and organize our resources. If we choose to waste billions of dollars both within the health arena and in our total notional economy, we should be aware of the price we are paying in serious community problems and in personal anguish. If we want to shift our national patterns of spending and resource allocation, it will take more planning than preaching to accomplish it. There are some, of course, who argue that pain and death are preferable to regimentation, for they fear that greater organization of our economy in general and our health service system in particular would mean an irreparable loss of freedom. This is a vast distortion, however, of the true meaning of freedom. We have built a great framework of public education in America—compulsory in its support through taxes and compulsory in its attendance by children—and it has enriched, not diminished, our freedom. Our social security system has enhanced our personal freedom in the later years of life by compelling us to save in the earlier years. Our public health system, with such compulsions as smallpox vaccination and pasteurization of milk, has helped to free us from disease, just as the workmen's compensation laws have helped to liberate workers from the hazards of industrial injury. A group-practice clinic frees the doctor from the preoccupations of the small merchant and permits him better to practice scientific medicine. The regionalized hospital system can assure the freedom of a country-dweller to get the scientific care he may need in an urban center. A flouridated water supply frees children from needless dental district and frees families from needless expenses. SCIENCE AND LEADERSHIP The path to freedom and to truth may be found more surely in the method of science than in that of tradition or faith or surmise. Yet scientific knowledge both about nature and about society itself has not yet reached the extent that all persons, or even the majority, can make the wisest decisions for their own good. Flouridation of the water supply is still submitted to community referendums, launched by public officials with a distorted view of the democratic process. More often than not, the people have voted against this safe and effective measure. Scientific medicine is still shunned by many in favor of quackery. The task of leadership in a democracy, it seems to me, is to apply social measures for the benefit of people, based on the best knowledge that science has produced at a given time and place. The next year, the next day, science may yield a better answer, and then the policy must be changed. Within these limits, political and social leadership must be responsive to the will of the people. In the provision of health service, we have learned a great deal both technically and socially over the centuries, but we are far from applying all that we know. There are manifold resistances to the social changes that would be necessary to apply that knowledge, and the ultimate source of strength to overcome those resistances is the understanding of the people. Social workers have a great role in increasing that understanding. They are carriers of a torch that is fed by a fuel of humanism-not just a merciful kind, with pity for the underdog, but a rational humanism that sees the importance of social responsibility for the personal well-being of every individual. They can help to advance the struggle of man to learn, in the achievement of health as in pursuit of other essential goals, that he is, indeed, his brother's keeper. ITEM 5: MATERIAL SUPPLIED BY DR. GEORGE JAMES* (Inaugural Address by George James, M.D., President, National Health Council) To some extent the National Health Council has become known as a sort of corporate representative of the voluntary health movement in the United States, and there is truth in this. But the real purpose and basic commitment of the Council is to promote health. If the National Health Council is thought of as speaking for voluntary organizations waging war against specific diseases or collections of diseases, the image is incomplete. But I think in some people's minds there is a picture of the Council as representing a number of groups that are free and independent, not much in *See statement, p. 71. contact with each other and not only out of contact with government, but rather suspicious of it. The fact is that if you consider the active members of the Council you quickly get a picture of the interrelatedness of American health effort and how we are all tied together. For example, the American Medical Association has as members doctors who conduct private practices, but it also includes many other doctors-some who are employed by government at various levels, and even some who are employed by pharmaceutical manufacturers. The American Nurses Association covers the whole field of nursing and that includes nurses in health departments, which are government, and nurses in voluntary health agencies, which are not. The Association of State and Territorial Health Officers is a voluntary group in that it is made up of men and women who have freely decided to keep it in existence and who choose its policies as they see fit. But in their daily work, these people are in government. This broad spectrum in my view is one of the strengths of the Council. Through the individual members of its member organizations it reaches every part of the American health movement. Only by touching all these parts and dealing with all of them can we hope to be an influential generalist and an effective catalyst in health today. THE PICTURE OF HEALTH TODAY If we in the Council are going to do anything that makes any sense, we have to meet the needs of public health today and in the foreseeable future. We aren't going to be useful solving problems that don't exist, or that have essentially been solved already. The nation, as you know, is experiencing an increase of population at both ends of the gamut: more youngsters, more old people. We have problems with the young, especially variations in infant mortality in different areas and we need much more effort in this field. But we already have a large number of sophisticated, well equipped and supported agencies and programs here. What really sobers us with its enormity and our unpreparedness is the medical problems of our older people. In my city we will have one million persons 65 or over in a few years and the nation will have about 25 million in this age group by 1980. These older people are going to want all the benefits of first-rate American medical and health care for acute disease, when it is needed. But the great problem among them is chronic disease, very often half a dozen or more concurrent long-term diseases for which, as yet, we have no biologic cure but for which we do have treatment that can be effective in sustaining their precious independence and self-sufficiency. I think I could convince you that if these older people do not get continuing care, then they are very apt to decline quickly and have to be put into hospitals or other institutions. The cost of institutionalization is high, however, and if it becomes the main instrument for care of the aged, the total expense will be so astronomical that it seems impossible to design budgets to include it. Estimated figures just for this city run to billions, rather than millions per year. The cost of keeping people independent, of preventing their conditions from becoming crippling, is far less than institutional care, but even this costs money. And older people have less money than the average. There is a great deal of poverty among them, much of it brought about by illness; and there is a great deal of illness among them, influenced and promoted by poverty; a vicious circle if there ever was one. When I say we don't have biologic cures for some of our long-term medical conditions, you will say: well, this is what we are looking for. We are looking for ways of curing arthritis and curing or preventing cancer and coronary heart disease. I believe that some of the organizations represented here will indeed contribute greatly to the solution of such problems some day, but these are complicated problems, likely to be overcome a little at a time, perhaps leukemia first, perhaps then another kind of cancer, perhaps over a period of many years, several others. But I think we must expect chronic disease to grow as a problem in the foreseeable future. It is in this environment that all of our member organizations, and all their chapters, and all their people, and all their professionals and all their laymen and indeed, all of American health effort must function. I need hardly emphasize 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. Medical Care Until 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. Sixth, 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 83-481 0-67-pt. 1-17 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 given 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 |