3. To help educate those who work for voluntary health agencies so that they can do their job better. The program of the Committee on Continuing Education is a case in point.

4. To influence member agencies and thus, by example, all agencies, to higher standards and greater responsibility in the performance of their work and in the handling and accounting for their funds.

5. To give direct special help to voluntary agencies when they need it. This might be in a proposed merger of two or three organizations. It might be in helping to improve their accounting procedures.

6. To nurture the spirit of voluntaryism in the field of health. I consider this the most important. Part of the public rejoices at criticism of voluntary organizations because it provides an excuse for not giving. I think that voluntaryism is both tender and strong. There is nothing in our present system of government, thank goodness, to keep people from organizing if they are interested in a certain disease and want to do something about it. I hope nothing ever does prevent this. It is essentially an extension of the right of assembly in the First Amendment of the Constitution. But there are forces tending to make voluntary agencies into a repetition of a single image. These forces tend to reduce the influence of voluntaryism which ought to be promoted. I hope the National Health Council will do all it can to promote it. Men can always invent a superstructure organization to gather together the various individual pieces of the independent sector of health and make them into some kind of unified whole. There are always those who wish to take over. This, however, is not the mission of the National Health Council. It does not seek to form all these groups into one block of concrete, but rather to provide the fertile soil where a large number of vigorous plants may flower gracefully.

It is perfectly fitting to talk about the role of the National Health Council, but for all of us the essence of being useful is that we recognize that the first aim is to serve the individual person in need, and that the role of the National Health Council or any other agency should flow out of that concept.

If we build around the individual every time, starting with him and his needs, we will do all right. If we become lost in problems of organization so that they occupy more of our time than consideration of the real objective, then we will not do so well.

In my own city we have a project in a low income housing development where a little clinic brings care to older people who are up and about and independent, but might otherwise be confined to institutions.

These are people with more medical problems than seems possible. It is a considerable feat to serve them properly.

But we have a little clinic and if you were to examine it you would find that in one way or another it is involved with government at three different levels and that a number of voluntary health agencies and professional societies are participating in it. And if all the rules of all these organizations and all their differences of opinion were written down and put in one place, it would be a tremendous pile of books. A pile dedicated to separateness, rigidity, red tape and legalisms.

But these various agencies, voluntary and governmental, have agreed that in this tiny pilot project, to set aside their rules and traditions and to start with the patient and meet his needs by whatever means possible. It is one of the most heartwarming and amazing things in all my experience in public health to see how, when this concentration on the patient is really achieved, the restrictive rules and regulations of these organizations and their defense of autonomy begin to fade away, and in a most human spirit, they cooperate in getting the job done without losing either their identity or their primary mission. It is this sort of thing, I think and believe, the National Health Council can achieve on a national scale. Just as the best of our voluntary agencies today channel the efforts of our most productive citizens by utilizing to the fullest their individual strengths while in turn strengthening each of them, so will the National Health Council be able to improve each of its member agencies and in the process continue to grow and develop as a powerful force for health progress. Operating not by law, not with the lure of money, not even by tradition, its power is at the very root of that which gives sustenance to the entire voluntary movement-the inherent desire of each man to strive for self betterment through the realization of his own strengths, his own interests and his own determination.

B-MEDICARE: WHAT ELSE DO WE NEED IN THE COMMUNITY?
(By George James, M.D., M.P.H.)

Sometimes the talk about Medicare reminds me about the way we talked about penicillin and syphilis a couple of decades back. Penicillin was so effective against syphilis that many thought the book was about closed on this disease. It has turned out, of course, that in recent years syphilis has risen sharply, especially in younger age groups. Penicillin is still effective enough; what was wrong with our calculations was that we forgot that no drug by itself accomplishes anything, that you have to find your cases of disease and track down contacts, and that you have to administer the drug in the right place at the right time. Human behavior and misbehavior are involved.

The coining of "Medicare" has given us a word that has the same misleading sound of finality that penicillin used to have in syphilis. No doubt many persons across the country are saying something like: "Well, it was a long fight, and perhaps we should have worked things out some other way, but what's done is done and the problem of medical care for older people has been settled." And, of course, it hasn't been settled. The fight for it has just begun.

The words that have been heaped on Medicare are certainly evidence that money talks because what we are doing is to provide payment for health services. Medicare hasn't built any hospitals and it hasn't added any nurses or doctors to the supply of health manpower. It hasn't developed any new vaccines or methods of treatment. People cared for under Medicare are cared for by precisely the same medical establishment that existed before Medicare.

But an influence on medical facilities and methods is sure to come as a result of Medicare. Whoever pays for large quantities of medical care can influence the quality of that care. This is true whether the purchaser is a government or an organization like Blue Cross. In New York City, for instance, the municipality buys a lot of hospital care and influences that care by insisting on certain standards. It can, for example, demand routine chest X-rays on admittance to hospitals for all city patients. Procedures established this way frequently wind up being adopted for all patients. There is little doubt Medicare can have a similar effect. In fact, the bill requires a review of hospital use, to be made by hospital staff committees or special outside panels. But, the actions of these panels are then to be reviewed by state agencies acting for the federal government.

The essence of the Medicare bill to me is that it is the first nationwide attempt, with any large segment of the free-living population, to implement directly the philosophy that everybody who needs care should get it. On a community level, we may have tried to get care to as many people as possible. We have emphasized child health services and even health maintenance for children. But across the country we have never taken any sizable group and tried to reach everybody in it with care for whatever might ail them.

In certain nonfree-living groups, we have brought medical care to all. We have done this for men and women in the armed services and, although inadequately, for persons in correctional institutions. But, the national attempt to provide services to more than 19 million elderly persons is revolutionary. We cannot quite say at this point that we are trying to provide whatever health services anybody needs because Medicare has limitations and was certainly written with existing medical facilities and present medical emphasis in mind. It is bound to change both.

It is inescapable that Medicare will focus a searchlight on the American system of health care as it now stands. We are saying to 19 million people "Come on in. We will pay the bills." But what are we asking them to come in to? We are asking them to come into our hospitals, most of which were designed for the treatment of acute conditions, not the kind of chronic disease that is particularly prevalent in old age. But Medicare does envision a rise in home care, and despite its limitations, Medicare seems to me at least a movement toward an open invitation to people to use our total medical care system, or whatever part they need, and have their bills paid.

Every aspect of our medical care system is going to be illuminated, and there is certainly going to be much more public criticism of our deficiencies in the near future than there has been in the past. Now, people are going to say that they have a legal right to adequate medical care and they are going to be very vocal if they do not get it.

Now, if Medicare is going to be a searchlight, what is it going to reveal? Some things it has revealed already. It has certainly shown us that while some people react almost instantly to an offer of care at government expense, others don't. We have had people rushing to sign up for the optional part of Medicare and others failing to sign up-members of the hard core that is so hard to reach in American medicine. We had people delaying hospitalization until Medicare went into effect. We have had the somewhat remarkable spectacle of public officials, entertainers, and volunteers trying to sell Medicare to the public. We have found out once again that having a program does not mean that the care involved and the people who need it will automatically come in contact.

But this is only the beginning of Medicare, the first contact, so to speak, between it and the public, as well as between it and the professions. What will we find as it goes along?

Certainly, we are going to find many hospitals overwhelmed with requests for the care of older people. Generally, in my view, these requests are not from people who don't need care but from people who need it very much, many of whom could not afford it before. The strain on services is going to be tremendous. Nowhere, are there enough hospitals in the United States to take care of the health problems of old age if we think of inpatient hospitalization as the main thrust of our effort.

After the first flurry about missing forms and lack of organization and as the problem of red tape dies down, I think we are going to take a deeper look at what we find and we are going to say: "We just can't keep up with this flood of elderly patients into our hospitals. Can't we do something to prevent their needing to be hospitalized?"

We do something already. We do give people smallpox vaccine and this keeps smallpox patients out of the hospital. We purify our drinking water and that keeps typhoid and diphtheria patients out of the hospital. But, if we think of preventive medicine in broad terms, we have hardly scratched its surface. In many of our elderly people, our problem is long-term disease for which we don't have a total preventive like smallpox vaccine. Yet, for many chronic conditions we do have treatment which, if early applied, could prevent such conditions from becoming seriously handicapping or requiring long stretches of hospitalization.

No doubt the life expectancy will further rise. But, we have a considerable challenge within the life-span as it is-some 70 years on the average but with very large groups reaching 80 and 90. We should look at this span and say: “Let's shorten the part of it during which the individual is unproductive and dependent."

There isn't much we can do to shorten childhood and the period of education. At the other end, however, we want to help our older people, to keep them functioning in society and to keep them independent. If we look at what makes old people sick, at what keeps them from remaining independent, we find ourselves pushed into a study of their lives before they became 65. When this happens, we repeatedly find actions that weren't taken that could have prevented their needing hospital care and kept them from becoming disabled.

We are going to find women in our hospitals with terminal cancer of the cervix who could have been cured if we had detected their problem early enough. We are going to find people in thees hospitals needing amputations because, as diabetics, they acquired infections that got out of hand-a situation which could have been prevented by adequate foot care.

We are going to find people handicapped by coronary heart disease, although we know the toll of coronary heart disease could be drastically cut if we could get to these people earlier and convince them not to smoke cigarettes and not to stuff themselves with saturated fats and to take reasonable and regular exercise. We are going to find many people whose ability to remain independent is fragile and who suffer from multiple chronic illness. They will have arthritis, bad eyesight, impaired hearing, and, perhaps, kidney problems. Whereas no one of their problems by itself may be serious enough to handicap such patients into dependence, the combination may well be.

We will find that many of these patients didn't get the care, the health maintenance, they needed, perhaps because the appropriate clinic wasn't open after they got through work or because they were grabbed, so to speak, by the kidney people and didn't really get to the arthritis clinic. Many patients are expected, because of organizational flaws in our medical system, to attend five or six different clinics; often, they give up.

So Medicare, at the same time that it directs attention to patients 65 and older, will eventually lead to public exploration on how they got that way. I hope this

will lead to our redoubling our efforts to provide the kind of community health maintenance services that now exist only as pilot projects.

For those who are already elderly, it is naturally too late for health maintenance in middle age or for heading off the cigarette habit in youth. We are going to have to take care of today's elderly as best we can, with whatever problems they have. Some, no doubt, will have acute episodes appropriate for hospitalization. Others we will keep in hospitals because there either are no other facilities or no adequate facilities to care for them. But mass inpatient hospitalization is so costly, not only in money but in the time of highly skilled and scarce personnel, that we will very carefully have to investigate other methods.

Particularly, it seems to me, we will have to enlarge our home care programs. We will also have to expand the provision of some kind of a minima level of medical care near where the older person lives, because often, even if he is able to live independently, he is simply too creaky to move very far very often to get medical attention. I think that expansion of care toward the patient through home services will in the long run cost us much less than the present emphasis on admittance to the hospital.

Some of the efforts now under way to supplement Medicare are well known. Blue Cross organizations in many states are arranging to meet some payments required of Medicare subscribers, including those for outpatient diagnostic care. In the main, however, I believe that what communities need beyond Medicare is what they have needed for some time, a rethinking and reorganization of their medical care systems. Among the changes called for are these:

1] Much more emphasis on the early stages of medical care, so that when the patient enters old age, he is in as good health as possible

2] A reduction in the emphasis on inpatient hospital care, coupled with a major expansion (and improvement in quality) of outpatient services; branch clinics, especially in areas where the percentages of older people are high; and home care services

3] A major overhaul and improvement of standards of nursing homes and, along with it, an overhaul in our thinking so that we begin to realize that often dependence in the older patient is reversible and, usually, vegetation should not be acceptable

4] An emphasis on comprehensive care: that is, wherever the patient applies for care he should be put in touch with all he needs for whatever condition or conditions he has

5] Greater emphasis on continuity of care-a prevention or elimination of the present tendency to transfer the patient from one jurisdiction to another, often without records

6] Increased recognition that the job of health care is so enormous that no one can now do it alone-neither government nor the private practitioner, nor the proprietary hospital, nor the voluntary health organization-and that we need all the varied resources that we have and must break down their isolation and get them working together.

I believe the beginning of a historic reorganization of our medical resources has begun. It seems proper to me that we now emphasize concern for the older patient with chronic disease but equally proper that a searching examination of health services for those below 65 has already begun. I am sure that this will lead us to an understanding that adequate care for the older person must begin in infancy and childhood, areas not now covered by Medicare. It is significant, perhaps, that the President has already proposed additional social security health benefits of the Medicare type for the dental care of children under six.

In any event, Medicare will surely ultimately result in far better health services than we now have, and the controversy it brings will be a major factor in that direction.

C-THE FUNCTION OF HEALTH FACILITIES IN THE TOTAL MEDICAL CARE COMPLEX

(By George James, M.D., M.P.H.*)

The general problem of where health facilities fit into the total medical care complex, some of the major problems we shall have to face in coming years, and

This article is based on Dr. James' talk at the annual meeting of the Conference of State and Territorial Hospital and Medical Facilities Survey and Construction Authorities, October 14, 1965, in Chicago. At that time Dr. James was commissioner of health, New York City Department of Health. He is now dean of the Mount Sinai School of Medicine, New York City.

some of the attempts currently being made to determine the pattern desirable for future development comprise the substance of my discussion.

Foremost, we must acknowledge several highly significant factors concerning our medical care system. The system, as we see it today, developed in response to a need for health services. This need has been changing, and now it is changing with extreme rapidity and thoroughness. It is no longer an acute disease problem. It is no longer a curative medical problem. It is largely rehabilitation, limitation of disability for the aged, finding causes of disease, and getting people to live in a certain way so that they do not develop chronic diseases in later life. For these needs, the present medical care system is not well oriented and, obviously, it therefore requires major adaptations. We cannot erase this system. If we had to do it over, I daresay we would end up with something quite different from what we now have. Since it is impossible to do it over, we must look to the system to develop that flexibility of approach and that attention to those needs which will lead to a future program.

Four stages of disease

I must start with epidemiology. It is convenient in discussions such as this to divide the natural history of disease into four stages. By "natural history of disease," I mean what happens with a given disease in a given patient, including the entire progress of the disease, all the many ways it develops in that patient, the period before it develops until long after it has ceased, and its effect on the patient. "Effect" includes all the short-range and long-range effects.

First stage. The first stage of disease is the period before the disease begins, the prepathogenic phase. What is important in this period are the factors which make a person more or less susceptible to a disease-the kind of cigarettes he smokes and the amount, the kind of ice cream he eats and the amount, his hereditary pattern, his occupation, many of his other health habits, whether he is immunized or not, whether he goes for routine medical examinations or notall of the things that put a person in a higher or lower category with reference to the risk of getting a specific disease. It is interesting, in our present health programs and present national health status, that we are doing a relatively miserable job of considering these factors.

We cannot rest on our laurels for having conquered typhoid, diphtheria, and smallpox. These are not our problems today. A look at the 20 leading causes of death today reveals that we are able to effect a major impact against only a few. Considering what could be done about them, it is evident that we are not performing all the tasks related to the removal of risk factors. We have a big void in this field in our present medical care structure.

Also, the individual citizen is not much interested in removing risk factors. He feels no pain before the disease begins. He can read many advertisements telling him to avoid this and that, but he has less motivation to do so. He feels that no immediate medical payoff exists to motivate him to change his habits. The individual hospital or department that wishes to enter this field has a wide open territory that has been relatively unexplored.

Second stage. The second stage of disease relates to pathology subject to early detection. It is a period during which the disease process has begun but the patient is not aware of it. However, a disease can be detected by various tests. Here, too, the priority given by citizens is extremely low. People do not feel pain. They do not see the need to take time off from work, to travel long distances, to wait in clinics or the private physician's office to receive this medical care. Some of it is painful. Payoff, again, is far removed from the difficulty of seeking care during this stage of disease.

Surprisingly enough, this low priority for early detection is also the rule for medical care institutions. The hospitals give stage-two medicine short shrift in most cases, and I know no hospital that does as complete a job as possible. In New York City, where we have given a good deal of attention to this, we are now finding less than one-fortieth of our unknown diabetic persons. Less than one-fiftieth of the annual crop of unknown cases of carcinoma of the cervix are being detected. And we are still finding only one out of every two cases of infectious tuberculosis, despite having one of the most extensive and farflung, tuberculosis casefinding programs in the country.

Casefinding is a wide-open field-hospitals are filled with patients who have other undetected diseases.

Third stage. Stage three is the clinical phase, when the patient has accepted the fact that he is ill. He goes to the physician and says, "I have pain, I want