AMERICAN JOURNAL OF
o e~~~~~~~~~~~~~~~~~~I
Octoer 977
akk.
Established 1911
Volume 67, Number 1 0
Behavioral Change and Public Attitudes Toward Public Health 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) George 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 Director/Managing Editor Allen J. Seeber Director of Publications Doyne Bailey Assistant Managing Editor Deborah Watkins Production Editor
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
AJPH October, 1977, Vol. 67, No. 10
Sidney H. Croog and Nancy P. Richards offer interesting data on smoking in an interesting population in their paper, entitled, Health Beliefs and Smoking Patterns in Heart Patients and their Wives. I In doing so they lead us to consider some important questions concerning our ability to promote the health of the public. The authors remind us how difficult it is to change patterns of cigarette consumption. Quite in line with dictates of common sense, men who survived heart attacks stopped smoking at a very high rate and held steady in this respect for eight or nine years depending on when they were interviewed in this longitudinal study. Their brush with death and the advice of their physicians apparently conspired to bring about behavioral change that would enhance their survival. Surprisingly, however, their wives showed no change in smoking despite the life-threatening attacks their husbands had suffered. One might have thought that such close calls would yield significant change in those so intimately touched by the experience. One is led to wonder what it would take to change people even less threatened. Yet widespread alteration of disease-producing behavior appears to be the imperative of contemporary efforts to advance the health of the people. The biggest challenge now is to crack the encrustations of personal behavior and life-style which are encouraged, in turn, by social customs in our corporate and industrial civilization. It is instructive, therefore, to examine how the United States has responded to the threat that smoking poses to the health of its people-for it exemplifies the peculiar paradox that characterizes the contemporary public health movement. Readers of this Journal are surely familiar with the basic picture. Convincing evidence has long been available to demonstrate that cigarette smoking contributes a great deal to preventable death and disability. Smokers and nonsmokers are aware of this fact and support action to reduce cigarette consumption in themselves and in the public at large. This support acts as the foundation for federal and state actions already taken to reduce smoking. And, indeed, cigarette smoking has declined since the mid- 1960s. At the same time, however, ominous signs tell us that all is not well: * A very large minority of the adult population still smokes. * The absolute number of smokers has increased. * The proportion of heavy smokers has increased among the smoking population. * Most ominously, too, smoking among teen-aged women has risen to about the same level as found among teen-aged men. Taking this into account, the American Cancer Society's Task Force on Tobacco and Cancer has placed a high priority on efforts to reduce smoking among teen-aged women.2 In sum, then, the paradox is that in spite of the available scientific information and in spite of widespread public awareness the public health movement has been unable to move beyond the incremental reductions characteristic of the 1960s and '70s. What, then, are the forces at work preventing more impressive results? In seeking the answer to this question we may be able to identify current attitudes to public 911
EDITORIALS
health that present new challenges to the public health movement. We may take it for granted that smoking, like any wellestablished habit, is extremely resistant to modification. Anyone who has been a smoker or nail-biter or over-eater can testify to that fact. But that alone is insufficient to explain a perceptibly growing opposition to public intervention on behalf of the public's health. Why, for example, have several states legalized the use of a worthless substance made from peach and apricot pits as an approach to cancer treatment? Such an outcome would have been unthinkable 20 or 30 years ago. Why did the United States Congress enact legislation restricting the use of certain accident-preventing devices on automobiles? Why has the Occupational Safety and Health Administration become a favorite whipping boy of many politicians and columnists? Why did the Food and Drug Administration become an "enemy of the people" after it proposed a ban on saccharin? Why is the counterattack on safety helmets seemingly on the road to success? And, returning to smoking, why has smoking increased among young women? One theme running through these and other examples of a rise in anti-public health sentiment is that of freedom of choice on the part of the individual. Protecting the health of the public falls into second place when it comes into conflict with the right of the individual to follow his own will. Legal, philosophical, and moral arguments surrounding this issue are too numerous and complex to discuss here. Suffice it to say, however, that the individual rights argument is increasingly appealing to the public. This is especially so among the younger generation and in the counterculture, but it is certainly not limited to these groups. Many, many old-fashioned conservative-minded persons show a deeply-rooted strain toward a philosophy of free enterprise and individualism that is hostile to public health intrusions. Old-fashioned individualism and the contemporary trend to "do your own thing," taken together, represent a powerful ingredient in current public attitudes toward public health. It would be a mistake for those concerned with public health to consider this as a transient phenomenon. On the contrary, it is very much imbedded in the cultural life of the United States. For this reason, among others, the public health movement should study and take into account this important component of public responses to public health initiatives. A related but separable theme is the concern that preventive measures may have a deleterious impact on the economy. Opposition by the corporate/industrial sector has often been effective in weakening needed health actions. To their opposition may be added the millions of workers who fear their family incomes would be jeopardized by undertakings such as anti-smoking and anti-pollution programs. The current energy problem also adds to the economic arguments to which increasing numbers subscribe as grounds for resisting large scale health promoting efforts. The economic argument is an old and familiar one. It is, nonetheless, one that should be taken quite seriously. The worsening economic trend facing millions of people may very well make them increasingly responsive to corporate foot-dragging with respect to public health measures. 912
Another theme in present day culture that is perhaps the most harmful to the public health cause is that of a burgeoning anti-intellectualism. It is, of course, not entirely new to the United States-yet its intensity and ubiquity represent a threat that should not be lightly dismissed. All the more so is this the case when one recognizes the anxieties and uncertainties provoked by the specter of atomic annihilation and environmental ruination. It is no surprise, therefore, that many of the best minds see science and technology as threats to humanity. The fact remains, however, that there is a continuing need for research concerning phenomena relevant to people's health. Without a sound basis in substantiated knowledge, public health programs are sure to encounter difficulties. Yet in the last decade or so there has been a significant diminution in the effective level of support for basic scientific research as well as social and behavioral research. This has expressed itself in the financial underpinning of research itself and, perhaps more damagingly, of the training of new researchers. Many factors have contributed to this state of affairs. Among these are: a severe downturn in the economy; an erosion of public confidence in science and technology; loss of faith in governmental agencies entrusted with the task of guiding health-related research; and decline in respect for the university system and its mission to create an disseminate knowledge. An anti-intellectual climate suffuses the entire scene. One feature of this climate is the derision of rational thought processes as tools for human progress and wellbeing. A second feature is a rising stress on emotional and extra-rational modes. Witness the resurgence of the occult and astrology along with an almost worshipful attitude toward that which is thought to be natural as opposed to that which is thought to be technological and therefore artificial. In practical terms, it is plain to see that attitudinal support is declining for the research needed to find solutions to problems that have their base in human behavior. Although social and behavioral research is no panacea, it is clearly an important element in the public health armamentarium. It is increasingly important that the public health movement understand public attitudes and emerging lifestyles as foundations for effective programs. It is encouraging, therefore, to note that examples are being set by people like Canada's Minister of Public Health and Welfare, Marc Lalonde, and the Commissioner of Public Health in Massachusetts, Jonathan E. Fielding. In a recent White Paper entitled, "A Program for Prevention,"3 the Massachusetts Department of Public Health proposes a major initiative in prevention, "'concentrating on individual actions-or lifestyles-that affect the health of the people of the Commonwealth."* Without losing sight of important large scale determinants, one can take heart that some efforts are underway to build upon and expand the social and psychological components of public health. Research exemplified by the
*For further information, see also "Health Promotion-Some Notions in Search of a Constituency," a commentary by Dr. Fielding which appears in next month's Journal. AJPH October, 1977, Vol. 67, No. 10
EDITORIALS
work of Croog and Richards should help us gain needed insight into health-related behavior and life-styles.
BERNARD M. KRAMER Address reprint requests to Professor Bernard M. Kramer, Department of Psychology, University of Massachusetts at Boston, Boston, MA 02125.
REFERENCES 1. Croog, S. H., and Richards, N. P. Health beliefs and smoking patterns ip heart patients and their wives: A longitudinal study. Am. J. Public Health 67:921-930, 1977. 2. American Cancer Society, Report of Task Force on Tobacco and Cancer. Undated (c.1976) 3. Massachusetts Department of Public Health, A Program for Preventioji. February 24, 1977. Mimeo, 87 pp.
Health Departments: Then and Now When I was growing up in Brooklyn, a telephone call to the Board of Health was the standard recourse of most of the population if the landlord didn't turn on the heat early enough in the winter. There was a comfortable assumption that the New York City Health Department was constantly concerned with everything that might affect a citizen's health, not just with cleaning up the tubercle bacilli, salmonellae, and innumerable other micro-organisms which polluted the enviroiiment. The city charter gave the Commissioner of Health enormous powers under which, for example, on February 12, 1946, the Commissioner, faced with a tugboat strike posing a dire threat to New York's vital coal supply, ordered all commercial establishments not already observing Lincoln's Birthday to close down in order to conserve fuel. The resulting Otnttetemps makes a fascinating chapter in the history of public health: Mayor O'Dwyer replaced the Health Comrfflissioner with someone lacking required public health exoerience; the Mayor's appointee resigned a week later, after rds6t4tions by the Board of Health and the New York Academy of Medicine had condemned his appointment as a menace'td the public health! Today, as society is faced with a whole new series of environmental problems, health department prestige is unfortunately at a low ebb. Some of this has to do with well motivated, and often not unfounded, criticism of the failure of many health departments to change with changing health problems. Many of these critics, frequently themselves workers in the health field, have been all too ready to announce: "the health department is dead." It is inconceivable that modern society, regardless of its form of government, should not have a government agency whose primary concern is with the health of the populace. What remains to be resolved is what agency will have what duties and responsibilities, how many agencies will be involved, and which of them will have ultimate responsibility. Comprehensive health planning councils, health systems agencies, or any other device for bringing about better coordination of health activities in the public and private sectors can be highly meaningful efforts and need support. On the other hand there can be no substitute anywhere for a unit of government with statutory responsibility for those health activities which require the power of the state to enforce. AJPH October, 1977, Vol. 67, No. 10
The striking difference between our government's approach to health in the 1970s as against the earlier decades of this century is its rejection of the concept that the health department should have basic responsibility for everything related to health in favor of limiting health department responsibility to those aspects of health not easily assignable elsewhere. An environmental protection agency includes health as one aspect of its work, and a state bureau of social seivices includes medical care as one aspect of social welfate. There is indeed a certain logic to such arrangements, but integration along one axis is always accompanied by fragmentation on another. How much dispersion of health activities can take place without serious duplication and gaps? It is important to review the reasons, logic, and process of these changes in allocating governniental health responsibilities, but the major task of the moment is to define an active, productive, and achievable role for the governtheht's health agency-whatever name it is given-at national, state, and local levels. It is a truism to the point of being a cliche that the major way to cut health care costs is to prevent disease from occurring in the first place: so-called primary prevention, whether addressed to the individual or to the envitonhieht. The type of pollution we face today may be less obviously life-threatening than was the microbiological contdtnination of earlier years, but it needs to be put into perspective and attacked just as vigorously. Secondary prevention, through early detection and treatment of disease, is obviodisly essential but it will increase rather than decrease short raiige health care costs, even as it extends life and productivity. Better organization and more effective health planning with less duplication can help contain health care costs, but eliminating them depends on the primary prevention which is a major focus of health department activities. And prevention is not without cost! The two articles by Arden Miller's group published in this issue of the Journal contribute in a significant way to the kind of direct sober factual examination that is needed for a real effort to revitalize local health services all over the country.1' 2 The monumental Emerson report "Local Health Units for the Nation"3 was published just over 30 years ago but updating is essential, both as to the best organization to 913
o e~~~~~~~~~~~~~~~~~~I
Octoer 977
akk.
Established 1911
Volume 67, Number 1 0
Behavioral Change and Public Attitudes Toward Public Health 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) George 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 Director/Managing Editor Allen J. Seeber Director of Publications Doyne Bailey Assistant Managing Editor Deborah Watkins Production Editor
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
AJPH October, 1977, Vol. 67, No. 10
Sidney H. Croog and Nancy P. Richards offer interesting data on smoking in an interesting population in their paper, entitled, Health Beliefs and Smoking Patterns in Heart Patients and their Wives. I In doing so they lead us to consider some important questions concerning our ability to promote the health of the public. The authors remind us how difficult it is to change patterns of cigarette consumption. Quite in line with dictates of common sense, men who survived heart attacks stopped smoking at a very high rate and held steady in this respect for eight or nine years depending on when they were interviewed in this longitudinal study. Their brush with death and the advice of their physicians apparently conspired to bring about behavioral change that would enhance their survival. Surprisingly, however, their wives showed no change in smoking despite the life-threatening attacks their husbands had suffered. One might have thought that such close calls would yield significant change in those so intimately touched by the experience. One is led to wonder what it would take to change people even less threatened. Yet widespread alteration of disease-producing behavior appears to be the imperative of contemporary efforts to advance the health of the people. The biggest challenge now is to crack the encrustations of personal behavior and life-style which are encouraged, in turn, by social customs in our corporate and industrial civilization. It is instructive, therefore, to examine how the United States has responded to the threat that smoking poses to the health of its people-for it exemplifies the peculiar paradox that characterizes the contemporary public health movement. Readers of this Journal are surely familiar with the basic picture. Convincing evidence has long been available to demonstrate that cigarette smoking contributes a great deal to preventable death and disability. Smokers and nonsmokers are aware of this fact and support action to reduce cigarette consumption in themselves and in the public at large. This support acts as the foundation for federal and state actions already taken to reduce smoking. And, indeed, cigarette smoking has declined since the mid- 1960s. At the same time, however, ominous signs tell us that all is not well: * A very large minority of the adult population still smokes. * The absolute number of smokers has increased. * The proportion of heavy smokers has increased among the smoking population. * Most ominously, too, smoking among teen-aged women has risen to about the same level as found among teen-aged men. Taking this into account, the American Cancer Society's Task Force on Tobacco and Cancer has placed a high priority on efforts to reduce smoking among teen-aged women.2 In sum, then, the paradox is that in spite of the available scientific information and in spite of widespread public awareness the public health movement has been unable to move beyond the incremental reductions characteristic of the 1960s and '70s. What, then, are the forces at work preventing more impressive results? In seeking the answer to this question we may be able to identify current attitudes to public 911
EDITORIALS
health that present new challenges to the public health movement. We may take it for granted that smoking, like any wellestablished habit, is extremely resistant to modification. Anyone who has been a smoker or nail-biter or over-eater can testify to that fact. But that alone is insufficient to explain a perceptibly growing opposition to public intervention on behalf of the public's health. Why, for example, have several states legalized the use of a worthless substance made from peach and apricot pits as an approach to cancer treatment? Such an outcome would have been unthinkable 20 or 30 years ago. Why did the United States Congress enact legislation restricting the use of certain accident-preventing devices on automobiles? Why has the Occupational Safety and Health Administration become a favorite whipping boy of many politicians and columnists? Why did the Food and Drug Administration become an "enemy of the people" after it proposed a ban on saccharin? Why is the counterattack on safety helmets seemingly on the road to success? And, returning to smoking, why has smoking increased among young women? One theme running through these and other examples of a rise in anti-public health sentiment is that of freedom of choice on the part of the individual. Protecting the health of the public falls into second place when it comes into conflict with the right of the individual to follow his own will. Legal, philosophical, and moral arguments surrounding this issue are too numerous and complex to discuss here. Suffice it to say, however, that the individual rights argument is increasingly appealing to the public. This is especially so among the younger generation and in the counterculture, but it is certainly not limited to these groups. Many, many old-fashioned conservative-minded persons show a deeply-rooted strain toward a philosophy of free enterprise and individualism that is hostile to public health intrusions. Old-fashioned individualism and the contemporary trend to "do your own thing," taken together, represent a powerful ingredient in current public attitudes toward public health. It would be a mistake for those concerned with public health to consider this as a transient phenomenon. On the contrary, it is very much imbedded in the cultural life of the United States. For this reason, among others, the public health movement should study and take into account this important component of public responses to public health initiatives. A related but separable theme is the concern that preventive measures may have a deleterious impact on the economy. Opposition by the corporate/industrial sector has often been effective in weakening needed health actions. To their opposition may be added the millions of workers who fear their family incomes would be jeopardized by undertakings such as anti-smoking and anti-pollution programs. The current energy problem also adds to the economic arguments to which increasing numbers subscribe as grounds for resisting large scale health promoting efforts. The economic argument is an old and familiar one. It is, nonetheless, one that should be taken quite seriously. The worsening economic trend facing millions of people may very well make them increasingly responsive to corporate foot-dragging with respect to public health measures. 912
Another theme in present day culture that is perhaps the most harmful to the public health cause is that of a burgeoning anti-intellectualism. It is, of course, not entirely new to the United States-yet its intensity and ubiquity represent a threat that should not be lightly dismissed. All the more so is this the case when one recognizes the anxieties and uncertainties provoked by the specter of atomic annihilation and environmental ruination. It is no surprise, therefore, that many of the best minds see science and technology as threats to humanity. The fact remains, however, that there is a continuing need for research concerning phenomena relevant to people's health. Without a sound basis in substantiated knowledge, public health programs are sure to encounter difficulties. Yet in the last decade or so there has been a significant diminution in the effective level of support for basic scientific research as well as social and behavioral research. This has expressed itself in the financial underpinning of research itself and, perhaps more damagingly, of the training of new researchers. Many factors have contributed to this state of affairs. Among these are: a severe downturn in the economy; an erosion of public confidence in science and technology; loss of faith in governmental agencies entrusted with the task of guiding health-related research; and decline in respect for the university system and its mission to create an disseminate knowledge. An anti-intellectual climate suffuses the entire scene. One feature of this climate is the derision of rational thought processes as tools for human progress and wellbeing. A second feature is a rising stress on emotional and extra-rational modes. Witness the resurgence of the occult and astrology along with an almost worshipful attitude toward that which is thought to be natural as opposed to that which is thought to be technological and therefore artificial. In practical terms, it is plain to see that attitudinal support is declining for the research needed to find solutions to problems that have their base in human behavior. Although social and behavioral research is no panacea, it is clearly an important element in the public health armamentarium. It is increasingly important that the public health movement understand public attitudes and emerging lifestyles as foundations for effective programs. It is encouraging, therefore, to note that examples are being set by people like Canada's Minister of Public Health and Welfare, Marc Lalonde, and the Commissioner of Public Health in Massachusetts, Jonathan E. Fielding. In a recent White Paper entitled, "A Program for Prevention,"3 the Massachusetts Department of Public Health proposes a major initiative in prevention, "'concentrating on individual actions-or lifestyles-that affect the health of the people of the Commonwealth."* Without losing sight of important large scale determinants, one can take heart that some efforts are underway to build upon and expand the social and psychological components of public health. Research exemplified by the
*For further information, see also "Health Promotion-Some Notions in Search of a Constituency," a commentary by Dr. Fielding which appears in next month's Journal. AJPH October, 1977, Vol. 67, No. 10
EDITORIALS
work of Croog and Richards should help us gain needed insight into health-related behavior and life-styles.
BERNARD M. KRAMER Address reprint requests to Professor Bernard M. Kramer, Department of Psychology, University of Massachusetts at Boston, Boston, MA 02125.
REFERENCES 1. Croog, S. H., and Richards, N. P. Health beliefs and smoking patterns ip heart patients and their wives: A longitudinal study. Am. J. Public Health 67:921-930, 1977. 2. American Cancer Society, Report of Task Force on Tobacco and Cancer. Undated (c.1976) 3. Massachusetts Department of Public Health, A Program for Preventioji. February 24, 1977. Mimeo, 87 pp.
Health Departments: Then and Now When I was growing up in Brooklyn, a telephone call to the Board of Health was the standard recourse of most of the population if the landlord didn't turn on the heat early enough in the winter. There was a comfortable assumption that the New York City Health Department was constantly concerned with everything that might affect a citizen's health, not just with cleaning up the tubercle bacilli, salmonellae, and innumerable other micro-organisms which polluted the enviroiiment. The city charter gave the Commissioner of Health enormous powers under which, for example, on February 12, 1946, the Commissioner, faced with a tugboat strike posing a dire threat to New York's vital coal supply, ordered all commercial establishments not already observing Lincoln's Birthday to close down in order to conserve fuel. The resulting Otnttetemps makes a fascinating chapter in the history of public health: Mayor O'Dwyer replaced the Health Comrfflissioner with someone lacking required public health exoerience; the Mayor's appointee resigned a week later, after rds6t4tions by the Board of Health and the New York Academy of Medicine had condemned his appointment as a menace'td the public health! Today, as society is faced with a whole new series of environmental problems, health department prestige is unfortunately at a low ebb. Some of this has to do with well motivated, and often not unfounded, criticism of the failure of many health departments to change with changing health problems. Many of these critics, frequently themselves workers in the health field, have been all too ready to announce: "the health department is dead." It is inconceivable that modern society, regardless of its form of government, should not have a government agency whose primary concern is with the health of the populace. What remains to be resolved is what agency will have what duties and responsibilities, how many agencies will be involved, and which of them will have ultimate responsibility. Comprehensive health planning councils, health systems agencies, or any other device for bringing about better coordination of health activities in the public and private sectors can be highly meaningful efforts and need support. On the other hand there can be no substitute anywhere for a unit of government with statutory responsibility for those health activities which require the power of the state to enforce. AJPH October, 1977, Vol. 67, No. 10
The striking difference between our government's approach to health in the 1970s as against the earlier decades of this century is its rejection of the concept that the health department should have basic responsibility for everything related to health in favor of limiting health department responsibility to those aspects of health not easily assignable elsewhere. An environmental protection agency includes health as one aspect of its work, and a state bureau of social seivices includes medical care as one aspect of social welfate. There is indeed a certain logic to such arrangements, but integration along one axis is always accompanied by fragmentation on another. How much dispersion of health activities can take place without serious duplication and gaps? It is important to review the reasons, logic, and process of these changes in allocating governniental health responsibilities, but the major task of the moment is to define an active, productive, and achievable role for the governtheht's health agency-whatever name it is given-at national, state, and local levels. It is a truism to the point of being a cliche that the major way to cut health care costs is to prevent disease from occurring in the first place: so-called primary prevention, whether addressed to the individual or to the envitonhieht. The type of pollution we face today may be less obviously life-threatening than was the microbiological contdtnination of earlier years, but it needs to be put into perspective and attacked just as vigorously. Secondary prevention, through early detection and treatment of disease, is obviodisly essential but it will increase rather than decrease short raiige health care costs, even as it extends life and productivity. Better organization and more effective health planning with less duplication can help contain health care costs, but eliminating them depends on the primary prevention which is a major focus of health department activities. And prevention is not without cost! The two articles by Arden Miller's group published in this issue of the Journal contribute in a significant way to the kind of direct sober factual examination that is needed for a real effort to revitalize local health services all over the country.1' 2 The monumental Emerson report "Local Health Units for the Nation"3 was published just over 30 years ago but updating is essential, both as to the best organization to 913
