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A Home for the Weekend program focusing on public health. Segments include success in battling small pox disease, followed by speeches from Dean of University of Texas School of Public Health, and author Ruth Sidel, at annual meeting of Minnesota Public Health Association.

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minister of Health in India at the celebrating two weeks or six weeks of having those pots in India said that he thought this was as important a thing as our landing on the moon. and I can't agree with it if we can follow it up smallpox in itself perhaps this is not all that significant, but if we can follow up the use of the Epidemiologic for the intelligent approach to Disease Control spending your money where you going to get some good out of it, then it will be worth it. Good morning, and welcome once again to home for the weekend. I'm Kim Hudson. And this morning will be taking a look at the general topic of Public Health later in the program will hear from dr. Royal Stallone as dean of the University of Texas School of Public Health Houston and Ruth Seidel and author who has traveled widely in China and has observed the public health system. They're still honest and sidel's remarks were recorded at the annual meeting of the Minnesota Public Health Association, which was held at Southwest State University in Marshall last month. We could get a program with a look at what will apparently be one of Public Health greatest success story. As an introduction we heard the words of Tom Kimmel a public health advisor for the Center for Disease Control in Atlanta, Georgia who recently returned from 4 months in Bangladesh. The next-to-last country in the world or smallpox is known to exist during Kimmel stay the number of outbreaks of the disease and Bangladesh dropped from over a thousand to 13 and all 13. We're isolated with no further outbreaks anticipated. Ethiopia is now the only country with uncontrolled smallpox. Their The Strain is a relatively mild one and political and cultural difficulties. If that's far made implementation of an intensive campaign impossible. But even in Ethiopia officials are hopeful that the disease will be completely under control by the end of 1976. The World Health Organization began the campaign to eradicate smallpox in 1966 and the United States joined in enthusiastic Lee motivated in part at least by the hope of eliminating the necessity of maintaining the public health Machinery necessary to prevent the disease from entering this country. In addition smallpox vaccination is not entirely without risk if the disease is totally eradicated. No further vaccinations will be needed. Why is the campaign to eradicate smallpox been so spectacularly successful so far during a recent visit to Atlanta. I put that question to dr. Michael Lane director of smallpox eradication at the Center for Disease Control and he told me that it has a great deal to do with the nature of the disease itself smallpox is unique because there are no carriers. The only source of the virus is a sick human being whose sickness is characterized among other things by a very obvious trash or anyone can see this gets more second of all, there are no non-human sources of the virus. So once the humans are dead. Passing it it it's it's gone. 30 there's no what we called subclinical disease anyone who gets the smallpox infection is sick and it's obvious sick. There's no there's no mild infection that makes it impossible to diagnose. Fourth are the disease of the disease or the vaccine give you long-lasting immunity. And lastly and I think this is terribly important. It's a it's a frightening hideous loathsome disease with a very high mortality rate and both politically and humanitarian late. It's a disease that people want to get rid of so that the the support both by local governments and by the International Community has been there. Then we can talk in some detail. If you wish about some of the not so much technical but you might say strategic changes and breakthroughs that we've had the only real technical breakthrough in small occurred really in the late thirties and forties when the British and Dutch and then finally American actually manufactures learn to life Eliezer freeze-dry vaccine just like now camping foods are life allies. And so many other thing when it when smallpox vaccine is freeze-dried, it becomes heat stable so that you can take it out into the bush and tropical developing countries where there isn't any electricity refrigerators and it will still retain its potency if the old vaccine didn't do and then we have also adopted this delightful little bifurcated needle which makes vaccinations very simple something easy to learn. It's no longer a mysterious medical procedure. So those are the only real Other breakthroughs have been really managerial and their breakthroughs that we here at CDC came up with when we in 1966 more less. Undertook is part of the worldwide radication program to eradicate smallpox from the 20 nations of Western West Central Africa. We learned a variety of things in very early in that campaign that made us change from the old strategy which was simply Mass vaccination vaccinate as many people as you can as quickly as you can and made us come up with the strategy to me now call surveillance in containment practices. The old match vaccination strategy was based on if you get to some arbitrary percentage of action of the disease will go away because of so-called herd immunity where we found very quickly that in one city in in Eastern State of Nigeria is the state of abakaliki the we did an excellent Campaign which by independent statistical assessment shows that we had reached 88% of the people in affected a man dies them, but two or three weeks later after this campaign, there was an outbreak of smallpox 37 cases that made it obvious that arbitrarily reaching some high percentage didn't do it. Smallpox moves in a more leisurely way than we had thought it's not as I said devastating disease, but that does not mean that it's a highly infectious disease. So we began to realize that if we simply found out where the cases were and then not isolated them in a physical sense, but isolated them immunologic Lie by making sure all of the people in their Villages all their potential social contacts were immunized we could get rid of the disease and if you want to make a kind of a US analogy if there's smallpox in San Francisco one doesn't vaccinate in New York when vaccinates in San Francisco and it didn't want to vaccinate in the express sific blocks or the the social groups of the people who would be contacted the cases. so with with this logic in mind, we we be emphasized Mass vaccination and began to look for ways that would give us information about where they were cases and then ways that we could rapidly and effectively immunize their contacts to those cases and there are what what is the date is transform the field Public Health worker into a little bit of an anthropologist or sociologist. If if you find If you're looking for cases of smallpox in a developing country, you don't really go to the medical infrastructure you go to the The Village leaders the the power to local power structure, which is maybe religious figures whatever kinds of people have real knowledge of what's going on at the Village level in in most developing countries. The medical people don't have that now it's cuz they're not really out in the Villages under routine basis. So our people learn more work with everything from which doctors to the local politicians and policemen than and the Agricultural Extension agents. Whoever was out in the valley. To find out is there smallpox there. The first case that I came across was reported to me by as I said earlier this guy who just walked in the office and want to claim is 50 taka reward. That's it. Where's the case? I said I knit and why don't you report earliest let him know about the reward. I came back to reclaim my job as I take a picture on a bus. and my uncle told me that if I went over to the to the office I would get to talk to me before so I went down 45 miles to the 40 miles to the airport ferry to to see his family and it did his daughter did have smallpox. panda put them in the car taking back to select to the Infectious Disease hospital and isolated them and went back to the village and was trying to vaccinate what was night and in that particular Village. There was a woman whose husband in the London and she had no warning that we were coming and she didn't know who we were and here was somebody pounding on her door at 11 at night and she wasn't going to come up and finally is I was beating on the door myself personally by minute one of the guys finally I understood among the people who think I like that were with me some of my staff and some of the local people that have cooperated and some that we're just curious. I been waking up in vaccinated in the middle of the night that it would be. Yes next morning that he would lend a member of his counsel to go to that house and that everything would be all right. She was just afraid. But on the way leaving there, I was accosted by another large group of bengalis with a London eat and he asked for an interpreter interpreter, but my driver is pretty go to Bengali. And I understood immediately began to speak with my driver that he spoke perfect English but was angry he was angry and the people that made him angry. He was incensed. Someone just bulldozing is people, right? And so I made it through the interpreter and I was like I said, I wanted to tell him this and I would say that we have found a case of smallpox here. That's all we're here for. I'm not afraid that people will leave the village. We won't find them tomorrow and I have made a grave error here and everything will be alright, we'll come back tomorrow and apologize to her and he began to speak to me in English and in fact became a great family. We find it if we vaccinate within the first 3 days after exposure you can abort incubating. Smallpox in the 4th through 5th 6th day or modify it and after the seventh seventh day or after he probably won't affect it until you may love me take me to make life happen repeatedly where you didn't get some kid and he's got smallpox and he died right in front of you. But we also find grade definite epidemiologic correlations between the numbers of days of exposure and the numbers of outbreaks that you can find. It was spread from any known foci. If you catch a case within the first week of rash from sense and isolating vaccinate, you can expect no more than 2 spreads on the average. Haha, nothing not but if you catching the 4th date 14th day of rash, you're going to have sex again on the average which means that much more work for you by the next case and you don't stop until you to get vaccinated at least everybody in the house hole and everybody within a hundred yards and you've hired somebody just live right there. If you don't do it yourself that night to make sure nobody gets into that house. And the next the whole next day talking to family about where they get it. Who visited here. Where is your brother off? You don't say, where did you get the fox? What did you get this disease? You asked where that travel to and who it is and then to the mother and the father. Where are your mother and father? Where are your brothers and sisters. Asking whether they came but then you have Nate list of all of these people and then you go back by detail. Where does he live? What does he do as he traveled here? Did he come by here and I'll send them say no he didn't come by because he only came by one night with their had to go on and didn't want to visit. It is much more social thing, but Sally face But then they will remember they don't. Yes. She did come by and there was somebody with him and he did have a fever that's mediate. That's right. Now that's the first thing you do in the family realize that no one's to come into the room you hire local VFW on the spot to watch the door get him some vaccine teach him how to vaccinate and then you go out with your containment team who may and my case is my driver my interpreter and an office assistant cuz all the teams were out doing surveillance assessment doing this search assessment. I was not an epidemiologist. I was just there. Getting a passport. And so we vaccinated that first hundred yards and that has to be done. We say just not stop until you find a case. And then you've got the next thing to do is a half mile. Vaccination within 3 days everybody within a half a mile. And then the next ring out is 2 Mile search. The same team or another team would go out and search out to listen to two months for another case of smallpox. We are right now getting underway and doing this for measles in this country measles is spread and a fashion somewhat similar to smallpox. It's not quite as easily easy to diagnose smallpox, but it's almost it's easy. And we think that we may be able to break transmission of measles by an aggressive approach pattern on the same method. So this is concept of surveillance and control is one that I think is going to replace the kind of willy-nilly blind Mass application of of medical and public health techniques and is already doing so in many of the field is another spin-off we've had in the smallpox eradication program. We made the decision very early on in West Africa. 2 make sure that the the day-to-day workings of the program was not in the hands of Physicians. I'm a physician myself, but I think Physicians are know something about disease. They don't know much about management and field operation. So we kind of turned over the running of the program to what we call Public Health advisors there people who know more than perhaps about management and running programs and they do necessarily about the biology of the disease. We also at the at the level of the sort of work a day individual in the in the developing countries relied heavily and almost exclusively on paramedical personnel and I think that this concept secretly Reliance on paramedical or non-technical people for the the bulk of delivery of of health and certainly preventive medicine services is an idea whose time Brittany is long come and we're going to see more of this certainly in preventive Medical Services. But I think and Curative medicine to over and above the concept. What about the structures that were actually created in these countries to deal with the smallpox program to those just collapse now, I know there was a lot of enthusiasm generated among the people who are involved. It seems that would be nice if you could continue to capitalize on that. Well, that's a good point and certainly that point has been made by others and it's very good in theory and practice is not going to be that easy for two reasons number one of the people who have kept these together have been largely assignees from here in the Center for Disease Control for smallpox without that these kinds of train managerial people. I think the the structures and many of these countries will rapidly fall apart and as they have unfortunately in much of West Africa and then other Second of all, it's so easy to document the good job in smallpox. If you switch this group into doing similar jobs for other diseases. It's very hard to show that they're that effective. We are hoping and who is very much behind a so-called multiple antigen program multiple engine simply means let's use as many other vaccines as we can with the same structure and and do something but when you're giving vaccines for diphtheria or pertussis or things like that, it takes a great deal of time before you can really show any change in the disease structure that the number of cases the member of deaths from the disease and I think that without this kind of Rapid identify Apple 6s that we've had smallpox and without these manager supervisor types from CDC. That's that these programs may not be anywhere near as effective and the enthusiasm for keeping their funding and keeping their their vehicles rolling may not be there. Imani Perry in spite of the progress so far and eliminating smallpox worldwide. It will be at least another couple of years before World Health officials will be able to announce with complete confidence that the scourge of smallpox has been wiped out says, dr. Lane as long as you're depending on information about the existence of a disease in areas where the medical and and Communications infrastructure isn't very good. You never really sure when the last case is taking place so friend since I I can't call a press conference next week and say it's all over in Bangladesh because we might find two more cases next week the World Health Organization I think about it wisely has said we'll wait for two years until it's been no cases and active search for cases before we officially declared a country free but it is true that it will probably be the only disease certainly In Our Lifetime perhaps in the history of mankind. We're in rather short. Man has By conscious effort and not an awful lot of money eradicated disease. No other disease has been eradicated by by conscious intent and my personal belief is that no other disease is eradicated will on a worldwide scale and if there's something that we in the US can eradicate because of our high technology and in large medical and public health infrastructure, but I really don't think any other disease will be eradicated from the from man. In the foreseeable future. What has this program meant the politically for WHL Well, it's my personal opinion. The WHL has not been terribly effective in field program since its Inception. It's been very effective in certain kind of expert Smitty's bringing together a group of experts to discuss the state-of-the-art to pool our knowledge and publish reports on authoritative reports on the estate of knowledge of of disease WHIO has not been very good at actually changing the way Health delivery services were given in developing countries. WHIO has been pretty heavily involved in the smallpox eradication program and quite frankly. I think if it weren't for the smallpox eradication who would be in political and physical hot water but this this success is going to enable them to keep their head above water and they certainly are going to get a lot of accolades from it. Other than that politically. I think it just Shows that International cooperation on a health topic works and and can be done without a lot of political hassle has been no political bad vibes at all in the in the program The Who expert committees thing is that Africans? Indonesian is Indians Russians British dutch-american. It's a real love Hands Across The Sea kind of Africa. Although there have been no bad vibes within the program itself. There have been those who have questioned the wisdom of pouring so many resources in to eliminate diseases like smallpox in countries such as India and Bangladesh where the population density is Extreme and the threat of starvation is a constant fact of life. There's no question that when you talk about death control in areas where population and undernutrition are the major health problems you immediately have to face the issue of is is death control-wise when birth control is more important or at least as important. But are feeling about that is very simple one. We believe in fertility control and family planning in developing countries once a child. However has been born. I think I can't see anyone who can make a serious ethical point that once the act of birth is taking place that we shouldn't do what we can to make that child healthy and productive and all if you take a child who is born who gets smallpox and doesn't die. He may be blind maybe permanently crippled the fact that he is at risk of dying may make his mother that more anxious to have another child instead of taking advantage of birth control. So I think that it's it's most unwise for people to say because we haven't done an adequate job on birth control. Let's stop trying to do anyting undeath control that just us. Make sense. It makes sense for me to continue to work as hard as possible on death control and simultaneously work on birth control indeed the success of a of a program such as smallpox eradication legitimizes the medical and public health structure. And I think people who would not have accepted birth control advice because I simply didn't trust the medical and public health authorities. Now that they see that these medical and public health authorities have brought to them something that they very much wanted which was freedom from fear of small fast. I think they're more likely to listen to them when they are advised to to take advantage of contraception. 3 something about yourself and eradication is he's very much and it's probably only one time then gives me very much a sense of historical perspective that I have the time and that's why I think kind of hard for people to Urban people these days to feel that there's something very particular in the history of Van that they have experienced singly or at least with other people. And I'm still bleeding. Suffolk County Even if it's just on the smallpox in the lessons not learned medications for Disease Control in Atlanta who recently spent four months as an advisor to the smallpox eradication project in Bangladesh. May you build a ladder. Forever Young River we now turn to look at Public Health in our own country where the problems are certainly harder to get a grip on then in the case of smallpox in developing countries. Dr. Lane of the Center for Disease Control explain why this is so if you look at the the big killers in this country. They are things that are that individuals by their lifestyle bring upon themselves. We die of heart disease cancer stroke, alcoholism suicide, These are diseases that people bring upon themselves by their own behavior and you can't eradicate heart disease as long as people want to eat butter and eggs and have you like marble steaks? You can not can Raticate lung cancer as long as people continue to smoke. You're not going to Raticate motor vehicle accidents as long as people want are addicted to our way of Mobility so that the public health problems in this country are not as amenable as the infectious disease scourges of the developing world to Eazy-E and Rapid success has that doesn't mean there aren't things that we can do with them in my feeling is the challenge of Public Health in this country. Is not to change the way we do things to. Confront specific disease entities, but rather to create systems that deliver Services more efficiently and less expensively. If you really talk to the average citizen when he thinks of Health in this country, he doesn't think of specific disease problem. He's he worries about money. And I think the the challenge of domestic public health is to do what we're doing, but do it less expensively and I think that there are lessons that we've learned from smallpox eradication in from working developing countries that are relevant. They're the biggest single one is is not to do the same thing to everyone but to look at the risks for disease not vaccinate against motor vehicle accidents the way things people who don't drive cars but and also to rely on paramedical Personnel so that you are paying $10 instead of $100 for the same simple act be done for you because you're you're it's being delivered by less costly person out. I really wonder about that. Because you said earlier that one of the things you learned was to sort of ignore the medical infrastructure in the countries where you are the health infrastructure. How do you but I think that this is it this is true sale in this country you I think you do ignore the medical infrastructure to get on with the with the significant victories that hopefully public south will bring in the next few years because for instance if you if you take on motor vehicle accidents if their successes in that area, it won't be through the medical infrastructure. It will be through talking with the engineers the traffic safety people public education campaign. The greatest Public Health victory in recent years has been the decrease in automobile accident death rate due to the limiting of speed limit to 55 brought on by the energy crisis. Well, you know that's certainly had nothing to do with the the medical power structure or intellectual structure. I think Physicians. I'm a physician Physician's can and children will do this, but they won't do it from hospitals. They'll do it from ways that get into the interaction of the individual with society and the individual Lifestyles and that's going to be in fun. It's going to be intriguing for those of us who live to these heady incredibly successful days of smallpox eradication. It's going to be frustrated because we're not going to have the eradication programs for heart disease or automobile accidents or alcoholism. Those kinds of things. You can major Killers to that people say that are public health problems in this country could be solved if we just had a national health policy. Speaking last month at Southwest State University in Marshall at the annual meeting of the Minnesota Public Health Association doctor Royals tulones dean of the University of Texas School of Public Health took issue with that point of view. The problem said doctors still on us is that we have several National Health policies and they are in conflict with one another. We have a national health policy that says the medical care is a human, right? Does that term has been heard often in the past few years? It's often qualified. It means different things to different people. But we have a Welter of federal legislation that can only be interpreted as an attempt to implement that policy. We have a policy that says it's better to be young and wealth and old and sick. But somewhere in that statement is a notion that prevention is a good thing. That prevention of disease is a worthwhile National goal. Unfortunately disease prevention cost money. And it may be less expensive than treating sick people but it still cost money and therefore it gets involved in the problem of allocation of resources. And when resources are limited choices must be made between preventive measures and Medical Care. And I know a very few instances where preventive measures have one. Medical Care gets the money first almost routinely Unfortunately, we live in the United States and we are rich enough here so that we probably can continue to afford both for quite a while. If we know pretty much what it is that we want and need. well health policy number three that affects our circumstances the United States is it anybody has a right to do any damn thing he pleases That's an old established American Health policy. It becomes National Health policy when it's applied to such matters as so whether a physician shall specialize or not. Where he will practice? Whether a proposed hospital will be built in an area that already has a surplus of hospital beds. This policy is clearly in conflict with the Assurance of equal access to medical care for everybody If Medical Care is a human, right and we attempt to implement that policy then we come into direct conflict with the policy that anybody has a right to do anything. He damn well pleases Health policy number for that has had a major impact on activities of the past few years. Is that the health problems that the United States will be solved if the government provides enough money to vastly increase the number of Physicians? This is expected to fulfill our societal commitment to Medical. Care is a human, right? But still not violate the principle that everybody can do what he pleases. Because when all those economically and climatologically desirable areas are saturated with Physicians will keep right on turning out Physicians and then some will have to slap over into the crummy places. out on the prairies Elven policies are in Conflict as these I think clearly are. Wars are fought and priorities are established on the basis of strength primarily and we are of course right now in the middle of just such a war. The major antagonist are the medical professions on one hand and the legislators federal and state on the other that's where the war is going on. Legislatures as individuals may be tall or short handsome or homely. Venal or if shining integrity. But whatever those personal characteristics they all share one thing in common, they count votes. poor people many of whom vote say that they don't have a fair share of the available Medical Care. And the rich people who vote say that is cost too much. for medical care So the legislatures are caught right in the middle. They're struggling to find ways to produce more medical care for less money. And almost every solution they come up with or they talk about is opposed by organized medicine. Which would just as soon see things left alone? The central issue it seems to me is not who will win in this battle that I think is foreordained. I believe that no profession can successfully oppose major movements within the Society of which it is a part. So the medical professions have lost this one. It's going to take time, but the battle is is decided. More to the point is the question of what will have been one. when the dust settles over this Suppose that in and some years from now we have squadrons of doctors marching out of the medical schools. Dutifully taking up their positions in rural villages. That Medical Care is prepaid by national health insurance plan for everybody in the country. That the hmos are superbly organized and serve millions of people. That the quality of medical care services is closely monitored by governmental agencies. And if the whole Enterprise is carefully planned by hundreds of planning agencies. Will the people of the United States then be any healthier? Not particularly. If they are a it won't be because of any of this. The two don't bear any particular relation to each other. The health of a population has very little something but very little to do with the quantity of medical services available to it. the large factors that determine Health are the genes that you got The food clothing and shelter with your able to acquire. What are you are gainfully unsatisfyingly employed? What kinds of habits and Customs you learn from your peers and schoolmates over the Arden protests of your parents? The books that we read and the Recreations we enjoy. And the toxins and pollutants and various assorted hazards that we are exposed to. Those are the determinants of Health. Those are the things that determine whether we will get sick and then need. the services of the Medical Care Systems and medical care doesn't address any of those things. Those things are all prior determinants and they are established in other ways by other forces. Therefore we can say that the health of a community is a function of Public Health Services and economically circumstances social and economic circumstances. Not a function of Medical Care. In 1900 the expectation of life from birth was 49 years. That's an exact statistic. And I never remember that unless it's written down. I remember 50 years in 1900. That's easy. By 1970 it was over 70. So we picked up 22 years of life per person on average. Lively of course through the reduction of infant and child deaths the infant mortality rate. What was the infant mortality rate 1900? None of you need to know cuz I have it written down it was approximately 140 per thousand live births. Do you know any place where it's 140 now? Maybe in some places in Latin America Africa, that's a hell of a high infant mortality rate, but it was a hundred forty-four thousand live births in the United States in 1919. This was cut in half. It was cut in half Again by 1945. And it's now around 17 17 and 1/2 something like that. So it's cut in half again. Now those are remarkable. statistics just fascinating statistics how much of this can be attributed to improve Medical Care? What have what has medicine contributed to the reduction in the infant mortality rate? the decline of the infant mortality rate began before 1900 before these modern concepts of disease were really established. Before we had anything that we would not call scientific medicine. And long before we had antibiotics. So the trends were well-established quite a long while ago. As a matter of fact, I don't propose at this statistic Bruce anyting but during the time that the infant mortality rate was decreasing. The number of Physicians per hundred thousand population was also decreasing. substantially So if you believe in interpreting statistics glibly you would say that the infant mortality rate decreased because there were fewer Physicians around. I wouldn't propose that not seriously. How about a few specific diseases antibiotics are very important in the treatment of of a lot of illnesses these days. So let's consider what happened between 1900 and 1940 before we had any significant use of antibiotics. Tuberculosis deaths fell from 194 to 5245 per hundred thousand population between 1900 and 1940 and that's a four-fold reduction. Once again, the decline was well established by 1900. Long before we had sanatoria before we started snatching on people's lungs and long before it. Well, we had a four-fold reduction before we even had streptomycin PSI NH on the scene. Becker was headed down and there's no way in the world to convince an epidemiologist that it would have done anything other than keep right on going down. typhoid fever was reduced 30-fold between 1900 and 1940. And we I think we know very precisely why that happened. The epidemiologist of the 1920s used to write about typhoid fever epidemics Every Spring at the time of the spring. Thaw When all of those deposits from all of those previous on all those hillsides in West Virginia came down the rivers. During the 1930s the Roosevelt administration. was involved in a stabbing it in. Developing sewage treatment plants and water purification plants in towns and cities all over the United States. It's almost certain that that's what this responsible for adduction of typhoid fever. So the epidemiological picture just changed totally between 1920 and 1950. That had to be Community hygiene Community Sanitation. The point is that Environmental Management and Community preventive medicine have had almost unbelievable beneficial effects. spectacular effects In comparison the most spectacular successes of medical care or inconsequential. A few years ago medical experts in this country set out to solve the heart disease problem. By applying the classical American manufacturing principle of interchangeable parts. Some researchers took a straightforward Orville and Wilbur approach attempting to develop mechanical pumps to replace biological ones. Some of the engineering problems proved difficult to resolve. And while this program stumbled along and alternative was developed based apparently on the religious rights of the Aztecs. Various Chambers of Commerce around the world began to Vive for the title transplant capital of the world. I happen to live in one. No, whatever else they were heart transplants were examples of superb surgical skill. And modern medical organization. We learned a great deal about Immunology through the study of the rejection phenomenon. I bet the bright promise of transplant surgery faded as the survivors dwindled. and now we can assess the situation will more soberly roughly 750,000 people die each year in the United States have heart disease. A substantial fraction of these perhaps the 3rd or more are young enough that their death represent serious waste of productive years. So even if everybody was the retirement age, there's still quite a number of people left him you'd like to say She got a quarter million people. This to me raises serious doubt that cardiac substitution whether it's biological or mechanical is a practical resolution of the problem on a community basis. For many of us this solution provides a dramatic illustration of the theoretical advantages of preventive over therapeutic medicine. The risk of death from coronary disease among middle-aged man in the United States is about 10 times greater than it is among middle-aged men in Japan. And we don't know yet how to explain this difference completely. But we do know that it's related to differences in lifestyle and is not due to genetic or racial difference. That's very clear. So this that establishes a basis for projecting or expectation of successful preventive procedures, we ought to be able to reduce the coronary disease death rate in this country to one tenth of what it is. That's that's go that's in an aspiration that we could reasonably put forth as working goal. if we knew how by changing environment and lifestyle this evidence with respect to coronary disease been lying around long time. How come we don't know? Well since at least 1967 some very serious proposals have been put forth to conduct major experiments on the benefits of dietary modification for reducing coronary disease mortality. Admittedly some thoughtful people to look at these proposals were not convinced that a definitive study was possible. But most of the objections didn't set her on whether it was scientifically feasible or logistically possible is centered on the cost is going to cost a lot of money. The die-hard feasibility study indicated that the study could be done, but it would be expensive. About 10 million dollars a year for five years was a figure that was proposed. Is this was thought by the people who were concerned with the problem be a staggering some 50 million dollars! And so this whole issue was buried in a Welter of indecision It Was Roses were never turned down. They were never approved. Nothing was done including no decision. Well, what is 50 million dollars mean? that's about Indeed, it's less than the current capital expenditure for a new medical school. And we've been building those as though they were going out of style. The annual expenditure would have been less than the operating annual operating budget of many ferrets most medical schools. Know if we got a negative answer some people might figure with that money was thrown down the drain and maybe so but suppose we got a positive answer and we found that by doing something like this. We might indeed affect the substantial reduction and coronary disease mortality in the United States wouldn't that be worth of medical school or two or a few? The theoretical case for prevention is so strong that we must wonder what constraints hamper is progress, and I think we know some of them. Preventive medicine is off an unpalatable. A practitioner of preventive medicine must seek his clients out. He doesn't sit in an office and wait for them to come in with a complaint because that's too late. So he has to seek them out. And Billy are coerced them into changing their Lifestyles and many of their comfortably established habits. It requires a good salesman to Pedal a program in which a present pleasure convenience is barted for an indefinite benefit in an uncertain future. Another one of the constraints and the development of preventive medicine has to do with the training of Physicians and medical school very early the students learn that their appropriate models. Are you there? This selfless scientist whose knowledge burns like a gemlike flame? Or those clinicians who arrived to make rounds at the charity hospitals. in their Mark Force and preventive medicine if it's taught at all in the medical school is all too often spread before then by a faculty who are neither intellectually nor economically privileged. What are the risk of disease to a community is very clear? Where your illness threatens me? And where the preventive procedure is inexpensive and not very Troublesome and examples are smallpox and diphtheria then the community the public Express is very forthrightly in compulsory programs. It's easy to get people to vote in favor of having their kids vaccinated. Cuz the only hurts the kids. But we're not willing middle-aged man will not vote to require the middle-aged men a run a mile each day. Or compel them to restrict their caloric intake. For these reasons and others we have developed a medical establishment, which is geared to the treatment of illness rather than the maintenance of Health. This attitude is pervasive and it controls the development of programs that are economically irrational such as a heart transplant program. When after a long and bitter debate our society finally decided to make a token attempt to ease the financial stresses. A medical care for the elderly this program was designed in a way that necessitated increasing costs. It could not do anything else then increase the cost the way it was proposed. Hospital care cost more than outpatient care, right, right. The hospital care was paid for but I patient care wasn't so you converted that patients and patience. Automatically and we all know that happened. preventive medicine cost less mostly then care of illness But there was no reimbursement for preventive medicine in these programs. So we've seen a situation where medical economics in the United States is one fast. uncontrolled implicit cost plus contract between society and and practitioners And like all costs plus contract. It has a tendency to drive costs up because that's the only way profits increase. And doesn't matter how people protest about this. We have seen it happen. We can draw some reasonable conclusions from some of these observations. The quality of Medical Care in this country is very high. And in comparison for some kinds of things in comparison with some other place is very inexpensive. Many specific illnesses can be dealt with very effectively. And that's important to me because I may get sick one of these days and I want that available to me and none of us want to give that up and I'm not suggesting that we should. however many misconceptions have developed As a result of the confusion of medical care with the broader concepts of health and disease prevention. And as long as these are confused we have the problem with these misconceptions. and Before the night is out. Some of you are going to be talking about health care when you mean a doctor treating a patient who's sick. I know that's going to happen. In fact, I might use the term myself. It is in our language. And it is a perversion if I ever heard one that's medical care. That's not Healthcare. Health Services Administration routinely refers to those people who administer facilities in organizations for the care of illness. They are illness Services administrators. We can only promote effectively. preventive medicine disease prevention and health If we turn our attention to the environmental determinants. So I propose a percent a few propositions to you. number one prevention of disease by Environmental Management offers the greater promise than any other means available to us. If you have to Aspire to something as fire to something important something that holds 4th great promise. And the lessons of the past 75 years indicate just as clearly as anything can that if you want to control disease modify the environment within which people live? I'm not just talkin about air pollution and water quality and sewage disposal and radiation hazards. I'm also talking about the most important part of my environment if you and what do you permit me to do in the way I react with you. Is of overwhelming importance so the social environment. where we let people live Where and what kinds of work we allow people to undertake? Are part of this whole business of managing the environment in the interests of human health. The basic argument of the environmentalist with traditional medical approaches is that the traditional medical approach has emphasized specificity at the expense of generality? Again, we could present many examples but the select just one if a community water supplies protected from contamination the community may enjoy protection from cholera. Typhoid amebiasis salmonellosis. Perhaps poliomyelitis Perhaps hepatitis depends on the nature protection shigellosis. an array of diseases since all of these diseases have alternate ways in which they may be spread and the control will not necessarily be perfect just by cleaning up the water supply typhoid didn't absolutely disappear. But it's effective enough to print to to prevent most catastrophic epidemics. What we need now is to depart from our studies of specific diseases taken one of the time. and study patterns of illness and mortality in the aggregate and common patterns in the absolute and proportional frequencies of illness. And relate those two patterns of physical biological and social characteristics of these communities. We are very powerful clues that lead us to believe that those will be most productive lines of research. Understanding of these broad environmental determinants of disease systems should lead to a more elegant perception of specific etiology and pathogenesis. So we'll learn more about how an individual disease works by watching how it operates in an environmental complex. Pursuit of this kind of research should provide us with a much clearer understanding of how we wish to design our future environments. Urban and Regional planners now plan with almost no informed assistance from experts in public health. the criteria relating to human health that should influence decisions about the allocation and arrangement of space color and light about the size and structure of communities. And about the social and political structures. We wish to have operating these communities. Just do not exist in any scientific sense. And no matter how we choose to order our priorities. We are required to up first for species survival followed by individual welfare and comfort. These considerations then it seems to me place. Health Affairs in a central position with respect to environmental planning I've had some modest awareness of a number of environmental planning centers academic centers and a good many cities that have urban planning offices. But I know none of them that has any significant component that has to do with health and disease related to that planning activity. I'll summarize. Two very sharply contrasting views exist with respect to health and disease. The first which is buttressed by most imposing successes over the past hundred years. Emphasizes the specificity of disease and the values that attend an Ever greater understanding of etiologic agents and their pathogenesis. And that's where all the Nobel prizes are. This has been very successful. It is resulted in more effective diagnosis and treatment of illness. And it's made great contributions to disease prevention through those M and logical procedures that can be employed. The second view is not in conflict with this but should be additive to it. It is concerned with the general non-specific influences in the environment that determine states of health and disease of human groups. This basic concept is very ancient. It goes way back Beyond Epocrates. And despite the fact that we have scattered observations that attest to its power and subtlety. The field has been neglected and overshadowed by the former by the first few. But it appears especially important with respect to disease prevention. And its potential significance is enormous. So I believe it to recognize the differences between these two fuse is an essential step toward formulating a national policy. They will provide for more rational allocation of resources. Then I think we may be taking some steps toward the time when we will indeed have less Medicine and More Health Doctor Royals tulones dean of the University of Texas School of Public Health speaking with members of the Minnesota Public Health Association at their annual meeting in Marshall last month. We conclude today's program with a look at some facets of Public Health policy in the People's Republic of China as reported by Ruth Seidel and author and recent visitor to China Seidel also spoke at the annual meeting of the Minnesota Public Health Association at Southwest State University in Marshall, and she told her audience that the Chinese have implemented a thoroughgoing and carefully enunciated National Health policy in 1950. They had a conference shortly after the Revolution and they decided that the four key points in delivering in organizing Health Services were to be one provision of healthcare to in the Chinese idiom the workers peasants and soldiers those who hadn't had least prior to the revolution. The second point that they decided in 1950, but the emphasis was going to be on prevention rather than on Curative measures the third Point decided upon in 1950 was a traditional and modern medicine would be integrated. And the fourth point was that Medical Care had to be integrated with a mass movement which we've called Mass participation up there. So it was these four points along with a fifth one that that mounts of Cheung added in 1965 which was to give more emphasis to the rural areas which has become the Chinese Health policy the other principles facilitate the delivering of healthcare within this larger framework the decentralization of decision-making which I've already mentioned and of services the recruitment of an indigenous workers such as the Barefoot doctor and the red medical worker the democratization of the system be attempting to break down the old boy. Is between doctors and everyone else in the system and to adopt a truly more democratic team effort and finally the stress on service the stress on serving the people would you see everywhere in China and which does seem to be slightly more than a slogan a medical care is provided on the lowest level the most Mass level in the Countryside by Barefoot doctors who are of course me the Barefoot nor doctors. They are rather indigenous workers who have been recruited from the the communes the production brigades and production teams because of their interest in medical care and their devotion toward providing medical care. They're given very short periods of training sometimes as short as 3 months in a local County Hospital and then sent right back to their communist and what is different about them than other xhilaration other parts of the world is that they only do medical care part time and they do agricultural work the other half time so that they remain integrated with a group in which they live in work. I just by the way, they got their term Barefoot doctor because if a doctors were first started in the south of China around Shanghai where because they worked in rice paddies switch were a highly irrigated. They often worked Barefoot, but it's also I think part of the Chinese way of keeping the connection with the peasantry with agricultural work to continue. Need to call them their foot doctors again an aside for those people are particularly interested in the role of women in China. We were told that about 1/2 of the 1 million Barefoot or women the Chinese make every effort to recruit women in all the medical profession's at the production Brigade level, which is the intermediate level of the Communist midwives deliver all the babies. They generally delivered in the mother's home without anesthesia. If there are complications the mother can be referred either prior to the delivery or at the time of delivery to a local communist hospital and a be delivered by fully trained Physicians and midwives also do all of the birth control work which as we'll talk about later with regard to the cities is very intense in China. There have been communist hospitals built on almost every communist China by now. These are staffed by fully trained Physicians and by Specialists who wrote aid from the city's out of the Side for a period of a year or more more both to train the workers on the Communists and to get the experience of being in the countryside themselves. If we moved from the rural areas to the urban areas health is given at the lowest or most Mass level. I really shouldn't use that term lowest at the most basic level by water called red medical workers. They are the urban counterpart to the Barefoot doctor and we're in the Chinese word Housewives which means they weren't working before they were recruited to be read medical workers. They have very brief periods of time training which vary depending on what city you're talking about. Things are so decentralized that each City can really make its own exact plans how it's going to go for in training Barefoot doctors are red medical workers or even medical schools very very much from place to place so that red medical workers would have as little as one month training. And perhaps as much as four or five months training after this period of training their sent back to their residents committees where they set up Health stations and and are involved in providing Health Care as well as Medical Care to their friends and neighbors. The health station is within easy walking distance of everybody in that immediate area. No one of their primary tasks in these Health stations in these residents committee is to teach health education. It is extremely important part of a malist belief really that you have to understand the world around you and participate in that world in order to really change the world at change your own environment and be changed by it. So health education has very high priority. There was a tremendous campaign to identify all the cases of venereal disease treat them and attempt to wipe it out a list was posted of a symptoms of venereal disease. People were trained up very quickly to know the symptoms and to go door-to-door again talking with their friends and neighbors going down a checklist. If anybody had significant symptoms, they were treated immediately and the Chinese report and we have no reason to disbelieve them that venereal disease has been virtually eliminated in China. So this emphasis on the participation of the people on mass movements is highly crucial in medicine in China today. Now the red medical workers are also involved in providing immunizations. This is a chart of the immunization rate in the neighborhood and became the we visited in 1971. The illness up at the top is Sesame pimple or measles and out of 160 children who were eligible to be immunized 156 were immunized for an immunization rate of 97% of the third one down. For example is DPT out of a hundred 6363 were immunized immunization rate of 100% and down, west of these really unbelievable percentages at least for the urban United States until we got to the bottom of them. We said, you know, haha what happened with that bottom when you slipped up there and they said no, you know don't get excited except I didn't say that I said that's smallpox. And since there hasn't been a case of smallpox in China since the early 1950s. We don't give the smallpox vaccine if there is any contraindication hints only 81% of the children are immunized against smallpox. Now, you know, you have to wonder how they Get an immunization right such as this when we have such problems. And of course it is the urban organization. It is the role of the red medical worker within that Urban organization. It is the philosophy that it is the responsibility of the health workers at every level to make sure that every family understands. What immunization is about that every child needs to be immunized is if a parent doesn't bring her child then or his child in the medical worker will go out to the house and if need be we'll bring a doctor out to the house to give the immunization in the house. It's a door-to-door intensive person-to-person kind of effort the same kind of effort has gone on in birth control in China. They have gone back and forth on the issue of birth control in the early 1950s. They tried to initiate a tremendous program of of plan birth as they like to call it, but it was not received well and they pulled back. But in the early to mid 1960s they started again with a very intense program. They have really politicized they act of birth control and made it into something that people do for the sake of the entire society, which of course the Chinese people are very into it's important for Education. It's important for defense. It's important for production. It's important for the society at large and they have Arch people strongly to have only two or three children and made birth control widely available and free to the people of China. I think it's important to note that Medical Care is not free. But anything that they are really serious about giving making available to everybody is free birth control is free abortion is free sterilization is free immunizations of free prevention is free. Healthcare costs a bit and the way in which they have. Dealt with birth control on the urban scene at a very local level is that red medical workers go out and go door-to-door and again educate women. This is a women to women kind of thing. This is one of the reasons that all the red medical workers are women the Chinese find it very difficult to cross sex lines and talking about these kinds of issues. So the female read medical workers go out to the home and talk to the women about what kind of birth control their using. When do they want their next child, you know how to do they have it planned out. Is there anything that can tell them for the what can they get them and so forth we found again it is a very intense person to person neighbor to neighbor without any class distinctions. These are women who are doing this or the woman next door literally who has had very little training who has not entered the professional classes has not become a health professional. She's still one of us. She straddles both of those rolls at the same time. It's kind of intensive person-to-person kind of effort has done remarkable. Things in lowering the birth rate in China cities China has no all over statistics. They don't collect them as yet so far as we know we have some statistics out of Shanghai which indicate the Shanghai may have the lowest birth rate of any city in the world to believe but it seems to be what the statistics show in any case they've done a fantastic job with these kinds of now just to go for a few moments to this issue of combining traditional and modern or Western medicine. This is really a very big component of Chinese Healthcare. They have tried to save in every sphere the best of the past with what they want the future to be in to combine them. They tried to do this in education. They've tried to do it and City Planning. They have not thrown out everything that was old by any means and in Medicine, of course, it means that huge body of tradition traditional medicine, which has come from the centuries. Obviously a country with a very different sense of the role of the individual in the society, and I think that this has a direct bearing on the health of a Nation. It is a society in which people are committed to something larger than self perhaps this best sums up the new kinds of attitudes, which the Chinese are trying to teach their people and I think which directly affect the health of the Chinese people in the well-being of the Chinese people in general. It is a society. It seems to us again with a very short. Of time that we were there that is attempting to teach people to cooperate rather than to compete and to work out of altruism rather than out of self-interest. It's hard to know how well the Chinese is succeeding, but I think it's a very exciting experiment that we would do well to watch. Thank you. Ruth Seidel author lecture and recent visitor to the People's Republic of China speaking to members of the Minnesota Public Health Association at their annual meeting in Marshall last month. Earlier on today's program you heard. Dr. Royals tulones dean of the School of Public Health at the University of Texas. Dr. Michael Lane director of smallpox eradication at the Center for Disease Control in Atlanta, Georgia and Tom Kimmel formerly a public health advisor to the smallpox eradication program in Bangladesh. weather Young

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