Public Health Then and Now
George Rosen and the American Public Health Tradition MILTON TERRIS, MD The founder of the American Public Health Association, Dr. Stephen Smith, stated the essential features of the public health tradition in 1873 when he gave the first Presidential Address to the Association: "This science of life reveals to us the stupendous fact that man is born to health and longevity, that disease is abnormal, and death, except from old age, is accidental, and that both are preventable by human agencies." The profoundly humanist basis of Smith's public health activity is indicated in his statement at the memorial service for Dorman B. Eaton, his co-worker in the New York City health reform movement that culminated in the precedent-setting Metropolitan Health Law of 1866: "'Mr. Eaton's own thought of true fame once was expressed to me thus: 'I ask only to be remembered as one who in his sphere of life's duties endeavored to improve the conditions of human life around him'. "2 Dr. Charles V. Chapin, the remarkable health officer of Providence, Rhode Island, whose book on Sources and Modes of Infection3 revolutionized public health practice in the United States, gave eloquent testimony in 1921 to the mainsprings of public health activity: "Figures do not measure the terror of epidemics, nor the tears of the mother at her baby's grave, nor the sorrow of the widow whose helpmate has been snatched away in the prime of life. To have prevented these not once, but a million times, justifies our half century of public health work."4 Five years later, C.-E. A. Winslow ended his Presidential Address to the American Public Health Association with these words: "What we are doing here in our several ways is to build up on earth the city of God. Like the forgotten craftsmen who labored on the lotos columns of Karnak or carved the glorious doorways of Chartres, we contribute in our humble fashion toward a mighty and a lasting end. The means are prosaic-report cards and spot maps, culture tubes and vaccines, clinics and nursing visits and the results may appear only in a smaller decimal behind the death rate per thousand of the population. Yet the real fact behind AJPH February 1979, Vol. 69, No. 2
it all is the saving of men, women and children from suffering and from death; and the building into the social machinery of mankind of a technic which shall yield the same beneficent results throughout the coming years."5 George Rosen carried forward this humanist tradition during a long and uncommonly productive career. He was both practitioner and teacher of public health, spending seven years in the New York City Health Department, another seven years in the Health Insurance Plan of Greater New York, then 18 years at the School of Public Health at Columbia University. His books, A History of Public Health6 and Preventive Medicine in the United States, 1900-1975,7 are important contributions to the history of our discipline. It is, however, in the editorials that Rosen wrote during his 16 years as Editor of the American Journal of Public Health editorials that dealt with urgent current issues-that his humanism and concern for the importance of ideas were most clearly evident. The year 1957, in which Rosen was named Editor, marked the end of an era in public health in the United States. Of the giants of the public health movement, one, Joseph Mountin, had died five years earlier; he was now followed by Reginald Atwater, Haven Emerson, Henry Sigerist and C.-E. A. Winslow. These men of great learning, vision, stature and idealism were now replaced by individuals with relatively narrow views of the mission and responsibilities of public health. Rosen was a brilliant exception. During these years he welcomed and encouraged articles of breadth and vision in the Journal. His editorials were a delight: masterfully written, erudite, and expressive of a consistent humanism. Rosen devoted a number of his editorials to outstanding health workers of the past and present: John Graunt, John Snow, Joseph Lister, Jules Bordet, John Fogarty, and Alice Hamilton. Of Bordet he wrote: "Jules Bordet was more, however, than a great scientist. He had a profound awareness of the social consequences of science, and believed that 173
PUBLIC HEALTH THEN AND NOW
the scientist had a responsibility to his fellow men. He did not believe that the scientific laboratory was an ivory tower to which the man of science should retreat when issues of great public moment were being discussed. In keeping with this position Bordet joined a group of noted scientists in 1924 to warn the League of Nations of the dangers involved in the possible use of poison gas for future wars. A similar motivation led him 34 years later to join other scientists in calling for a suspension of nuclear bomb testing.'"8 In a centennial salute to Alice Hamilton, Rosen noted that "As one might expect from a woman of independent mind, Dr. Hamilton has at various times advocated causes and positions that have met with opposition. She has been an advocate of international cooperation, an opponent of war and militarism, a proponent of the rights of workers, and of rights of the individual vis-a-vis the state. These causes and actions have made up the record of a life which sets a shining example for all those who wish to improve the well-being of their fellow men and to leave the world a little better than they find it. On her centenary we salute Alice Hamilton, a gallant fighter in the continuing battle against ignorance, selfishness, and apathy to obtain a square deal for the men and women who labor to produce what society needs."9 Rosen's editorials covered almost every aspect of public health. In the environmental area, he called for prohibition of the manufacture, storage, and use of beta-naphthylamine in order to prevent bladder cancer;10 urged that "the health and welfare of people must not be subordinated to economic considerations" in dealing with radioactive wastes;" and called for "national and international agreement to restrict exposure to radiation and production of fission products until the hazards are well appraised."'12 He ended an editorial on the fluoridation controversy with these words: "Last but not least-on various ceremonial occasions we express our filial piety for our public health ancestors, but we seemingly forgot that we can also learn from them. Lemuel Shattuck, Stephen Smith, Dorman B. Eaton, and the others did not shrink from the political arena when necessary. They were not afraid to stand up and be counted, and they called a spade a spade. Certainly we can do no less today. What a particular community needs, what action it requires, must be decided locally. But public health people have a definite responsibility for leadership, for education, and to see to it that the welfare of the majority is recognized. This is the responsibility of the health officer, the sanitary engineer, the public health nurse as well as of the public health dentist. "Resolutions ... passed at annual meetings are helpful, but they become meaningful only as they are translated into action in the field. Now is the time for action."'I3 George Rosen maintained a continuing interest in the political aspects of health problems. In an editorial on "'The Politics of Public Health,"14 he pointed out that: ''"mercantilist princes, Jacobin revolutionaries, Benthamite utilitarians, and New Deal liberals have all seen that the solution of community health problems involves not alone scientific and technical knowledge, but equally and perhaps even more important-political action.... In fact, 174
throughout the development of public health the element of political action is so intimately intertwined with social organization and scientific knowledge that it is often difficult to consider the effects of each factor independently. ""No conception of the political process is adequate, however, that does not take into account the dynamic and power implications of class structure in the community. The informal power structure of the community and its significance must be as familiar to the public health worker as the formal organization of government and administrative bodies.... The political highway in the community is one that public health workers must learn to travel, despite its twistings, turnings, and ruts. Their skill in avoiding its dangers and in maste.ring its geography will no doubt be reflected in their ability to deal effectively with the health problems of the community." In the two-year period from August 1962 to August 1964, Rosen wrote four editorials on cigarette smoking. In the last, titled "The Smoke of Death,"'5 he emphasized that "'action by voluntary groups is not enough. A vigorous program of education and control by government is needed now. Rosen did not limit his editorials to specific health problems, but addressed broad issues such as poverty, unemployment, racial discrimination, population, and the environment as powerful determinants of health. He was also greatly concerned with problems of public health leadership. In an editorial on environmental health services, for example, he decried the failures of public health departments to cope with new problems, stating that ""perhaps the sense of purpose, the depth of commitment to public health as a professional field, or the taste for leadership is lacking. Perhaps preoccupation with an insistent present obscures the opportunities for the future. Perhaps precarious financial support or comfortable tradition inhibits vigorous innovation and courageous change. But it is certain that if health departments do not move to meet these challenges, others will. The needs are the needs of society and they will not in the long run be denied."16 In 1970 he noted that, "Developments in New York City are symptomatic of a more widespread trend to downgrade the complexity of community health problems, and to consider them simply as exercises in fiscal management and technical administration. The need for expertise in safeguarding the health of millions of people appears to have fallen victim to the current anti-intellectualism. Unless this trend is halted, all the fine words about improved health care will remain just that-fine words."'7 Rosen's doctoral thesis, published as a book in 1944, was concerned with "The Specialization of Medicine."''8 This concern persisted throughout his lifetime. In 1960 he argued for liberal education in public health, stating that, "If the student can be equipped with fundamental knowledge, with the skills required to put this knowledge to practical use, and if he can be helped to formulate a philosophy in terms of which the purpose and activities of his professional existence may be given meaning, then the school of public health has fulfilled its function in giving the student not only competent training but also a comprehensive education."'9 AJPH February 1979, Vol. 69, No. 2
PUBLIC HEALTH THEN AND NOW
Five years later, Rosen warned that "we must be alert to the dangers of too high a degree of specialization in the various disciplines that contribute to the practice of public health."20 Finally, in 1972, he devoted an editorial to "'Specialization in Public Health,'"2' stating that: ... it is clear that the continuing specialization of public health is one of the important factors underlying the malaise and disarray which marks it. The centrifugal tendencies inherent in specialization could be effectively controlled as long as the goals of public health were clearly envisaged within an accepted program, and an institutional form was available to encompass the diversity of knowledge and professional identity which emerged with the expansion of public health in the earlier decades of this century. Essentially, this involved the control of bacterial pollution in the environment, the prevention of communicable diseases and conditions produced by defective nutrition, and the achievement of these aims through an official health agency, a local or a state health department, complemented in various ways by voluntary health agencies. "'The achievement of these aims to a considerable extent, the emergence of newer health problems, and the consequent change in the scope and focus of public health disrupted the previously existing situation, and left the various groups of public health workers without a generally accepted integrated program or an institutional structure through which it might be put into practice. In this situation centrifugal tendencies of special groups have led to a multiplication of agencies concerned with health problems. Fragmentation which appeared earlier in clinical medicine as a consequence of specialization is now fully apparent in public health." To deal with this problem, Rosen urged "the creation of an institutional structure to take the place of the older official health agency." He believed that "The need is to establish an integrated system of comprehensive health services based on local administrative units tied together by an overall strategic plan and guidelines on its implementation.' '21 George Rosen's concern with the need for effective public health organization is nowhere more apparent than in his short but incisive editorial on federal reorganization. He noted that "Reorganization of the federal health services has been going on continuously for a number of years. Task forces and reexaminations have followed and continue to follow one another until one is reminded of a parade of circus elephants tail-to-trunk. There has been no discernible pause in this churninig nor have time and effort been spent to test any pattern of administration . . . uncertainty prevails to such a degree that the accomplishment of any useful work is a minor miracle.' '22 He wrote extensively on the medical care aspects of public health, including papers on medical care and social policy in 17th century England,23 on hospitals, medical care and social policy in the French Revolution,24 and on the historical sociology of the hospital as a community institution.25 His discussion of "The Efficiency Criterion in Medical Care, 1900-1920'"26 gives a fascinating vignette of the growth and deficiencies of dispensaries in the United States. In a thoughtful review of the rise and fall of the first neighborhood health center movement,27 he raised the question: AJPH February 1979, Vol. 69, No. 2
... should neighborhood centers remain purely local, or should they become part of a larger system of health care toward which we appear to be moving?" His concept of medical care went far beyond current practice. In describing his experience as Director of the Division of Health Education and Preventive Services of the Health Insurance Plan of Greater New York, he emphasized that "No medical care plan can be considered comprehensive unless it includes preventive and educational services ... The integration of these services into organized medical care offers an opportunity and a challenge. It offers an opportunity to achieve the long overdue realization of a goal which has been honored chiefly through lip service, namely, the promotion of health and the prevention of disease at the source, among those who are apparently well. It is a challenge, because the achievement of this goal will not be easy ... To be sure, there will be opposition. There are always some among us who move into the future looking backward 28 nostalgically . George Rosen never succumbed to the occupational disease of many academicians-the tendency to become divorced from reality. His thinking occurred at a high theoretical level, and at the same time was anchored in the hard facts of economic and social life. As a scholar and a realist, he had the prescience to challenge the conventional wisdom on national health insurance. In 1969, when Walter Reuther and the Committee for National Health Insurance announced the plan that was later to become the Kennedy-Corman bill, Rosen responded with an editorial in which he pointed out that "the adoption of a national health insurance system is long overdue."29 But, he asked: ' . . . even if the United States embarks on such a program, is it enough? How far will it help to deal with the crisis in health care which we confront? . . . The basic fact is that scientific knowledge and complex technology have created a situation where the economic, social, and political mechanisms upon which we have depended for the distribution of health services are no longer adequate. At present as in the past we still endeavor to adjust these changes and the relations between demand, supply, and cost through a market mechanism. This applies to hospitals, voluntary health insurance, private practitioners, drugs, and a variety of health goods and services. The unplanned, helter-skelter relationship among these elements has thus far not been altered by voluntary health insurance, Medicare, or 'comprehensive' health planning. "One must therefore ask what a national health insurance system will accomplish in relation to this broader problem. If a national health insurance plan is to come into being, and if it is to be effective in providing health care, it cannot be just another autonomous element on the health services scene. We have seen in the case of Medicare what happens when this is the case. If such a program is to be truly effective, it must be part of a larger and more comprehensive program, in short, of a national health policy to be set at the highest levels of government, as we now do for economic policy. This might also be related to comprehensive health planning in a meaningful way. In the establishment of a national health policy, health insurance would have to be re.
.
175
PUBLIC HEALTH THEN AND NOW
lated to demographic factors, the problem of health manpower, the equitable and rational distribution of health service, economic factors, and many others. "By all means let us have national health insurance, but let us also be clear that it is not enough if it remains isolated. Let us remember that it can be only one step, even though an important one, toward the goal of adequate health services for all Americans. To paraphrase Galileo, it does move, but we still have a long way to go.'"29 The retrogression in public health and medical care in the past 10 years underscores George Rosen's comment that "it does move, but we still have a long way to go." Rosen was realistic but not downhearted; he had an unquenchable zest for learning and for life, unbounded energy and enthusiasm, a buoyant optimism, and a deep commitment to the scientific and humanist traditions of the public health movement. Such men are rare, and difficult to replace. We are honored to have known George Rosen.
REFERENCES 1. Public Health Reports and Papers Presented at the Meetings of the American Public Health Association in the year 1873. Hurd and Houghton, Riverside Press, New York, 1874. 2. Smith S: The City That Was. Metuchen, NJ: Scarecrow Reprint Corp., 1973. 3. Chapin CV: Sources and Modes of Infection. New York: John Wiley & Sons, Second Edition, 1916. 4. Ravenel MP (Editor): A Half Century of Public Health: Jubilee Historical Volume of the American Public Health Assn. New York: Am. Pub. Health Assn., 1921. 5. Winslow C-EA: Public health at the crossroads. Am J Public Health 16:1075-1085, 1926. 6. Rosen G: A History of Public Health. New York: MD Publications, 1958. _: Preventive Medicine in the United States, 1900-1975. 7. _ New York: Science History Publications, 1975. 8. __: (Editorial) Jules Bordet (1870-1961). Am J Public Health 52:311-312, 1962.
9. __: (Editorial) A centennial salute to Alice Hamilton. Am J Public Health 59:205-206, 1969. 10. _ (Editorial) Beta-Naphthylamine. Am J Public Health 52:500, 1962. : (Editorial) Issues and needs in radioactive waste dis11. posal. Am J Public Health 62:129-130, 1972. 12. __: (Editorial) Pride goeth... . Am J Public Health 49:803804, 1959. 13. __: (Editorial) Fluoridation: The case for action. Am J Public Health 51:598-599, 1961. 14. __: (Editorial) The politics of public health. Am J Public Health 49:364-365, 1959. 15. __: (Editorial) The smoke of death. Am J Public Health 54:1330-1331, 1964. 16. __: (Editorial) Environmental health services-yesterday, today, tomorrow. Am J Public Health 53:1453-1454, 1963. 17. __: (Editorial) The health administrator-expert or amateur? Am J Public Health 60:225-227, 1970. : The Specialization of Medicine. New York: Froben 18. Press, 1944. 19. __: (Editorial) Liberal education and public health. Am J Public Health 50:1589-1590, 1960. 20. __: (Editorial) Science, values, and public issues. Am J Public Health 55:1508-1510, 1965. 21. __: (Editorial) Specialization in public Health. Am J Public Health 62:624-625, 1972. : (Editorial) Reorganization-an administrative means, 22. not an end. Am J Public Health 59:899, 1969. 23. __: Medical Care and Social Policy in Seventeenth Century England. Bull. N.Y. Acad. Med. 29 (2nd ser.): 420-437, 1953. 24. __: Hospitals, Medical Care and Social Policy in the French Revolution. Bull Hist. Med. 30:124-149, 1956. _: The Hospital: Historical Sociology of a Community In25. stitution. In Freidson, E. (Editor), The Hospital in Modern Society. New York: Macmillan, 1963, pp. 1-36. : The Efficiency Criterion in Medical Care, 1900-1920. 26. Bull. Hist. Med. 50:28-44, 1976. 27. _____: The first neighborhood health center movement-its rise and fall. Am J Public Health 61:1620-1637, 1971. 28. __: Health education and preventive medicine-new horizons in medical care. Am J Public Health 42:687-693, 1952. 29. __: (Editorial) National health insurance-yes. but is it enough? Am J Public Health 59:1977-1978, 1969.
Address reprint requests to Dr. Milton Terris, Professor and Chairman, Department of Community and Preventive Medicine, New York Medical College, 5th Avenue at 106th Street, New York, NY 10029.
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AJPH February 1979, Vol. 69, No. 2
George Rosen and the American Public Health Tradition MILTON TERRIS, MD The founder of the American Public Health Association, Dr. Stephen Smith, stated the essential features of the public health tradition in 1873 when he gave the first Presidential Address to the Association: "This science of life reveals to us the stupendous fact that man is born to health and longevity, that disease is abnormal, and death, except from old age, is accidental, and that both are preventable by human agencies." The profoundly humanist basis of Smith's public health activity is indicated in his statement at the memorial service for Dorman B. Eaton, his co-worker in the New York City health reform movement that culminated in the precedent-setting Metropolitan Health Law of 1866: "'Mr. Eaton's own thought of true fame once was expressed to me thus: 'I ask only to be remembered as one who in his sphere of life's duties endeavored to improve the conditions of human life around him'. "2 Dr. Charles V. Chapin, the remarkable health officer of Providence, Rhode Island, whose book on Sources and Modes of Infection3 revolutionized public health practice in the United States, gave eloquent testimony in 1921 to the mainsprings of public health activity: "Figures do not measure the terror of epidemics, nor the tears of the mother at her baby's grave, nor the sorrow of the widow whose helpmate has been snatched away in the prime of life. To have prevented these not once, but a million times, justifies our half century of public health work."4 Five years later, C.-E. A. Winslow ended his Presidential Address to the American Public Health Association with these words: "What we are doing here in our several ways is to build up on earth the city of God. Like the forgotten craftsmen who labored on the lotos columns of Karnak or carved the glorious doorways of Chartres, we contribute in our humble fashion toward a mighty and a lasting end. The means are prosaic-report cards and spot maps, culture tubes and vaccines, clinics and nursing visits and the results may appear only in a smaller decimal behind the death rate per thousand of the population. Yet the real fact behind AJPH February 1979, Vol. 69, No. 2
it all is the saving of men, women and children from suffering and from death; and the building into the social machinery of mankind of a technic which shall yield the same beneficent results throughout the coming years."5 George Rosen carried forward this humanist tradition during a long and uncommonly productive career. He was both practitioner and teacher of public health, spending seven years in the New York City Health Department, another seven years in the Health Insurance Plan of Greater New York, then 18 years at the School of Public Health at Columbia University. His books, A History of Public Health6 and Preventive Medicine in the United States, 1900-1975,7 are important contributions to the history of our discipline. It is, however, in the editorials that Rosen wrote during his 16 years as Editor of the American Journal of Public Health editorials that dealt with urgent current issues-that his humanism and concern for the importance of ideas were most clearly evident. The year 1957, in which Rosen was named Editor, marked the end of an era in public health in the United States. Of the giants of the public health movement, one, Joseph Mountin, had died five years earlier; he was now followed by Reginald Atwater, Haven Emerson, Henry Sigerist and C.-E. A. Winslow. These men of great learning, vision, stature and idealism were now replaced by individuals with relatively narrow views of the mission and responsibilities of public health. Rosen was a brilliant exception. During these years he welcomed and encouraged articles of breadth and vision in the Journal. His editorials were a delight: masterfully written, erudite, and expressive of a consistent humanism. Rosen devoted a number of his editorials to outstanding health workers of the past and present: John Graunt, John Snow, Joseph Lister, Jules Bordet, John Fogarty, and Alice Hamilton. Of Bordet he wrote: "Jules Bordet was more, however, than a great scientist. He had a profound awareness of the social consequences of science, and believed that 173
PUBLIC HEALTH THEN AND NOW
the scientist had a responsibility to his fellow men. He did not believe that the scientific laboratory was an ivory tower to which the man of science should retreat when issues of great public moment were being discussed. In keeping with this position Bordet joined a group of noted scientists in 1924 to warn the League of Nations of the dangers involved in the possible use of poison gas for future wars. A similar motivation led him 34 years later to join other scientists in calling for a suspension of nuclear bomb testing.'"8 In a centennial salute to Alice Hamilton, Rosen noted that "As one might expect from a woman of independent mind, Dr. Hamilton has at various times advocated causes and positions that have met with opposition. She has been an advocate of international cooperation, an opponent of war and militarism, a proponent of the rights of workers, and of rights of the individual vis-a-vis the state. These causes and actions have made up the record of a life which sets a shining example for all those who wish to improve the well-being of their fellow men and to leave the world a little better than they find it. On her centenary we salute Alice Hamilton, a gallant fighter in the continuing battle against ignorance, selfishness, and apathy to obtain a square deal for the men and women who labor to produce what society needs."9 Rosen's editorials covered almost every aspect of public health. In the environmental area, he called for prohibition of the manufacture, storage, and use of beta-naphthylamine in order to prevent bladder cancer;10 urged that "the health and welfare of people must not be subordinated to economic considerations" in dealing with radioactive wastes;" and called for "national and international agreement to restrict exposure to radiation and production of fission products until the hazards are well appraised."'12 He ended an editorial on the fluoridation controversy with these words: "Last but not least-on various ceremonial occasions we express our filial piety for our public health ancestors, but we seemingly forgot that we can also learn from them. Lemuel Shattuck, Stephen Smith, Dorman B. Eaton, and the others did not shrink from the political arena when necessary. They were not afraid to stand up and be counted, and they called a spade a spade. Certainly we can do no less today. What a particular community needs, what action it requires, must be decided locally. But public health people have a definite responsibility for leadership, for education, and to see to it that the welfare of the majority is recognized. This is the responsibility of the health officer, the sanitary engineer, the public health nurse as well as of the public health dentist. "Resolutions ... passed at annual meetings are helpful, but they become meaningful only as they are translated into action in the field. Now is the time for action."'I3 George Rosen maintained a continuing interest in the political aspects of health problems. In an editorial on "'The Politics of Public Health,"14 he pointed out that: ''"mercantilist princes, Jacobin revolutionaries, Benthamite utilitarians, and New Deal liberals have all seen that the solution of community health problems involves not alone scientific and technical knowledge, but equally and perhaps even more important-political action.... In fact, 174
throughout the development of public health the element of political action is so intimately intertwined with social organization and scientific knowledge that it is often difficult to consider the effects of each factor independently. ""No conception of the political process is adequate, however, that does not take into account the dynamic and power implications of class structure in the community. The informal power structure of the community and its significance must be as familiar to the public health worker as the formal organization of government and administrative bodies.... The political highway in the community is one that public health workers must learn to travel, despite its twistings, turnings, and ruts. Their skill in avoiding its dangers and in maste.ring its geography will no doubt be reflected in their ability to deal effectively with the health problems of the community." In the two-year period from August 1962 to August 1964, Rosen wrote four editorials on cigarette smoking. In the last, titled "The Smoke of Death,"'5 he emphasized that "'action by voluntary groups is not enough. A vigorous program of education and control by government is needed now. Rosen did not limit his editorials to specific health problems, but addressed broad issues such as poverty, unemployment, racial discrimination, population, and the environment as powerful determinants of health. He was also greatly concerned with problems of public health leadership. In an editorial on environmental health services, for example, he decried the failures of public health departments to cope with new problems, stating that ""perhaps the sense of purpose, the depth of commitment to public health as a professional field, or the taste for leadership is lacking. Perhaps preoccupation with an insistent present obscures the opportunities for the future. Perhaps precarious financial support or comfortable tradition inhibits vigorous innovation and courageous change. But it is certain that if health departments do not move to meet these challenges, others will. The needs are the needs of society and they will not in the long run be denied."16 In 1970 he noted that, "Developments in New York City are symptomatic of a more widespread trend to downgrade the complexity of community health problems, and to consider them simply as exercises in fiscal management and technical administration. The need for expertise in safeguarding the health of millions of people appears to have fallen victim to the current anti-intellectualism. Unless this trend is halted, all the fine words about improved health care will remain just that-fine words."'7 Rosen's doctoral thesis, published as a book in 1944, was concerned with "The Specialization of Medicine."''8 This concern persisted throughout his lifetime. In 1960 he argued for liberal education in public health, stating that, "If the student can be equipped with fundamental knowledge, with the skills required to put this knowledge to practical use, and if he can be helped to formulate a philosophy in terms of which the purpose and activities of his professional existence may be given meaning, then the school of public health has fulfilled its function in giving the student not only competent training but also a comprehensive education."'9 AJPH February 1979, Vol. 69, No. 2
PUBLIC HEALTH THEN AND NOW
Five years later, Rosen warned that "we must be alert to the dangers of too high a degree of specialization in the various disciplines that contribute to the practice of public health."20 Finally, in 1972, he devoted an editorial to "'Specialization in Public Health,'"2' stating that: ... it is clear that the continuing specialization of public health is one of the important factors underlying the malaise and disarray which marks it. The centrifugal tendencies inherent in specialization could be effectively controlled as long as the goals of public health were clearly envisaged within an accepted program, and an institutional form was available to encompass the diversity of knowledge and professional identity which emerged with the expansion of public health in the earlier decades of this century. Essentially, this involved the control of bacterial pollution in the environment, the prevention of communicable diseases and conditions produced by defective nutrition, and the achievement of these aims through an official health agency, a local or a state health department, complemented in various ways by voluntary health agencies. "'The achievement of these aims to a considerable extent, the emergence of newer health problems, and the consequent change in the scope and focus of public health disrupted the previously existing situation, and left the various groups of public health workers without a generally accepted integrated program or an institutional structure through which it might be put into practice. In this situation centrifugal tendencies of special groups have led to a multiplication of agencies concerned with health problems. Fragmentation which appeared earlier in clinical medicine as a consequence of specialization is now fully apparent in public health." To deal with this problem, Rosen urged "the creation of an institutional structure to take the place of the older official health agency." He believed that "The need is to establish an integrated system of comprehensive health services based on local administrative units tied together by an overall strategic plan and guidelines on its implementation.' '21 George Rosen's concern with the need for effective public health organization is nowhere more apparent than in his short but incisive editorial on federal reorganization. He noted that "Reorganization of the federal health services has been going on continuously for a number of years. Task forces and reexaminations have followed and continue to follow one another until one is reminded of a parade of circus elephants tail-to-trunk. There has been no discernible pause in this churninig nor have time and effort been spent to test any pattern of administration . . . uncertainty prevails to such a degree that the accomplishment of any useful work is a minor miracle.' '22 He wrote extensively on the medical care aspects of public health, including papers on medical care and social policy in 17th century England,23 on hospitals, medical care and social policy in the French Revolution,24 and on the historical sociology of the hospital as a community institution.25 His discussion of "The Efficiency Criterion in Medical Care, 1900-1920'"26 gives a fascinating vignette of the growth and deficiencies of dispensaries in the United States. In a thoughtful review of the rise and fall of the first neighborhood health center movement,27 he raised the question: AJPH February 1979, Vol. 69, No. 2
... should neighborhood centers remain purely local, or should they become part of a larger system of health care toward which we appear to be moving?" His concept of medical care went far beyond current practice. In describing his experience as Director of the Division of Health Education and Preventive Services of the Health Insurance Plan of Greater New York, he emphasized that "No medical care plan can be considered comprehensive unless it includes preventive and educational services ... The integration of these services into organized medical care offers an opportunity and a challenge. It offers an opportunity to achieve the long overdue realization of a goal which has been honored chiefly through lip service, namely, the promotion of health and the prevention of disease at the source, among those who are apparently well. It is a challenge, because the achievement of this goal will not be easy ... To be sure, there will be opposition. There are always some among us who move into the future looking backward 28 nostalgically . George Rosen never succumbed to the occupational disease of many academicians-the tendency to become divorced from reality. His thinking occurred at a high theoretical level, and at the same time was anchored in the hard facts of economic and social life. As a scholar and a realist, he had the prescience to challenge the conventional wisdom on national health insurance. In 1969, when Walter Reuther and the Committee for National Health Insurance announced the plan that was later to become the Kennedy-Corman bill, Rosen responded with an editorial in which he pointed out that "the adoption of a national health insurance system is long overdue."29 But, he asked: ' . . . even if the United States embarks on such a program, is it enough? How far will it help to deal with the crisis in health care which we confront? . . . The basic fact is that scientific knowledge and complex technology have created a situation where the economic, social, and political mechanisms upon which we have depended for the distribution of health services are no longer adequate. At present as in the past we still endeavor to adjust these changes and the relations between demand, supply, and cost through a market mechanism. This applies to hospitals, voluntary health insurance, private practitioners, drugs, and a variety of health goods and services. The unplanned, helter-skelter relationship among these elements has thus far not been altered by voluntary health insurance, Medicare, or 'comprehensive' health planning. "One must therefore ask what a national health insurance system will accomplish in relation to this broader problem. If a national health insurance plan is to come into being, and if it is to be effective in providing health care, it cannot be just another autonomous element on the health services scene. We have seen in the case of Medicare what happens when this is the case. If such a program is to be truly effective, it must be part of a larger and more comprehensive program, in short, of a national health policy to be set at the highest levels of government, as we now do for economic policy. This might also be related to comprehensive health planning in a meaningful way. In the establishment of a national health policy, health insurance would have to be re.
.
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lated to demographic factors, the problem of health manpower, the equitable and rational distribution of health service, economic factors, and many others. "By all means let us have national health insurance, but let us also be clear that it is not enough if it remains isolated. Let us remember that it can be only one step, even though an important one, toward the goal of adequate health services for all Americans. To paraphrase Galileo, it does move, but we still have a long way to go.'"29 The retrogression in public health and medical care in the past 10 years underscores George Rosen's comment that "it does move, but we still have a long way to go." Rosen was realistic but not downhearted; he had an unquenchable zest for learning and for life, unbounded energy and enthusiasm, a buoyant optimism, and a deep commitment to the scientific and humanist traditions of the public health movement. Such men are rare, and difficult to replace. We are honored to have known George Rosen.
REFERENCES 1. Public Health Reports and Papers Presented at the Meetings of the American Public Health Association in the year 1873. Hurd and Houghton, Riverside Press, New York, 1874. 2. Smith S: The City That Was. Metuchen, NJ: Scarecrow Reprint Corp., 1973. 3. Chapin CV: Sources and Modes of Infection. New York: John Wiley & Sons, Second Edition, 1916. 4. Ravenel MP (Editor): A Half Century of Public Health: Jubilee Historical Volume of the American Public Health Assn. New York: Am. Pub. Health Assn., 1921. 5. Winslow C-EA: Public health at the crossroads. Am J Public Health 16:1075-1085, 1926. 6. Rosen G: A History of Public Health. New York: MD Publications, 1958. _: Preventive Medicine in the United States, 1900-1975. 7. _ New York: Science History Publications, 1975. 8. __: (Editorial) Jules Bordet (1870-1961). Am J Public Health 52:311-312, 1962.
9. __: (Editorial) A centennial salute to Alice Hamilton. Am J Public Health 59:205-206, 1969. 10. _ (Editorial) Beta-Naphthylamine. Am J Public Health 52:500, 1962. : (Editorial) Issues and needs in radioactive waste dis11. posal. Am J Public Health 62:129-130, 1972. 12. __: (Editorial) Pride goeth... . Am J Public Health 49:803804, 1959. 13. __: (Editorial) Fluoridation: The case for action. Am J Public Health 51:598-599, 1961. 14. __: (Editorial) The politics of public health. Am J Public Health 49:364-365, 1959. 15. __: (Editorial) The smoke of death. Am J Public Health 54:1330-1331, 1964. 16. __: (Editorial) Environmental health services-yesterday, today, tomorrow. Am J Public Health 53:1453-1454, 1963. 17. __: (Editorial) The health administrator-expert or amateur? Am J Public Health 60:225-227, 1970. : The Specialization of Medicine. New York: Froben 18. Press, 1944. 19. __: (Editorial) Liberal education and public health. Am J Public Health 50:1589-1590, 1960. 20. __: (Editorial) Science, values, and public issues. Am J Public Health 55:1508-1510, 1965. 21. __: (Editorial) Specialization in public Health. Am J Public Health 62:624-625, 1972. : (Editorial) Reorganization-an administrative means, 22. not an end. Am J Public Health 59:899, 1969. 23. __: Medical Care and Social Policy in Seventeenth Century England. Bull. N.Y. Acad. Med. 29 (2nd ser.): 420-437, 1953. 24. __: Hospitals, Medical Care and Social Policy in the French Revolution. Bull Hist. Med. 30:124-149, 1956. _: The Hospital: Historical Sociology of a Community In25. stitution. In Freidson, E. (Editor), The Hospital in Modern Society. New York: Macmillan, 1963, pp. 1-36. : The Efficiency Criterion in Medical Care, 1900-1920. 26. Bull. Hist. Med. 50:28-44, 1976. 27. _____: The first neighborhood health center movement-its rise and fall. Am J Public Health 61:1620-1637, 1971. 28. __: Health education and preventive medicine-new horizons in medical care. Am J Public Health 42:687-693, 1952. 29. __: (Editorial) National health insurance-yes. but is it enough? Am J Public Health 59:1977-1978, 1969.
Address reprint requests to Dr. Milton Terris, Professor and Chairman, Department of Community and Preventive Medicine, New York Medical College, 5th Avenue at 106th Street, New York, NY 10029.
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