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what might happen to budgets and contributions if the problem of chronic disease is allowed to get out of hand. And, of course, it must be handled along with all the others, along with all we do in acute disease, along with our programs of immunization, environmental sanitation and all the rest. Vedical Care
l'ntil research gives us preventives or cures, care is going to be the chief weapon we have to use against many of our worst medical conditions. The importance of care in public health is rather recent. In the earlier days of public health, we emphasized mass programs such as water purification, or one shot immunizations, in which we did help the individual but didn't come in very frequent contact with him. We still have those programs, but in chronic illness we have to deal with the patient very personally and frequently. There is no escaping it.
Chronic disease in an individual may require continuing care for 10 or 20 or 30 years. It seems to me inevitable that with the population growing, we are in a situation in which the amount of care per health worker (doctor, nurse, etc.) is going to be more than it is now. I admit that "amount of care" is an unsatisfactory term. What is evident is that continuing care for chronic disease tends to take more man-hours of work than quick, episodic treatment or prevention for acute disease. To keep up or to go ahead, we are going to have to become more efficient in our use of the resources we have. Today we have a situation where an indigent individual with four or five things wrong with him (not at all unusual in chronic disease in the elderly) may have to go to four or five different clinics for treatment. In a city like this it may mean a series of repeated trips of several miles : very difficult miles for an elderly man slowed up by arthritis, for example.
We have established six criteria for adequate health and medical care and I will pass over five of them quickly and talk a little about the sixth.
First, if it is adequate medical care, it must be available to everybody. From the public health point of view, we do not accept the concept of any group being left out. So-called "adequate care" that only a few can receive is of little interest.
Second, care must be of high quality, which means simply that professional competence is a prime element. It should be given by qualified people.
Third, prevention must be emphasized. Not just the traditional kind of prevention that comes from a vaccine. but prevention that involves early detection of disease so that action can be taken to prevent its becoming disabling, even if it cannot be cured.
Fourth, care must be patient-centered and family-centered. If we put the children one place for care and the father and mother somewhere else, we wind up by missing something and the quality of the care is reduced. We should not be concerned solely with fitting the patient into our medical system, we should be concerned with making that system adapt in new ways to these patients' needs.
Fifth, we must have continuity of care. We are suffering today from too much interrupted, disjointed medical care. Some is unavoidable. We know that about one out of five individuals in this country moves from his home county to another county in a given year. Usually his medical records don't go with him. When he gets to his new home, if he needs medical care, he has to start all over again. But even when people don't move, we chop up medical care. We give care to people on relief, and if they get off relief, which they try to do, they are often shifted to entirely new batches of doctors.
Sometimes we start a patient out with a private general practitioner. He may be dealt out to three or four specialists, winding up in the hands of a surgeon. Here again, complete medical records may not accompany him and a great deal of work is done over every time that does not have to be. What we need is for somebody to be in charge of the patient all the way through.
Sirth, we want comprehensive care. We want a patient to get all the care he needs whenever and wherever he needs it. If he receives treatment for diabetes we want that treatment to be comprehensive enough to discover tuberculosis if he has it; and if he starts with tuberculosis, we want the treatment comprehensive enough so that diabetes will be discovered and brought under care, if he has it.
Part of the lack of comprehensiveness in medical care has been brought about by dividing the individual into organ systems and then having payments made according to those organ systems. A separation of organ systems in a file cabinet
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in Albany or Washington can mean that you have two separate institutions by the time you get down to the patient's level and he has to travel a long way from one to the other to get the care he wants. I don't at all deny the need for specialization nor the need to concentrate on certain specific conditions at certain times. Nobody can know all about medicine. We are all laymen about most of medicine.
If money is spent by government or by voluntary agencies for, let us say, the liver, I have no objection to its being earmarked so. But when that money gets to the level of patient care, then I say it must be spent as part of a total package whereby the patient gets comprehensive care that handles whatever his problems may be. Care facilities over-emphasizing single diseases are becoming old hat because today's and tomorrow's patients inconveniently don't restrict themselves to single diseases.
Most of you have read the report of the President's Commission on Heart Disease, Cancer and Stroke. I hope very much that the suggested program will help move us further toward comprehensive medical care. I am struck by the recommendation of a regional network of heart disease, cancer and stroke centers where clinical investigation, teaching and patient care will be brought together. Let us hope that these centers will provide us with new ideas on the interrelationship of our chronic diseases. I have no doubt that in the stroke and heart disease centers particularly, doctors will speedily find themselves dealing not so much with individual diseases as with different patterns of multiple problems in their patients and their families.
GOVERNMENT AND THE VOLUNTARY AGENCIES
A great deal has been written and said about the difference in function between government and voluntary agencies. It has become customary to say that government is both slow moving and threatening, and that voluntary agencies are both quick and reliable.
I don't know. Government can move pretty fast. Just you dare to distribute some thalidomide to the drug stores in New York and then see how fast government moves to get rid of it!
My own view is that within government health units, just as within voluntary agencies, there is not only room but a crying need for imaginative action. I think there has been imaginative action in both camps and to suggest that either group has a monopoly is foolish.
Some of the responsibilities of government are health programs for which, at least at the moment, there is not much fund raising potential. The voluntary agency is dependent on contributions and those contributions often depend on how convincing a picture is drawn of the problem being fought. Conditions which can be very specifically pictured appear to attract money more than collections of conditions. A great many health activities by government, such as assuring pure food, are not matters about which there is now public hue and cry, except when things go wrong. They have little present fund raising potential.
Neither government nor the voluntary agencies can operate on the basis of allocating money exactly according to a statistical estimate of the importance of a disease. This has never worked. In the first place, there is no agreement on relative importance. How many points do you assign disease A, which kills a lot of people but kills them quickly and quietly, as against disease B, which kills very few people but causes many man-hours of misery and crippling over many years?
It is true, even in government, that there are some diseases that people are exercised about that are not actually major problems. But the public considers them particularly ugly-I am thinking of rabies, for instance_and demands what might be called extreme measures against them.
Since we are dealing with human beings and working for them, we listen to these views. And a human being does have the right to make up his own mind about what he considers a bad disease, with or without statistics. In fact, his freedom to decide what he thinks is worth doing something about is a cornerstone of voluntaryism.
I want to say just one more thing about government and the voluntary agencies, something quite unrecognized. I think, by the general public. That is that the two groups work together over and over again. The New York City Health Department is working now with over a half dozen voluntary agencies that belong to the Council and works constantly with the professional groups among the active members. Government advisory committees are studded with scientists who serve the voluntary agencies.
In my view, the federal government has gone to great lengths to encourage lay participation in the field of health and local participation in the field of health. It has done this not only by tax deductions but it has repeatedly made grants to voluntary groups as, for example, to the National Commission on Community Health Services. I think the relationship between government and the voluntary agencies, admittedly sometimes difficult, is nonetheless flourishing and will improve.
Today with the growing significance of incurable chronic disease, we are realizing that any useful attack must be comprehensive and not narrowly specialized. Diabetes control, for example, requires the use of educational tools to motivate people to come for disease detection, home nursing to assist patients to give themselves insulin and test their urines, dieticians to help the patient regulate his diet, laboratory technicians to perform more complex analyses, and so on. So complex have become these programs that any given professional worker is a layman in more phases of the total effort than in those where he is an expert ! What more proof do we need of the importance of lay participation in health programs, since the term "lay” truly includes all of us who picture ourselves as qualified professionals! The fallacy of bigness
It is the fashion to sound the death knell of the voluntary health organizations that are involved in research. The claim is that with so much government money going into research, there must be little left for the voluntary agencies to do.
I don't agree with this. It seems to me we have been oversold on the fallacy that bigness is desirable. We have been led to confuse massiveness with effectiveness.
This is a little surprising, since the record of the voluntary sector of American scientific research is very good indeed. One need not go over the polio story again, nor review the very fine early work of the National Tuberculosis Association, especially in the Framingham project in Massachusetts. One could look at the histories of America's Nozel Prize winners, and one would find that the nongovernmental side of medical research has acquitted itself very well.
Money does not always talk. Not to the extent that you can judge the relative merits of two research programs by their budgets. The great scientific discoveries of the future will come from individual minds, from the minds of what Sir C. P. Snow calls alpha-plus scientists.
The vast government programs are necessary. The nation does not intend to overlook their possibilities and hopes for their continued expansion. But the voluntary agencies have an important role to play. Their smaller research programs, easier to understand and to manage, often tailor-made to fill important gaps in more distantly controlled federal programs, can be beautifully controlled and highly productive. In the present state of science we have to continue and increase the huge federal effort, but there is a clear need for the sensitive, highly flexible investigation pioneered and continued so well by the voluntary agencies.
So I think voluntary organizations should divest themselves of their fear of smallness. It was smallness, audacity and mobility that sank the Spanish Armada and this approach may continue to sink some of our towering health problems.
The essential question to me is not whether a voluntary organization in a giren field is necessarily better or worse than government in the same field. The question is whether we should let either side preempt a field, or might better agree that there is not only room for both, but need for both. Accreditation and criteria
Much has been said about government controls, and about accreditation and criteria in the independent sector of American health effort.
Criteria pertain to membership in the National Health Council. We all want to maintain standards for our organization, and to admit only such member organizations as conduct themselves properly. The storm rages over what words like "properly” mean.
Certainly there are some groups in the country claiming to be professional organizations that most of us would not want to admit to the Council. There are some voluntary health agencies whose handling of funds is such that we might not approve of them.
It is the details that are hard to arrive at. I think, therefore, that we should all be grateful that the Council has come up with a set of standards of accounting and financial reporting for voluntary health and welfare organizations. I very much hope that every member organization to which these standards are applicable will adopt them.
There can hardly be anyone here who has not read reports of irresponsibility among voluntary health agencies. In some cases there has been legal action and some people have been sent to jail. I make two points about this: first, it does not help us very much when an offending organization happens to be outside our membership. The bad operations hurt all voluntary health agencies. The damage does not stop at the line of National Health Council membership. The Council must be as much interested in the fly-by-nights as in its own membersperhaps more so.
Second, there is no such thing as voluntary health agencies operating without government control, if by control you mean a framework of law. Many states already require extensive financial reports on a county to county basis. In many areas one has to have a permit to solicit funds. In some places fund raising costs may not legally exceed a certain percentage of the contributions received. Practically everywhere, so far as I know, there are laws relating to misrepresentation. If you publicly raise money for disease X and spend it all on disease Y, you are very likely, at the least, to have to do a lot of explaining to the representatives of the law.
I don't think our position in the Council is or should be that we want the independent sector in American health to operate outside the law, beyond any control. To use one of the oldest, and maybe best, of the familiar analogies: it is not a loss of freedom when we are required to drive on the right hand side of the road. It increases our chances of getting from here to Chicago. A framework that will assure that voluntary health agencies show the same responsibility that a driver shows when he stays to the right should increase their productivity, not reduce it.
The problem is to achieve cooperation and assure responsible practices without giving up individuality and initiative--without cutting off the crisp wind of freedom that blows through the voluntary agencies. This is not easy to do, but neither is it impossible.
We should surely examine the proliferation of local laws and ordinances. It is as difficult for a national health agency to deal with these regulations as it is for the building industry to contend with thousands of codes. I know that the voluntary agencies would rather cooperate toward some reasonable national model state law in place of the increasing tangle of local restrictions.
If all agencies were responsible operations there would obviously be little need for regulation of any kind. One method that has been suggested to this end is accreditation, similar to the accreditation of medical schools and hospitals. This might be done by a special group developed by the National Health Council through its membership. Some have reacted privately, saying this smacks of vigilanteism, adding that if there is to be accreditation, it should be by government. But accreditation differs from the governmental mission of issuance of a license or a permit. In the health field accreditation has traditionally been a function of voluntary rather than government groups. The criteria for membership of the National Health Council already go far toward being a useful accrediting device. I urge that we build on this rather than try to start a new movement.
In any event, we cannot divorce ourselves from those in the voluntary field whose actions are less responsible than ours. And in my view there is much room for improvement, viewing the field as a whole. If all the voluntary agencies (and government, too, for that matter) were to run a tighter ship, our total achievement would surely increase.
AFTER THE NATIONAL COMMISSION
We are living through a revolution in medical and health care in the United States, in part because we have been living through the period of the National Commission on Community Health Services, sponsored jointly by the National Health Council and the American Public Health Association. The Commission grew out of the Advisory Commission on Local Health Departments, which in turn grew out of a conference some 18 years ago of which Dr. Haven Emerson served as chairman.
Then, as now, there was general agreement on one point: that people should get better health services. We thought then primarily in terms of providing adequate health departments because so many counties were really without public health units. Today we have broadened our viewpoint. We are after adequate bealth services, and if they can be provided by a health department that's fine; and if they can be provided by someone else or a collection of someone else's, that's fine, too.
I don't know how many of you have seen the National Health Commission's work at a local level, but it is very impressive and the impressive thing about it is that it is really the work of local people. What they are finding out is motivating them to move ahead. If you would review, for example, the Lucas County Community Health Study in the Toledo, Ohio area, you would find that it is a fascinating thing, filled with facts not before gathered together. It is hard to believe that anyone could participate in such a study without being moved to action by its findings and, remember, these are the findings of the citizens themselves, not the professional health planners.
Interest and support for the Commission has come roughly half from government and half from private or voluntary sources. There are 21 community action studies and there are six task forces on environmental health, health services manpower, health facilities, organization of community health services, comprehensive health care, and financing health services. There is, of course, a great deal more.
The National Commission is now planning its 1965 National Health Forums which will be cosponsored by us as the National Health Council 1965 Health Forums. There are to be four regional forums, in San Francisco, Chicago, Atlanta and Philadelphia where the experiences of the study communities and the implications of the task force recommendations will be discussed.
There is no question that the National Health Council, as well as the American Public Health Association, as the original sponsoring organizations of the National Commission, will have their work cut out for them when the Commission ends in September of next year, a short 18 months from now. Whatever suggestions are agreed on, the job of implementing them will certainly fall on the members of the National Health Council and also of the American Public Health Association.
You will remember that when the National Advisory Committee on Local Health Departments was formed, its link to the National Health Council was purposefully made loose because it took controversial stands. The National Health Council itself does not take such stands because that is not its business. Its business, however, is to bring together people from all branches of our bustling civilization who very often don't think in the same way--who very often think exactly opposite and in the productive discussion that results, to help get things started.
In the period after the work of the Commission, it will be the job of the National Health Council not to tell its member agencies what position they should take-they would react unfavorably to that anyway—but to help them in every way possible to show their own leadership.
I don't think we need to fear that nothing will be done as a result of the National Commission. Too many needs have been stirred up and illuminated, too many movements already begun, too much momentum already created. But unless the National Health Council acts skillfully, much less will be done than otherwise, particularly in areas where there were no local studies. If we can bring some of the enthusiasm that now exists in those communities to the others, we will have accomplished a great deal. Undoubtedly the implementation of the National Commission's recommendations is going to concern us greatly during the coming 18 months, and we will all be talking and, I hope, doing a great deal more about it. Conclusion
That the National Health Council exists and continues to expand its influence is eridence of how much it is needed. Its member agencies, however independent, recognize deeply the need to reach out, touch each other and learn from each other. Let me just review briefly what seem to be areas in which the National Health Council has an emerging mission :
1. To bring together as a combination of catalyst, harsh irritant and house mother, the member agencies and sometimes others-agencies representing a great variety of effort and sometimes almost total disagreement on methods of accomplishing what needs to be done.
2. To promote a constant bubbling up and dissemination of truth, particularly the kind of truth that an organization needs to know about the field outside its primary responsibility.