AMERICAN JOURNAL OF VW pgk
Editorials:2 January 1977 Volume 67, Number 1
Established 191 1
A Ray of Hope EDITOR Alfred Yankauer, MD, MPH
EDITORIAL BOARD Michel A. Ibrahim, MD, PhD (1977) Chairperson Rashi Fein, PhD (1978) Ruth B. Galanter, MCP (1977) H. Jack Geiger, MD, MSciHyg (1978) George E. Hardy, Jr., MD, MPH (1978) C. C. Johnson, Jr., MSCE (1977) Geroge M. Owen, MD (1979) Doris Roberts, PhD, MPH (1977) Pauline 0. Roberts, MD, MPH (1979) Ruth Roemer, JD (1978) Sam Shapiro (1979) Robert Sigmond (1979) Jeannette J. Simmons, MPH, DSc (1978) David H. Wegman, MD, MSOH (1979) Robert J. Weiss, MD (1977) STAFF
William H. McBeath, MD, MPH Executive DirectorlManaging Editor Allen J. Seeber Director of Publications Doyne Bailey Assistant Managing Editor Deborah Watkins Production Editor Janice Coleman Administrative Assistant CONTRIBUTING EDITORS George Rosen, MD, PhD Public Health: Then and Now William J. Curran, JD, SMHyg Public Health and the Law Jean Conelley Book Section
Appearing elsewhere in this issue of the Journal is an application of political scitheory to the make-up of the Board of Directors of our nation's Fifth Edition* of the local health planning agencies.1 Its author asserts that this latest version, the HSA, represents a reprinting (with a new cover and perhaps slightly improved indexing) rather than a rewrite: "Congress has not revised the rules of the health-care game, but merely added another player, one that can be expected to perform much like the others." Vladek's major concerns center around the holdover from the CHPRMP days of a Board dominated by vested interests and provider accountability, a Board whose "consumer" participants have no public accountability and whose government official representation is treated as just another vested interest. His reasoning will appeal to those health care providers who believe in the underlying democratic principle of elective accountability. His commentary is one more entry in the growing competition in these pages for the title of most tragic HSA flaw of the year. The reckoning is pretty stiff! Consider: the lack of clear mandate, the inadequate funding, the rigid guidelines, the undermining of gubernatorial authority and of the compounding of local and state government prerogative. How then could Congress have made this series of tragic mistakes, and what will be the consequence of these flaws? At least part of the answer is that as a nation we approach improvement of our social institutions incrementally-through the legislative process so aptly described by Vladek. Furthermore, "Planning", whose technology is primitive, smacks to us of totalitarianism and the sacrifice of individual freedom. Thus in the HSA, authority is granted to a non-governmental body lest the authority be too great for the state of the art. Perhaps, also, the likelihood of reaching an initial consensus-however watered down-may have seemed greater with this model. Regional planning bodies linked directly to general-purpose elective (and therefore truly representational) government make logical sense. However, our nation is not yet covered with such a network, and the problem of defining the boundaries of such regional bodies so that they are co-terminal with health care marketing areas remains to be solved.2 It is in this context that we must view the HSA edition of the nation's health planning book. Because of its flaws, the HSA edition may bring about only a transient burst of progress as Vladek assumes. However, there can be progress along the way-if persons concerned with assuring, promoting, and protecting the public's health force the issue. For the new HSA does contain significant progressive features, extolled perhaps too little in our zeal to do even better sooner. Local government is once again ence
*The Health Systems Agency (HSA) is the latest revision of U.S. strategy to blanket the country with local health planning agencies. The precise edition of this revision may be subject to some debate. However, the HSA can be considered a fifth edition (or generation) if the CHPAs are considered a fourth, Health Planning Councils a third, Hill-Burton Planning Councils a second, and Haven Emerson's county health departments a first. Address reprint requests to Dr. Hugh H. Tilson, Health Officer and Director, Division of Health Services, Department of Human Services, Multnomah County, 426 S.W. Stark Street,
Portland, OR 97204.
AJPH January, 1977, Vol. 67, No. 1
19
EDITORIALS
involved in a big way. Witness the eager pursuit of public representation on the boards. Witness the major National Association of Counties' push for local government control. And witness some of the existing new coalitions, especially of representatives of rural governments, in the HSA development process. The new HSA does contain a requirement to actually develop a plan. While this may seem trivial and while the first version will clearly contain many compromises, the fact is that we shall have, finally, the beginnings of consensus based upon the beginnings of nationwide criteria. The new HSA is planning around new dollars and will in the foreseeable future have to allocate scarce resourcesprobably with many of the compromises described by Vladek. To do this, however, it must develop mechanisms to make priority decisions among competitive claims for the same pot. In this process, a mechanism may be developed for the longer range and more awesome planning responsibilities of the future, a future when tougher priority decisions about how to distribute the consolidated federal-state-local government
health financing fund under national health insurance will need to be made. At very least the HSA legislation has pumped new local political energy into a planning effort which needed revitalization. With all of its imperfections, this seems a real step forward toward the sixth edition. When we take that next step, perhaps Congress may be ready to return the power to the only agencies we grassroots voters know how to control-state and local governments. Perhaps also by that time, our locally elected general purpose representative governments will be ready to join together to form the regional agencies that can respond to the challenges of planning for the health and welfare of our future.
HUGH H. TILSON, MD REFERENCES 1. Vladek, B. Interest-group representation and the HSAs: Health planning and political theory. Am. J. Pub. Health, 67:23-29, 1977 2. Hammond, J. R. Substate District, HSA and PSRO designations, Am. J. Pub. Health, 66:788-790, 1976.
The Quiet Desperation of Public Health Conscience "How few ever get beyond feeding, clothing, sheltering and warming themselves in this world, and begin to treat themselves as human beings-as intellectual and moral beings."* Professionals and scientists are among those privileged few, in spite of the bad odor they somehow acquired during the 1960s. "The mass of men live lives of quiet desperation." Even in the electronic excitements of the present era, the mass are bound to the monetary rewards of monotonous jobs. The privilege of the professional and scientific few-among whom health workers may be counted-is the intellectual challenge of their work in terms of the creative opportunities it affords and the moral rewards of their role in terms of service to fellow human beings. In the twentieth century this privilege exacts a price. Before the scientific explosion it may have been accurate to state that "it is safest to invest in knowledge, for the probability is that you can carry it with you wherever you go." But today's scientist or professional cannot work in isolation, without tools, without exchange, without access to two-way communication. It may not be inappropriate to compare his or her thrall to that of the nineteenth century rich man, who, "not to make an invidious comparison-is always sold to the institu-
tion which makes him rich. Absolutely speaking, the more money, the less virtue." In many countries of the world today-62 according to Amnesty International'-the scientist who incurs the displeasure of his government, sometimes for utterly trivial reasons, sometimes for voicing his objection to official policies, risks not only imprisonment, death, and physical torture, but also his access to the world of science, his communication with peers, in short an end to his career as a scientist or professional, in or out of prison. He cannot take his knowledge with him wherever he goes because the body of knowledge is no longer fixed. He cannot pursue a life of service because the service is linked to government no matter what the government politics. This is hard. It is even harder for the professional who wants to serve than for Thoreau's "freest of neighbors," about whom he observed, "whatever they may say about the magnitude and seriousness of the question (ed. note: slavery and militant abolitionism) . . . the long and the short of the matter is, that they cannot spare the protection of the existing government, and they dread the consequences to their property and their families of disobedience to it.... this makes it impossible for a man to live honestly, and at the same time comfortably, in outward respects." It is in this context that readers should turrn to the Report of the American Public Health Association's Task
*AIl quotations in this editorial, unless otherwise noted, are taken from the published works of Henry David Thoreau (1817-1862): his book, Walden, or Life in the Woods, his Journals, and his essay, Civil Disobedience.
Force on Chile, published on page 71 of the current issue of the Journal and the APHA policy statement on International Health published on page 97. The Chilean prisoners of conscience and exiles are unusual because so many of them
20
AJPH January, 1977, Vol. 67, No. 1
Editorials:2 January 1977 Volume 67, Number 1
Established 191 1
A Ray of Hope EDITOR Alfred Yankauer, MD, MPH
EDITORIAL BOARD Michel A. Ibrahim, MD, PhD (1977) Chairperson Rashi Fein, PhD (1978) Ruth B. Galanter, MCP (1977) H. Jack Geiger, MD, MSciHyg (1978) George E. Hardy, Jr., MD, MPH (1978) C. C. Johnson, Jr., MSCE (1977) Geroge M. Owen, MD (1979) Doris Roberts, PhD, MPH (1977) Pauline 0. Roberts, MD, MPH (1979) Ruth Roemer, JD (1978) Sam Shapiro (1979) Robert Sigmond (1979) Jeannette J. Simmons, MPH, DSc (1978) David H. Wegman, MD, MSOH (1979) Robert J. Weiss, MD (1977) STAFF
William H. McBeath, MD, MPH Executive DirectorlManaging Editor Allen J. Seeber Director of Publications Doyne Bailey Assistant Managing Editor Deborah Watkins Production Editor Janice Coleman Administrative Assistant CONTRIBUTING EDITORS George Rosen, MD, PhD Public Health: Then and Now William J. Curran, JD, SMHyg Public Health and the Law Jean Conelley Book Section
Appearing elsewhere in this issue of the Journal is an application of political scitheory to the make-up of the Board of Directors of our nation's Fifth Edition* of the local health planning agencies.1 Its author asserts that this latest version, the HSA, represents a reprinting (with a new cover and perhaps slightly improved indexing) rather than a rewrite: "Congress has not revised the rules of the health-care game, but merely added another player, one that can be expected to perform much like the others." Vladek's major concerns center around the holdover from the CHPRMP days of a Board dominated by vested interests and provider accountability, a Board whose "consumer" participants have no public accountability and whose government official representation is treated as just another vested interest. His reasoning will appeal to those health care providers who believe in the underlying democratic principle of elective accountability. His commentary is one more entry in the growing competition in these pages for the title of most tragic HSA flaw of the year. The reckoning is pretty stiff! Consider: the lack of clear mandate, the inadequate funding, the rigid guidelines, the undermining of gubernatorial authority and of the compounding of local and state government prerogative. How then could Congress have made this series of tragic mistakes, and what will be the consequence of these flaws? At least part of the answer is that as a nation we approach improvement of our social institutions incrementally-through the legislative process so aptly described by Vladek. Furthermore, "Planning", whose technology is primitive, smacks to us of totalitarianism and the sacrifice of individual freedom. Thus in the HSA, authority is granted to a non-governmental body lest the authority be too great for the state of the art. Perhaps, also, the likelihood of reaching an initial consensus-however watered down-may have seemed greater with this model. Regional planning bodies linked directly to general-purpose elective (and therefore truly representational) government make logical sense. However, our nation is not yet covered with such a network, and the problem of defining the boundaries of such regional bodies so that they are co-terminal with health care marketing areas remains to be solved.2 It is in this context that we must view the HSA edition of the nation's health planning book. Because of its flaws, the HSA edition may bring about only a transient burst of progress as Vladek assumes. However, there can be progress along the way-if persons concerned with assuring, promoting, and protecting the public's health force the issue. For the new HSA does contain significant progressive features, extolled perhaps too little in our zeal to do even better sooner. Local government is once again ence
*The Health Systems Agency (HSA) is the latest revision of U.S. strategy to blanket the country with local health planning agencies. The precise edition of this revision may be subject to some debate. However, the HSA can be considered a fifth edition (or generation) if the CHPAs are considered a fourth, Health Planning Councils a third, Hill-Burton Planning Councils a second, and Haven Emerson's county health departments a first. Address reprint requests to Dr. Hugh H. Tilson, Health Officer and Director, Division of Health Services, Department of Human Services, Multnomah County, 426 S.W. Stark Street,
Portland, OR 97204.
AJPH January, 1977, Vol. 67, No. 1
19
EDITORIALS
involved in a big way. Witness the eager pursuit of public representation on the boards. Witness the major National Association of Counties' push for local government control. And witness some of the existing new coalitions, especially of representatives of rural governments, in the HSA development process. The new HSA does contain a requirement to actually develop a plan. While this may seem trivial and while the first version will clearly contain many compromises, the fact is that we shall have, finally, the beginnings of consensus based upon the beginnings of nationwide criteria. The new HSA is planning around new dollars and will in the foreseeable future have to allocate scarce resourcesprobably with many of the compromises described by Vladek. To do this, however, it must develop mechanisms to make priority decisions among competitive claims for the same pot. In this process, a mechanism may be developed for the longer range and more awesome planning responsibilities of the future, a future when tougher priority decisions about how to distribute the consolidated federal-state-local government
health financing fund under national health insurance will need to be made. At very least the HSA legislation has pumped new local political energy into a planning effort which needed revitalization. With all of its imperfections, this seems a real step forward toward the sixth edition. When we take that next step, perhaps Congress may be ready to return the power to the only agencies we grassroots voters know how to control-state and local governments. Perhaps also by that time, our locally elected general purpose representative governments will be ready to join together to form the regional agencies that can respond to the challenges of planning for the health and welfare of our future.
HUGH H. TILSON, MD REFERENCES 1. Vladek, B. Interest-group representation and the HSAs: Health planning and political theory. Am. J. Pub. Health, 67:23-29, 1977 2. Hammond, J. R. Substate District, HSA and PSRO designations, Am. J. Pub. Health, 66:788-790, 1976.
The Quiet Desperation of Public Health Conscience "How few ever get beyond feeding, clothing, sheltering and warming themselves in this world, and begin to treat themselves as human beings-as intellectual and moral beings."* Professionals and scientists are among those privileged few, in spite of the bad odor they somehow acquired during the 1960s. "The mass of men live lives of quiet desperation." Even in the electronic excitements of the present era, the mass are bound to the monetary rewards of monotonous jobs. The privilege of the professional and scientific few-among whom health workers may be counted-is the intellectual challenge of their work in terms of the creative opportunities it affords and the moral rewards of their role in terms of service to fellow human beings. In the twentieth century this privilege exacts a price. Before the scientific explosion it may have been accurate to state that "it is safest to invest in knowledge, for the probability is that you can carry it with you wherever you go." But today's scientist or professional cannot work in isolation, without tools, without exchange, without access to two-way communication. It may not be inappropriate to compare his or her thrall to that of the nineteenth century rich man, who, "not to make an invidious comparison-is always sold to the institu-
tion which makes him rich. Absolutely speaking, the more money, the less virtue." In many countries of the world today-62 according to Amnesty International'-the scientist who incurs the displeasure of his government, sometimes for utterly trivial reasons, sometimes for voicing his objection to official policies, risks not only imprisonment, death, and physical torture, but also his access to the world of science, his communication with peers, in short an end to his career as a scientist or professional, in or out of prison. He cannot take his knowledge with him wherever he goes because the body of knowledge is no longer fixed. He cannot pursue a life of service because the service is linked to government no matter what the government politics. This is hard. It is even harder for the professional who wants to serve than for Thoreau's "freest of neighbors," about whom he observed, "whatever they may say about the magnitude and seriousness of the question (ed. note: slavery and militant abolitionism) . . . the long and the short of the matter is, that they cannot spare the protection of the existing government, and they dread the consequences to their property and their families of disobedience to it.... this makes it impossible for a man to live honestly, and at the same time comfortably, in outward respects." It is in this context that readers should turrn to the Report of the American Public Health Association's Task
*AIl quotations in this editorial, unless otherwise noted, are taken from the published works of Henry David Thoreau (1817-1862): his book, Walden, or Life in the Woods, his Journals, and his essay, Civil Disobedience.
Force on Chile, published on page 71 of the current issue of the Journal and the APHA policy statement on International Health published on page 97. The Chilean prisoners of conscience and exiles are unusual because so many of them
20
AJPH January, 1977, Vol. 67, No. 1
