basis at the hospital. These organizations represent the most effective propaganda mechanism for achieving community wide coverage through its membership and influence. The appeal will be not on the basis of good health per se, but on the basis that good health is a social right. It should, therefore, become a component of the social action. program of the community organizations. The individual is thereby pressured by the group to conform. He will therefore become involved initially, not because of health considerations, but because it is what his peers expect him to do. And to strengthen our identification with the community, we have provided concrete benefits amongst which are setting up and staffing a first aid unit at a fair organized by one of the community organizations, establishing a modest scholarship fund for needy high school students, providing material and guidance for career development programs conducted by these organizations. Our community health educator, who is a respected member of the community, will work with the health committees of these organizations, and guide and coordinate the activity of our community health aides. These aides will be selected from the community, and trained to be our representatives and educators in specific assigned geographical areas. The aides will work with the blockworkers of these organizations. Hopefully, this kind of community involvement will recruit registrants for the periodic health examinations. In the process, good health concepts will be disseminated, and eventually have an impact on a significant portion of this population, and once the individual becomes involved in this project, we have the opportunity to bring him into the mainstream of medical care, and keep him there. More importantly, this will have been accomplished by the members of the community and not by outsiders. This should bring a sense of pride and accomplishment which is so sorely lacking in underprivileged communities, and perhaps it will to some degree counteract the characteristic alienation and apathy which we see. The second operational segment, I will say little about, except that it will be an adaptation of the Kaiser-Permanente model. With respect to the referral and followup segment, the impressive computer read out of the results of the multiphasic test process is of value only if it is used as an aid to the physician in arriving at a diagnosis. I will pursue this no longer, because this has been pointed out by a number of other witnesses. The difficulties cited in discussion of the first operational segment exist here as well. This is the question of motivation. It is our responsibility to insure that the patient visit the private physician or other provider of medical care, and the community mechanisms designed to get the patient registered in the program will be just those utilized to get him to a physician. Here, however, we have an additional factor to be considered. The involvement of the practicing physician. The current changing medical scene may very well present difficulties. We have had discussions with local organizations of physicians, and hope to have them appoint representatives to the liaison committee of our program. In addition, we are completing a survey of physicians and dentists practicing in our hospital area. We will meet with them to discuss their role in the program, and expect to make referrals of all patients financially able to pay physicians' fees. Those unable to do so will be referred to the ambulatory care services of the Brookdale Hospital Center. Now may I return to the three questions posed earlier in my remarks. First. Is the periodic health examination a valid approach to the problem of preventing chronic illness? For the reasons I have outlined, I believe the answer is in the affirmative. Second. Is an effective economically feasible process available? There is no question in my mind that the prototype exists. Third. Will the population, especially the poor, accept the periodic health examination? I believe we can achieve acceptability, providing we shed our preconceived ideas and stereotypes, and are cognizant of the results of research of social scientists working in this area, and are willing to face up to these situations. At the very least, we have the opportunity to study in depth the phenomenon of the resistance to health care innovations. I firmly believe this becomes the crucial consideration in our efforts to bring the fruits of medical research to the consumer. The experience gained in our program will most certainly have more than local significance. The problems confronting us in Brooklyn exist in almost every large urban area in this country. The guidelines which we will formulate and the experience gained should have applicability in every large city in the United States. Finally, legislation supporting the development of modern multiphasic health examination programs throughout this country will close the gap between medicare benefits and the socially desirable goal of true comprehensive health care. This kind of legislation will constitute a historic milestone in the development of medical care in this country. Without it, we shirk our social responsibilities, and court disaster. Thank you. (Dr. Gitman's prepared statement follows:) PREPARED STATEMENT BY LEO GITMAN, M.D., DIRECTOR, DEPARTMENT OF COMMUNITY HEALTH, THE BROOKDALE HOSPITAL CENTER, BROOKLYN, N.Y. Senator Neuberger and Members of the Subcommittee on Health of the Elderly, I am here because of a deep concern for what is probably the most important problem facing the medical profession and society today-the prevention of chronic illness. I speak as a physician who has been in clinical investigation, and now is devoting his entire professional activity to community medical care programming. I speak as a human being dismayed by the anguish and social wastage of chronic illness, especially in the poor and the aged. I squirm on hearing the euphemism "golden years" for old age. For thousands of people these are "black years"-years of chronic pain, disability, horrible loneliness, despondency, and mental and physical deterioration. Undoubtedly, statements by economists and statisticians will present to this Committee detailed discussion of the dollar costs of chronic illness. I will cite a few facts, using arthritis as the model, merely to indicate the enormity of the problem. It has been estimated that the cost of arthritis amounts to almost 2 billion dollars annually. Each year it causes 186,000,000 days of restricted activity; 57,000,000 days of bed disability; 12,000,000 days of work loss; 1,500,000 days of hospitalization; and 30,000,000 visits to a doctor. There is a clear cut relationship between the incidence of arthritis and economic status. The highest rates for arthritis are found at lower income levels. Under $2,000. annual in come, the overall rate is three times that at the $4,000. or over level; i.e. 138.7 per 1,000 as compared to 45.6.1 Not only is the incidence higher in the poor, but the impact of the disease is greater. Low income families (which include more older persons than higher income families do): (1) Report relatively more activity limitation due to arthritis; As a footnote, I have a statistic furnished by Dr. Paul Densen, Deputy Administrator, Health Services Administration, New York City. In comparing Flushing, a middle class area, 97.6 percent white with Bedford District of Brooklyn which is a poor section, roughly two-thirds Negro and Puerto Rican, the death rate from diabetes is 200 percent greater in the depressed Bedford area. Parenthetically, it may be noted that the infant mortality rate (infant deaths per 1,000 live births) is almost 300 percent greater in the Bedford District. These data, as aggregate entities, fail to convey the consequences in terms of individual people. It is in the microcosm of clinical practice that they become meaningful. The 60 year old man, a diabetic, with gangrene of the foot, who refuses to permit amputation despite constant pain, drags his wife, his children and their families into his orbit of despondency, bickering and emotional turmoil. The 55 year old widow, crippled by arthritis, living with an unmarried daughter who is living in quiet desperation. The 75 year old man who had prided himself on the fact that he has never been to a doctor-until a chronic sore of the face began enlarging and is now a hideous foul-smelling disfigurement. One could go on, literally, ad nauseum. One can estimate the dollar costs of chronic illness. How does one assess human costs? In the present state of knowledge, one must accept the premise that periodic health examinations are an effective approach to the problem of chronic illness. It is logical to assume that detection of disease in its earliest stages will provide the opportunity to alter the natural history of that disease. This approach has already made significant contributions in diabetes, glaucoma, arthritis, and cancer. The potential for prevention has been demonstrated by a number of studies. I present two citations as illustrations. One authority estimates that at least one significant abnormality that could be benefitted by medical advice would be encountered in 80 percent of "normal" persons over 40 years of age who were examined carefully.2 In another report based on an analysis of periodic health examinations of business executives, 40 percent of the group were found to have some previously unrecognized abnormal condition. Forty-six percent of the abnormalities, if untreated, were potential causes of disability or death.3 The traditional periodic health examination has several serious disadvantages. Too often, it is a superficial perfunctory procedure which often recognizes disease only after it has already progressed too far to permit meaningful intervention. I believe the following would be accepted as constituting a high quality periodic health examination for adults: careful, detailed history and physical examination; examination of the urine; blood count; determination of the blood sugar, urea nitrogen, cholesterol, sedimentation rate; sigmoidoscopy in patients over age 40; cervical ("Pap") smear and mamography in females; x-ray of the chest ; testing of hearing, visual acuity and ocular tension. How many patients can afford the costs of these procedures as a recurrent medical expense? I would state, without fear of contradiction, that this kind of examination is infrequently done even if the patient is able to pay the sizable costs. In the case of the low middle class and poor, the percentage is infinitesimal. It is generally recognized that the number of available health professionals, e.g. physician, nurse, social worker, etc., to provide adequate care in the United States, is inadequate. This estimate relates to the treatment of people who are 1 Arthritis Source Book. P.H.S., U.S. Dept. H.E.W., PHS publication No. 1431, April 1966. 2 Smillie. W. G., and Kilbourne. E. D., Preventive Medicine and Public Health 3rd Ed. The MacMillan Co.. New York. 1963, page 373. a Elson, K. A. J.A.M.A. 172: 55, 1960. ill. Periodic health examinations are aimed at the asymptomatic individuals. How are we to take care of this additional patient load? The answer is that up till a few years ago, it was not possible. There are two few professionals to implement this kind of programming. Even if the current intensive efforts to build the necessary schools, recruit and train health professionals are successful, it will be years before we reap the benefits. It seems to me that we must utilize the resources of modern technology to relieve the professional of functions which could be performed by non-professional personnel. Accepting the magnitude and urgency of the problem of chronic illness and the validity of periodic health examinations as a preventive procedure, our next consideration is the requirements of such a program. A practical program is one which: 1) utilizes modern diagnostic tests and techniques, 2) requires minimal professional involvement in the screening proceaure, 5) evaluates medical and psychosocial function, 4) is economically feasible, 5) permits examination of large numbers of individuals in a comparatively short period of time, and 6) provides a summary for the use of the physician in his evaluation of the patient in conjunction with his physical examination. It is my considered judgment that the program of the Kaiser-Permanente Group is a prototype fulfilling these requirements. These are general statements. Let us reconsider them in the context of a specific program-the program we are developing at the Brookdale Hospital Center in the Borough of Brooklyn in New York City. The Brookdale Hospital Center is a voluntary general hospital whose 340 bed complement will be increased to 500 beds by 1969. As Director of the Department of Community Health at this Institution, I am responsible for the initiation, coordination and facilitation of all hospital-based programs relating to community health programming and servicing. I might add that it is probably the only voluntary hospital in the country with a Department of Community Health with status equal to that of the traditional departments such as: Medicine, Surgery, Obstetrics and Gynecology, Pediatrics, etc. The population in the Hospital's service area is 500,000. About one-third of the geographical area contains a high density, low income, multi-ethnic population. In some of the subdivisions, designated as health areas, the combined percentage of Negroes and Puerto Ricans is over 80 percent; 30-40 percent of families have annual incomes under $3,000 and 50-70 percent under $4,000; the unemployment rate is 8-11 percent.* The Brookdale Hospital Center's commitment to community health consists of two large areas of responsibility: 1) treating the person who is ill, and 2) preventive medicine. It is the second component, which is the concern of this Subcommittee, to which I address myself. Until several years ago, I was extremely pessimistic over the solution of the problem of preventive medicine, especially in our high-density, low income, multiethnic population. The large numbers of people to be evaluated, the poor health orientation of the poor, the lack of adequate numbers of health professionals to handle the problem, the enormous expense of a sophisticated examination— all these were difficulties which appeared overwhelming and the problem insoluble. Should we spread our professional manpower to such an extent as to court the possibility of harassed, overworked doctors, nurses and others forced to render superficial, and perhaps, careless service? Should we restrict the numbers of individuals examined so that the professional could perform adequately? But then, whom do we select for preventive medical care? This becomes a decision with moral overtones—a decision we should not be compelled to make. This approach would also run the risk of inducing communal expectations which could not be fulfilled. The publications of the Kaiser-Permanente Group caused tremendous excitement for those of us struggling with this problem. It appeared to provide a solution. The Gerontology Branch, Division of Chronic Diseases, U.S. Public Health Service, stimulated much interest in the multiphasic health evaluation mechanism, and it is with its encouragement and support that we, at Brookdale, are developing a similar program. We are no longer pessimistic. The multiphasic procedure fúrnishes a method which can screen large numbers of The Brookdale Hospital Center: Core Area Preliminary Survey of Selected Demographic and Epidemiologic Characteristics, January 1966. Prepared by Anna C. Gelman. MPH, Asst. Professor of Epidemiology, Columbia University School of Public Health and Administrative Medicine, New York City. individuals, requires few highly trained health professionals, and is economically feasible. We are now confident that the preventive medicine component of our Hospital's responsibility for community health can be discharged satisfactorily. The projected program at the Brookdale Hospital Center consists of three operational segments: 1. Health education and motivation. 3. Referral and follow-up. HEALTH EDUCATION AND MOTIVATION The population of our community differs significantly from that serviced by the Kaiser-Permanente Program insofar as it is a low income, high-density, multi-ethnic group involved in no organized medical care program. We are, therefore, immediately faced with the problem of motivation of this population. This is, in turn, dependent on the poor person's concept of health. As one consequence of poverty, the poor are tragically ignorant of the causes, treatment, and curability of disease. Dental decay and loss of teeth, hacking morning cough, joint pains, low back pain, urinary difficulty, are among the many conditions believed to be inevitable, and therefore it would be useless trying to do anything about them. In a family existing on bare essentials, top priority is given to improvement of living space, household equipment, clothes for the children, a second-hand car, radio, etc. If symptoms like joint pain and stiffness occur, self-medication, generally patent medicine, is resorted to. It is estimated that arthritics spend $435,000,000. annually for non-prescription drugs and devices for relief of pain, which includes $250,000,000. for questionable remedies. If this fails to bring relief, neighbors are consulted. With continued discomfort, the pharmacist's advice is sought. Only when the individual is incapacitated does he seek medical care, i.e. only then does he consider himself "sick". It is, therefore, not surprising that the sophisticated concept of preventive medicine, based on periodic health examinations, is foreign to much of this segment of society. The factors of ethnic background, foreign birth, age and educational level, also play an important role in determining the individual's attitude toward health. In our program, we first identified the characteristics of the community by analysis of demographic data and consultation with experts familiar with this population. Educational approaches, specifically tailored for each major group, are being formulated. We have approached the several broad based action groups in the community with the suggestion that each form a strong health committee, and each of these send representatives to a joint committee which would represent the community at regular frequently held meetings with the Department of Community Health, the Brookdale Hospital Center. These organizations represent the most effective propaganda mechanism for achieving communitywide coverage through its membership and influence. Our community health educator, who is a respected member of the community, will work with the health committees of these organizations and guide and coordinate the activity of our community health aides. These aides will be selected from the community and trained to be our representatives and educators in specific assigned geographic areas. The aides will work with the block workers of the community organizations. These efforts will be supplemented by the standard techniques of radio announcements, newspaper stories and notices, church announcements, posters at strategic locations, etc. Hopefully, this kind of community involvement will recruit registrants for the periodic health examinations. In the process, good health concepts will be disseminated, and eventually have an impact on a significant portion of the population. Once the individual becomes involved in this project, we have the opportunity to bring him into the mainstream of modern health care and keep him there. Most importantly, this will have been accomplished by the members of the com Arthritis Source Book. P.H.S., U.S. Dept. H.E.W., PHS publication No. 1431, April 1966. |