U
U
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A~~~
ARE SOME PUBLIC HEALTH PROBLEMS MORE EQUAL THAN OTHERS? In mid-September I attended a meeting on a topic which I feel has public health implications that are vitally important to this Journal's readers. The meeting-a briefing about air bags-was held in a dark, high-domed old room behind the United States Senate chambers. Senate staff members convened it to hear views on whether Congress should pass pending legislation, the effect of which would be to outlaw or to delay greatly the introduction of standard equipment air bags for sears to come. By the time these comments appear, the matter will probably have been decided-Congress will have voted for or against the far better protection of human beings in car crashes. And it will have done so without the involvement or even visible concern of the public health community. I wonder whv. The work of the organization that I am with is concerned with reducing highway death and injury through research into crash loss causes and countermeasures and dissemination of the results. I have always thought that our task involved a central, very large piece of the public health field. After all, isn't the purpose of public health work to reduce needless human wastage? What difference is there between the human losses produced when adults and children are denied the most effective available protection from the hazards of contaminated air and water and milk and food, and the losses in damaged people that occur when they are denied the most effective available protection from the hazards of being smashed to death against an A-pillar or a dashboard in a car crash? Moreover, the amount of avoidable human wastage and associated social cost produced in highway crashes is stupendously large even in the context of all other national public health problems and needs-an average of 13,000 crash casualties a day in the U.S. alone. Yet at that air bag meeting, Io one showed up from the organized public health field. No one was there to put public health workers on record as opposing legislative attempts to outlaw passive, universal crash protection for car occupants-a step akin to outlawing required pasteurizatioIn of milk, purification of drinking water, and control of vehicle emissions. No one from the public health field was there even to hear the statements of people wh}o did show up-statements revealing, for instance, that air bags need cost only about half the amount claimed by the auto industrv; that General Mlotors was demonstrating the effectiveness of passive restraint air bags in internal testing conducted as long ago as 1958: and that standard equipment air bags on all cars would annually keep 182
AJPH FEBRUARY, 1975, Vol. 65, No. 2
thousands of crash occupants out of the morgue and millions out of the hospitals. The issue, however, is not just air bags. In the dozens of highway and motor vehicle safety hearings that Congress has held in the past decade, the scores of legislative debates that have involved life-and-death highway loss matters. the hundreds of Department of Transportation rulemaking cases oIn which the future of critically needed safety standards was hanging, rarely can I recall seeing the voice, hand, eye, or ear of organized public health. This meeting was no different except that it catalNzed me, for better or worse, into writing these observations. Strangely, the organized public healthl field acts as if the death and injury produced in highway crashes were somehow less important that the death and injury produced by other environmental hazards. It has yet to accept its obligation to be concerned withl all public health problems. including this one. Albert Benjamin Kelley Insurance Institute for Highway Safety Washington, DC
PHYSICIANS AND THE PRESSURES OF INDUSTRIALIZATION Physicians working in the Anmerican health care system are currently being exposed to intense nonsystem or pressure. The stress comes from many sources-governmentally instituted programs such as Medicare. PSRO, HMO, and fee constraints are the most prominent sources of stress: consumerism serves as a second source: further stress occurs as a result of peer review and periodic recertification programs. Physicians are forced to actively relate to divergent factors which are having a progressively increasing influence upon the character of health care in America. This complex matrix for chanige is difficult for the physician to understand, much less wNork with. As a result of these intense and persistent forces and the confusion which thev have created, a sense of tensioin and conflict exists for many physicians. The objectives of this essay are, first, to describe one important source of the conflict and to discuss the factors whiclh contribute to the tensioIn which surrounds this source of conflict, and second, to demonstrate how this subliminal conflict complicates the development of a unified healthl care delivery s-stem in the United States. Private medical practice represents one of the last opportunities for true independent achievement in the United States. Physicians have been able to function as individual units of production with their productivity being
U
-
A~~~
ARE SOME PUBLIC HEALTH PROBLEMS MORE EQUAL THAN OTHERS? In mid-September I attended a meeting on a topic which I feel has public health implications that are vitally important to this Journal's readers. The meeting-a briefing about air bags-was held in a dark, high-domed old room behind the United States Senate chambers. Senate staff members convened it to hear views on whether Congress should pass pending legislation, the effect of which would be to outlaw or to delay greatly the introduction of standard equipment air bags for sears to come. By the time these comments appear, the matter will probably have been decided-Congress will have voted for or against the far better protection of human beings in car crashes. And it will have done so without the involvement or even visible concern of the public health community. I wonder whv. The work of the organization that I am with is concerned with reducing highway death and injury through research into crash loss causes and countermeasures and dissemination of the results. I have always thought that our task involved a central, very large piece of the public health field. After all, isn't the purpose of public health work to reduce needless human wastage? What difference is there between the human losses produced when adults and children are denied the most effective available protection from the hazards of contaminated air and water and milk and food, and the losses in damaged people that occur when they are denied the most effective available protection from the hazards of being smashed to death against an A-pillar or a dashboard in a car crash? Moreover, the amount of avoidable human wastage and associated social cost produced in highway crashes is stupendously large even in the context of all other national public health problems and needs-an average of 13,000 crash casualties a day in the U.S. alone. Yet at that air bag meeting, Io one showed up from the organized public health field. No one was there to put public health workers on record as opposing legislative attempts to outlaw passive, universal crash protection for car occupants-a step akin to outlawing required pasteurizatioIn of milk, purification of drinking water, and control of vehicle emissions. No one from the public health field was there even to hear the statements of people wh}o did show up-statements revealing, for instance, that air bags need cost only about half the amount claimed by the auto industrv; that General Mlotors was demonstrating the effectiveness of passive restraint air bags in internal testing conducted as long ago as 1958: and that standard equipment air bags on all cars would annually keep 182
AJPH FEBRUARY, 1975, Vol. 65, No. 2
thousands of crash occupants out of the morgue and millions out of the hospitals. The issue, however, is not just air bags. In the dozens of highway and motor vehicle safety hearings that Congress has held in the past decade, the scores of legislative debates that have involved life-and-death highway loss matters. the hundreds of Department of Transportation rulemaking cases oIn which the future of critically needed safety standards was hanging, rarely can I recall seeing the voice, hand, eye, or ear of organized public health. This meeting was no different except that it catalNzed me, for better or worse, into writing these observations. Strangely, the organized public healthl field acts as if the death and injury produced in highway crashes were somehow less important that the death and injury produced by other environmental hazards. It has yet to accept its obligation to be concerned withl all public health problems. including this one. Albert Benjamin Kelley Insurance Institute for Highway Safety Washington, DC
PHYSICIANS AND THE PRESSURES OF INDUSTRIALIZATION Physicians working in the Anmerican health care system are currently being exposed to intense nonsystem or pressure. The stress comes from many sources-governmentally instituted programs such as Medicare. PSRO, HMO, and fee constraints are the most prominent sources of stress: consumerism serves as a second source: further stress occurs as a result of peer review and periodic recertification programs. Physicians are forced to actively relate to divergent factors which are having a progressively increasing influence upon the character of health care in America. This complex matrix for chanige is difficult for the physician to understand, much less wNork with. As a result of these intense and persistent forces and the confusion which thev have created, a sense of tensioin and conflict exists for many physicians. The objectives of this essay are, first, to describe one important source of the conflict and to discuss the factors whiclh contribute to the tensioIn which surrounds this source of conflict, and second, to demonstrate how this subliminal conflict complicates the development of a unified healthl care delivery s-stem in the United States. Private medical practice represents one of the last opportunities for true independent achievement in the United States. Physicians have been able to function as individual units of production with their productivity being
