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REPORT FROM STUDY COMMISSIONS

Governor's commission on aging.-This 15-member study group appointed by Governor Hodges in 1956 has three basic objectives:

1. To review (quarterly) current activities within the State to meet the needs of older people.

2. To evaluate growing or unmet needs and plan together how best to meet these needs.

3. To report from time to time on matters in this area which affect the economic and social progress of the State.

Major areas which have been reported upon include :

1. Special programs for placement of older people in employment.

2. Plans for expanding adult education programs.

3. Increased activity in stimulating recreation among older people.

4. A wider range of public health programs and services for older people, including a new division on chronic illness in the State board of health.

5. More attention and emphasis on the training of medical students to cope with the needs of older people.

6. Courses in geriatrics at the North Carolina School of Public Health Nursing.

7. Increasing the wide range of services through the public welfare program in terms of subsistence grants for older people, increased hospitalization, more adequate provision of domiciliary facilities, and other specalized services, including a demonstration of homemaker services for the aged.

8. Emphasis by the State mental hospitals, working with local agencies, especially welfare departments, as to home placement programs.

9. Strengthening the State requirement system.

10. Helping to bring information to rural people about services needed by and available for the aging through the auspices of the Agriculture Extension Service. The coordinating committee serves as a clearinghouse for all activities in this field of interest and work. Two other major accomplishments are:

1. Organization of county workshops on aging: I have already mentioned the fact that some 51 of our 100 counties have held such meetings at the local level, and to the fact that these groups are cooperating with the county medical society chronic illness chairmen.

2. Proclamation of a special week by the Governor: The week of July 12 has been set for 1959 and will provide opportunities for wide coverage of various programs conducted throughout the State in the interest of the aged.

The Governor has designated this commission to plan for the State conference on aging for 1960 and for the 1961 White House Conference on Aging. The medical society has been requested to work very closely with this group at both State and local level for study, evaluation, and for recommendations as to present and future needs of our older citizens.

The commission for cancer control.-The general assembly renewed its appropriation to this study commission and requested it to continue its study of improvements made and those needed for the next 2 years. A report of this commission has been prepared, reported to, and approved by the general assembly this year.

The commission on nursing and boarding homes.-This commission and the Nursing and Boarding Home Association were primarily interested in getting the mandatory licensing law passed for all boarding and nursing homes. This law was passed and becomes effective as of January 1, 1960.

BASIC RESEARCH AT DUKE MEDICAL CENTER

Under the able leadership of Dr. Ewald Busse, the Duke University Council on Gerontology was formally established by President Edens in 1955. A panel on interdisciplinary research was formalized and received its first grant September 1, 1957, from the U.S. Public Health Service, through the National Heart and Mental Health Institutes in the amount of $1 million. This grant is to be used over a 5-year period to set up a pilot regional center for research on aging. The panel is charged with the responsibility (1) of determining the policies of the research program, and (2) of collaborating with the project director in major decisions in regard to the areas of research activity, the selection of key personnel, and the coordination of the investigation.

The center for the study of aging has as its aims: (1) Encouragement and support of fundamental research concerned with the phenomenon and health pro

grams of aging, (2) training of investigators for research in the problems of aging, and (3) development of a source of scientific knowledge in the field of aging for State and local government, as well as for private groups and individuals. The Public Health Service funds will support a teamwork approach to aging problems by workers in the fields of psychology, sociology, and economics, as well as medicine. During the past 12 years, 19 separate research projects have been initiated by means of these funds. Additional support of the work of the center has come from Duke University as well as from other granting agencies. The Ford Foundation (February 1959) has granted $200,000 for 32 years of basic research in the areas of social and behavioral sciences to complement the activities of the health and health-related areas. The research to date has involved a great many disciplines, including psychiatry, medical psychology, internal medicine, electroencephalography, anatomy, dermatology, ophthalmology, neurology, anthropology, and socio economics.

Projected institute training program.-Another proposal being made by Duke University, which is still in the formative and discussion stage of development, is the possibility of establishing a continuing training institute designed to bring together from local areas physicians, representatives of all agencies concerned with health, paramedical services, hospitals, and the public, for special instruction and training. The methodology and text content of such an institute would undergo continual evaluation in order that changing conditions might be met. Such an institute would be expected to coordinate all health endeavors with the center of aging at Duke University, thereby merging their energies to focus on the problem of total patient care.

Conclusion. From this report of programs and activities now being conducted in the State of North Carolina, I feel that you will agree with me, representing the Medical Society of the State of North Carolina, that—(1) we are aware of the increasing numbers of older people and their needs; (2) we know our own resources and are combinging our efforts to meet present needs and we are increasingly meeting the needs, as well as anticipated needs of the next few years; and (3) through basic research we expect to learn shortly some of the causes and effects of aging so that we may develop services, facilities, and trained personnel to meet these newly defined needs as they are discovered and identified. Financial assistance in the areas under consideration is but a single part of the total problem of the aging, and trying to solve one portion, in largess, while neglecting the minute factors involved in the practical and adequate care of the aged, is not the answer to the total need. I would like to close with the results of a sample survey of the adult population conducted by the Opinion Research Corp., Princeton, N.J., for the American Medical Association. "More than three-fourths of the population of the United States want to choose their own physician. In addition, they want to assume all or part of the responsibility for paying their doctor bills." I make this point to emphasize that the attainment of health and human happiness involves a great many choices which the individual must make for himself and that these choices involve the interplay of personal relationships out of which the whole may develop. Therefore, goals of the Forand-type legislation may well miss these important factors, even for the aging population, by removing factors of choice and self-participation, which are so essential in a life such as we have so notably founded by experience here in America.

At this time. I would like to recognize other representatives of the Medical Society of the State of North Carolina, President John C. Reece of Morganton, N.C. J. P. Rousseau, M.D., Winston-Salem, N.C.; and Mr. James T. Barnes, executive director, Headquarters Office, Raleigh, N.C. Thank you for your kind attention.

Dr. KERNODLE. In conclusion, you must agree with me that North Carolina is making progress toward meeting the needs of our chronically ill and aging patients, and through cooperative efforts, greater advancement will be made with greater efficiency and at less cost to the individual and to the community than proposals you have under consideration.

I point up again that:

(1) We are aware of the increasing numbers of older people and their needs.

(2) We know our own resources and are combining our efforts to meet present needs and the anticipated needs of the coming years. (3) Through basic research we are learning some of the causes and effects of aging so that we may develop services, facilities, and trained personnel to meet these newly defined needs as they are being discov

ered and identified.

(4) We feel that financial assistance in the areas under consideration is but a single and small part of the total problem of aging, and trying to solve one portion in largess while neglecting the minute factors involved in the practical and adequate care of the aged is not the answer.

(5) In view of these achievements, we in North Carolina are convinced that the Federal Government can never match this program. We intend to pursue this direction and further emphasize it.

Therefore, we are opposed to the Forand bill and any similar type legislation because we feel that the programs, services, demonstrations, and voluntary means of financing such care can and will meet the basic needs of our older citizens.

In closing, may I simply refer the committee to the presence with me of our president, Dr. John C. Reece; our past president and legislative chairman, Dr. James P. Rousseau; and our executive director, Mr. James T. Barnes.

Thank you for your kind attention.

(The following letter and article were filed with the committee:)

Mr. JAMES T. BARNES,
Executive Director,

Medical Society of the State of North Carolina,

Raleigh, N.C.

MCPHERSON HOSPITAL,
Durham, N.C., July 28, 1959.

DEAR JIM: Thank you for your letter of July 22, in regard to medical care of indigent aged in North Carolina.

In our field of ophthalmology, there is no person of any age group who fails to receive medical care because of inability to pay. Through the work of the North Carolina State Commission for the Blind and Vocational Rehabilitation, all those persons on whom a hardship is worked through payment of medical bills have a means whereby they can obtain good medical care at no cost to them when this is necesesary.

If instances occur in which persons are denied medical care in our field in North Carolina from inability to pay, I am not familiar with them.

I hope that this information will be of some use to you.
Very sincerely yours,

S. D. MCPHERSON, Jr., M.D.

[From the North Carolina Medical Journal, July 1959]

A VIEW OF AMERICAN MEDICINE FROM EUROPE1
(Charles T. Pace, M.D., Greenville)

A worldwide social revolution is in progress. The concept of man as an individual is being replaced by that of "man in the mass." Responsibility and control of his life are passing from the individual to the group. Group responsibility usually means Government responsibility. We call it socialism. This process has gone far in Europe. The fact of socialism is the chief difference between European and American medicine. By examining briefly medical practice in Europe, perhaps we can find meaning for us in the United States.

Read before the Section on the General Practice of Medicine, Medical Society of the State of North Carolina, Asheville, May 5, 1959.

MEDICINE IN EUROPE

Germany

German medicine has been under federal control since Bismarck. Hitler multiplied by three the annual output of doctors. Germany is now two separate nations.

East Germany represents the ultimate in socialism. Medical care there can best be illustrated by the fact that the famous university city of Leipzig, a cultural center of 600,000 people, does not have a single pediatrician. Doctorsa group fortunate enough to carry their means of livelihood in their heads-have emigrated to West Germany.

West Germany has instituted the most aggressive free-enterprise economy in all Europe, and has the prosperity to show for it. Its medical care program has neither free enterprise nor prosperity. In fact, it is on the verge of collapse. Understanding that the Germans are the best disciplined and most scientific people in the world and that the supply of doctors is adequate, one cannot avoid blaming the socialized system for the failure.

Competing political parties have granted one increase after another in social welfare benefits, which despite incredibly high taxes are not covered by income. Costs are uncontrollable. Doctors are dissatisfied under a system of payment that encourages inferior practice. Mortality of the newborn and maternal mortality are the worst in the Western World. All services are overutilized and hospitals are bankrupt, but the public wants no reform that does not include the principle of "free service."

Great Britain

Socialized medicine spread over most of Europe by gradual Government intrusion and absorption of private insurance and private facilities. Such was not the case in England, where, by act of Parliament, medicine suddenly became the ward of the state in 1948. The opposition of British doctors was almost unanimous, but they were not organized and remained passive. The proponents of socialism, being unencumbered by busy medical practice, had plenty of time to guide their program through Parliament. Action by the doctors was slow, and by the time they were organized, it was too late.

The program is called insurance. It is hardly that, since the individual contribution covers only 12 percent of its cost. The remainder comes from taxes, mostly income taxes. First-year costs were four times the amount estimated by Government advocates of the system.

I asked the assistant secretary of the British Medical Association if medical care were better now than before, and if the British people were receiving medical benefits which they lacked heretofore. The answer was, "No; they're just paying more for the same thing." The cost of the program has now risen to 20 percent of the national budget, and, according to the same gentleman, it is impossible to control the costs of such a system in a democratic country. Hospitals are used a great deal more than is necessary; the waiting time for elective admissions is sometimes 2 years. There has not been sufficient capital to build one new hospital in the 15 years since the war. Private clinics are appearing now to perform surgery for pay, and interest in private health insurance is rising. That people are willing to pay double, membership in the National Health Service being compulsory, is certainly a significant repudiation of the Government scheme. The financial problems of the National Health Service are insoluble, but no politician who wants to remain in office would dare suggest a change. The voters like "free" medicine.

Holland

Statistically, Holland is among the world's leaders in health. The death rate is low, and maternal and neonatal mortality figures are excellent-better than in United States. Most deliveries are done in the home; 40 percent are done by midwives. Compulsory insurance covers the low-income group. Most of the remainder of the people are insured in private programs. Private bodies exert control over all aspects of medical care in Holland-preventive medicine, compulsory insurance, and private insurance Government-subsidized programs are privately controlled for the most part.

Scandinavian

Denmark, Norway, and Sweden have a system of socialized medicine which began a hundred years ago, as private insurance associations were gradually absorbed by Government.

In Denmark the patient makes absolutely no direct payment for medical care. His taxes and insurance contribution cover the cost. Control of the patient is established by strong authority vested in the doctors; the patient cannot leave his assigned doctor unless referred. The program is not compulsory in Denmark. Ten percent of the people do not belong to the system. In Norway and Sweden, control of the patient is established by having the patient pay a large part of the initial bill and a small part of later bills. Night calls and extra services are charged directly and heavily. The people of the United States would never agree to the disciplinary control that is possible in a small country containing a single national ethnic group.

Socialized medicine is more efficient in Scandinavia than in Germany and Britain, possibly for these reasons: the smallness and homogeneity of population; the absence of pressure groups; a different political organization from that of Britain, Germany, or the United States; participation in private insurance plans; the use of local governing bodies; the strong authority of doctors, and the self-reliant, hardy character of the people. Chiefly, the medical program works well because the doctors have retained a large measure of control and have stoutly resisted attempts by Government to wrest it from them. It is still true, however, that this system, even in its ideal execution, lays a heavy hand on medicine and on society. While being proud of their medicine and their country, my medical informants in Scandinavia preferred the U.S. system. (They did say

that not having to collect bills was pleasant.) Somebody has to collect the bill at the end of the year, however. In Scandinavia it is the tax man who does so, and he cuts the life out of the economy. It is unthinkable that this system, costly as it is, will ever return to private hands.

Summary of medicine in Europe

A government monopoly now controls medical care in northern Europe. Its permanence is assured by the belief tha it is free. Far from free, it is costly beyond the early imaginings of any of its proponents. Cost control is impossible to attain. All available money is spent to maintain basic services. In the search for funds, taxes have risen so high that the citizen cannot accumulate savings. Capital is no longer in the possession of individuals, but belongs to government. The consequent rigidity of the economy inhibits medical care just as it restricts the entire society. European economy has lost the flexibility needed to change, adapt, shape, or better its medical program. The dual relationship between doctor and patient is now a triple one, with the government calling the tune.

Medicine is not "free" in Europe. It costs more.

There is less freedom for medicine, for the individual, and for the group when the government owns all the money. I urge the members of this society to study European medicine in order to improve our own.

Medicine in the United States

The essence of the free enterprise system of the United States is that it leaves some of the capital, and therefore some of the power, in the hands of individnals. Society gains from the flexibility granted by that system. The United States gives more materially to its citizens than any other nation. That includes medical care. Yet we too are moving toward state medicine, a system that will give less. Only one group in the country has the power to stop the drift to Government ownership of health care. Unhappily, however, that group the doctors-is not leading but following the movement of medicine today. They are characterized by newspapers and politicians as being against much, but not for anything.

Devoting themselves to the scientific aspects of their profession, doctors have ignored the social. They have abdicated a grave responsibility. Doctors must stop being technicians and start being executives. The biggest problems facing medicine today are not in the laboratory or on the wards. They are not clinical. They are socioeconomic. The chief objection of the physician is to assume his rightful place as the leader in medical planning. Only he is qualified to understand and solve these problems. Instead, medical planning is now being done mostly by uninformed laymen whose concepts are unrealistic and generally involve intervention by a third party. It is the duty of the medical profession to set up its own program and refuse to participate in any other. The times call for radical thinking and aggressive action.

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