the role of atmospheric pollution. We are beginning to do things in the field of smog control and on the general problem of atmospheric pollution which may have future benefits in the primary prevention of this type of disorder.
These are some of the direct measures of primary prevention. There are also many indirect actions which have probably led to a reduction of chronic disease. The general reduction in streptococcal infection because of drug therapy may well be responsible for the appreciable decline in rheumatic heart disease, once a major form of heart disease and now relatively uncommon. There has certainly been a reduction in osteomyelitis, which was a relatively common cause of locomotive disorder in past years, and in problems of mastoiditis and other infections. These complications caused by bacteria are less frequent today, largely because of the antibiotic drugs. The improvement of obstetrics and perhaps better prenatal care has led to a reduction of those congenital disorders associated with the birth process.
We have knowledge about obesity, which is not being very well applied. Some health agencies, however, are using education and special clinics to attack the problems of obesity with its associated diabetes, gall bladder disease, and, to some extent, cardiovascular disorder.
Early Detection of Disease
Unfortunately, much of what can be done today for chronic illness is not confined to primary prevention but must depend on a less direct method of prevention. It involves the early detection of the disease and the application of prompt therapy, on the grounds that if a disorder is detected early, its therapy can be more effective. Health departments and other agencies are doing a great deal about the early detection of diseases-diseases which might become chronic. The chest X-ray for tuberculosis and other conditions of the chest, including cardiac enlargement, is widely practiced. Case-finding methods for syphilis, of course, have been long practiced through blood tests, and examination of the blood and urine for glucose as an early method of detecting diabetes is widespread.
Cancer detection through formal clinics and through education of people-selfexamination of the breasts in women, for example has been widely extended. The extension of cytology for uterine cancer, the Papanicolau smear, and to a lesser extent the use of this technique on the sputum as a method of early detection of lung cancer, are important approaches. The early detection of glaucoma through examination of the eye pressure and through vision tests is another measure. Streamlined medical histories have been developed for simplifying the examination of large numbers of people, with respect to early symptoms of many chronic diseases.
These and other measures for early detection of chronic disorder require organization. One approach has been the use of multiphasic screening or combinations of various detection tests as a public health activity. Such programs are being practiced in industry and in many public health agencies.
The simple every-day practice of most hospitals, a work-up on all patients admitted, is a major measure for early detection of chronic disease. Almost one out of eight people enters a hospital in the United States each year, and among the older adult propulation the proportion is higher. The performance of a simple medical history, physical examination, and routine laboratory tests on these people constitutes a major approach to the early detection of chronic disorder. Payment plans, which are covering an increasing proportion of the population, also often provide encouragment for general medical examinations as a benefit of membership.
Prompt Medical Care
The next level of action against chronic disease from a public health point of view is the provision of early therapy. The procurement of medical care, following the detection of a possible sign of an illness, involves three sets of problems: cost, motivation of the patient, and organization of services.
To cope with the cost problems a great deal has been accomplished, although more remains to be done. The health insurance movement is a major contribution to the attack on chronic disease, by its effectiveness in easing the access of people to prompt medical care. It is a central feature of the public health approach to
the problem of chronic illness. In just the past 20 years, health insurance has grown to a point where over 70% of the American population is now protected by some form of insurance for hospitalization, and probably some 50% with respect to physician's care. In the rapidity of this growth, we have acquired types of health insurance that leave something to be desired in their concern for the qualitative content of the service provided. The largest form of health insurance in the United States today is that carried by commercial proprietary insurance companies, and this is a form in which the cost problem is met but with very little concern for the content of service purchased. We have a long way to go in improving the level of professional surveillance over the type of medical care that is financed by insurance programs.
Public medical care for the indigent, which is being improved and extended, is another way of coping with the cost problem of chronic illness. Probably the major political issue in the health field today is the problem of costs of hospital care for aged persons. We have had limited progress in the Kerr-Mills bill passed in 1960, but the issue is still very much alive.
Regarding motivation, we know that the problems of procuring medical care is not just a question of providing payment for services. People must be educated and motivated to use them. In many medical care programs, those for the indigent as well as health insurance programs, even when costs are met there are still many people who do not use the service. This may be a problem of education. It also relates to the physical convenience of medical care facilities, particularly in very large cities, where the task of intra-city transportation is great. It is also true, of course, in rural areas. Social scientists are doing a great deal to examine the feelings and attitudes of patients in the doctor-patient relationship. Most studies have shown that a major factor in the patient's willingness to see a physician, and his response to the instructions of the physician, is the patient's feelings about how the physician regards him as a person.
Regarding the organization of services for more effective application of therapy after the disease has been detected, we have seen tremendous progress in the field of medical services within hospitals. Hospital organization in the United States has improved very rapidly in finding ways to apply known techniques systematically. We see increasing use of consultations in general hospitals. We see many special measures like intensive care units, special rehabilitation units, more skillfully organized nursing services, etc. The field of physicians' self-discipline through medical staff organization in hospitals is receiving increasing attention. In the hospital setting, physicians are organizing themselves in a teamwork arrangement which is making possible a high quality of medical care. Institutional care and rehabilitation
Next in the levels of prevention is the problem of the patient in whom primary prevention has failed, and in whom prompt diagnosis has not resulted in effective therapy, so that he continues with his chronic disorder and becomes confined to bed. Even at this stage, there is still room for some effective action from the public health point of view. Something can be done to reduce disability and to extend life. There is very rapid development of interest among general hospitals in special units for long-term patients. The Medical Care Research Center in St. Louis is conducting a major study on the details of long-term care units in general hospitals throughout the United States (see page 34). The "progressive patient care" concept of hospital organization has gained acceptance as a way of reorganizing according to the level of bed care or ambulatory care that the patient may need, rather than strictly according to pathological diagnosis.
Institutional care for those who do not need the active level of service of the hospital is being rapidly expanded through tens of thousands of nursing homes, convalescent institutions, and special wings of homes for the aged. This field has grown rapidly, however, that there is a woeful lack of quality standards in nursing homes, most of which, in this country, have proprietary management, but at least the problem has been recognized. There is now a new national association tackling this problem, in the same way that the hospital movement and the various professions have tackled the problem of standards and discipline in their own ranks.
As for other types of disabled patients, the hospitals have taken initiative in developing care for the bed patient at home. "Home care programs" are now part of the everyday vocabulary in the hospital field.
Many other forms of organized activity are coping with the problems of the bed-patient at home. The visiting Nurse Association, the homemaker services, the
extended bedside nursing services of the Health Department are all measures for providing more effective care of the bed-patient at home.
Finally, when all this has been done, we must still face the problem of rehabilitation of the disabled patient, to help him get back on the job.
The panorama of activities which represent the public health approach to chronic illness involves problems that are enormously complex, administratively and economically, and also psychologically and culturally, and in every community the tying together of thes activities presents a large task of coordination. It is a task of bringing together all of the activities, public and private, including the voluntary health insurance movement, the governmental programs of medical care, the hospitals and the other voluntary agencies-bringing them together for a coordinated attack at all the levels of prevention of long-term illness that we have discussed. There are hundreds of councils and committees now functioning in communities to cope with the needs of the long-term patient. What is needed is a permanent, continuing, and well-staffed agency to concern itself with the coordination of these many measures of attack on long-term illness, and the logical agency to provide leadership toward that objective is the local Department of Health.
C-HEALTH: CAN WE AFFORD TO MEET THE NEEDS?*
(By Milton I. Roemer, M.D.)
This paper was prepared for presentation at the Louisiana Conference of Social Welfare, New Orleans, March 19, 1964. The author is a member of the faculty of the School of Public Health of the University of California, Los Angeles.
Future historians, I think, will look back upon the nineteenth and twentieth centuries as the time when man was struggling to act upon the precept that he is, indeed, his brother's keeper. They will see evidence of this struggle in the great convulsions of international affairs and in the birth pains of a United Nations that is truly united and in the maturation of a world government. They will see it in the development of a vast industrial technology and system of agriculture, the products of which are distributed to meet the needs and reasonable expectations of people. They will see it in the gradual extension of education to whole populations, not only in the childhood years but throughout life, in order to enrich the meaning of daily experience. And they will see it also in the evolution of social responsibility for the maintenance of personal health and for its recovery when it is lost.
This evolution, which we see going on all around us, derives its impetus not only from the humanitarianism that the biblical prophets were teaching through Cain's ugly question. Its strength comes mainly from the growing realization that the personal welfare, indeed the survival, of each of us depends ultimately on the welfare of every other individual. This fact has been easy enough for even the most self-centered person to understand in regard to contagious disease; social action has been taken to prevent or control epidemics since man first recognized the process of contagion. Efforts to deal with mental illness followed recognition of the community hazards that may result from the behavior of psychotic persons. But social action has been increasingly taken to deal with the totality of physical and mental illness. It has been taken when the only impact of one person's misfortune on another's well-being has been through the vast and complex mediation of his living in the same society or, indeed, on the same planet.
SOCIALLY ORGANIZED HEALTH SERVICES
The forms taken by social action to protect or recover health have been of a bewildering variety. The organization of public health programs to cope with the hazards of environmental filth or squalor and to prevent the spread of communicable disease is only the most obvious type. Preventive efforts have also been launched in scores of other spheres: in the surveillance of expectant mothers to help assure healthy childbirth; in the prevention of accidents-now
From the Social Service Review, September 1964.
the major cause of death for persons aged one to thirty-five; in the promotion of balanced nutrition, with all its secondary influences on health and well-being; in the achievement of mental and emotional harmony; in the prevention of congenital or even genetic disorders; in the avoidance of specific entrapments like those of narcotics, alcohol, or even tobacco; in the strengthening of human resistance to metabolic breakdown of the vital organs due to arteriosclerosis, cancer, or other pathologies.
Social organization has been as extensive, if less effective so far, in the application of scientific medical care when prevention has failed. In our free-enterprise society, no less than in the other political and economic systems throughout the world, it has taken two principal forms: organization of the patterns of economic support for personal medical care and organization of the manner of technical provision of that care. To finance care the social devices of tax-support, voluntary insurance, and philanthropy have been applied everywhere, at a generally expanding tempo. On the other dimension-the technical provision of service we see increasing specialization, systematization, and group discipline to cope with the infinitely expanding knowledge and skills of science and technology. More and more services are being provided through hospitals and ambulatory clinics, through agencies and programs, as distinguished from the ministrations of the solo practitioner.
The effect of this increasing rate of social organization for both the prevention and the treatment of disease has been, without any doubt, to increase the years of healthy life enjoyed by people. We have paid some prices in terms of the aggregate burden of disease, because of the fact that people who are kept alive for more years eventually become prey to disorders that would not have occurred otherwise. But there can be no doubt that the organization of preventive service has reduced countless deaths and pains, and the organization of diagnostic and therapeutic service has made scientific skills accessible to treat countless maladies which would otherwise have been attended poorly or not at all.
PERSISTENT UNMET NEEDS
Yet, despite the great progress that social organization of health services has made possible, there are still enormous unmet health needs all around us. There are pains and hardships suffered because, within our currently available national resources, we have failed to apply the knowledge and skills that we already possess. We have not yet taken the social steps necessary to mobilize our resources for our own maximum personal good. Just a few examples are presented : All the studies of mortality and morbidity made in America during the last forty years (and it was probably more strikingly so before then) have shown a generally higher burden among the lower income groups.' We know that this fact stems from many environmental and social factors other than health service per se. Nevertheless, the volume of medical services received by people bears generally an opposite relationship; that is, low-income families get less service, despite our extensive development of special programs for the indigent. That the poor among us are no mere handful is reflected by the fact that, in 1961, 32.5 per cent of all American families earned less than $4,000 a year-a proportion of poverty now dawning anew on our national consciousness. Adjustment to the higher illness toll of the poor has been somewhat better in the hospital sector, where illness is treated as a last resort, but the services of physicians, dentists, and nurses for the patient living at home become decidedly fewer, as one descends the income ladder. They tend also to become poorer in quality and sensitivity, more often involving the general practitioner than the specialist, the patent medicine than the scientific prescription. And, as we all know, these social inequities apply even more to American Negroes, whose handicaps in access to medical care compound social discrimination with poverty.
Aside from poverty as such, rural populations throughout America suffer numerous handicaps in their access to sound and scientific health service. Despite the steady urbanization of our country, service in rural areas is not a dwindling problem; in 1960, there were still over fifty million persons living in rural places (even by the more limited definition that counts suburbia as urban)-more than the total national population in 1880. Rural people have much
1 U.S. National Center for Health Statistics. Medical Care, Health Status, and Family Income: United States (Public Health Service Publication No. 1000 [Washington, D.C., May, 1964]).