Association News PICKETT ASSUMES APHA PRESIDENCY; ELLIS NAMED PRESIDENT-ELECT George E. Pickett, MD, MPH, was installed as President of the American Public Health Association on October 21, 1976 at the close of the Association's 104th Annual Meeting, held in Miami Beach, Florida. Dr. Pickett is Director of the San Mateo County (California) Department of Public Health and Welfare, a position he has held since 1970. As APHA President, Pjckett pledged to _ lead the natiof's health professionals and consumers in an effort to explore and develop a national health service as a S possible alternative to national health insurance. Pickett inPICKETT dicated that one of his major goals for APHA during his presidency is to attempt to define the alternatives the nation faces in personal health services. Those alternatives, Pickett said, "are to either declare health care to be a privilege-which is what we have made it-or to declare it to be a right-which we've never done nationally, and to face the alternatives of assuring that right." He also said that the traditional form of practice in the United States has not produced what is needed at a reasonable cost to consumers, and that the most feasible alternative is public ownership of the health system. Dr. Pickett is past vice-chairman of the Health Administration Section of APHA, a fellow of the Association, has served on the Program Area Committee for Environmental Health, and has been a member of the Executive Board since 1970-71. Prior to his current position in San Mateo County, he was Deputy Director, Wayne County (Michigan) Health Department in 1967, and Director of the Detroit and Wayne County Health Departments in 1968. Dr. Pickett received his bachelor's degree from Harvard University, his MD from McGill University, and his MPH from the University of Michigan. He is a diplomate of the American Board of Preventive Medicine, a fellow of the American College of Preventive Medicine, and a member of the American Medical Association. He also served on the Board of Trustees of the U.S. Conference of City Health Officers in 1969-1970. AJPH January, 1977, Vol. 67, No. 1

E. Frank Ellis, MD, MPH, was chosen President-Elect of APHA by the Governing Council on October 20, 1976. Dr. Ellis, the second black physician to be named to head the 104-year-old, 50,000 member organization, will assume the presidency following the Association's Annual Meeting in Washington, DC next fall. Dr. Ellis, a past Speaker of the Governing Council and a member of the Medical Care Section, is Regional Health Administrator,

Region

V,

of

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the Department of Health, Education, and Welfare. He has been a member of APHA since 1967 and has served on ELLIS the Action Board and the Council on Education for Public Health. He was also first president of the Black Caucus of Health Workers. Ellis received his medical degree from Meharry Medical College and his public health degree from the University of Michigan School of Public Health, where he served as president of the School's board of governors. He has held faculty appointments at the University of Missouri School of Medicine and Case-Western Reserve University's College of Medicine, and is currently a visiting lecturer at Northwestern University's School of Community Medicine. Beginning his career in Missouri as hospital administrator of the Kansas City General Hospital, Ellis later headed the Cleveland (Ohio) Department of Public Health and Welfare. As administrator of one of HEW's largest regions, Dr. Ellis currently directs all of the decentralized programs in the U.S. Public Health Service. Serving some 45 million people, his office administers federal health programs in Illinois, Indiana, Michigan, Minnesota, Wisconsin, and Ohio. Asked what direction he believes APHA should target its efforts in coming years, Dr. Ellis stressed the need for the Association to "continue its aggressive stance in health since the health care industry has already demonstrated its need for a broader range of expertise. Economists, marketing professionals, legal experts, planners, and others," he said, "need to be embodied under the rubric of APHA, where all disciplines can gather, to improve the health care system." 63

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In discussing current issues, Dr. Ellis said that a high priority should be increasing APHA's membership, which would allow an expanded role for the Association in developing a single economical system of high quality health care for all Americans; stimulating the Association's scientific bases in order to increase impact on health programs in the public and private sectors; and helping national, regional, state, and local programs further resolve remaining inequities in health and social programs. The Governing Council elected Arthur Bushel, DDS, MPH, as Chairperson of the Executive Board for 1977, and Iris Shannon, RN, MA, as Vice Chairperson. Dr. Bushel, Professor and Chairperson of the Department of Public Health Administration, The Johns Hopkins University School of Hygiene and Public Health, has served currently on the Executive Board since 1974, and previously between 1970 and 1973; Ms. Shannon, Chairperson of Community Health Nursing, Rush Presbyterian-St. Luke's Medical Center, Chicago, is currently serving her second term on the Executive Board. Beverlee A. Myers, MPH, Deputy Commissioner, Medical Assistance, New York State Department of Social Services, is Speaker of the Council.

BUSHEL

The Governing Council also elected three internationally known health professionals to positions of VicePresident, representing different regions of the Western Hemisphere. These are: United States-Evalyn Gendel, MD, Director of the Bureau of Maternal and Child Health, Kansas State Department of Health and Environment. Dr. Gendel is a past member of the Executive Board and is affiliated with the School Health Section; Canada-Theodore Tulchinsky, MD, MPH, Deputy Minister, Department of Health and Social Development, Manitoba, Canada, re-elected to a second term as Vice-President. Dr. Tulchinsky has been a member of APHA since 1967 and is affiliated with the Medical Care Section. He is also active in the Canadian Public Health Association. He received his medical degree at the University of Toronto and his MPH at Yale University. Latin America-Hugo Behm, MD, MPH, Centro Latino Americano Demogratio, San Jose, Costa Rica, re-elected to 64

a second term as Vice-President. Dr. Behm was previously a consultant in statistics, epidemiology, and demography to the Government of Panama at Children's Hospital, Panama City, after having been imprisoned for one year in Chile as a result of the military takeover in that country. Following international appeal by the Government of Panama, APHA, and the Association of Deans of Public Health, Dr. Behm was released from prison without legal procedure and came to Central and North America. He received his medical degree from the University of Chile, Santiago, and his MPH from The Johns Hopkins University School of Hygiene and Public Health. He has also served as Dean of the School of Public Health, Universidad de Chile, Facultad de Medicina. Henry C. Daniels, MA, was re-elected to a second term as Treasurer of APHA. Daniels, who recently retired as Administrative Officer, United Mine Workers Welfare and Retirement Fund, Washington, DC, is a fellow of the Association and has been a member since 1946. Affiliated with the Medical Care Section, for which he served as secretary and chairperson, Daniels also served previously as a member of the Executive Board. He is also active in the District of Columbia Public Health Association and the American Labor Health Association; and has served on the Board of Directors of the Group Health Association of America, and on the Board of Trustees of the Group Health Association in Washington, DC. The Governing Council also elected four individuals to fill vacancies on the Executive Board created by expiring terms of three members, and by the appointment of Seiko Baba Brodbeck to an APHA staff position. The three elected Board Members who will serve until 1980 are: Caesar Branchini, MA, Director of Program Development, National Center for Health Education, New York City. Branchini has been an APHA member for 25 years, is affiliated with the Public Health Education Section, and served two terms as Chairman of the Association's Standing Committee on Membership. Formerly director of health education for Blue Cross-Blue Shield of Greater New York, Branchini is active in the Society for Public Health Education (SOPHE), and is a past president of the New York State Public Health Association. Marjorie Costa, MPH, DMA, Assistant to the Administrator for Community Affairs, Health Services Administration, DHEW, Rockville, MD, has been a member of APHA since 1969, and is affiliated with the Public Health Education Section. She is a fellow of the Society for Public Health Education, a member of the National Association of Health Services Executives, and is chairperson of the March of Dimes Task Force on Maternal and Newborn Health of Minorities and the Poor. Jack Kasten, JD, MPH, Vice President, for health education and manpower, Arthur D. Little, Inc., Cambridge, Massachusetts, is a fellow of the Association and a member since 1948, and is the Massachusetts Public Health Association's representative to the Governing Council. Kasten is also past chairman of the Medical Care Section, and past chairman of the Association's Committee on Nominations. He holds memberships in the American Hospital Association, AJPH January, 1977, Vol. 67, No. 1

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the Gerontology Society, the American Bar Association, andthe College of Hospital Administrators. Elected to fill a one-year vacancy on the Executive Board, Stanley Matek, Executive Director of the Orange County Health Planning Council of California, will serve un-

til the fall of 1977. Matek is a member of the Community Health Planning Section Council. He is also active in the American Association of Hospital Planners, the American Society for Public Administration, and the California Public Health Association.

MERRILL AWARDED 1976 SEDGWICK MEMORIAL MEDAL Malcolm H. Merrill, MD, MPH, Director of International Health Programs for the American Public Health Association, received the prestigious Sedgwick Memorial Medal from APHA during the Association's 104th Annual Meeting in Miami Beach. Dr. Merrill was honored for his accomplishments as a leader and staff member in developing and administering extensive international health programs involving family planning and nutrition services in developing countries. The Ministry of Health or other responsible agencies of more than 50 developing counMERRILL tries have been assisted in virtually all phases of planning, developing, managing, and evaluating humanitarian programs for delivery of services for health, family planning, and nutrition as a result of Dr. Merrill's efforts. Dr. Merrill, who was president of APHA in 1959-60, was also Director of the Association's Community Health Action Planning Services (CHAPS) from 1968-71, following which he assumed direction of international health programs. As director of CHAPS, Dr. Merrill conducted a study of the Los Angeles County Health Department's organization, while simultaneously directing international consultations in health. He has had several successful careers in public health as a researcher and a program administrator, including: Director of VD Control and later of the laboratories of the California State Health Department; Administrator of that state's health department; and later of the Agency for International Development's Office of Health. In his present position with APHA, Dr. Merrill has increased APHA's work in the international health field, through contracts with AID, so that it is now the major part of the Association's contract work. The International Health Division's staff is developing an inventory and analysis of health delivery activities throughout the world, with special attention given to identifying innovations. Dr. Merrill is also directing the staff in offering support and guidance to 20 Central and West African countries who have joined with the AJPH January, 1977, Vol. 67, No. 1

World Health Organization and AID to undertake activities to improve the health infrastructure in those countries. The Sedgwick Memorial Medal, APHA's oldest award, was first presented in 1929 in honor of the bacteriologisteducator who helped found the Harvard and MIT Schools of Public Health. Sedgwick, a pioneer in the public health movement, was president of APHA in 1915. Previous recipients of the Sedgwick Memorial Medal include: Leroy E. Burney, MD, MPH (1975); Myron E. Wegman, MD (1974); I. S. Falk, PhD (1973); and Paul B. Cornely, MD, DrPH (1972).

Excerpts from the Citation for Dr. Merrill "Laboratory investigator and director, disease control specialist, State health officer, national leader and international health adviser, Malcolm Merrill is recognized for outstanding contribution to any enterprise he has undertaken.... As a virologist with the Rockefeller Institute for Medical Research in the 1930s, Dr. Merrill's studies deepened our understanding of the differences among the viruses causing encephalomyelitis and of the mosquito-cycle of those viruses.... "For his next venture he tackled venereal disease control. He entered that field only a short time after Thomas Parran as Surgeon General first dared to say the word syphilis on the radio. Immediately Dr. Merrill saw the necessity of developing and standardizing his serologic test for syphilis in public health laboratories as a basic tool in the California campaign against venereal disease.... "Dr. Merrill became Chief of the Division of Laboratories in the California State Department of Public Health which he developed into one of the finest such laboratories in the world.... "These accomplishments might have been more than sufficient for even a good man, but we are speaking of an extraordinary one.... "He linked his academic public health work in mid-career with his responsibility in the (California) State Health Director's office to formulate a genuine State-local public health partnership, . . . which comprised the basis for much of the progressive public health work in California during the 1950's and 1960's. "His leadership was recognized nationally in his election as President of the American Public Health Association, as President of the Association of State and Territorial Health Officers, and in numerous other ways.... "Then in 1965 after having served frequently as an international health adviser in Southeast Asia, Latin America, the Soviet Union and elsewhere, he began working in the U.S. Agency for International Development and, more recently, became head of the substantial American Public Health Association international health program.... "Rare indeed is the person so gifted as to make highly significant contributions to these many elements of public health-labora65

ASSOCIATION NEWS tory science, disease control, public health administration and international health. Throughout his career, in addition to these major thrusts accomplishments, Dr. Merrill has steadily and effectively supported and written about the many other aspects of public health such as environmental control, occupational health, health education and nutrition. He has done it all with modesty, with insistence

upon equal credit with his colleagues and with loyalty to organizations. Those who have known him personally have been fortunate indeed-as have the many effected by his good works. "For Distinguished Service in Public Health, the American Public Health Association awards the 1976 Sedgwick Memorial Medal to Malcolm H. Merrill."

CDC DIRECTOR RECEIVES APHA AWARD FOR EXCELLENCE IN INTERNATIONAL HEALTH David J. Sencer, MD, MPH, Director of the Center for Disease Control of the U.S. Public Health Service, received the American Public Health Association's Award for Excellence in the Field of International Health for his accomplishments in his progressive administration at CDC and other posts. The Award was presented October 18, 1976 at the Awards General Session of APHA's 104th Annual Meeting, before a large crowd of national and international health authorities. Having held numerous public health posts during his career, Dr. Sencer became the SENCER head of CDC ten years ago. The Award cited his "career qualities of insight and commitment of the highest caliber," and his Accomplishments and those of the Center which he has served for 15 years and directed for more than ten years which "speak eloquently of his initiative, imagination, management skills, and social conscience. They account for the high esteem in which he is held by public health professionals around the world." A native of Grand Rapids, Michigan, Dr. Sencer did his undergraduate work at Wesleyan University and attended medical school at the University of Mississippi and the University of Michigan, where he received his MD degree. He trained in internal medicine at University Hospital in Ann Arbor, Michigan, and received his MPH at the Harvard University School of Public Health. After he joined the Public Health Service in 1955, one of his first assignments was to work with Mexican-American agricultural migrants in Idaho. It was his basic documentation of migrant health conditions which eventually stimulated action toward more permanent, long-lasting migrant reforms. The APHA Award for Excellence in Promoting and Protecting the Health of People in the Field of International

66

Health is presented annually, and is made possible by a gift from the Sarah and Matthew Rosenhaus Peace Foundation. Established in 1973, the Award consists of a $5,000 honorarium and a symbolic crystal trophy. Previous recipients of the international award include James Westland Wright, MPH (1973); Nevin Stewart Scrimshaw, PhD, MD (1974); and Donald A. Henderson, MD, MPH (1975). The citation also noted: "The receding hazard of communicable disease in the world has been one of the great triumphs of public health in our current century. A few individuals have played truly outstanding roles in this success. David Sencer is one of them. Since 1960, when Dr. Sencer joined the Center for Disease Control, this organization has made unsurpassed contributions to communicable disease control. These contributions have extended beyond domestic confines to many corners of both developed and underdeveloped nations of the world. "Under his direction the Center's Bureau of Laboratories has become, both for the United States and the world, an impressive force in leadership for the accurate diagnosis of disease and the uncovering of outbreaks of both common and exotic infections. It now serves the World Health Organization through its 19 collaborating centers as the final reference center for determining the precise characteristics of infective micro-organisms wherever they may appear on the globe. "Whether it was cholera in Italy and Spain; smallpox in Africa and Asia; malaria, the as yet undefeated world-wide disease; or outbreaks of plague in Java-under Dr. Sencer's direction the Center for Disease Control has been ever-present, providing surveillance, establishing methods for control and evaluation, providing competent laboratory service and training a world-wide network of workers to organize effective public health programs in the far corners of the globe, as well as in our own country. "Among all the significant accomplishments achieved under his direction mention should be made of the eradication of smallpox in 19 countries of West and Central Africa by the technique of containment and the overhauling of the U.S. foreign quarantine program to serve as an example to the world of how quarantine should be practiced during the last decades of the twentieth century. Also noteworthy is the Center's work with two tropical African high-mortality diseases: Marburg and Lassa virus. The surveillance and study of these diseases, accomplished both in the field and in the Center's maximum security laboratory, is a unique contribution to virology and disease detection. "For his distinguished and dedicated leadership in these achievements, the American Public Health Association takes pride in granting its 1976 Award for Excellence in International Health to David J. Sencer."

AJPH January, 1977, Vol. 67, No. 1

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NYC MENTAL HEALTH COMMISSIONER HONORED BY APHA FOR EXCELLENCE IN DOMESTIC PROGRAMS Cited for her leadership in innovative mental health programs, June Jackson Christmas, MD, received the American Public Health Association's 1976 Award for Excellence in the Field of Domestic Health. Dr. Christmas, who is Commissioner of the New York City Department of Mental Health and Mental Retardation, was given this honor during APHA's 104th Annual Meeting in Miami Beach. The presentation was made October 18, 1976 during the Association's Awards General Sesk AA sion. Serving as New York City's mental health commisCHR1STMAS sioner since 1972, Dr. Christmas has led the development of preventive, rehabilitative, and treatment programs in mental health, retardation, alcoholism, and other fields. Praised for her sensitivity to minority populations, her research and actions have greatly facilitated improved race relations. As commissioner, Dr. Christmas established the Borough-wide Federations of Mental Health, Mental Retardation, and Alcoholism Services in order to involve consumers and providers at local levels in the planning and decisionmaking processes. She has led an information campaign to increase public awareness of the needs of the mentally disabled, and she has established priorities for the underserved groups such as the retarded, the elderly, and disturbed children and adolescents. Civil Service job titles, created for paraprofessional mental health workers, have resulted in the employment or career upgrading of more than 1,200 individuals under her leadership. Prior to her appointment as commissioner, Dr. Christi iST

mas served as director of the Harlem Rehabilitation Clinic which, under her direction, gained national recognition as an effective model for the delivery of community-oriented services-using a socio-psychiatric approach pioneered there. She implemented a program in which paraprofessional staff served as the primary rehabilitation agents. By hiring the under-employed and unemployed from the community and developing an on-the-job training program, she enabled workers to rise to unexpectedly high levels and play an important role in the rehabilitation of clients. Her efforts have influenced the development of new career programs throughout the United States. The APHA Award for Excellence in Promoting and Protecting the Health of People in the Field of Domestic Health, presented annually, is made possible by a gift from the Sarah and Matthew Rosenhaus Peace Foundation. Established in 1973, the Award consists of a $5,000 honorarium and a symbolic crystal trophy. Previous recipients of the domestic award include H. Jack Geiger, MD (1973); philanthropist John D. Rockefeller III (1974); and Kurt W. Deuschle, MD

(1975). Dr. Christmas' citation read, in part, as follows: "Dr. Christmas has developed genuinely comprehensive mental health services that combine medical, psychological and social approaches to prevention, diagnosis and treatment, and rehabilitation. As a skilled leader she has undertaken this work not in an abstract way but in the day-to-day tumult of governmental administration in a large metropolitan American community. In this sense especially Dr. Christmas is a true model for the public health professional. "Thus, in recognition of her ability to define highly significant but still neglected health problems, to focus attention on persons outside the social mainstream, to develop innovative approaches to assist them, to give meaning to community self-help almost before it was a concept, to launch a whole new set of under-valued people on health careers, to find administrative tactics for bringing mental health services to a situation that few if any would dare tackle-for all these abilities and her magnificent exercise of them, the American Public Health Association proudly presents its 1976 Award for Excellence in Domestic Health to June Jackson Christmas."

CANADIAN HEALTH MINISTER DELIVERS ROSENHAUS LECTURE The honorable Marc Lalonde, Canada's Minister of Health and Welfare, and Minister Responsible for the Status of Women, delivered the fourth annual Matthew B. Rosenhaus Lecture at the American Public Health Association's 104th Annual Meeting, in Miami Beach, Florida. The Minister's lecture, entitled "Health Care: The Canadian Experience," was delivered at AJPH January, 1977, Vol. 67, No. 1

LALONDE

the Awards General Session ofthe meeting, October 18, 1976. The Rosenhaus lectureship is awarded annually to an individual whose sphere of action and interest includes current issues in public health. Canada has had national health insurance for 18 years, and spends less per capita on doctors and hospitals than does the United States. While the United States is still debating national health insurance, Canada's government-financed program permits unlimited care, with no limits on hospital treatment or length of stay. While all of Canada's political parties endorse the nation's health program, the federal government took steps last year to limit increases in its share of the financing in each province to 13 per cent. As a result of this re-thinking, Mr. 67

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Lalonde issued a working document, "A New Perspective on the Health of Canadians," which focuses on prevention. "The Government of Canada," Mr. Lalonde said, "now intends to give to human biology, the environment and lifestyle as much attention as it has to the financing of the health care organization so that all four avenues to improved health care are pursued with equal vigor." Mr. Lalonde, who holds a Bachelor of Law degree and a Master's degree in Law from the University of Montreal, was political advisor to Prime Minister Lester B. Pearson, 1967-68, and Principal Secretary to Prime Minister Pierre Trudeau from 1968 to 1972. Elected as a Member of Parliament in 1972, he was chosen by the Prime Minister to occupy the portfolio of Minister of National Health and Welfare in the new cabinet. Re-elected to Parliament in 1974, Mr. Lalonde was also appointed as Minister Responsible for the Status of Women, in addition to continuing as Health and

Welfare Minister. Minister Lalonde also holds a Master's degree in economics and political science from Oxford, and has taught business law and economics at the University of Montreal, and administrative law at the Doctorate level at the University of Ottawa and the University of Montreal. Mr. Lalonde's Rosenhaus Lecture will be published in the American Journal of Public Health in early 1977, and will be distributed in hard cover editions to libraries throughout the world. A $2,000 honorarium accompanies the lectureship. The lectureship is made possible through a gift from the Sarah and Matthew Rosenhaus Peace Foundation. Former Pennsylvania Governor Raymond P. Shafer delivered the 1973 lecture; the 1974 lecture was delivered by James G. Haughton, MD, MPH; and the 1975 lecture by John Higginson, MD.

TRAIN RECEIVES APHA PRESIDENTIAL CITATION Russell E. Train, Administrator of the federal government's Environmental Protection Agency, received the 1976 Presidential Citation awarded by the American Public Health Association, in recognition of significant and exceptional contributions to public health. The citation was presented during the Closing General Session of the 104th Annual Meeting of the Association in Miami Beach, October 21, 1976. As Administrator of the EPA since 1973, Mr. Train has directed an organization that has had a profound effect upon public health through its programs to protect the environment. Among EPA's achievements under Train's leadership have been the passage and implementation of the Federal Safe Drinking Water Act, the preservation of the integrity of the Clean Air Act and its non-degradation provisions, and the acceleration of the Waste Water Treatment Construction Grant program to a funding level of $10.5 billion, making it the largest public works and jobs program in the United States. The Agency played a major role in securing the passage of the comprehensive Toxic Substances Control Act and has established policies, procedures, and regulations to provide guidance in determining the risks, benefits, and proper use of pesticides. As EPA Administrator, the 56-year-old Train has been heralded in many quarters for his tough stands in defense of the quality of the nation's environment. Last June the United States Supreme Court upheld the validity of EPA rules requiring the phase-out of lead in gasoline. The agency regulations state that the lead in gas represents a significant 68

risk of harm to the health of urban populations. Early this year, APHA commended EPA and its Administrator for decisions to curtail the use of the pesticides heptachlor and chlordane and to recommend denial of landing rights for the Concorde supersonic transport planes on American soil. Prior to his work with EPA, Russell Train served as the first Chairman of the Council on Environmental Quality. While Chairman, Mr. Train was the Chief Advisor to the President on environmental policy. During this period, the Council developed extensive legislative and administrative programs dealing with land use, pesticide regulation, ocean dumping and toxic substances control. The Council also provided leadership in the implementation of the far-reaching National Environmental Policy Act. Russell Train has been a moving force in encouraging international efforts to protect the environment. He has represented the United States in a variety of international environmental conferences. Since 1971, he has been the U.S. representative to the NATO Committee on the Challenges of Modern Society. In 1972, Mr. Train headed the U.S. Delegation to the United Nations' Conference on Human Environment in Stockholm and became Co-Chairman of the U.S.U.S.S.R. Joint Committee on Cooperation in the Field of Environmental Protection. In 1973 he headed the U.S. Delegation to the Inter-Governmental Maritime Consultative Organization conference to develop a convention to prevent the pollution of the ocean by ships. AJPH January, 1977, Vol. 67, No. 1

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Russell Train has long been in the forefront of efforts to protect the public health through strong environmental controls. For these and other significant contributions which have served to protect the human environment, he was awarded the 1976 APHA Presidential Citation. The Presidential Citation is awarded by the American Public Health Association for significant and exceptional achievements in the field of public health. This award is not

presented every year, but is awarded only on occasions of unusual merit. Previous recipients of the Presidential Citation include: Betty Friedan, feminist author, and Eula Hall, health and welfare rights activist (1975); Reverend Jesse L. Jackson (1974); the Honorable Paul G. Rogers, M.C. (1973); the Honorable Lister Hill, former U.S. Senator from Alabama (1972); and then EPA Administrator William D. Ruckelshaus (1971).

DENTAL PIONEER RECEIVES APHA BROWNING AWARD John W. Knutson, DDS, DrPH, one of the great pioneers in preventive dental health, received the American Public Health Association's Edward W. Browning Achievement Award on October 18, 1976 during the Association's 104th Annual Meeting, held in Miami Beach. During his 44-year career, Dr. Knutson has been a part of many major developments in dental care. Shortly after entering the U.S. Public Health Service in 1936, he participated in the development of an epidemiological index to measure dental caries in primary and permanent KNUTSON teeth of children. The indices he produced on that experience have been universally adopted for comparison-data gathering. His studies were largely the basis for the Council on Dental Therapeutics approving the use of topically applied fluoride for the prevention of caries. At the time Dr. Knutson was Chief of the PHS Division of Dental Public Health, he planned and justified before Congress the first major nationwide preventive dentistry program-the Topical Fluoride Demonstration Program. Over a period of four years, teams of dentists and hygienists conducted demonstration projects in 37 states and territories. In January 1945, he participated in the initiation of what proved to be the safest, most effective, and practical public health measure in the realm of preventive dentistry; Grand Rapids, Michigan was the first city to have its water fluoridated artificially under controlled conditions. Dr. Knutson actively promoted fluoridation of city water supplies during the following year. AJPH January, 1977, Vol. 67, No. 1

Studies implemented by Dr. Knutson led to the development of methods for comparing the cost of maintenance of dental health to the cost of treatment needs, and showed the efficiency factors for dentists working in a seated position and using auxiliary personnel. These studies are now considered classics. After completing 30 years in the U.S. Public Health Service, nine years of which were as Assistant Surgeon General and Chief Dental Officer, Dr. Knutson started a second career as Professor of Preventive Dentistry and Public Health at the University of California at Los Angeles. His most innovative contribution was the integration of a social sciences component into the dental curriculum. In 1975, after serving in a number of roles and assignments at UCLA, he became Professor Emeritus at that University, the culmination of 14 years as teacher and scholar. He was the first dentist to be elected President of the American Public Health Association, in 1956-57. Throughout his career, Dr. Knutson served on scores of committees, commissions and advisory bodies at national and international levels. He has published many scientific papers, served as editor and co-editor of several journals and monographs, and was for years a dental consultant to dozens of countries. His name is synonymous with dental prevention because he has been instrumental in establishing and promoting this aspect of dental health more than any other individual. The American Public Health Association is proud to recognize his accomplishments in dental health and to select him for the Edward W. Browning Achievement Award for the Prevention of Disease in 1976. Established in 1971, the Browning award consists of a $5,000 honorarium. It is presented by APHA for the New York Community Trust. Previous recipients include: E. Cuyler Hammond, ScD (1972); Hildrus A. Poindexter, MD, MPH (1973); Harriet L. Hardy, MD, MPH (1974); and C. Henry Kempe, MD (1975). 69

HAGGERTY RECEIVES MARTHA MAY ELIOT AWARD Robert Johns Haggerty, MD, former professor and chairman of the Department of Pediatrics at the University of Rochester, New York, received the American Public Health Association's Martha May Eliot Award for unusual achievement in the field of maternal and child health. The award was presented to Dr. Haggerty at a luncheon session during the Association's 104th Annual Meeting, October 1721, 1976, in Miami Beach. Dr. Haggerty has been a leader in the field of maternal and child health for over 20 years through his activities as a clinician, teacher, investigator, and administrator. He has initiated education programs in community pediatrics for medical and nursing students, and pediatric and family practitioner house officers. His students at the Harvard Medical School and the University of Rochester School of Medicine have carried his ideas and teachings throughout the world. A leader in emphasizing the family unit in child health, he has created models for the improvement of health care to children and their families in urban, rural, and school settings. Scholarly research by Dr. Haggerty in both health serv-

ices and clinical subjects have added greatly to the knowledge of child and family health. His research has ranged widely over the entire field of clinical ambulatory pediatrics. Because of Dr. Haggerty's influence on his students who entered practice or teaching, his work on boards and committees, and his publications, professionals in the health sciences have a broader knowledge of the social and environmental aspects of health care. His paper given at the awards session is entitled "Family Stress: New Challenges and Opportunities for Maternal and Child Health." The Martha May Eliot Award is awarded by the Maternal and Child Health Section of APHA, and is named in honor of the physician who organized early child health services. Nominees are professional workers in MCH, usually from the United States, Canada, and Mexico. The award consists of a plaque bearing a bronzed bas-relief of Dr. Eliot and an honorarium of $1,000. Previous recipients of the award include: Eleanor Pavenstedt, MD (1972); William Morris Schmidt, MD (1973); Henry K. Silver, MD (1974); and Sidney Shaw Chipman, MD, MPH (1975). Ross Laboratories, of Columbus, Ohio, sponsors the award.

TAMPA TIMES HEALTH REPORTER IS WINNER OF 1976 RAY BRUNER AWARD Sara Schwieder, health and medical writer for The Tampa Times (Florida), has been named the winner of the sixth annual Ray Bruner Science Writing Fellowship. Established by the American Public Health Association in 1971 to encourage the development of medical and science writing specialists in the mass media, the award commemorates the 48-year career of the late science editor of The Toledo Blade. Schwieder, 26, was honored at a press reception, hosted by Lederle Laboratories, sponsor of the fellowship, on October 19, 1976, during the 104th Annual Meeting of APHA in Miami Beach, Florida. She was selected for the award by an independent panel of judges on the basis of a series of articles she wrote for The Tampa Times concerning the manner in which the medical profession disciplines its errant members. The series was based on six months of research by the news staff. Schwieder's entries in the Bruner competition also included a series on Medicaid patients who were refused services at area hospitals; an investigative series on evaluation of emergency medical services at a Veterans Administration hospital; and several stories dealing with health legislation, mental health, 70

Florida's air pollution and its effect on human health, malpractice, and other health issues. The Bruner Award is presented annually to a reporter covering the science/medical/health beat at least half-time for five year or less. The winner is invited to cover APHA's Annual Meeting, and receives an engraved plaque and a portable typewriter, in addition to travel and living expenses during the five-day meeting. Mrs. Louise Bruner of Toledo, Ohio, widow of the late science editor, is honorary chairman of the selection committee. This year's panel of judges was chaired by Victor Cohn, science writer for the Washington Post, and included Harold Schmeck of the New York Times, Don Kirkman, Scripps-Howard Newspapers, Anita Smith, Birmingham News, and Nancy R. Bernstein, Chicago public relations. Previous Ray Bruner Fellows are: Howard Wolinsky, Cocoa Today (Florida), 1975; Rudolph W. Brewington, WWDC Radio (Washington, DC), 1974; Chuck Michelini, Birmingham Post-Herald (Alabama), 1973; Barbara Chapman, Rockford Morning Star (Illinois), 1972; and Sarah Watke, Green Bay Press (Wisconsin), 1971. AJPH January, 1977, Vol. 67, No. 1

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Report of the APHA Task Force on Chile* PAUL B. CORNELY, MD, DRPH, ROBERTO BELMAR, MD, LESLIE A. FALK, MD, GARY L. FILERMAN, PHD, HELEN RODRIGUES-TRIAS, MD, VICTOR W. SIDEL, MD, GEORGE A. SILVER, MD, MPH, AND MYRON E. WEGMAN, MD

Introdiuction Health workers who attended the Annual Meeting of The American Public Health Association in November 1973 were appalled by the report of what had happened to their colleague health workers in Chile-ousting from jobs, imprisonment, disappearance, torture, and summary executions.' The reaction of the APHA membership and the governing bodies was strong, resulting in a resolution condemning these actions and calling on our Government and various international organizations to intercede.2 An Ad Hoc Committee was appointed by the Executive Board of the Association to study the situation and make recommendations for further action. At the APHA 1974 Annual Meeting, the Association's Governing Council received an interim report from the Committee3** and charged it with preparing a report on the status of health services and the treatment of health workers in Chile, authorizing support for a fact-finding commission to make a visit to Chile for this purpose.4 A four-person delegation was named. The Chilean Embassy set certain conditions for such a visit in order, it said, to "insure objectivity" and the American Public Health Association accepted those conditions. After first agreeing to accept the delegation, the Chilean Ambassador to the U.S. subsequently withdrew permission, on the ground that there had already been enough investigations and a United Nations team was about to visit Chile for a similar purpose.5 That team, too, was subsequently excluded. The Executive Director of the American Public Health Association informed the Chilean Ambassador that the Governing Council expected a report and, if permission for a personal visit was not granted, it would have to be based on available information.6 The following report is thus not as complete as the Task Force would have liked. It is essentially a summary, pre-

*See also "The Quiet Desperation of Public Health Conscience," (page 20) and "History of the Health Care System in Chile," (page 31).

**Hereinafter called the APHA Task Force on Chile.

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pared from a compilation of published documents, conversations with U.S. citizens who were present in Chile before, during, and after the military coup, conversations with exiles, and a wide range of written communications:

Effect on Chilean Health Workers Over many decades Chile has taken pride in the high level of professional accomplishment and training of its health workers. New ideas were constantly being introduced but both organization and technical personnel retained a remarkable degree of stability, even though different ministers and directors-general took over leadership with the various changes in government. It had long been traditional in the government of Chile that with each major change in government all of the top personnel in the Health Ministry would be changed but that the career personnel were maintained in office. After the 1973 military coup in Chile, however, this tradition did not apply. Health workers were discharged, imprisoned without charges, and many were summarily executed.7-12 Reports from a number of international agencies, as well as the exhaustive study carried out by the Organization of American States, the official intergovernmental agency of the countries of the Americas, were devastating in their analysis of what went on in Chile. The special O.A.S. Commission established to investigate the Chilean situation which included former Ambassador Robert Forbes Woodward of the United States, issued a report of some 200 pages with extensive documentation of their findings. 13 That report states: "Not only are there no human rights in Chile, but torture has been established as a commonly used method of interrogation, using sexual aggression in all its forms, application of electrical currents in genital zones, torture and physical attack in the presence of relatives, torture of children in the presence of parents, use of drugs such as pentothal, burning of the body with cigarets." The Commission rightfully concluded that there are very serious violations of human rights in Chile. In the final chapter of the report, details of these violations are given under a series of headings, including: treatment of prisoners; personal security; personal freedom; habeas corpus; free71

ASSOCIATION NEWS

dom of expression and information; freedom of unions; freedom of association; freedom of opinion and equality before the law; exercise of political rights. In June 1976, Secretary of State Henry Kissinger, in a statement highly critical of the Chilean government, bluntly told the O.A.S. Conference held in Santiago: "A country that tramples on the rights of its citizens denies the purpose of its existence."'14 Since Secretary Kissinger had been the key foreign policy figure in the U.S. Government when it imposed the severest of economic and political pressure to harass, handicap and destabilize the Allende government, the Secretary's statements can hardly be taken as anti-Junta propaganda.'5. 16 The situation of Chilean health workers, sad to say, was even worse than the average citizen of that country and a great many were among the thousands jailed, tortured, and killed. Vindictiveness apparently extended to medical colleagues and one group of physicians was told by a Chilean Air Force General: "Don't blame us, the military. On the contrary, we have been generous, for had we followed your colleagues' request, many of you right now would be dead."''7 Details of the maltreatment given many physicians and health workers are beyond the scope of this summary but are documented in the source material."s 3, 7-12 For some prisoners, however, clearly related to the international outcry and protests, at least quasi-legal procedures were followed. It is a revealing commentary that after months of interrogation, pressure, threats, and actual torture, many health workers have been released with the admission that proof of wrongdoing could not be established. Three years after the coup, health workers and others are still being held, without charges, although a number of prisoners were released coincidentally with the holding of the 1976 O.A.S. Conference. From a variety of reliable sources a list of those known to have been killed has been compiled. An even longer list could be given of those who have had to flee the country and are now scattered over the world in exile.t By far, the largest number are the skilled health workers still captive in Chile and unable to do the tasks for which they have been trained. The Code of Ethics of the Colegio Medico proclaims, as a basic principle, protection and defense of physicians in jeopardy. 18 Visiting delegations to Chile have indicted the Colegio for failure to inquire about the well-being of its colleagues imprisoned by the Junta and for deliberately refraining from advocacy on their behalf. Many United States citizens are deeply disturbed over the unsavory role our own government had in the events leading to the military overthrow of a constitutionally-electtA moving extemporaneous description of his personal experience was presented at the 1975 APHA Annual Meeting in Chicago

by the former Director of the Chilean School of Public Health, Dr. Hugo Behm, who had been elected to his position during the Frei government, prior to Allende, as had another distinguished physician exile, the Dean of the Faculty of Medical and Biological Sciences, Dr. Alfredo Jadresic. 72

ed President. The covert, and sometimes overt, interference organized or financed by agencies of the United States Government has been overwhelmingly documented in Congressional speeches and reports'6' 19, 20 and in the national press.'5' 21 There is small satisfaction in current disavowal of such actions in the future, but the American Public Health Association can feel a certain amount of pride that its repeated protests, added to those of many other concerned groups, succeeded in mitigating somewhat the situation of health workers in Chile.

Future Policy It is the right of any people to decide its own destiny. While members of the APHA Task Force on Chile may find the public policies and form of government of the military rulers of Chile highly objectionable, this is not our major concern-but violation of the rights and security of human beings, so much a part of health, is. We value all of humanity while we speak primarily for our colleagues in the health field. The proud Chilean tradition of stability and continuity for health workers has been shattered. Promising health programs, representing careful development antedating the Allende government, have been dismantled or sharply curtailed. Technical competence is being wasted and highly trained public health workers are held idle. Criticisms by the current Chilean regime of the way health programs were carried out, of poor planning, or of mounting administrative inefficiency in no sense justify imprisonment, torture, and executions. The APHA Task Force believes it essential that opposition to the present state of affairs be maintained, and that continuing efforts for improvement in the status of health workers, our colleagues, be made. The least our own Government can do to attempt to make up for now repudiated acts is to bring economic and diplomatic pressure on the Chilean Government to right the wrongs, rather than continue present policy of bolstering that Government with international aid and commercial credits. The Task Force reiterates its support for the Resolution adopted by the Association's 1975 Governing Council.22

REFERENCES 1. Report on Chilean Health Workers. 101st Annual Meeting, American Public Health Association; San Francisco, November 4-8, 1973. 2. Resolution, "Lives and Safety of Public Health Colleagues in Chile." Adopted by APHA Governing Council, November 7, 1974. Am. J. Public Health, 64:194, 1974. 3. Interim Report of Ad Hoc Committee on Chilean Health Workers, 102nd Annual Meeting of the American Public Health Association, New Orleans; October 20-24, 1974. 4. Action taken by Governing Council at 102nd Annual Meeting, American Public Health Association, New Orleans; October 20-24, 1974. 5. Chile Withdraws Permission to APHA for Fact-finding Visit. The Nation's Health, May 1975. 6. Letter from APHA's Executive Director, William H. McBeath, MD, to Walter Heitman, Chilean Ambassador, April 15, 1975.

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ASSOCIATION NEWS 7. Kandel, J. Thirteen Doctors in Chile Reported Slain After the Coup; The New York Times, April 8, 1974. 8. Navarro, V. What does Chile mean? Health and Society, 93130, Spring 1974. 9. Styron, R. Terror in Chile II; Amnesty International Report, New York Review of Books, 21:42-44, 1974. 10. Waitzkin, H. and H. Modell. Medicine, socialism and totalitarianism: lessons in Chile. N. EngI. J. Medicine, 291:171-177, July 25, 1974. 11. Argus, A. Medicine and politics in Chile; World Medicine, 9:1544, 1974. 12. Belmar, R. and V. W. Sidel. An international perspective on strikes and strike threats by physicians: The case of Chile; International Journal of Health Services, 5:53-64, 1975. 13. Organization of American States, Inter-American Commission on Human Rights, Report on the State of Human Rights in Chile. November 21, 1974. 14. Onis, J. Kissinger Assails Chile over Curbs at O.A.S. Meeting; He Said Relations of Human Rights Impairs Ties with the U.S.; The New York Times, June 8, 1976.

15. Hersh, S. Kissinger Called Chile Strategist; The New York Times, September 14, 1975. 16. U.S. Congress: Senate Select Committee to Study Governmental Operations with Respect to Intelligence Activities. Covert Action in Chile 1%3-1973; Staff Report, December 1975. 17. N.N. Personal Communication by Chilean APHA Member. 18. Jansen, A. R., A. Paredes, and L. Segan. Doctor in politics: A lesson from Chile; In Letters to the Editor, N. Engl. J. Medicine, 291:472-473, 1974. 19. U.S. Congress: Select Committee to Study Governmental Operations with Respect to Intelligence Activities. Alleged Assassination Plots Involving Foreign Leaders. Interim Report, November 1975, pp. 225-254. 20. Moffett, Anthony T. "Remarks on Chile." Congressional Record, Vol. 121, No. 150, October 7, 1975. 21. Harrington, Michael J. The CIA in Chile: A Question of Responsibility. The New York Times, January 2, 1976. 22. Resolution. "Public Health Worker Collaboration with Certain Governments." Adopted by APHA Governing Council, November 19, 1975. Am. J. Public Health 66:200, 1976.

CONSTITUTIONAL AMENDMENTS APPROVED At the 104th Annual Meeting of the American Public Health Association, held October 17-21, 1976 in Miami Beach, Florida, the Governing Council approved the following amendments to the Constitution of the Association. In

compliance with Article VIII of the Constitution, those changes are published here. Ballots will be sent to all members of APHA for voting in the near future.

PROPOSED AMENDMENT NO. 1 To modify the use of traditional epicene language by specifically stating the female gender in addition to the male gender and by making other gender alterations. Aniendatory Language: The constitution is amended by changing the following terms in each place they appear.

Purpose:

EFFECT Current

Amended Version Chairperson Vice-Chairperson He/She Her/Him Hers/His Herself/Himself

Chairman Vice-Chairman He Him His Himself

PROPOSED AMENDMENT NO. 2 To eliminate reference to life members and fellows in the Constitution. Purpose: Amendatory Language: Constitution Article III, Section 1 is amended by substituting the word "two" for the word "four" and deleting the words "Fellows, Life Members," Constitution Article III, Section 3 is deleted in its entirety. Constitution Article VI, Section 6 is amended by substituting the word "and" for the word "Fellows" and by deleting the words "and Life Members."

EFFECT Current ARTICLE III Membership Section 1. There shall be four classes of individual constituents to be designated as Members, Fellows, Life Members, and Honorary Members; and five classes of organization conAJPH January, 1977, Vol. 67, No. 1

Amended Version ARTICLE Ill Membership Section 1. There shall be two classes of individual constituents to be designated as Members and Honorary Members; and five classes of organization constituents to be designated 73

ASSOCIATION NEWS

stituents to be designated as Affiliated Associations, Chapters, Regional Branches, Agency Members, and Sustaining Members. Section 3. A Member may become a Life Member under procedures and financial arrangements prescribed by the Executive Board. A Life Member shall have the same rights and privileges as a Member. ARTICLE VI Governing Council Functions Section 6. To elect the Executive Board, the officers of the Association, Fellows, Honorary Members and Life Mem-

as Affiliated Associations, Chapters, Regional Branches, Agency Members, and Sustaining Members.

Section 3. Deleted.

ARTICLE VI Governing Council Functions Section 6. To elect the Executive Board, the officers of the Association, and Honorary Members.

bers.

PROPOSED AMENDMENT NO. 3 To make Past-Presidents of the Association ex-officio members of the Governing Council, without vote. Amendatory Language: Constitution, Article IV, Section 1 is amended by adding a new item (g) to the list of Governing Council ex-officio members without vote as follows: (g) PastPresidents of the Association. Purpose:

EFFECT Current ARTICLE IV Governing Council Composition Section 1. There shall be a Governing Council which shall consist of voting and nonvoting members as follows: The ex-officio members without vote: (a) The Chairperson of each Association Council. (b) The Chairperson of the Program Development Board. (c) The Chairperson of the Action Board. (d) The Chairperson of each Standing Committee of the As-

sociation. (e) The Executive Director. (f) Chairperson of the Sections.

Amended Version ARTICLE IV Governing Council Composition Section 1. There shall be a Governing Council which shall consist of voting and nonvoting members as follows: The ex-officio members without vote: (a) The Chairperson of each Association Council. (b) The Chairperson of the Program Development Board. (c) The Chairperson of the Action Board. (d) The Chairperson of each Standing Committee of the As-

sociation. (e) The Executive Director. (f) Chairpersons of the Sections. (g) Past-Presidents of the Association.

PROPOSED AMENDMENT NO. 4 Purpose: To place provisions for financial matters in the Constitution. Amendatory Language: The Constitution is amended by adding a new Article IX as shown below. At the same time present Article IX is renumbered X. Article IX. Finances. Section 1. All funds received by the Association shall be deposited promptly in such accounts as may be approved by the Executive Board. The Executive Director shall arrange for their disbursement in accordance with duly authorized vouchers. The Executive Board may give signatory powers to others responsible to the Executive Director to facilitate her/his work. Section 2. The financial records of the Association shall be audited annually by certified public accountants to be selected by the Executive Board. The report of this audit shall be published annually in an official publication of the Association. Section 3. All individuals having access to the Association's assets and/or accounting records shall be covered by a fidelity bond to be purchased by the Association. Section 4. The Treasurer shall monitor the financial affairs of the Association and shall report on the financial status at all regular meetings of the Executive Board and the Governing Council. 74

AJPH January, 1977, Vol. 67, No. 1

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EFFECT Amended Version ARTICLE IX Finances Section 1. All funds received by the Association shall be deposited promptly in such accounts as may be approved by the Executive Board. The Executive Director shall arrange for their disbursement in accordance with duly authorized vouchers. The Executive Board may give signatory powers to others responsible to the Executive Director to facilitate her/his work. Section 2. The financial records of the Association shall be audited annually by certified public accountants to be selected by the Executive Board. The report of this audit shall be published annually in an official publication of the Association. Section 3. All individuals having access to the Association's assets and/or accounting records shall be covered by a fidelity bond to be purchased by the Association. Section 4. The Treasurer shall monitor the financial affairs of the Association and shall report on the financial status at all regular meetings of the Executive Board and the Governing Council.

Current

PROPOSED AMENDMENT NO. 5 To eliminate the provision for an Assistant Treasurer. Purpose: Amendatory Language: Constitution Article VIII, Section 3 is amended by deleting the second paragraph in its entirety.

EFFECT Current It may designate an Assistant Treasurer whose powers shall be limited to the disbursement of funds in accordance with duly authorized budgets for the ordinary conduct of Association business. Such powers shall be exercised only during a period when, in the opinion of the Board, an emergency is created due to the absence or disability of the Treasurer. Such Assistant Treasurer may be a member or a corporate fiduciary institution. In the event of a vacancy in the office of Treasurer, the Executive Board shall elect a member to serve as Treasurer for the unexpired term.

AJPH January, 1977, Vol. 67, No. 1

Amended Version

Deleted

75

_

Association News

RESOLUTIONS AND POLICY STATEMENTS* Adopted by the

GOVERNING COUNCIL of the

AMERICAN PUBLIC HEALTH ASSOCIATION October 20, 1976 GROUP A-PERSONAL HEALTH SERVICES Policy Statements 1. Accountability in Health Planning and Resources Development: Considerations for the Implementation of Public Law 93-641 ................................................................................................ 77 11. Improving the Organization and Financing of Ambulatory Preventive and Primary Health Services in Today's Econ82 omy .................................................................................................. Resolutions Committee for a National Health Service ............................................. 84 ................................................... Health Insurance for Preventive Services................................................................................................ 85 Roleofthe Heritage Community in Delivery of Mental Health Services ................. Spanish ..................................... 85 Joint on the Accreditation of Hospitals ................................................................................................ Commission 86 Establishment of a National Health Service .............................................................. 86 .................................. Home Health Services ................................................................................................ 87 Local Input into the Health Systems Agency ........................................................................................ 87 Government the Subarea Supporting Council Role within the Health Systems Agency ...................... .......................................... 87 A Sound Basis for a National Health Program .................................................................................................. 87 Role ofTheExpanded Nurse: the The Nurse Practitioner Concept .................................. ........................................ 87 The of Community Health Services .............................................................. Bureau .................................. 88 The New York City Public Health Crisis ....................................... ......................................................... 88

GROUP B-ENVIRONMENT Policy Statements I. Development and Use ................................................................................................ Energy 11. Environmental Health Planning ..................................................................................................

88 89

*A Resolution is a statement of a specific action or series of actions endorsed by the Association. A Policy Statement is defined as a major exposition of the Association's viewpoint on broad issues affecting the public's health. 76

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RESOLUTIONS AND POLICY STATEMENTS

111. Public Health Support for Controlling Unrestrained Dogs and Cats .......................................................................... IV. The Utilization of Environmental Control Officers in Hospitals .................................................................................. V. Safe Drinking Water Act ............................................................................................................................................ VI. National Solid Waste Legislation............................

93 93 95 96

GROUP C-MANPOWER, INTERNATIONAL HEALTH, AND OTHER Policy Statements 1. Policy on M alpractice ................................................................................................................................................ 11. Policy Statement on International Health ..................................................................................................................

96 97

Resolutions 99 Role of Spanish Heritage Ancillary Health Care Workers in the Delivery of Service to Spanish Heritage Population Challenge Funds for Affiliates.................................................................................................................................... 100 Implementation of Affirmative Action for Minorities and Women ................................................................................ 100 Professional Consultation from DHEW ...................................................................................................................... 100 GROUP D-SOCIAL FACTORS Policy Statement 1. Policy Statem ent on Prevention ................................................................................................................................

101

Resolutions

Handgun Regulation

................................................................................................................................................

The Lack of Data on the Health Status of the Spanish Heritage Community in the United States.............................. Television and Health................................................................................................................................................ Labeling of Colored and Flavored Foods .................................................................................................................. Infant Feeding Practices............................................................................................................................................ Voluntary Sterilization ............................................................................................................................................... The Right to Abortion for All Women..........................................................................................................................

103 103 104 104 105 105 106

GROUP A: PERSONAL HEALTH SERVICES Accountability in Health Planning and Resources Development: Considerations for the Implementation of Public Law 93-641 In January 1975, the American Public Health Association's Community Health Planning, Health Administration, and Medical Care Sections decided to develop jointly a paper on public accountability as it related to Public Law 93-641.* This decision directly resulted from the three groups' divergent *The National Health Planning and ReDevelopment Act of 1974.

sources

AJPH January, 1977, Vol. 67, No. 1

approaches to this Act as it progressed through the Congressional channels to become law.

Accountability in Health Planning and Resources Development at the Local Level

Public accountability-how it is defined, achieved, and assessed-was the critical question at issue among these

I.

groups.

A. Purpose of This Monograph

A Working Draft was prepared by a tri-sectional task force and widely circulated and discussed during the Association's 1975 Annual Meeting. Comments and suggestions received from that review have been employed by Stanley J. Matek and William Mc.Hiscock in editing this draft for official consideration by the American Public Health Association in 1976.

Accountability in the development and delivery of human services is widely recognized as necessary, but is not widely understood or adequately defined.

Accountability Defined

In discussions of the new National Health Planning and Resources Development Act of 1974 (P.L. 93-641), and particularly of the area Health Systems 77

RESOLUTIONS AND POLICY STATEMENTS

Agencies (HSAs) created by this Act, the issue of accountability has been brought up time and time again, usually by the advocates of one or another form of agency governing structure. In this position paper, the APHA comments on some fundamental issues in public accountability-how it is defined, achieved, and assessed. This paper is not intended as an exhaustive treatment of the subject, but rather as an expository basis for common discussion and action by those engaged in HSA program development, implementation, and evaluation. B. Working Definition

"Accountability" means an obligation to reveal, explain, and justify what one does or how one discharges one's responsibilities. Accountability as a tool of organization is a means to an end. It consists essentially in a series of disclosures made for the purpose of permitting evaluations or judgments to be made so that, in turn, policy decisions can be made or specific actions taken. To be complete, accountability disclosures must provide adequate information on the following aspects of any given activity, enterprise, or assignment: 1. the purposes for which it is being undertaken;

2. the principles or assumptions and values which underlie the project; 3. the procedures being used; 4. the relationships involved (both organizational and personal, so that actual or potential conflicts of interests, for example, can be examined); 5. the results of the effort; 6. the incomes and expenditures involved throughout the project.

The accountability disclosures should be made not only in adequate de78

tail but in consistent form and on a regular basis so that interested observers or responsible authorities can regularly and easily assess the operation.

vention, funding cuts, or possibly removal or recall (depending on the kind of program and the nature of the problem).

In order to make the accountability requirements and assessment opportunities clear to everyone, it is appropriate that the specific terms and schedules for accountability disclosures be formally stated. (This is commonly done by legislation, regulation, or contract.) C. Promoting Effective Accountability

The keys to assuring accountability as a basis for proper evaluation and appropriate subsequent action are principally, then, matters of representation, reporting, and responsiveness. Each of these "three Rs" is independently important. But more important is the fact that all are intertwined: No one by itself will adequately guarantee accountability in a society as complex and large as ours. A program might be "per-

Common experience has produced some organizational and social categories which help promote the effective exercise of accountability, and which help assure the public or its representatives that accountability is present and satisfactory.

fectly" representative, for example, and yet not be responsive or be complete in its reporting. Only through a constant interplay among all three critical considerations can the disclosures which constitute the essence of accountability be made reliable, responsible, and really credible.

The most usual structural or organizational safeguard is representation of interest groups and the general public. The basic considerations in such representation have come to include an equitable balance of geographic, social, and ethnic groups, and the involvement of elected or appointed government officials.

The standard procedural safeguard is the open conduct of program affairs, access to files and records, and adequate efforts to disseminate information and findings. On the basis of the accountability procedures themselves, and these standard approaches to assuring accountability, there should be demonstrable responsiveness to community needs and concerns. These considerations are the grounds upon which an evaluation of a program should be made. If grounds for dissatisfaction exist, then modes of effective recourse must be available so that, if necessary, the appropriate sanctions or reforms can be applied. The avenues of recourse may be formal or informal, direct or indirect; but sanctions themselves will always be direct. They may take the form of administrative inter-

These considerations can be applied to health planning and review under P.L. 93-641 as follows: 1. Representation The Act itself specifies the representation which is required in Health Systems

Agencies. The basic intent of the law so far as representation is concerned centers on whether or not the general public and the various interests affected by planning and review are involved in the agency's structure and processes, particularly on the HSAs' governing bodies and working committees. The Act uses the categories of "consumers", "providers", and "elected or other public officials" as the key to representation. However, affected and involved elements of the public can be identified according to a variety of other criteria. The Act also uses race and income levels as indicators, along with type of professional employment, the nature of financial involvement in the health care system, geographical location, and language groups. Ultimately, however, representation AJPH January, 1977, Vol. 67, No. 1

RESOLUTIONS AND POLICY STATEMENTS

will be achieved in an HSA by following the spirit of the Act rather than merely its letter. The "community" or the "public" is almost infinitely divisible, and, as society grows more complex, interest groups grow more specific and plentiful. It is impossible to represent all interest groups on the governing board of an HSA at any one time. It is also difficult within the membership guidelines established by the Act to achieve representation of the "silent consumers" whose needs are quite real though often unexpressed. The Act and the regulations offer minimum criteria, and can be a refuge in case of controversy; but the assurance of representation will ultimately be achieved by constant local dialogue about what is fair and reasonable year by year.

Membership itself is but one device for assuring adequate representation. The selection procedures for such membership provide other means which can increase community involvement. The Act leaves open several options for determining membership on the HSA governing board. Members may be elected or appointed; the board itself may be a governmental unit or a private corporation. But whatever selection procedures are used, the mandate of the representatives should be renewed regularly by those whom they formally represent. An important consideration in assessing the capacity of an HSA to maintain accountability, therefore, is whether the HSA has and uses methods for: (1) continuously consulting community and interest group opinion on proprosed programs; (2) reporting actions taken; and (3) assuring broad community involvement in its nomination or election process. In these contexts the specific reconfirmation of mandates for HSA members by the interest group they represent is a major assurance and safeguard. AJPH January, 1977, Vol. 67, No. 1

2. Reporting Reporting is a key process by which activities, proposals, and decisions are communicated between planners and their publics. But to be meaningful, its reporting process requires informed interchanges; and this can be achieved only through regular and effective communication efforts.

Communication is fostered through open, public proceedings and readily available data. But in this case, more is needed than merely allowing access to HSA information. There must be an active dispersion of information, so that the somewhat esoteric nature of health system planning can be understood by the public. Naturally, different publics will find different information relevant, and some will require their own form and content for HSA reporting. The process by which goals and plans are determined, and review judgments made, must also be open, accessible, and made known to the public. Such exposure will serve to remind both the public and the planning body of their mutual responsibilities. 3. Responsiveness Responsiveness is that feature of the planning and review process that demonstrates whether or not the public and special interests have had their comments taken into consideration. In order to determine the responsiveness of the planning and review agency processes, there must be a clear definition of shortterm program goals and a periodic assessment of the planning and review decision-making processes. The importance of such evaluation cannot be overstated. It is the chief means for distinguishing responsiveness from simple representation, and for making reporting a matter of HSA commitment rather than just rhetoric. The issues in this case are: (1) what was proposed? (2) what reactions were received? (3) how were the reac-

tions responded to? (4) what specific commitments were made? (5) what happened as a result of the commitments? and (6) how proper or appropriate were the steps used throughout the process? The answers to these questions will clearly establish responsiveness or the lack thereof. If the answers are not readily available, the accountability is inadequate. But if the accountability is adequate, then the evaluation of responsiveness is perhaps the best key to assuring that the accountability has purpose and value to the public-and to the HSA itself.

I. The Hierarchy of Accountability in P.L. 93-641 A. Federal-State 1. Federal The National Council on Health Planning and Development is advisory to the Secretary of Health, Education, and Welfare in the implementation and administration of the Act. Through membership of a variety of federal officials, representatives of governing bodies of Health Systems Agencies, representatives of state agency advisory groups, i.e. Statewide Health

Coordinating Councils (SHCC) and of consumers, the Council provides one mechanism for advising the Secretary and evaluating his performance in administering the Act. The federal government has reviewing authority over both state and local planning agencies. The Secretary of Health, Education, and Welfare must review the budgets of State Health Coordinating Councils annually and evaluate "in detail at least every three years, the structure, operation, and performance of the functions of each state agency." In addition to annual budgetary reviews of HSAs, the Secretary reviews the structure, operation, and performance of the local agencies to determine "the adequacy of the health 79

RESOLUTIONS AND POLICY STATEMENTS

services plan . . . for meeting the needs of the residents of the area . . . the extent to which the agency's governing body ... represents the residents . . . and the extent to whiCch . .. the health of the area's residents . . . and that the accessibility, continuity and quality of health care in the area has been improved." Explicit performance standards are to be prescribed by the Secretary to cover the structure, operation, and performance of each HSA. A reporting system to monitor local conformity is also to be established. 2. State The Statewide Health Coordinating Council has an advisory function to the state health planning and development agency as well as independent plan approval functions. Again, the mandated makeup of the SHCC provides the potential for communication between constituencies in the state and the state agency. The Statewide Health Coordinating Council has direct reviewing authority over the HSA's annual budget and is also required to review the state agency's own fiscal procedures. On the basis of recommendations by the HSA, the state agency is empowered to issue a certificate of need for new facilities. State planning agencies are obliged to evaluate the services of state institutions and to review and revise a statewide health plan. Review on the state level acts to check or supplement evaluations performed by the local HSA. B. Executive (Line) and Legislative

In both the federal and state government health planning and development agencies, the agency head has a line responsibility within the executive branch of government. He must account to the chief executive (the president or governor) for the activities of the agency, their effect on the health system, and the public's perception of their effectiveness or lack of effectiveness in meeting public expectations. 80

Similarly, federal and state agencies administering health planning and development programs are accountable to the Appropriate legislative bodies through the budget process. They must, in order to justify allocation of sufficient resources to support their operations, respond to the concerns of the legislators and their constituents as they relate to the operation of the agency in carrying out its statutory responsibilities. Although chief executives and legislative bodies are found in most forms of local government, the patterns of HSA governance and administration differ from the above as described in the following section. C. Health Systems Agency

Whether the planning and review agency is a community nonprofit agency, associated to local government, or a public regional planning body, its mandate and accountability requirements are identical and explicitly stated in the statute and regulations. Agencies which are units of local government may also have these requirements duplicated because of their own existing policies and procedures. The desirability of these duplications is a matter of local preference in HSA structure under the law. As modern government has grown more complex, it has developed new program approaches for independent analyses of its own operations and for more flexible and independent ways of

operating. These developments include an increase in the range and frequency of contract arrangements with private nonprofit organizations to promote the achievement of specific public purposes.

In creating, or contracting with private organizations for the pursuit of a public purpose, however, government must always be concerned about how proper control can be exercised over those groups to which power or responsibility is being delegated. This problem is essentially one of balance between control, on the one hand, and

flexible independence on the other (since independence and flexibility were primary considerations in turning to private organizations in the first place). The formal criteria for the public accountability for any private organization performing a public or quasi-public function are usually established in specific terms by the governmental act or agency which creates or implements the program or contract. Accountability is formally achieved, therefore, by fulfilling the terms of the program or contract. But there is a need to supplement these specifics with a set of general principles and guidelines which can serve as a common base for understanding. Hence, this position paper. D. Health Institutions, Agencies, and

Organizations To achieve stable consistency and adequacy in community health care systems, individual health institutions, agencies, and organizations, whether nonprofit or proprietary, must meet public accountability requirements. This will require involvement by their governing bodies, by management, and by staff in the development of agency statements which specify goals, objectives, and schedules, and identify the equipment, facilities, personnel, capital, operating budgets, and proposed methods of financing needed to implement their goals and objectives.

Such planning is an inherent responsibility of management, and the legal and moral responsibility for public accountability rests with the governing board authorizing the development of proposals for the continuation, modification, expansion, or discontinuation of agency services to the public. To fulfill these responsibilities effectively a periodic re-examination of agency services and community needs is required; such re-examinations will be more accountable and credible if those affected by agency policies and services, particularly the direct service providers and the public, are involved in the reconsideration process. It is desirable to establish incentives AJPH January, 1977, Vol. 67, No. 1

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for innovation, and all levels of the health care system must therefore seek to balance the necessary values of flexibility and independence with the equally important considerations of accountability and appropriate control.

III. Recourse and Sanctions A. Recourse

The Act mandates a "town meeting" approach to health planning and resources development. That is, all parts of the affected community participate as peers in discussing issues and mapping strategies. Thus, the general public can attempt to influence non-accountable planning through: * Individual action (letters, visits, testimony, etc.); * Concerted activities (demonstrations, boycotts, mass meetings covered by the media to the embarrassment of the planners and planning bodies); * Overt and covert stimulation of local, state, and federal political pressures.

In addition, private individuals may also find sufficient legal interests to bring lawsuits challenging the HSA's planning processes. At the same time, these same public energies may be marshaled to support the HSA's planning and development strategies against inhibiting state or federal authorities. B. Sanctions

Legal precedent presents several possibilities for judicial sanctions. While Section 1512b-4 of the law seems to grant immunity from financial liability for governing board members for their planning activities, there are a variety of legal remedies and theories of liability which are not foreclosed. A challenging party can seek a court order that the HSA must perform or consider certain affirmative acts, or that prevents the AJPH January, 1977, Vol. 67, No. 1

HSA from continuing certain objectionable activities. The legal concept of fiduciary duty applies to an HSA. This duty arises because one person or agency is invested with the trust of another person or group of persons, and by that trust is obligated to exercise its authority and confidence on behalf of its constituency.

The concept is most frequently applied in the area of corporate law where boards of directors are said to have a fiduciary duty toward stockholders and, at times, toward employees. (A corporate stockholder, can, for example, file a "derivative action" lawsuit against directors who have breached their fiduciary duty.) With an expanded definition of protection, interests, and fiduciary trust, health services consumers might bring similar "derivative action" to challenge the adequacy of the HSA's consideration of its constituencies' health needs. This notion of expanded "public interest derivative suits" is a relatively new and developing area of the law and has little judicial recognition thus far; but, it has received the attention and support of commentators.

the form of money damages, but can be equally effective if it simply mandates reconsideration of a non-accountable plan. A third potential judicial sanction is found in the Federal Administrative Procedures Act. This Act establishes standards and processes against which courts review the actions of government agencies. "A person suffering wrong because of agency action, or adversely affected or aggrieved by agency action within the meaning of a relevant statute, is entitled to judicial review thereof' (Five USCA 702). In order to be reviewable under this statute, an agency's action must be "final". "A preliminary, procedural, or intermediate agency action or ruling" is subject to review only after it has become finalized by the agency. At the very least, this provision would mean that tentative decisions or plans of the HSA could not be reviewed by a court until they are submitted by the governing board as its official Health Systems Plan (HSP) or Annual Implementation Plan (AIP). (Conceivably, given the HSA-State relationships in the Act, an HSA action might not be considered final until after a plan for sanctions by recall or removal for cause has been adopted to help encourage accountable performance.) The personal accountability of governing body members or Health Systems Agency staff is better insured by the possibility of their own removal than by impersonal mandates for official agency action.

If a "derivative suit" is filed by a disgruntled community member against an HSA, some suggest that the directors will be unable to define on the basis that, after reasonable investigation, they had reasonable ground to believe, and, in fact, did believe that (their) decision was consistent with federal standards of corporate responsibility. In the case of HSAs, of course, the relevant standards would be the criteria for public accountability. (The performance standards established by the Secretary of HEW for HSAs provide guidance for developing these criteria into specific actionable requirements.)

Removal efforts might be undertaken by particular constituencies, by elected officials, or by entire jurisdictions (subarea councils); or, in the case of a public regional body, they might take the form of electoral sanctions, referenda, or recall of parent body members or the agency.

Nonconformity by an HSA to its statutory mandate might also result in legal liability for "malplanning". While the legal theory has not been fully developed, it seems in light of the planning duties enumerated by the Act, that further consideration is warranted. Again, liability for malplanning need not be in

The federal and state governments can trigger a variety of financial and administrative sanctions against nonaccountable local and state planning agencies. Through its budgetary authority the federal government can disapprove certain expenditures or deny funds entirely to an HSA or a state 81

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agency. The Act's proviso that operation and planning grants are made by the Secretary of HEW to an HSA on such conditions as the Secretary deems appropriate enhances the flexibility and utility of the federal financial sanction. Complete refusal of federal funding would effectively incapacitate a nonaccountable planning agency. Actual dissolution of a planning agency can be accomplished by Secretarial determination that an HSA has failed to adequately perform its functions.

IV. Mutuality in Accountability Thus far this paper has addressed the accountability of Health Systems Agencies to (1) the citizens of the communities they serve, (2) the state, and (3) the federal government. It is important to note that the entire structure established under P.L. 93-641 can be viewed as essentially an accountability mechanism. This can be said particularly of the HSA, the role of which is not primarily to be regulatory (for that is clearly a state function), but to promote the accountability of the local health care system, and to promote the effectiveness of these systems and thus to improve the health status of

people. Not only is the HSA supposed to be responsive, representative, and accountable through regular and complete reporting of its functions, but each of these obligations and functions is supposed to generate reciprocity.

The state and federal governments, for example, are supposed to be responsive to the contents of the local health systems plans; they are supposed to involve representatives of HSAs in their advisory and deliberative groups for health planning, review, and resources development; and they are expected to report in detail the grounds for their actions if they act contrary to the policies and priorities of the local health plans. Most important, however, is the accountability which the health service agencies, the media, and the people of the community are supposed to mani82

fest toward their own Health Systems Agency-by reporting their health program actions, needs, problems, and perceptions; by responding to the recommendations and priorities in the health plan, by reporting throughout the community the issues and the procedures on the basis of which the Health Systems Agency will generate its planning and review decisions. This agency accountability to the public through the Health Systems Agency is only implied in the law, but is essential for the effectiveness of the system and the community welfare.

Accountability is a two-way street. The Health Systems Agencies can, by following the principles set forth in this paper, demonstrate accountability well enough to merit continuance. But only if these agencies are, in turn, responded to effectively by the public in their planning areas can their work become fully responsive to their communities, and thus be accountable and productive in the best and richest sense. Making HSA accountability work is a shared responsibility.

Improving the Organization and Financing of Ambulatory Preventive and Primary Health Services in Today's Economy Statement of the Problem Provision of primary health care is a basic need. Primary health care includes the delivery on an ongoing ambulatory basis of preventive, diagnostic, and treatment services to infants, children, and adults. In any one year, although one out of ten persons requires inpatient care, nine out of ten individuals require preventive, diagnostic, or therapeutic treatment in an ambulatory care setting: hospital outpatient department, emergency room, neighborhood health center, community mental health center, or a physician's office. 1-3 Priorities in the allocation of funds must shift from provi-

sion of inpatient care to reliance on less costly ambulatory care. Mental health care can no longer be separated from the mainstream of personal health services and must be integrated into comprehensive health programs at the community level. Studies indicate that more than half the patients who initially present with physical symptoms also have psychiatric problems.4 Psychiatric treatment is shorter, more effective when rendered on an ambulatory basis in the community where the patient lives. In the future a National Health System may be achieved which will provide essential primary care for people of all income levels. Until that time, there must be interim measures which will maintain the financial viability of ambulatory care, continue basic service for all people, eliminate duplication

of services, discourage competition for clinic patients among various facilities, and decrease over-utilization of inpatient beds.

Recommendations 1. In many urban and suburban areas there is an overabundance

of hospital inpatient beds in public, voluntary, and proprietary hospitals. Health planning agencies estimate that four beds per 1,000 population are adequate to meet the need for inpatient care. Hospital beds can be eliminated. This should be done, not by decertification of eight to ten beds in a single institution, but by total closure of hospitals and elimination of underutilized units in other hospitals. Decertification of a few beds within a hospital does not decrease costs nor save money. The funds saved through the elimination of hospital beds can be rechanneled into ambulatory, preventive, and primary health care programs. Closure of inpatient beds need not eliminate the ambulatory care services, which can continue on-site or in an adjacent facility accessible to the community served. AJPH January, 1977, Vol. 67, No. 1

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2. Blue Cross/Blue Shield and other third-party insurers must make available to their subscribers coverage for all ambulatory care services at reasonable cost. This will include coverage for preventive, diagnostic, and therapeutic ambulatory care services in outpatient departments, neighborhood health centers, and offices of private physicians. Coverage should include provisions for ambulatory treatment of mental illness, including psychotherapy and drug and alcohol addiction. Only in this way can unnecessary expensive hospital care be eliminated. 3. Hospital-based ambulatory care units should be fiscal entities and not incorporated into either the capital or operating budget of the hospital. The ambulatory care organization may then contract clinical, laboratory, and other services from the hospital. This will more accurately reflect the true costs of the ambulatory care operation which in almost all cases will be decreased.

The high unit cost of hospitalbased ambulatory care programs may be due to several factors: the stepdown formula allocating a disproportionate amount of the hospital's general operating costs to ambulatory care; the inclusion of teaching and research programs in calculation of ambulatory care costs; the large number of specialty and sub-specialty clinics; and excessive utilization of laboratory procedures. In order to more accurately compute cost factors for teaching, research, and direct patient care, costs must be identified separately. This in no way diminishes the commitment to the principle of student education in primary care in an ambulatory care setting. Allocation of the costs of education to the ambulatory care programs should be made if health professionals are taught to provide comAJPH January, 1977, Vol. 67, No. 1

prehensive primary care to the patients. 4. Medicaid reimbursement rates for patient visits to an organized ambulatory care facility should not be an all-inclusive basis, but should be broken down into units of service provided. The denominator should be the specific unit of service rendered rather than the patient visit. 5. Reimbursement to hospital-based and free-standing ambulatory care facilities through a capitation mechanism must be encouraged in order to prevent unnecessary

utilization by the providers. Capitation rates should be available for Medicaid and Medicare patients, in order to discourage "ping-ponging" on the part of the physician and "shopping" by the consumers, which can result in improved care for people and decreased costs to federal, state, county, and municipal governments.

6. Physician's assistants, nurse practitioners, and other physician extenders in the delivery of primary ambulatory care must be utilized to the greatest extent consistent with the provision of adequate care. Medicaid, Medicare, and Blue Cross must reimburse for patient care provided in an organized ambulatory care setting by all health professionals. 7. Patient care in day-treatment or mini-surgical centers is essential as an alternative to inpatient care and reimbursement must be provided by third-party carriers. Cosmetic surgery, tonsillectomies and adenoidectomies, and herniorrhaphies on infants might all be provided at minimum expense on an ambulatory basis, with adequate reimbursement available.

8. The delivery of home health services must be financially encouraged as an alternative to institutional care. Maintenance of indi-

viduals at home rather than in a nursing home can take place only if all services needed by individuals become reimbursable. These include nursing care, personal health services, and homemaker services, as well as the services provided by the physician. 9. There must be effective regionalization of ambulatory care programs with the goal of available, accessible, and adequate primary care for all individuals. Analysis of existing data shows maldistribution of ambulatory care programs. In major urban areas, some communities have a plethora of primary care units and an absence of specialized services; other areas have gaps in the delivery of primary care and an excess of specialty clinics. Ambulatory care programs in hospitals and

free-standing ambulatory care facilities must be included in a system of regionalization. This can be done by cutting off reimbursement to programs and clinics which are considered non-essential by the planning and regulatory agencies because of duplication of services or patient underutilization. 10. Regionalization in ambulatory care must be aimed at elimination and/or consolidation of under-utilized specialty clinics. Many patients regularly attend a multiplicity of specialty clinics in addition to a general clinic. Primary care clinics should be available in every outpatient department and in every free-standing ambulatory care center. Patients can receive the major portion of their care within the primary care clinic. Specialty clinics should function as consultation clinics and not provide ongoing care. This will cut down on both personnel and number of clinic sessions. Underutilized specialty clinics should not be included in the reimbursement formula. 11. Development of referral mecha83

RESOLUTIONS AND POLICY STATEMENTS

nisms of both patients and patients' records among health facilities must be established. Duplication of history taking, physical examination, and in particular, laboratory and x-ray procedures must be eliminated. Costs will be saved and patient re-exposure to possible traumatic and injurious procedures will be eliminated. This system can also be utilized to advantage among intraclinic referrals in the same facility. 12. The burden for reduction in cost containment of the delivery of health service should not be placed solely on the provider of health care. Consumers of health care must assume responsibility for appropriate utilization of health services. The consumers of health service must also learn the benefits of ongoing health services in lieu of crisis-oriented medical care. This should be the primary function of health educators and community health aides. Patients enrolled in organized ambulatory care programs frequently refer themselves to many specialty clinics, and attend outpatient departments at several hospitals. Consumers must be encouraged to remain with one facility of their choice, and receive care in the clinic most appropriate to their needs. Both providers and consumers must accept ap-

propriate utilization of qualified allied health professionals in the delivery of ambulatory care. Health education and many preventive and supportive services are frequently performed more competently by allied health professionals than by physicians. The physician must accept allied health professionals gratefully and restrict his role to the services for which he is best qualified. This educational process can take place in a hospital setting and can be performed by physicians trained in community medicine and ambulatory care. Consumers will more readily accept qualified health personnel if physicians have a more 84

complete understanding of their own role and the role of these personnel.

1. Universal coverage * for all civilian residents of the United States;

Role of the APHA The American Public Health Association affirms the importance of preventive and primary health care for people. Because, in today's economy, cutbacks are occurring in outpatient health care, strong efforts must be taken by the State Public Health Associations in conjunction with state and local government for adequate financing of ambulatory care and elimination of unnecessary inpatient care. Through state and local government legislative and administrative actions, and through dialogue with the major providers of care, the State Public Health Associations, with the backing of the American Public Health Association, can implement these recommendations to improve the organization and financing of ambulatory preventive and primary health services.

REFERENCES 1. White, K. L. Life and death and medicine. Scientific American 229 (3):23-33. September, 1973. 2. Current Estimates from the Health Interview Survey. United States-1974. National Center for Health Statistics. Series 10-Number 100. 3. Utilization of Short Stay Hospitals. Summary of Non-Medical Statistics. United States- 1971. National Center for Health Statistics. Series 13-Number 17. 4. Hollinshead, A. B. and Redlich, F. R. Social Class and Mental Illness. John Wiley & Sons, Inc., 1958.

2. Comprehensive benefits * including preventive, diagnostic, therapeutic, health maintenance, and rehabilitative services for all illness categories and health conditions; * provided through primary care teams of physicians, dentists, nurses, and allied health workers that are linked with specialty consultative personnel, hospital, nursing home, home care, and all other necessary services to meet patients' total health needs;

* and meeting federal quality standards;

3. Financing by a combination of federal social insurance and general tax revenues * to insure health care as a social

right; * to achieve reasonable equity in paying for it;

4. Reform of the health care delivery system * to assure equal access to good health care for all; * to achieve efficiency and effectiveness in the delivery of health care; * to facilitate interaction between private sector delivery functions and governmental financing functions;

Committee for a National Health Service WHEREAS in 1970 the American Public Health Association took an initial step toward development of a rational health system in this country by recommending a "national health care program to include democratically constituted, consumer-majority, policy making bodies at every level of administration and with:

5. Organization and administration involvingfederal, state, and local governments with the assistance ofregional organizations forplanning and evaluation * with health-oriented direction at all levels; 6. Public accountability

* that assures maximum responsiveAJPH January, 1977, Vol. 67, No. 1

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ness of the health system to public needs;

9. Adequate manpower, service, and facility resources with

* with adequate data systems for monitoring performance and comparative evaluation;

* massive federal support for reorientation and expansion of basic and continuing education programs in the field of health; recruitment and support of students from segments of the population heretofore largely excluded from the health professions by economic, race, and sex discrimination; fostering the education of more professional health personnel who are interested in providing primary, personal, family health care; retraining present health workers and developing new types of health workers on a career ladder who can assume many of the tasks now performed by present types of health workers;

7. Economic leverage of governmental financing on the delivery system including

* payment to providers of care for professional and institutional services to defined population groups on a per capita basis; * annually negotiated rates for institutional providers and choice of prepayment or fee-for-service payment for professional providers; * incentives for providers to adopt patterns of organization and payment aimed at achieving more effective and efficient services, particularly those embracing prevention ofillness, accessibility, and continuity of care;

* redirection and enlargement of federal support of organized health services and facilities, with emphasis on support or regionalized health services; development of organized health care delivery systems with emphasis on primary care teams and internal linkages among various providers of services;

8. Revamped state programs for licensure of health facilities and health personnel to insure that

* expanding research in health services to discover new and better ways of providing quality care most economically;" and

they

Health Insurance for Preventive Services WHEREAS there are many illnesses for which effective preventive measures have been identified; and WHEREAS preventive measures can be delivered in a variety of ambulatory settings such as hospitals, neighborhood health centers, outpatient departments, and homes; and WHEREAS a variety of health care professionals are qualified to deliver specific preventive services; and WHEREAS the delivery of many preventive services such as screening, education, and counseling had been demonstrated to be cost effective; and WHEREAS preventive services rendered by the appropriate health personnel frequently are not reimbursed through insurance plan; and

WHEREAS non-reimbursement for preventive services results in consumer failure to seek care, provider omission of preventive services, and inappropriate use of hospital services and reimbursement mechanisms;

WHEREAS in subsequent years additional resolutions have been passed calling for the integration of specific components of health care (e.g. family planning, mental health, nutrition, others) into a coherent unified system;

THEREFORE BE IT RESOLVED that the American Public Health Association urge insurers (both public and private) to recognize preventive health services, the benefits of which have been demonstrated, and which are delivered by qualified health personnel as a reimbursable expense.

* provide for reciprocity of professional licensure of health workers moving from one state to another;

THEREFORE BE IT RESOLVED that the American Public Health Association modify the 1970 resolution to call for establishment of an actual National Health Service; and

Role of the Spanish Heritage Community in Delivery of Mental Health Services

* promote facility development and franchising in proper relation to social needs;

WHEREAS there now exist several proposals for a National Health Service bill;

WHEREAS the delivery of mental health services to the Spanish heritage population must be different from the traditional model; and

* include periodic inspection offacilities and examination of personnel;

BE IT FURTHER RESOLVED that a specific APHA task force study these

* provide prompt disciplinary action against those failing to comply with standards and other requirements;

proposals in order that the Association be able to promote that proposal which would establish an accessible, quality, rational National Health Service.

* meet a federal minimum standard; * encourage the elevation of standards to the highest possible level; * provide for consumer participation in policy-making bodies;

AJPH January, 1977, Vol. 67, No. 1

WHEREAS these differences have not been recognized or addressed or have at best been minimally, in the implementation of mental health program services to the Spanish heritage population; and 85

RESOLUTIONS AND POLICY STATEMENTS

WHEREAS this lack of recognition has created an insensitivity as well as ineffectiveness in the delivery of mental health services to Spanish heritage communities; and WHEREAS the Latino Caucus/ APHA recognizes: 1. The absence, in many cases, of Spanish heritage consumer participation in the planning and/or implementation of mental health services in their communities;

2. The neglect on the part of mental health providers serving these communities to involve Hispanic members in the decision making process; 3. The need for Spanish Heritage Community input in the legislative and regulatory processes dealing with delivery of mental health services; and

WHEREAS the American Public Health Association has, through past resolutions and policy statements, gone on record supporting the concept and practices of mental health being an integral part of public health and having the common goal of providing comprehensive and continuous care to satisfy the needs of the community whereby making mental health programs maximally effective and efficient; THEREFORE BE IT RESOLVED that APHA, through its members and their organizations, supports and encourages Spanish heritage community involvement as an essential requirement in the planning, implementation, and monitoring of all mental health programs allegedly serving Spanish heritage communities and/or populations; and BE IT FURTHER RESOLVED that APHA exhorts its members, as well as others, who are providers charged with the delivery of mental health services to Spanish heritage populations to make every effort to learn of the special needs of this group and provide the Spanish heritage community with infor86

mation on services that are available; and BE IT FURTHER RESOLVED that APHA in commenting on federal legislation, regulations, and guidelines which cover public and mental health services to minority populations make specific the inclusion of Spanish heritage representation so that such regulations and guidelines specify the inclusion of Hispanic representation, thus insuring that the intent of the legislation is in fact carried out.

Joint Commission on the Accreditation of Hospitals WHEREAS the federal government relies on the Joint Commission on the Accreditation of Hospitals to survey hospitals as a basis for participation in Medicare and Medicaid payments; and

WHEREAS the Joint Commission is a consortium of health care provider organizations whose expertise and interests do not necessarily include the concerns of state and local government and individual health consumers; and WHEREAS the Joint Commission on the Accreditation of Hospitals survey reports are confidential, as are certain public agency findings; and WHEREAS recent validation surveys conducted by the Department of Health, Education, and Welfare have found some hospitals to be delivering substandard care and having significant violations of federal and state health and safety standards; and

ment, the Joint Commission on Accreditation of Hospitals, state and territorial health officers and other appropriate agencies, and consumer groups to establish a balanced representative perspective on inspection of hospitals and other related health facilities; and BE IT FURTHER RESOLVED that APHA take the appropriate actions necessary to insure that all the findings of inspections and corrective action reports are readily available to the public within the confines of state and federal law.

Establishment of a National Health Service WHEREAS the current economic crisis has caused not only general increased unemployment but also continuing cutbacks in human services, particularly preventive health services, exacerbating the inadequacies and injustices of the existing health system; and,

WHEREAS a national health program is needed to insure the American public free comprehensive health care of the highest quality within a progressively financed, democratically controlled health system; and WHEREAS the National Health Insurance proposals currently being discussed in the United States Congress will simply support the present inadequate system of private health care delivery and would neither make high quality health care available to all Americans nor effectively control the rising costs of health care; and,

WHEREAS the sole use of JCAH accreditation as a means of quality control has proven to be inadequate;

WHEREAS the APHA has adopted a policy resolution establishing a Task Force to promote the establishment of an accessible, quality, National Health

THEREFORE BE IT RESOLVED that the American Public Health Association urge that the federal government review the use of JCAH as the sole guarantor of quality of medical care paid for by public funds; and

Service;

BE IT FURTHER RESOLVED that APHA work with the federal govern-

THEREFORE BE IT RESOLVED that we, the American Public Health Association, strongly urge the Congress to consider the creation of a nationally-financed health service based upon the delivery and control of health care services at the community level. AJPH January, 1977, Vol. 67, No. 1

RESOLUTIONS AND POLICY STATEMENTS

Such a community-based national health service would: * provide comprehensive health care, including preventive, curative, and occupational health services, to every person without charge and without regard to race, sex, income, national origin, citizenship, or place of residence; * eliminate the unnecessary inflation of cost and utilization resulting from the current fee-for-service system of remuneration;

* be planned and controlled locally, regionally, and nationally by representatives chosen by the people who use health services and those who deliver them; and * be financed by progressive taxation of individuals and corporations.

Home Health Services WHEREAS institutionalization of a patient in a skilled nursing facility or health-related facility can be expensive, impersonal, and does not always support independence; and WHEREAS community-based and hospital-based home health services are not always able to provide patients with alternatives to institutionalized care because of financial constraints; and

WHEREAS a full range of home health services including medical, mental health, nursing, nutrition, social work, podiatry, physical therapy, speech therapy, homemaking and personal care services, and ancillary services should be accessible to provide human care outside of the institutional setting that may be less costly; THEREFORE BE IT RESOLVED that the American Public Health Association recommend to Congress and the states that a full range of home health services provided by not-for-profit hospital and community-based home health services be reimbursed by public and private health insurers; and AJPH January, 1977, Vol. 67, No. 1

BE IT FURTHER RESOLVED that reimbursement can be received for home health services without the requirement of prior hospitalization; and

process of decentralization, appropriate and meaningful subarea councils which have representation on the Health Systems Agency governing council and executive committee.

BE IT FURTHER RESOLVED that home health services be held accountable through a statewide program of utilization review and quality control.

A Sound Basis for a National Health Program

Local Government Input into the Health Systems Agency WHEREAS over forty per cent of the funds for health facilities and programs comes from the taxpayer's pocket; and WHEREAS all health planning agencies should have ultimate accountability to the communities which they serve; and

WHEREAS by law almost all health regulatory functions are mandated to be performed by government agencies;

THEREFORE BE IT RESOLVED that all Health Systems Agencies which are not under public auspices immediately develop a permanent relationship with local government whereby local government has sustained input into policy, decision making, and implementation.

Supporting the Subarea Council Role within the Health Systems Agency

WHEREAS it is likely that a national health program will be established in the future; and WHEREAS the American Public Health Association has long advocated a national health program; and

WHEREAS the success of such a system will depend largely upon the establishment of a sound data base-for planning, decision-making, and evalua-

tion of impact; THEREFORE BE IT RESOLVED that the American Public Health Association urges the President and the Congress to begin planning now for the development of an information system which will be required for a national health program. Emphasis should be on coordination with existing health data systems, particularly those maintained by the National Center for Health Statistics, the Bureau of the Census, the Health Systems Agencies, and the Professional Standards Review Organizations; a new system should not be superimposed on existing systems.

The Expanded Role of the Nurse: The Nurse Practitioner Concept

WHEREAS in large urban centers with a population of over a million people, the needs, priorities, and resources within communities differ widely; and

WHEREAS both the education and utilization of nurse practitioners in a variety of clinical specialities has become widespread in recent years; and

WHEREAS in health service areas encompassing several counties, there are communities also having varying needs, priorities, and resources;

WHEREAS more than 30 states have either passed legislation or adopted rules and regulations sanctioning the expanded role of the nurse; and

THEREFORE BE IT RESOLVED that the American Public Health Association through its State Public Health Associations strongly urges that Health Systems Agencies develop, through a

WHEREAS national certification examinations have been developed and administered in several clinical specialities, and others are in the process of development; and 87

RESOLUTIONS AND POLICY STATEMENTS

WHEREAS plans for the national accreditation of nurse practitioner programs are going forward; and WHEREAS practitioner skills, increasingly, are being incorporated into undergraduate (primarily baccalaureate) nursing curricula; and WHEREAS nurse practitioners are continually demonstrating their competence in rendering quality care; and WHEREAS acceptance of the expanded role of the nurse, both by other health professionals and by patients alike, is becoming increasingly widespread;

THEREFORE BE IT RESOLVED that the American Public Health Association endorses the concept of the expanded role of nurses, believing that: a) nurse practitioners add a qualitative dimension to the ideal of complete and comprehensive health care for all persons; and

b) their widespread utilization will help to enable more persons receive appropriate, high quality health care; and BE IT FURTHER RESOLVED that the American Public Health Association, being aware that controversies vis-a-vis some of the specific activities of nurse practitioners may arise, will participate with other appropriate agencies and institutions, calling attention to the need for evaluation and research in this field; and BE IT FURTHER RESOLVED that the American Public Health Association recognizes that the nurse practitioner concept applies not only to the personal health services arena but also to that of community health; and

BE IT FURTHER RESOLVED that the American Public Health Association will take such actions it may deem necessary and appropriate to further the expanded role concept-both at the educational and at the service levels.

The Bureau of Community Health Services WHEREAS, The Bureau of Community Health Services (BCHS) has announced its intention to implement a system of common reporting; and WHEREAS, the system proposed would be used as a means of allocation of HEW funds for migrant health, community health centers, and family planning; and

WHEREAS, the system proposed requires a substantial amount of new information not currently collected by all these programs; and WHEREAS, there are substantial problems with regard to definitions, duplication of reported activities, performance criteria, and similar concerns; and

WHEREAS, there is no allowance for additional resources to assist in implementation, therefore the costs will have to be obtained by reduction in service funds; THEREFORE BE IT RESOLVED that the American Public Health Association communicate to the Secretary of HEW that the BCHS common reporting requirements not be used for policy information until the problems are resolved by appropriate period of field trial and that further impact be obtained from states and local projects and appropriate sections of APHA.

The New York City Public Health Crisis WHEREAS, there exists a generalized attack on the public hospitals and the health and mental health programs in New York City by the Mayor's Office and major banks; and

WHEREAS, this attack currently centers on the destruction of the New York City Health and Hospitals Corporation; and WHEREAS, the attempt to fire Dr. John L. S. Holloman, the President of the NYC HHC, by the Mayor's Office is an effort to remove a staunch advocate of the public hospitals and public health activities in general, in order to further their goal of giving away the public hospitals to the private sector; and WHEREAS if these efforts are successful in New York City the ability of similar forces to destroy public hospitals and health and mental health services throughout the country will be strengthened; and WHEREAS this destruction will adversely affect the health of the poor, with a disproportionate representation of Black, Latino, and other national minorities; THEREFORE BE IT RESOLVED that the Governing Council of the American Public Health Association declares the need of strengthening the public hospitals and health and mental health services, not of their destruction; and BE IT FURTHER RESOLVED that the APHA Governing Council calls upon the Mayor of the City of New York and its financial control board to stop their efforts to destroy the public health sector in their city.

GROUP B: ENVIRONMENT Energy Development and Use The nation's energy substantially has been provided by fossil fuels resulting 88

in diminishing domestic supplies of available oil and natural gas. President Ford, in his State of the Union Message, outlined several programs and actions that would reduce our depen-

dence on foreign energy supplies of oil. These action programs called for increasing use of the most readily abundant domestic fuels-coal and uranium. AJPH January, 1977, Vol. 67, No. 1

RESOLUTIONS AND POLICY STATEMENTS

WHEREAS there has been increasing concern that health and environmental quality standards might be compromised in favor of energy production and utilization; and

4. evaluation of the health and environmental consequences resulting from the long-term radioactive waste storage and transportation of these wastes, and

WHEREAS all types of energy development and use result in some degree of environmental health hazard which should be considered and minimized; and

5. continued attention to the question of safeguards against plutonium diversion; and

WHEREAS the allocation of support among energy alternatives at any time should reflect prospects for contribution to short-term energy needs, potential contribution to long-term energy needs, and the capacity of the existing research and development machinery to respond to additional input; and WHEREAS APHA has emphasized conservation of energy as being in the interests of environmental health protection and natural resources conservation (1973); and APHA has called attention to the need for resolution of nuclear safety and security issues (1974);

THEREFORE BE IT RESOLVED that in view of the nation's need for full development of all energy technologies, rather than calling for nuclear moratorium, it would be more appropriate to call for action related to unresolved questions of all energy sources. Such action would include: 1. thorough studies and continued updating of the health and environmental effects of all energy systems including the cost effectiveness of the control tech-

nologies, 2. development and application of new standards and technologies to assure that energy production does not result in avoidable unacceptable health and environmental consequences, 3. evaluation of the normal operational and accident consequences of the plutonium fuel cycle in studies comparable to those applied to the uranium fuel cycle, AJPH January, 1977, Vol. 67, No. 1

BE IT FURTHER RESOLVED that the American Public Health Association urges the development of a national energy policy that stresses: 1. energy conservation through low-

ered demands and efficient utilization, and 2. the development and rapid introduction into this society of energy technologies based upon renewable energy sources, particularly solar related technologies.

Environmental Health

Planning I. Purpose To promote integration and development of a philosophy for development of environmental health concerns as a vital component of the planning process.

I. Existing Problem Today the interaction of man and his environment is much more complex than it was 10 or 15 years ago. It is estimated that each year more than 500 new chemical compounds are introduced into industry, along with countless operational innovations, many without adequate knowledge or concern for potential hazards. The continuing environmental problems arising from pesticides, solid wastes, occupational hazards, accidents, radiation, noise, "miracle drugs", food additives, housing, and the increasing population give a clue to the necessity of understanding and reducing or eliminating environmental health problems. The complexities of the interaction between man and his environment lead

to organizational problems when addressed through current program philosophies and methodologies. Planning is one of the methodologies suitable for establishing balance and priorities in this complex relationship. In 1975 a survey was made of environmental health activities in nine representative states. "None of the states indicated an effective environmental health planning component or effective input to the environmental planning of other agencies. The lack of health input was noted particularly in the area of land use planning. Most of the program activities were related to state statutes and had little relationship to an established plan of action to meet any future goals and objectives for environmental health in the state."1I A review of the resolutions and policy statements adopted by APHA Governing Councils in recent years indicates a growing awareness of the importance of environmental health planning and increasing understanding of its practice. The problem, however, is a lack of policy and program to match the developing professional un-

derstanding.

III. Position Concern for the environment must become an important and viable element in the planning process to enhance and ensure the health, safety, and well-being of present and future

generations.

IV. Environmental Health Plan-

ning A. Definitional Basis for Environmental Health Planning

"Health is a state of physical, mental and social well-being and ability to function, and not merely the absence of illness or infirmity."2 At the wellness end of the health spectrum, "Health is the product of a harmonized relationship between man and his ecology."3 Environmental Health, therefore, is the environmental part of health. In program terms, it is part of the preventive 89

RESOLUTIONS AND POLICY STATEMENTS

aspects of health. In action terms environmental health becomes the harmonizing interventions made and defended in the name of human health. Environmental health planning, in turn, is the program element that assures attention to both the present and predicted environment. It has both categorical and systems aspects as well as programmatic and strategic features. B. Guiding Principles for Environmental Health Planning 1. Basic principles

a) Human ecology, the science of investigating man's relationship to his environment, provides the basic model for environmental health planning.

b) Environmental health is not the totality of environmental quality although almost all modifications of the environment do have impacts on human health. It is a continuing assessment of the impact of the environment on man. c) The human ecology model provides for program, strategy, and systems planning to take place in a communicating interrelated system.

d) The health system is not separate from the economic system. The health field, and environmental health planning in particular, should examine the economic system to find suitable relationships based on gains in human health. The term "social costs" provides a starting point. Societal affluence, coupled with changing values and conservation imperatives, provide the impetus. Both cost-benefit and cost-effective approaches to improved human health status can result from a close examination of the interface between the health and economics systems. 90

e) Environmental protection infers protection of the environment from outside influences. It relates to the total quality of

the environment. Environmental health pertains to the health of people in an environment. As such it must consider the life-styles of people and how the various living patterns affect health, all within a society that puts great emphasis on human value and freedom of choice.

f) Criteria are descriptions of effects expressed in numbers. Standards are criteria enacted into law. Health criteria and standards are the primary standards for planning and decision-making. 2. Policies

a) Land use planning agencies, also called A-95 agencies, are an important part, though not the only part, of planning with people and for geographic areas. In every state and area the relationship between environmental health planning and land use planning should be established and publicized. The organizational form and the documents expressing it will vary from simple agreements to ordinances, laws, and regulations.

b) Manpower development and position opportunities must be modified to reflect the changes inherent in the human ecology model. c) Research systems, as well as information and training systems, must recognize and become supportive of the shift to a human ecology model. 3. Methods

a) Both categorical and systems elements are needed in environmental health programs.

The means should be designed and implemented for continually updating program balance and emphasis in keeping with a human ecology model.

b) Environmental health planning programs should list the important environmental components for their planning areas with explanation and justification. These component lists should be prioritized, for-

mally adopted, publicized, and made available for policy decisions.

c) Land use planning in the practice of its technical functions uses numerous criteria and standards; therefore, all health programs can take part in land use planning by

developing

land based criteria and standards and the program means to assure their incorporation in plans and planning actions.

d) Available environmental health criteria and standards should be used to assure that all planners work toward a healthful environment. 4. Organization

a) Programs for comprehensive (systems) environmental health planning should be part of those agencies that are oriented toward prevention and have a planning base that is ample in scope to facilitate participation in land use planning, economic decisions and social welfare. This paper does not attempt to define the roles of the many agencies (federal, state and local) or private interests, but it does recognize the important leadership role involved. By providing policy and other guidance this paper hopes to encourage initiative and competition toward leadership and other roles while assuring responsible action. AJPH January, 1977, Vol. 67, No. 1

RESOLUTIONS AND POLICY STATEMENTS

b) Shared data systems, or systems that have a built-in capability to facilitate communications, are essential for environmental health planning. c) The state of the "health planning art" as well as policies, statutes, and funding priorities preclude planning in all health related areas equally. As a result, regional councils and others are doing human services planning, water and air quality planning, criminal justice planning, and other health related work. The need for such planning should not be denied. The immediate organizational need is for a means to establish the "health components" and prioritize them. This institutional capability plus adequate health criteria and a mutual working system between agencies, recognizing that they work with the same population and geographic area, provide the basis for a formalized institutional structure.

d) Research is essential for vitality in organizations. It should be organized to focus on problems and yield criteria and other useful program materials. Research is part of a process requiring federal, state, and local cooperation and the participation of researchers from many organizations.

e) Fundamental questions of law, authority, and economics exist regarding organization for health services at the areawide level. Since some of these matters are presently in the courts, it is appropriate that the role of the legal process be recognized and the importance of the division of powers between the states and the federal government be reaffirmed. At the same time it is important that the health of the people be uppermost among the objectives of those AJPH January, 1977, Vol. 67, No. 1

debating these questions. Regardless of the organizational arrangements devised, there is only one set of people and health problems in each planning area. Surely it is not beyond the nation's competence to develop innovative arrangements needed to resolve these fundamental questions in favor of people's health. C. Guidelines for Planning in Environmental Health Programs

Existing public health agencies are often limited in scope by statute or operating policies including funding. Until these limitations are resolved it is essential that agencies utilize the best available channels for listing and prioritizing environmental health components as part of comprehensive planning for environmental health. The following guidelines are intended to help agencies incorporate environmental health plans into health, land use, and other plans for their respective areas. As a minimum plans should include: 1. Provision for environmental health services, related to all pertinent factors, as part of all activities for the prevention of disease, trauma, or chronic conditions. A

comprehensive preventive effort incorporating environmental health services as an integral part will result in the maximum reduction of illness and injury from all causes, restrain increases in total costs, increase the quality of services being rendered, and aid in preventing unnecessary duplication of program activities; 2. An analysis of environmentally induced illnesses and injuries appropriate to a given area's needs, as determined by incidence data and local demographic, geographic, climatic, and other conditions with plan provisions to prevent and correct the problems found; 3. Provision for use of community survey instruments to accurately

assess existing environmental conditions affecting the health of the area's population; 4. Strategies to effectively integrate

traditional treatment-oriented services with preventive activities; 5. Demonstration projects which will result in reduction of environmentally-induced illnesses and in-

juries in the home, recreational and work environments; 6. Assurance that environmental factors impinging upon human health are given adequate consideration in the preparation, development, and implementation of master plans (land use, transportation, zoning, etc.) for urban and rural

communities. Environmental health plans, environmental impact statements, letters of agreement, trained manpower, ordinances, criteria, rules and regulations are examples of program means for obtaining assurance; 7. Strategies for development and

implementation ofhealth and safety codes applicable to conditions within the area; 8. Criteria for the evaluation of preventive environmental health activities including:

a) Changes in the incidence of environmentally-induced illness

and injuries; b) Changes in the prevalence of conditions that affect the health of the residents of the area;

c) Changes in the patterns that assess or prevent these environmental conditions.

Information relative to the activities above should be developed for, but not limited to, the components of environmental health shown in the Appendix.I 91

RESOLUTIONS AND POLICY STATEMENTS

V. Recommendations To guide, develop, and promote environmental health planning as a vital component of the planning process it is recommended that: a) The states working with local agencies share responsibility with the federal government for objective determination of environmental health program priorities;

b) The federal government aid the states and, through them, the designated health planning agencies in achieving longrange environmental health planning capabilities and initiation of plans; c) Federal resources be used to aid in identification of environmental health problems with the states and in the process the federal responsibility in the resolution of those problems be clearly delineated. The federal resources should be used to aid the states in developing long-range program plans and achieving a common future goal orientation for the state, local, and federal governments.

d) That a lead federal agency be designated to work with and coordinate the activities of all federal agencies involved in program areas cited in the Appendix in order to improve the administration and implementation of technical assistance, problem identification and assessment, and planning aid to appropriate state and local agencies; e) The federal government increase its capabilities to identify training needs. It should support those capabilities needed for environmental health programs as part of the over-all strategy for health services training; 92

The objectives of environmental health training should be defined within and incorporated into a program which studies, surveys, evaluates, and identifies the health and social impacts of those factors which comprise the manageable environment of the people of the nation. On the basis of priorities determined from such a program, a plan should be developed for a nationwide educational effort to produce new and improve existing resources adequate to deal with the identified priorities. Participation of govemmental organizations at all levels, educational institutions and other identifiable participants should be promoted. Within this format, the federal government should engage in the following efforts:

62:1140-1142, 1972. From Occupational Health and Safety Program. Urban Planning Aid, Boston, May 1971, Page 1.

APPENDIX Components of environmental health to be considered in environmental health planning activities include but are not limited to the following: 1. Air Quality

2. Food Protection a) Food service operations

b) Food and beverage vending machines c) Food processing establishments

d) Milk sanitation e) Nutrition f) Labeling 3. Water Quality

1. Traineeship support,

a) Drinking water supplies

2. Course support by all federal agencies involved in environmental health planning, and

b) Reuse/multiple use c) Aquaculture 4. Liquid Waste Management

3. Improvement of the university and college capability to train environmental health personnel;

f) All environmental health programs be modified to reflect new priorities in human health needs and all steps possible be taken by individual programs, or feasible program groupings to meet those needs. In this process it is anticipated that suitable institutional arrangements will evolve and that these will function primarily through planning. REFERENCES 1. Association of State and Territorial Health Officers, Survey of Environmental Health Services in Nine States-A Report and Recommendations for the Center for Disease Control, August 1975. 2. Terris, M. Approaches to an epidemiology of health. Am. J. Public Health 65: 1037-1045, 1975. 3. Reverby, S., A perspective on the root causes of illness. Am. J. Public Health

a) Community and individual sewage

b) Industrial liquid waste c) Agricultural

d) Runoff 5. Solid Waste Management

a) Residential

b) Commercial c) Industrial 6. Shelter

a) Housing (single family and multiple dwelling) b) Hotels, motels c) Mobile home parks d) Migrant labor camps e) Health care institutions and domiciliary care

f) Schools g) Institutional (prisons)

AJPH January, 1977, Vol. 67, No. 1

RESOLUTIONS AND POLICY STATEMENTS h) Emergency and temporary shelter 7. Recreational Safety and Health a) Camps (public and private)

cite only one parameter) for medical and governmental manpower, medical and governmental facilities, and money at an estimated $50 million annually for bites alone;2 and

b) Overnight RV parks c) Highway rest areas

d) Swimming pools and other bathing

places e) Public assembly areas f) Parks and playgrounds

WHEREAS unrestrained dogs and cats are a well known cause of destruction of private and public property; the cause of pollution3 and nuisance; the cause of approximately 6 per cent of personal injury and property damage which results from street and highway accidents ;4 and

8. Rural and Urban Planning

a) Land use

b) Transportation c) Environmental impact and conservation

d) Demographic analysis e) Growth planning 9. Vector Control 10. Occupational Health 11. Injury Control

WHEREAS unrestrained dogs and cats are a menace to the health and well-being of valued pets, as well as deer, song birds, and other desirable wild life which are frequently molested and killed by unsupervised dogs and cats;5 and WHEREAS much urgently needed protein for human consumption derived from livestock is lost due to the annual wanton killing of well over 100,000 of these food animals by unrestrained dogs;6 and

12. Radiological Health

13. Hazardous Substance Control 14. Noise Control

WHEREAS the curative measures employed in essentially all communities to control the unrestrained pet problems have proven ineffective; and

15. Animal Control

Public Health Support for Controlling Unrestrained Dogs and Cats WHEREAS unrestrained dogs and cats contribute to human health problems in ways which include 1 out of 200 people suffering annually from wounds caused by biting and scratching,' and the spread of significant diseases as shown by numerous surveillance reports by the Center for Disease Control (CDC) and in numerous scientific journals; and WHEREAS these conditions result in the creation of unwarranted demands (approximately 1/2 million doses of human rabies vaccine annually to AJPH January, 1977, Vol. 67, No. 1

WHEREAS the public health philosophy of prevention has not been applied to this problem as highlighted by the 1974 National Conference on the Ecology of the Surplus Dog and Cat Problems;7

cal governments give an administrative priority to establishing preventive programs that attempt to solve pet animal control problems which adversely affect public health for which tangible results would be measurable by determining the relative incidence of bites, number of uncontrolled animals, the number of animals impounded, and the incidence of wanton killing of food animals.

REFERENCES 1. Center for Disease Control, Zoonose Surveillance: Rabies, June-August, 1972. 2. Djerassi, C., Israel, A., and Jochle, W. Planned parenthood for pets? Bull. Atom. Sci.: January 1973, pp. 10-19. 3. Beck, A. M. The public health implications of urban dogs. Am. J. Public Health 65:1315-1318, 1975. 4. Carding, A. H. The significance and dynamics of stray dog populations. J. Sm. Anim. Practice, 10:419-446, 1969. 5. Caras, R. Meet wildlife enemy number 2. National Wildlife, February-March 1973, pp 30-31. 6. Personal communication to Dr. Alan Beck by E. Dolnick of the Sheep and Fur Animal Research Branch, USDA, Beltsville, MD, April 1972. 7. Proceedings of the National Conference on Ecology of the Surplus Dog and Cat Problems, May 21-23, 1974, in Chicago,

Illinois.

The Utilization of Environmental Control Officers in Hospitals

Statement of the Problem

THEREFORE BE IT RESOLVED that the American Public Health Association urges all state and local health departments to cooperate with state and local education departments to develop educational materials for school use to teach the fundamental responsibility which need accompany pet ownership, and that these materials give emphasis to public health problems that can be controlled by proper pet restraint; and

Over the past six years we have witnessed a national drive to clean up the physical environment and protect the health of the worker and public. Numerous federal, state, and local regulatory agencies have been established, goals have been identified and standards set. The National Environmental Policy Act (NEPA) of 19691 and the Occupational Safety and Health Act (OSHA) of 19702 have stimulated legislation, rules, and regulations which have provided the impetus for many actions.

BE IT FURTHER RESOLVED that all state and local health departments in cooperation and coordination with lo-

A number of OSHA3 and national consensus standards4-6 include sections applicable to hospitals. However, 93

RESOLUTIONS AND POLICY STATEMENTS

there are no comprehensive national standards. Most state regulatory agencies have developed their own standards or have relied upon those of the Hill-Burton7 and Medicare-Medicaid8 programs, and the Joint Commission on the Accreditation of Hospitals (JCAH).9 Specific standards for operations unique to hospitals and guidance regarding the scope of occupational health programs are being developed or have been proposed.10 The College of American Pathologists, for example, has adopted standards for accreditation of medical laboratories.11 The passage of such standards has resulted in increased attention being focused on the essential requirement to provide a safe and healthful environment in all hospitals for patients, staff, and visitors.

Licensing and accreditation requires that effective occupational safety and health programs be established and implemented on a continuing basis. Such programs include nosocomial infection surveillance and control, safety, and occupational health. The scope of these programs and specific information regarding standards and implementation is available.12-17 Failure to control the physical facilities and actions of individuals concerned may lead to patient, employee, or visitor injury, infectious disease, potential job related disability, and property damage. It should be noted that the hospital industry, employing over 3,000,000 individuals, is the third largest employer in the United States. The American Hospital Association reports that "in 1972 there were approximately 31 million admissions to hospitals. Approximately 5 per cent (or 1.5 million) of these patients developed nosocomial infections during their hospitalization." This extra burden placed upon the health care system, resulted in 11.5 million additional patient days at a cost of $1.1 billion for direct hospital costs plus additional physician services of about $1 10 million.

Implementation of a comprehensive environmental health program in hospitals should provide immediate benefits. The average present length of stay, per 94

hospital infection, is 7.4 days. Reduction in infection would decrease the length of stay and patient or third-party cost. In 1960, the cost of hospitalization was about $30 per day. In 1975, costs to the health consumer have risen to a national average of over $130 per day. The spiraling costs of delivering health care mandates strong effective measures. The hospital Infection Control Committee is given overall responsibility for supervising Infection Control in the JCAH Standards: "(1) develop written standards for hospital sanitation and medical asepsis, and (2) develop, evaluate, and revise on a continuing basis the procedures and techniques for meeting established sanitation and asepsis standards." Usually no one member is professionally qualified or has the time required to manage this aspect of an environmental program.

Adequate ventilation, chemical exposures, radiological hazards, noise control, good food hygiene, appropriate disposal of solid and liquid waste, proper sterilization of equipment and supplies, extermination of insects and rodents, and better housekeeping practices are all among the areas of environmental concern. In addition, equipment, supplies, and new products brought into the hospital require careful evaluation for potential hazard prior to use.

Another area of concern demanding attention is the establishment and implementation of a medical safety program. The responsibility for various aspects of the safety program are normally given to either the hospital safety committee, engineering/maintenance department, or an administrative assistant.10 Although certain individuals may be interested in particular elements of the medical safety program and may possess, as in the engineering department, qualified personnel technically competent in a specialized area, no one individual is usually qualified to organize and implement a comprehensive safety program. The revised JCAH Standard on Safety calls for the designation of a Safety Director or Officer who

should have training and/or experience in safety as well as time to direct and coordinate all phases of the program. The problem of control over all environmental areas within the hospital is compounded because responsibilities are frequently divided among the individual specialty areas. This fosters a fragmented approach. The economy of assigning added tasks to persons who may already be over-utilized tends to be counterproductive. The absence of an environmental control officer responsible for management of comprehensive environmental programs on the staff of many hospitals has resulted in the lack of comprehensive and effective environmental health programs. A qualified environmental control officer would provide the necessary coordinated control over the total environment including development of comprehensive accident prevention and safety programs for patients, employees, and visitors. The environment control hospital officer should have the administrative authority to use professional discretion with wide latitude in affecting needed changes. An environmental control officer should be able to move affirmatively in every situation involving the environment which requires immediate response. The moral imperative to provide a safe and healthy environment is best accomplished utilizing the professional services of a qualified environmental control officer charged with the responsibility for implementing decisions and coordinating departmental efforts.

Purpose The purpose of this position paper is to emphasize the need for and urge the adoption of appropriate standards re-

garding the utilization of environmental control officers in hospitals.

Objectives The objective of this paper is to initiate action which will assure the creation and maintenance of a safe, healthful environment in all hospitals for patients, staff, and visitors through the AJPH January, 1977, Vol. 67, No. 1

RESOLUTIONS AND POLICY STATEMENTS

utilization of individuals specifically qualified to coordinate and implement environmental control programs.

Action Desired The American Public Health Association should exercise a national leadership role advocating the utilization of environmental control officers in health care facilities. The person holding the title of environmental control officer on the hospital's administrative stall should have specific academic training and/or experience to cope with the myriad components of the hospital environment. Minimum requirements should include a baccalaureate degree (graduate degree preferred) from a recognized institution in environmental health science or a related degree with an internship or training in institutional health management, a;ministrative techniques, and environmental control.

Implementation of Position Paper Following endorsement of the position paper, the Health Care Facilities Committee, Section on Environment, should be designated to prepare model standards and guidelines and coordinate their adoption with appropriate agencies. It is suggested that the following guidelines be used in development of standards: a) education and work experience of environmental control officers; and b) utilization of the environmental control officer as a function of hospital size. REFERENCES 1. Public Law 91-190, National Environmental Policy Act of 1969, January 1, 1970. 2. Public Law 91-596, Occupational Safety and Health Act of 1970, December 29, 1970. 3. Title 29, Labor, Chapter XVII, Occupational Safety and Health Administration, Department of Labor Occupational Safety and Health Standards, Federal Register, Volume 39, Number 125, June 27, 1974. 4. American National Standards, American National Standards Institute, New York, NY, October 1975. 5. Standards, Underwriters' Laboratories, Inc., Chicago, IL 60611.

AJPH January, 1977, Vol. 67, No. 1

6. Standards, National Fire Protection Association, Boston, MA 02110. 7. Minimum Requirements of Construction and Equipment for Hospital and Medical Facilities, US Department of Health, Education, and Welfare, Publication No. (HRA) 74-4000, 1974, US Government Printing Office, Washington, DC 20402. 8. Hospital Survey Report, Form SSA1537, 11-74, US Department of Health, Education, and Welfare, Social Security Administration, US Government Printing Office, Washington, DC 20402. 9. Accreditation Manual for Hospitals, 1970, updated 1973, Hospital Accreditation Program, Joint Commission on Accreditation of Hospitals, Chicago, IL 60611. 10. Hospital Occupational Health Services Study, Volumes I through VI, US Department of Health, Education, and Welfare, National Institute for Occupational Safety and Health, Cincinnati, OH 45202. 11. Standards for Accreditation of Medical Laboratories, Commission of Laboratory Inspection and Accreditation, College of American Pathologists, Chicago, IL 60601, September 1974. 12. Mabbett, A. N. and Flynn, M. M., Infection control-A self evaluation, Hospital Topics, 53(6), pp. 29-34, November/December 1975. 13. Infection Control in the Hospital, American Hospital Association, Chicago, IL 60611, 1974. 14. Proceedings of the Intemational Conference of Nosocomial Infections, Center for Disease Control, August 3-6, 1970, American Hospital Association, Chicago, IL 60611, 1971. 15. Bond, R. G., Michaelson, G. S., and DeRoos, R. L. (Eds), Environmental Health and Safety in Health Care Facilities, MacMillan Publishing Co., New York, NY 10022, 1973. 16. Top, F. H. (Ed), Control of Infectious Disease in General Hospitals, American Public Health Association, Washington, DC 20036, 1967. 17. Center for Disease Control, National Nosocomial Infections Study, Quarterly Reports, January 1970 through December 1975, Atlanta, GA 30333. 18. Health Care Facilities Section, National Environmental Health Association, Qualified environmentalist/sanitarian needed in every health care facility, Journal of Environmental Health, 38(1), pp 24-25, July/August 1975.

Safe Drinking Water Act WHEREAS the theme of the 104th Annual Meeting of the American Public Health Association is "Prevention in Today's Economy"; and

WHEREAS the passage of P.L. 93523, the "Safe Drinking Water Act," provides the nation with a most significant piece of preventive health legislation; and WHEREAS the legislative history of the Act reveals the concern of Congress for providing, and repeatedly calls upon the Administrator of the Environmental Protection Agency to provide the maximum protection to the public health; and

WHEREAS continuing research and technological advances in analytical techniques and instrumentation have made possible the discovery of more specific information about the quality of the nation's water supplies; and WHEREAS low levels of some 300 toxic substances, including many known or suspected carcinogens to humans and laboratory animals, have been found in the nation's water supply; and WHEREAS sustained exposure to chronic low level contaminants may have unknown adverse health effects, and in some instances can cause acute conditions, evident only under stress or after long-term exposure; and

WHEREAS a very substantial portion of the public's drinking water supply is obtained from sources contaminated by or subject to contamination by liquid waste and runoff resulting from industrial, agricultural, and municipal operations; and WHEREAS such industrial, agricultural, and municipal operations are regulated by the Environmental Protection Agency under the National Pollution Elimination Discharge Systems for the protection of the public health; and WHEREAS preventive public health is best served by keeping contaminants out of the nation's drinking water supply rather than by taking them out during the course of treating drinking water for public use; and WHEREAS maximum protection of 95

RESOLUTIONS AND POLICY STATEMENTS

the public health associated with the consumption of water is achieved when permits issued under the National Pollution Elimination Discharge System for regulating the discharge of waste waters to the nation's waterways are integrated with limitations imposed by the National Primary Drinking Water Regulations; THEREFORE BE IT RESOLVED that the Administrator of the Environmental Protection Agency be requested to: 1. Continue current and expand future resources and efforts of EPA assigned to the health aspects of water resources research-not limited to identification of maximum contaminant levels for the "National Primary Drinking Water Regulations," but including the identification of other potentially dangerous substances discharged to or found in our water supply sources; and

2. Publish periodically, but not less than once each year, the results of research associated with contaminants in drinking water and its implications regarding the establishment of contaminant limits for wastewater standards for the protection of the public health; and 3. Provide maximum program emphasis to reducing to an absolute

feasible minimum the discharge into water supply sources of industrial, agricultural, and municipal operations of toxic substances regulated by the National

Primary Drinking Water Regulations; and 4. Identify significant concerns and correlate the level of health protection afforded by each discharge permit issued under the National Pollution Elimination Discharge System with the National Primary Drinking Water Regulations when the effluent from a wastewater treatment facility is discharged to a water supply source; and 5. Proceed cautiously in the promulgation of additional primary standards (chemical organic and inorganic) for drinking water pending release and assessment of the report of the National Academy of Sciences committee which was established by law to make recommendations to the Administrator of the EPA for this purpose.

ment is an essential element of compre-

hensive environmental health and pollution control, and should therefore be accorded increased emphasis; and

WHEREAS, both resource recovery and hazardous waste control require close cooperation of the private and public sectors; THEREFORE BE IT RESOLVED that the American Public Health Association endorses the concepts expressed in the Resource Conservation and Recovery Act of 1976, and urges private industry and local, state and federal governments to cooperate in its effective implementation; and BE IT FURTHER RESOLVED that the Administration and the Congress be requested to fully fund the authorizations of the Act; and

National Solid Waste Legislation

BE IT FURTHER RESOLVED that the Environmental Protection Agency provide for administrative procedures which are flexible and with minimal red tape and paper work as expressed in the intent of Congress; and

WHEREAS, Congress has enacted the Resource Conservation and Recovery Act of 1976, which authorizes increased programs for research, demonstrations, and technical development and mandates regulation of hazardous wastes; and

BE IT FURTHER RESOLVED that the states, local governments, and private industry are urged to undertake resource recovery programs to conserve national resources and energy, as well as to protect environmental quality; and

WHEREAS, this legislation would further build upon the foundations developed through existing state and local programs, and previous federal statutes; and

BE IT FURTHER RESOLVED that APHA urges that EPA designate a trained and experienced professional to the newly created position office established by the law to direct the office of solid waste which will administer the law.

WHEREAS, solid waste manage-

GROUP C: MANPOWER, INTERNATIONAL HEALTH, AND OTHER Policy on Malpractice The escalating cost of medical malpractice insurance has caused a crisis in the delivery of health services, and has adverse effects on patients, health care providers, and insurance com96

panies. Despite dramatic premium increases, only a fraction, variously estimated at 17-40 per cent' of the approximately $1 billion spent in 1975 on malpractice insurance premiums, will actually go to patients or their survivors. The rest will be spent for legal

fees and expenses of the tort law liability system for administrative and marketing costs of professional liability insurance.2 The high cost of malpractice insurance is passed along by providers of AJPH January, 1977, Vol. 67, No. 1

RESOLUTIONS AND POLICY STATEMENTS

services to consumer-patients and, through health benefit plans, to workers and their families, and through Medicare and Medicaid to the tax-paying public, thereby adding to the already high cost of health services. Additional costs of an unknown amount are imposed on patients because fear of malpractice suits leads providers to change their mode of practice by introducing services and procedures not necessarily required for adequate care. The malpractice insurance crisis is accentuated by basic problems in the health care system, including: a) risks associated with advancing technology; b) inadequate mechanisms for evaluating and improving the quality of care; c) lack of access to services because of economic barriers; d) patient frustration with the system; and e) actual negligence on the part of health care providers. The American Public Health Association has adopted a strong policy endorsing national health insurance and quality controls over health care. The Association, furthermore, recognizes that untoward outcomes are an inherent risk of modern medical care with its advancing technology. Even if national health insurance and quality controls are fully implemented, the issue of compensation for untoward outcomes will still remain.

Discussion 1. The main objective in the resolution of the malpractice insurance crisis should be to develop an appropriate system of compensation for injured patients. 2. It is the position of the Association that the present system of tort law liability does not meet that objective in an efficient manner.

natives must be compensation for untoward outcomes regardless of

negligence. 4. Such alternatives should include: a) definition of compensable events; b) creation of a sound administrative structure; c) provision for appeal, d) development of incentives for improved provider performance; and e) adequate mechanisms for financing.

5. Close scrutiny should be given to short-term solutions designed to reform current compensation mechanisms to assure that the burden of "shoring up" the system does not fall unfairly on the injured patient. 6. Any new system of compensation should be fully integrated with other compensation systems, in-

cluding workers' compensation, health insurance, and social security.

Action 1. The American Public Health Association will actively seek funding from the appropriate HEW source to develop a Task Force Study on a long-range basis to gather data and project an alternative to the current system of tort

law liability. 2. The Association will share its position and all subsequent findings with each state government.

REFERENCES 1. The Report of The Special Advisory Panel on Medical Malpractice of The State of New York, p. 250 (January, 1976). 2. Ibid, p. 251, (For a list of marketing

costs).

Policy Statement on International Health

History and Background 3. The goal of the Association is to support the development of alternatives to the current tort liability system. The essence of such alterAJPH January, 1977, Vol. 67, No. 1

The American Public Health Association's involvement in international health is almost as old as the Associa-

tion itself. Its membership has included health workers from other countries since 1884. Today the Association embraces membership from around the world. Vice Presidents from Canada and Latin America are elected at our annual meetings. APHA's annual meetings have provided locale for the annual meetings of the National Citizens Committee for World Health-now called the American Association for World Health. The APHA is one of the founding members of the recently established World Federation of Public Health Associations. On the scientific front, the deliberations of APHA's technical committees have produced publications and program guides that command worldwide distribution. For example, Control of Communicable Diseases in Man is in its eleventh edition and has been translated into 12 languages. APHA's Standard Methods for the Examination of Water and Wastewater (developed in cooperation with the American Water Works Association and the Water Pollution Control Federation) is recognized throughout the world as "the manual" for laboratory practices in the field. The educational contributions of these and many other special publications of APHA are acknowledged by all practitioners in the public health field.

Dating back to at least the 1955 annual meeting, the Association has adopted significant resolutions and policy statements relative to international health. These include urging the U.S. Government to become more involved in international health activities, support for global campaigns to eradicate malaria and smallpox, implementation of a worldwide domestic water supply program, endorsement of the 5th World Conference on Health and Health Education, and support for increased research in international health. Throughout the history of the Association, the annual meeting has included topics of significance to international health. "Public Health is One World" was the theme of the 87th annual meeting in Atlantic City, NJ in 1959. That annual meeting also saw the 97

RESOLUTIONS AND POLICY STATEMENTS

initiation of the formal recognition of international health as a continuing organized function of the Association.

Earlier Position In 1967 the Association adopted an explicit policy statement on international health. That statement set forth seven basic considerations as guidelines for more active participation in the international health field. Today this policy is implemented through the Association's International Health Committee, formally established in 1959, and its Division of International

Health.

New Developments The broad mandate established by the 1967 policy statement stimulated further relationships between APHA and the U.S. federal government. It took on special importance in 1968 when it appeared that the U.S. foreign aid program was reducing its investment in health services. Following discussions between the Agency for International Development and the Association, APHA was engaged in 1969 to do a study in South Korea relating to maternal and child health and family planning. Since then, an ever-increasing proportion of APHA's activities, and especially those of its full-time staff members in the international health field, have been involved in work under contracts to U.S. AID. This work has included many projects in the field of population policy and family planning, promotion of voluntary health agencies in other countries, strengthening of health education programs, launching a program in the development and evaluation of integrated delivery systems for health, family planning, and nutrition (DEIDS), and a wide-ranging consultation service in the population/family planning field.

Current Situation: A Policy for Today While this work has contributed positively to the improvement of world health and has been consistent with official APHA policies, there are addition98

al areas of interest and concern that were outlined in the broad perspective of the 1967 policy statement which are deserving of attention. APHA is aware that we live in a dramatically turbulent world, a world beset with political upheavals, national catastrophies, enormous inequities, and constant social change. The health status of and the health services for millions of human beings are affected daily by these events. The APHA continues to believe that support of health services and programs for all people is an essential instrument for world peace and international social and economic development. In order to provide a balanced framework in which APHA can broaden its participation in the achievement of the objective embodied in this belief, a restatement and updating of the APHA policy statement on international health seems appropriate at this time. Accordingly, APHA renews its previously stated intention to: * Participate in the development of staff and programs, at home and abroad, that enable the implementation of recognized and accepted practices in the public health field. This requires working, when appropriate, with national governments, philanthropic foundations, health and related missions, voluntary agencies, and others. It involves the solicitation of funds for worthy international health projects from U.S. government agencies, international agencies, philanthropic foundations, and other sources. APHA will make a special effort to cooperate with professional health workers and associations in other countries and will increase its efforts in international health activities by working more closely with the World Federation of Public Health, World Health Organization, International Development Research Centre, United Nations Fund for Population Activities, and United Nations International Children's Emergency Fund;

* Encourage the U.S. Government, through its appropriate agencies and organizations, to develop an effective career service in the field of international health. This also involves the provision

of increased financial support to schools of the health professions, to enable them to expand support of educational programs in international health. APHA will work closely with these government agencies and professional schools and share with them appropriate experiences and information gleaned from its international and activities programs;

* Encourage public and private agencies to support the expansion of carefully planned international exchange programs of scholars, students, and professionals-involving educational institutions, official and voluntary health agencies, and health related professional organizations and associations. APHA will provide staff assistance in furthering and effecting these exchanges whenever it is desired;

* Work for broadened support from government and private sources of all research programs in international health. APHA will work to expand the publication and distribution of significant research findings and recommended public health standards and guides so that all persons that may benefit from such information will have access to it. APHA believes that encouraging close collaboration among health and scientific scholars of all countries can reinforce each of their contributions to improving the health of the world's people; * Cooperate with individuals and other agencies working in sectors such as

agriculture, education, and economic development so as to contribute to comprehensive development and improvement in the quality of life.

Association Roles The special strength of APHA is the independence of its 50,000 members, as members of this Association.* The APHA is accordingly beholden to no arm of government nor of private inter*Ed. Note: APHA's membership, includ-

ing its 51 state and local affiliates, is comprised of more than 50,000 health professionals.

AJPH January, 1977, Vol. 67, No. 1

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ests in the formulation and execution of its policies. Because governments are inevitable instrumentalities of changing political ideologies at different times and places, APHA must guard especially against becoming merely an agent of any government, domestic or foreign, with which a majority of its members may not agree. The dangers of such innocent servility would seem to be particularly marked in the field of international health. APHA must be ever mindful of this principle in considering proposed contracts and recruiting the staff to execute them. APHA should exert its influence in helping to achieve for all countries the health goals formulated in the Constitution of the World Health Organization-a global body representative of all nations. When situations arise anywhere in the world in which those goals appear to be thwarted, the Association should speak up in the interests of promoting the people's health. At such times such a policy may prove to be harmonious with the political posture of the U.S. Government, and at other times it may not be. The attractions of fiscal support from either governmental or private agencies must never be permitted to inhibit or distort the exercise of independent judgment of the Association on such matters.

Formulation of generalized and permanent principles on all matters affecting the health of people at different times and places is virtually impossible. APHA should, nevertheless, be on the alert for events in all countries which may have a significant bearing on the public health and on which APHA might exert a positive influence. The Association should speak up openly and clearly on such events. To guard against parochialism, APHA should, to the greatest extent possible, look upon the public health workers of other countries, not the governments of those countries, as their kinsmen. Its international activities, therefore, should be carried out as much as feasible in collaboration with the World Federation of Public Health Associations. Likewise, insofar as the AJPH January, 1977, Vol. 67, No. 1

leadership ofgovernments in many matters is essential, APHA should look to the World Health Organization-an organ of essentially all governments in the world-rather than to the United States government or any other specific government for policy guidance. To promote the health of all mankind, regardless of race, religion, political belief, or other personal attributes, APHA should do whatever it can to help the forces of democracy, humanity, and equity in all countries. To use most prudently its limited resources, it should concentrate its efforts on attempting to correct any social conditions anywhere which we believe to have a deleterious effect on health-be it the spread of pathogenic organisms, the smoking of cigarettes, the pollution of the environment, or the suppression of the freedom of public health workers. The implementation of these principles, we realize, will not be easy. We affirm, however, our resolve to attempt to do this, with complete objectivity, scientific honesty, and humanity.

Contractural Support of Activities The Association has several contracts with AID which increasingly make the Association an effective world leader and force for developing and evaluating humanitarian programs for the improvement of health, family planning, and nutrition services and environmental conditions for the least served populations in developing countries who are subject to overwhelming burdens of disease. These contracts are reviewed and approved by the Committee on International Health and by the Executive Board of APHA, and are consistent with Association policies as well as with those of the WHO as adopted by representatives of all countries participating in the World Health Assembly, and these are directed toward the enhancement of all countries' capability to provide effectively for the health care needs of their people. The Governing Council of APHA herewith endorses and encourages continuance of the international health ac-

tivities of the Association, including continuing contractual arrangements with AID or other organizations when and as approved by the Executive Board of the Association.

Role of Spanish Heritage Ancillary Health Care Workers in the Delivery of Service to Spanish Heritage Population WHEREAS the health care needs of the Spanish heritage population in the current health care delivery system have been generally misunderstood and misinterpreted, due to the language barrier and other things; and WHEREAS Spanish heritage ancillary health care workers in the current health care delivery system are not widely recognized by that system to have a special role in the Spanish heritage community and are often used inappropriately or are under-utilized or are not always accepted as an integral part of the direct provider system itself; and WHEREAS underutilization denigrates the professionalism of the Spanish heritage ancillary health care workers and leads to unnecessary waste of scarce health manpower resources; and WHEREAS the American Public Health Association recognizes that the general population is not aware of such inequities and mistakenly perceives that health care services for the Spanish heritage population are fully and

comprehensively rendered; THEREFORE BE IT RESOLVED that the American Public Health Association, recognizing the seriousness of the problem, encourages its members and the organizations for which they work to be sensitive to the special role of the Spanish heritage ancillary health care workers and to take corrective action where appropriate; and BE IT FURTHER RESOLVED that APHA supports the incorporation of Spanish heritage health manpower at all levels of the health care delivery sys99

RESOLUTIONS AND POLICY STATEMENTS

tem in the United States, including the assessment and treatment phases of health care as well as the development of career ladder opportunities for Spanish heritage ancillary health care workers; and BE IT FURTHER RESOLVED that APHA, through statements at Congressional hearings or other legislative liaison means, supports health manpower legislation that is categorically oriented to improving the skills and increasing the number of bilingual ancillary health care workers.

Challenge Funds for Affiliates WHEREAS the American Public Health Association has recently reaffirmed its interest in working with and strengthening relationships with Affiliates through the reconstitution of the Committee on Affiliated Associations, Regional Branches and Chapters (CAARBC) and through the formation of the Affiliate and Section Affairs Office in the APHA central office; and WHEREAS challenge funds recently have been made available to APHA Sections; and WHEREAS support of Sections has increased from $25,464 in 1971 to $154,944 in 1976, and support of Affiliates and Regional Offices has increased only from $82,669 in 1971 to $98,553 in 1976;* THEREFORE BE IT RESOLVED that the Governing Council of APHA approve in principle the making available of challenge funds to affiliates in FY 1977; and BE IT FURTHER RESOLVED that the Governing Council direct the Committee on Affiliated Associations, Regional Branches, and Chapters to work with the appropriate APHA unit(s) to implement this proposal.

Implementation of Affirmative Action for Minorities and Women WHEREAS minorities and women have been either seriously under-repre*Source: The Nation's Health, April 1976 100

sented or in some instances excluded from elected offices in major organizations within the American Public Health Association; and WHEREAS the great numbers of qualified minorities and women who are or have been members of APHA preclude all arguments that there is a lack of qualified candidates for elected offices within APHA; and WHEREAS racism and other prejudices represent major causes for the under-representation of minorities and women in the elected offices of APHA; and

WHEREAS APHA's history and organizational procedures continually contribute to the under-representation of minorities and women; and WHEREAS APHA has, for years, had an affirmative action policy for minorities and women as set forth in its Constitution and By-laws; and WHEREAS some components of the Association are not in compliance with the accepted policy; THEREFORE BE IT RESOLVED that the Equal Health Opportunity Committee, after receiving the staffproduced affirmative action report, make recommendations to the Governing Council; and

Equal Health Opportunity Committee in all activities necessary to carry out this activity.

Professional Consultation from DHEW WHEREAS in early summer 1976 the U.S. Department of Health, Education, and Welfare initiated a process whereby the professional designations for health program consultants (e.g., medicine, dentistry, nutrition, social work, and nursing) are being eliminated through reclassification of these positions into the generalist series which eliminates requirements for specific professional qualifications; and

WHEREAS specific and expert professional consultation is essential for local health professionals to plan, implement and evaluate health programs; and WHEREAS this reclassification of consultant personnel abrogates the HEW mandate under Section 301 of the Public Health Service Act and the regulations published in the Federal Register on January 9, 1974 to provide consultation to states, local agencies, and the general health community; THEREFORE BE IT RESOLVED that the American Public Health Association convey to appropriate Congressional committees, the Secretary of HEW, and the Assistant Secretary for Health its grave concern about the impact of this trend toward reclassification of HEW professional consultants and to request that this trend be halted immediately; and

BE IT FURTHER RESOLVED that the Governing Council representatives, upon acceptance of this report, and the EHOC recommendations, be charged with working with their respective sections, affiliates, regional branches, and chapters which do not demonstrate compliance with the APHA policy of affirmative action in order to assure their coming into compliance, and to report back to the Governing Council on actions taken to come into compliance; and

BE IT FURTHER RESOLVED that APHA urge the reemphasis and promotion of professional consultation services for greater effectiveness and efficiency in implementing federal health programs; and

BE IT FURTHER RESOLVED that the Executive Director of APHA be instructed to provide staff and other administrative support to work with the

BE IT FURTHER RESOLVED that APHA forward this resolution to other health organizations urging their support and endorsement. AJPH January, 1977, Vol. 67, No. 1

RESOLUTIONS AND POLICY STATEMENTS

GROUP D: SOCIAL FACTORS I.

Policy Statement on Prevention

Since its inception, the American Public Health Association has been the pre-eminent national health organization concerned with the promotion of health and the prevention of death and disability through community organization and effort. If prevention may be defined as any measure taken to avoid physical or mental illness, including those measures which will prevent further damage from illness or injury already sustained, then prevention may be seen as a broad rubric under which all of public health activity takes place.

The largest proportion of health dollars is spent in the provision of medical services after illness or injury has occurred.' However, there is good evidence from a variety of sources that dollars spent in the prevention of occurrence and in the early detection of illness and injury usually have a far greater impact on the health of the public than dollars spent in medical care.26 The purposes of this paper are to present some issues regarding prevention which may provide a basis for discussion within the Association and to advance some priorities for prevention activities within the Association. In an economy of scarce resources and ever increasing competing needs, the American Public Health Association must expand its traditional leadership role in the reordering of our national priorities for health.

Classification of Prevention Strategies Prevention strategies may be classified in a number of dimensions, including: 1) the time of intervention relative to the illness or injury sequence; 2) "active" vs. "passive" measures; and 3) mandatory vs. voluntary measures. With regard to the time of intervention, it may be postulated that the earlier the intervention is made, the greater the health benefits to be derived. Cancer deaths are more effectively averted by avoiding exposure to carcinogens than by detecting cancer in its early stages; AJPH January, 1977, Vol. 67, No. 1

on the other hand, it is more effective to detect cancer in its early stages than to make the discovery after it is no longer vulnerable to therapy.

Preventing or regulating exposure to environmental hazards which cause disease or traumatic injury will result in decreasing rates of death and disability from these agents. An increasing body of literature warns that industrial and technological advances are creating physical, chemical, and radiological hazards to which all citizens may be exposed, especially in the workplace and on the highway. Control of exposure to such hazards depends not only on the availability of adequate technological means, but also on the adoption of control measures by those groups which produce the hazards. Control may be voluntary or accomplished through governmental regulation, a vitally important prevention measure. However, regulation of hazards is a matter of public policy which emerges from debate among competing interests, and health is only one of a number of values which are considered. Public health professionals will be required to take a strong advocacy position in order to achieve appropriate regulatory measures.7

tion, and program efforts in maternal and child health, occupational health, dental health, mental health, family planning, and preventive services offered as part of the delivery of personal health services. Early detection and screening programs are essential to counteract further damage from many diseases. Emergency medical services, not usually considered as prevention, play a critical role in the prevention of death or other severe consequences of traumatic injury and cardiovascular events. A second dimension of prevention is the degree to which action is required by each individual to insure protection. "Passive" measures which require no action on the part of individuals are generally more effective in preventing injury and illness than "active" measures which do require individuals to act. Purification of water prior to distribution is more effective than each household boiling its own supply; removal of roadside hazards is more effective than exhortations to avoid them. Immunization, while requiring some initial activity of individuals, thereafter passively provides more effective protection than depending on quarantine or the use of protective masks. The implementation of passive preventive measures such as sanitation, water and air purification, water fluoridation, immunizations, and improved design of machinery and highways to reduce the probability of injury has been demonstrated to result in significant decreases in rates of death, disability and disease.

Health education often attempts to intervene before the occurrence of illness and injury. Health education programs are offered at all levels of the school system and in extracurricular programs to all ages, covering every conceivable health related topic. Health education includes a broad spectrum of activities from the dissemination of information through print, electronic media, and film to innovative workshops, sophisticated multi-media presentations, and community organizing around health issues. Health educators have long emphasized prevention as the leading focus of their activities.

Active measures require individuals to act in their own behalf to protect themselves from disease and injury. In recent years public health professionals have become increasingly aware of the contribution of the lifestyle of most Americans to ill health through obesity,

Other prevention techniques are used either before the onset of adverse health conditions or early in the illness sequence to prevent further deterioration. These include research, educa-

consumption of alcohol, cigarette smoking, and stress. Programs which encourage individuals to alter their lifestyle require active individual participation. Many efforts of health educators rely on active strategies. Seat belt use 101

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is an active measure, as is the following of a prescribed medical regimen. The effectiveness of active strategies depends on how many people act to protect their own health and how consistently. The need to increase rates of adoption of active measures has long been a concern and focus of effort in public health. A third way to classify prevention programs is the degree to which participation is voluntary. We may increase the rate of adoption of active measures by making adoption mandatory. We have a tradition of mandatory prevention measures for many acute infectious diseases, including tetanus, whooping cough, polio, diphtheria, and rubeola (red measles). Most states require that children be immunized against these diseases before entering school.

Many other laws embody mandatory preventive measures. Federal laws require industry to provide safe working environments and to manufacture safe foods, drugs, and household products; further, federal agencies regulate the dumping of hazardous industrial byproducts into the air and water supply. Although legislation exists under which the public may be passively protected from such hazards, the actual impact on rates of death and disability depends on adequate program funding, appropriate standard setting, efficient and effective program administration, and enforcement which will insure compliance. Some laws prescribe certain individual behavior in the interest of prevention, namely immunization laws and laws prohibiting people from driving with a blood alcohol [content] above a certain level. In many cases the imposition of legal restrictions on behavior (e.g., mandatory helmet use for motorcycle riders, prohibitions against smoking in certain locations) are perceived as governmental limitations on personal freedom and are staunchly resisted by a vocal segment of the public. The issue of how far government can go and ought to go in the interest of community health is extraordinarily complex and involves all segments of society. 102

Some Areas For Discussion The American Public Health Association encourages public and professional discussion of issues around prevention as an essential step in clarifying our national health priorities. Such discussion must include several major areas of thought: 1. Epidemiologic information which can forecast potential reductions in morbidity and mortality to be realized from prevention strategies and which can distinguish degrees of risk as a basis for devel-

oping high-yield interventions; 2. Medical and engineering considerations to clarify issues of technological efficacy, feasibility, practicality, and acceptability of proposed prevention strategies; 3. Economic information on the feasibility of proposed measures, on cost/benefit projections, on cost effectiveness comparisons among objectives and strategies, and on the value of preventive services in national health plans; 4. Ethical considerations of personal

freedom, social responsibility, equitable distribution of societal values including health, and the just distribution of the costs of preventing death and disability; and 5. Political considerations which weigh the value of prevention against other societal values competing for the same resources; which decide on the balance between social risks and benefits; which determine how the distribution of power affects decisionmaking with regard to health policy; and which can produce strategies for improving the saliency of prevention as a political value.

The arguments of health professionals are essential in this debate. Prevention is a broad issue; health professionals will be obliged to become advocates for health in the face of

competing economic, social, and cultural values.

Recommendations The American Public Health Association is in an outstanding position to provide leadership furthering the cause of prevention. To this end, the following recommendations are made:

1. Internal Activities of APHA a) Encourage each section to develop position papers, specific plans and recommendations within its own area of concentration through the Action Board and Program Development Board;

b) Through the Program Development Board, develop and publish an authoritative manual on prevention giving technical and scientific information that will help bridge the gap between knowing and doing. 2. Activities in Relation to the Federal Government

a) Provide testimony at appropriate hearings stressing the need for adequate funding of prevention programs, related research, and personnel training programs;

b) Provide testimony on legislation, such as National Health Insurance, emphasizing the importance of prevention;

c) Work with appropriate Congressional committees to see that oversight hearings are held on the status of prevention programming in all governmental agencies including the Occupational Safety and Health Administration (Department of Labor), and the Consumer Product Safety Commission, the National Highway Traffic Safety Administration (Department of Transportation), the Environmental ProAJPH January, 1977, Vol. 67, No. 1

RESOLUTIONS AND POLICY STATEMENTS

tection Agency, and relevant agencies of the Department of Health, Education, and Welfare; and

d) Seek ways to expand governmental support of research in all aspects of prevention technology. 3. Activities in Relation to State and Local Governments through Local Affiliates

a) Encourage APHA affiliates to give priority to prevention in the health service programs of state and local agencies; b) Encourage APHA affiliates to give support to prevention programs through state and local agencies dealing with education, social service, environmental protection and other health related matters; and c) Encourage APHA affiliates to provide testimony emphasizing prevention before state legislatures and local governing bodies. 4. Activities in Relation to Non-Governmental Organizations

a) Urge voluntary and private health and related agencies to incorporate and emphasize prevention in their programs;

b) Establish linkages with appropriate organizations, both health and non-health, to stimulate prevention-related dialogue and activities; c) Encourage medical and other health professional training schools to expand and emphasize concepts of prevention in their educational programs; and

d) Encourage all educational programs to stress prevention of all illness and maintenance of health. AJPH January, 1977, Vol. 67, No. 1

REFERENCES 1. Skolnik, A. M. and Dales, S. R., Social welfare expenditures, 1950-1975. Social Security Bulletin 39:3-20, January 1976. 2. Axnick, N. W., Shavell, S. M., and Witte, J. S. Benefits due to immunization against measles. Public Health Reports

84:673-680, August 1969. 3. Dietz, P. E. and Baker, S. P. Drowning: epidemiology and prevention. Am. J. Public Health 64:303-312, April 1974. 4. Grosse, R. N. Cost-benefit analysis of health services. Ann. Amer. Acad. Political Soc. Sci. 339:89-99, January 1972. 5. Brennen, A. J. Environmental health: a look at the cost of air pollution. Journal of School Health 43:300-302, May 1973. 6. U.S. Congress. Subcommittee on Economy and Government of the Joint Economic Committee. The Analysis and Evaluation of Public Expenditure: The PPB System. 1969. 7. Beauchamp, D. E. Public health as social justice. Inquiry 13:3-14, March 1976.

Handgun Regulation WHEREAS about 28,000 Americans are killed each year by firearms. Firearms are also a major cause of spinal

cord injuries with their consequent long-term disabilities;' and

WHEREAS assault with a gun is five times as likely to result in death as assault with a knife, the next most dangerous weapon;2'3 and WHEREAS the weapons involved in the majority of firearm deaths are handguns. Handguns are used in more than 80 per cent of all firearm homicides;27 and

WHEREAS the supply of handguns grows unhindered. More than two million new handguns are legally sold to the public each year. At least 100,000 privately owned firearms are stolen each year, thus placing even more weapons in criminal hands;2 and

WHEREAS the United States has the greatest number of handguns in the world and the highest handgun homicide rate. Other industrial nations have more stringent gun control laws, including in some countries the banning of pri-

homicides in recent years in the United States has been in handgun homicides, which increased by 49 per cent between 1969 and 1974;2 5 THEREFORE BE IT RESOLVED that the American Public Health Association, recognizing the crisis created by the increase in fatal injuries inflicted by those in possession of handguns, endorses and supports legislation prohibiting the manufacture, sale, transfer, or possession of handguns and handgun ammunition for private use.

REFERENCES 1. Baker, S. B. 28,000 Gun deaths a year: What is our role? J. Trauma 16:510-511, 1976. 2. Alviani, J. D. and Drake, W. F. Handgun Control: Issues and Alternatives. Washington: United States Conference of Mayors, 1975. 3. National Commission on the Cause and Prevention of Violence: To Establish Justice, To Insure Domestic Tranquility. Washington: Govt. Printing Office, 1969. 4. Costantino, J. P. An Epidemiologic Study of Homicides in Allegheny County, Pennsylvania, 1966-1975. Annual Meeting of the Society for Epidemiology Research, Toronto, June 17, 1976. 5. Federal Bureau of Investigation: Uniform Crime Reports for the United States, 1974; (also, 1969). U.S. Department of Justice, Washington, DC 6. Gerber, S. R. Statement Before the House Committee on the Judiciary on Federal Firearms Legislation, June 19, 1975. 7. Hirsch, C. S. et al: Homicide and suicide in a metropolitan county. JAMA 223:900-904, 1973.

The Lack of Data on the Health Status of the Spanish Heritage Community in the United States WHEREAS information pertinent to the health status of the Spanish heritage population in the United States, which data include vital statistics, mortality statistics, and health statistics as well as other information on the health status of the Spanish heritage community does not exist or is, at best, unavailable in readily usable form; and

vate possession of handguns ;2 and

WHEREAS the

greatest

increase in

WHEREAS primary information on the health status of the Spanish heri103

RESOLUTIONS AND POLICY STATEMENTS

tage population is of the utmost importance for appraising in a more accurate and factual manner the real health status of that population through independent research as well as research by various government agencies who are responsible for developing policy and planning, operating, and evaluating public health programs; and

WHEREAS such information could not only stimulate but further expand a wide variety of research endeavors, especially comparative research which could benefit society as a whole; and

WHEREAS the American Public Health Association and the Latino Caucus recognize the lack of Spanish heritage community health data at the national, state, and local levels and the need for such data and for making it usable and available to policy makers and independent researchers, and the need for those public agencies that are already collecting and tabulating data on the Spanish heritage population to publish it and make it available tp the public; and WHEREAS Public Law 94-311, Section 2, dated June 16, 1976, requires the Department of Commerce, the Department of Labor, the Department of Health, Education, and Welfare, and the Department of Agriculture to collect, and publish regularly, statistics which indicate the social, health, and economic condition of Americans of Spanish origin or descent; THEREFORE BE IT RESOLVED that the American Public Health Association, also recognizing the seriousness of the problem, will, through its staff and Statistics Section, contact the National Center for Health Statistics and the Bureau of the Census and will collaborate to the extent possible with these agencies for bringing about a better statistical and informational data base for the Spanish heritage population in the United States; and BE IT FURTHER RESOLVED that APHA through appropriate letters of concern exhorts those public agencies, especially the National Center for 104

Health Statistics and the Bureau of the Census, that are already collecting and tabulating data on the Spanish heritage population, to publish such data and make it available to public scrutiny as is required by P.L. 94-311; and BE IT FURTHER RESOLVED that APHA will make the necessary adjustments to its own data base in order to identify the Spanish heritage popu-

lation within its entire membership.

Television and Health WHEREAS television has powerful implications, both positive and negative, for health, particularly the health of children and young people; and, WHEREAS there are indications that excessive violence in television programming is a contributing factor in anti-social behavior as reported to the U.S. Public Health Service and the Surgeon General by the Scientific Advisory Committee on Television and Social Behavior (1972) and others; and,

WHEREAS television commercials for health-related products and services may have a marked impact on the hgalth practices of children and adults; antd,

WHEREAS television commercials for drugs, for example, may lead to dangerous overconfidence in drugs as the solution to life's problems, although research has not proven the connection, as reported in testimony at the Federal Communications Commission (FCC) hearings held in Washington, D.C., in May, 1976, and; WHEREAS much television advertising offood products and nutrient supplements makes misleading claims regarding nutritional benefits; and WHEREAS proposals have been made to change restrictions concerning television, to provide financing for positive health messages, and to extend public service time requirements;

THEREFORE BE IT RESOLVED that the American Public Health Asso-

ciation stimulate discussion and policy development among its members concerning the impact of television programming and advertising on health through APHA Section projects, convention sessions, and articles in the American Journal of Public Health and The Nation's Health, including input from such groups as behavioral scientists, communications experts, educators, advertising, industry, and consumers; and BE IT FURTHER RESOLVED that APHA join with other health-minded organizations in seeking funding to provide staff for identifying and publicizing those offending TV programs; and, BE IT FURTHER RESOLVED that APHA support efforts by government and by other appropriate organizations to evaluate the positive as well as the negative health impact of television on children and adult audiences and to develop desirable public policy concerning television programs and adver-

tising.

Labeling of Colored and Flavored Foods WHEREAS the Life Science Research Office of the Federation of American Societies for Experimental Biology has: 1) reviewed many of the Generally Recognized as Safe (GRAS) substances and have made specific recommendations on over two-thirds of their list which includes the removal of some substances and further study of others; and 2) just (August 1976) submitted to the Food and Drug Administration (FDA) criteria for the evaluation of the Flavors and Extracts Manufacturers Association (FEMA) GRAS List; and WHEREAS over 80 per cent of the several thousand artificial food flavors are chemically the same as their natural counterparts as they were derived and synthesized from the study of the natural source; and WHEREAS the National Academy of Sciences is reviewing the food colors (approximately 30) which has resulted AJPH January, 1977, Vol. 67, No. 1

RESOLUTIONS AND POLICY STATEMENTS

in the banning of their use in the U.S. food supply; and

WHEREAS the FDA is in the process of making a complete scientific review and evaluation of the FEMA GRAS list; and WHEREAS many complex decisions are needed involving the use of GRAS substances, including not only their potential hazard to public health but also their use in preserving and maintaining: safety, nutritional quality and quantity, public appeal and acceptance;

THEREFORE BE IT RESOLVED that the American Public Health Association recommend to FDA and the National Academy of Sciences that they: 1) continue the study of all GRAS substances; 2) take quick action to ban from the food supply GRAS substances when competent scientific review and evaluation recommends their removal; and 3) rapidly initiate further studies on GRAS substances where competent scientific review and evaluation identifies the need for further study and in the interim (time required for definitive data) make recommendations for effective and economically feasible labeling method(s) to educate consumers so they can make informed decisions when purchasing food.

Infant Feeding Practices WHEREAS infant feeding practices have undergone a number of major changes in the last decade; and

WHEREAS a number of these changes, including the change from breast to bottle feeding for nursing infants and the early introduction of highsugar, nutrient-diluted solid foods are not consistent with authoritative medical advice in regard to infant feeding; THEREFORE BE IT RESOLVED that the Governing Council of the American Public Health Association direct the Food and Nutrition and the Maternal and Child Health Sections, in conjunction with all other interested sections, to consider and study the A.JPH January, 1977, Vol. 67, No. 1

question of infant feeding, and provide documentation concerning specific issues for developing a strong comprehensive statement to be presented at next year's APHA Annual Meeting.

Voluntary Sterilization WHEREAS, the American Public Health Association endorses the right of women and men to voluntary sterilization and supports its availability as a medically accepted means of permanent contraception restricted to mentally competent adults of at least 21 years of age regardless of marital status; and WHEREAS, in view of the significant increase in the number of individuals choosing sterilization, and in the number of sterilization procedures performed during the past several years; and WHEREAS, in view of public concern for the protection of freedom of choice in fertility methods and for the civil rights of all individuals, particularly poor and minority group populations; and

WHEREAS, the American Public Health Association believes that consistent with the APHA Recommended Program Guide for Voluntary Sterilization,' special vigilance must be observed in order to guard against coercive or abusive practices in connection with a patient's decision regarding voluntary sterilization; THEREFORE BE IT RESOLVED that the American Public Health Association advocate the following principles for application in voluntary

sterilization: 1. All patients seeking sterilization services must give voluntary and informed consent, in writing, to the procedure. Voluntary and informed consent requires the power of free choice without inducement or any element of force, fraud, deceit, duress, or other form of constraint of coercion. In

the case of sterilization, a full un-

derstanding of the irreversibility of the procedure is basic to informed consent;

2. The basic elements of information necessary to such consent include a thorough explanation of the procedures to be followed and their purposes; a description of any attendant discomforts and risks reasonably to be expected including those of guilt and regret; a description of ahy benefits reasonably to be expected; a discussion of any appropriate alternative procedures that might be advantageous to the patient; an offer to answer any inquiries concerning the procedures; and an assurance that the person is free to change the decision without loss of other benefits or services; 3. Before consent is given, specific assurance should be provided, both orally and in writing, that the patient's decision to have or not to have a sterilization procedure will not affect in any way the receipt, obtainment, or loss of any benefits or services, and is revocable at any time; 4. A suitable waiting period, generally at least two weeks, between counseling and the performance of the procedure must occur and the patieht must have the opportunity to consider its implications away from the health care institutions. Various waiting periods have been recommended by numerous health service agencies, practitioners, and concerned individuals. These are intended to insure appropriate exercise of free choice; however, it must be recognized that such waiting periods may put the patient at risk of unwanted pregnancy and may increase the risks of anaesthesia and surgery; 5. More crucial than a period of some specific length of time is the need for the patient to have sufficient time to receive complete in105

RESOLUTIONS AND POLICY STATEMENTS

formation and to arrive at a full understanding which will permit informed consent, as well as a complete medical and psychosocial history and physical examination, a review of all information concerning the procedure, its risks, etc., and an adequate opportunity to reaffirm or cancel the decision prior to surgery; 6. Every effort should be made to foster discussion of sterilization with both partners, including the relative risks attendant to sterilization methods in both males and females, and to utilize sterilization techniques which present the lowest possible risk for the patient. In most instances, high risk procedures such as hys-

terectomy for contraception should be avoided; 7. As in any other voluntary request for medical or surgical care, the physician should take care to inquire and to be fully satisfied that the patient is competent to sign a medical consent on his or her own behalf. The language in which the information is given is as important as the content of that information. The information should be presented in the language and in a manner best understood by the in-

dividual patient; 8. Every patient should be able to bring a person of his or her own choosing to each counseling and information session, who may serve as the patient's advocate and have the right to ask questions about all aspects of the pro-

cedure; 9. If, in the opinion of the health worker involved, the patient seeking sterilization cannot understand the nature and all consequences of the procedure, the patient may not be competent to give informed consent. In all such instances, it is incumbent upon the health worker to seek further 106

assistance in identifying the barriers to understanding. If there still remains doubt that the patient understands the nature and consequences of the operation, the sterilization should not be performed; 10. Acceptance and enforcement of these guidelines requires continuous attention and education through appropriate organizations, agencies, and institutions; 11. Development of enforcement mechanisms for protective guidelines should assume high priority. BE IT FURTHER RESOLVED that the APHA (1) will encourage affiliates and sections to critically examine practices and legislation regulating sterilization in their appropriate areas and support adoption of standards, in conformance with APHA policy, by the regulating bodies and health service agencies; and

(2) shall give high priority to seeking resources for the establishment of the following: a) Liaisons and communications with appropriate groups to encourage their inclusion and implementation of similar standards (e.g. Joint Commission on Hospital Accreditation);

b) A national conference on the problems and issues of sterilization; c) Educational materials for patients (non-professional) such as bibliographies, model consent forms, and self-instructional materials;

d) Professional education and inservice workshops; and

(3) will review and expand the APHA Recommended Program Guide for Voluntary Sterilization to conform with adopted policy.

REFERENCE 1. APHA Recommended Program Guide for Voluntary Sterilization, Am. J. Public Health 62:1265-1267, 1972.

The Right To Abortion For All Women WHEREAS, a Connecticut District Court held that a ban on medical payments for abortion is unconstitutional because it discriminates by refusing access to medical care for abortion to indigent women while providing them with medical assistance to continue their pregnancies to term1; and

WHEREAS, the Pennsylvania Appeal Court has ruled on statutory grounds that states are required to pay for abortions as a "necessary" medical service as necessary as medical care

during child birth2; and WHEREAS, the January 1973 Supreme Court decision declaring unequivocally the right and guarantee to abortion for all women; and WHEREAS, withholding Medicaid funding for abortion results in economic and social discrimination to women across the country who are unable to pay for private care; and

WHEREAS, the Medicaid program is to guarantee that poor people have access to quality medical care; and

WHEREAS, once young women with children end up on the Aid for Dependent Children (AFDC) rolls, they have great difficulty breaking out of the welfare cycle and they tend to become trapped in a life of permanent dependence upon social service institutions with concomitant frustration and despair; and WHEREAS, since there is no 100 percent effective contraceptive method, abortion is a necessary backup to enable women to avoid having unwanted childbirth; and,

WHEREAS, the provision of aborAJPH January, 1977, Vol. 67, No. 1

RESOLUTIONS AND POLICY STATEMENTS

tion services has been associated with a dramatic decrease in maternal mortality rates and a demonstrable decrease in infant mortality rates; and

WHEREAS, P.L. 94-439 forbids the use of federal funds to pay for abortions provided to women eligible for Medicaid; and

WHEREAS, women desiring abortions and not receiving them are driven into hands of incompetent practitioners or forced to bear children they do not want;

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THEREFORE BE IT RESOLVED that the American Public Health Association reaffirm the right of all women to receive abortions and that the economic barrier to receiving this medical service be removed; and BE IT FURTHER RESOLVED that the APHA deplores enactment of the provision in P.L. 94-439 which denies federal medical payments for abortion; and BE IT FURTHER RESOLVED that

the APHA support all actions to erase this pernicious provision; and BE IT FURTHER RESOLVED that the Executive, Legislative, and Judicial branches of national government be informed of this resolution.

REFERENCES 1. Roe vs Maher (formerly Roe vs Norton). 380 F. Supp. 726 (D. Conn. 1974). Appealed to the U.S. Court of Appeals for the 2nd circuit 408 F. Supp. 660. 2. Doe vs. Beal. 523 F.2d 611. (3rd Cir. 1974).

'New Adventures in Public Health' Program Launched

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A "New Adventures in Public Health" Program is being launched this year by the American Public Health Association's newly developed Division of Professional Education. Accredited continuing education courses will be offered in 22 subject areas, and are intended to provide constructive learning experiences to health professionals in an effort to improve the practice and delivery of health services and programs. Courses on new and innovative public health practices will be presented in both on-campus and off-campus settings. The sessions will usually last two days and cost $50 to $99 each. Professional continuing education credits will be awarded from the American Dental Association, the American Medical Association, and the American Nurses' Association. Faculty and conference staff for the seminars will include many eminent practitioners and educators from public health and related fields. For further information, contact: Frederick Hering, EdD, Division of Professional Education, APHA, 1015 18th St., NW, Washington, DC 20036.

European Study Tour Set for Spring The "New Adventures in Public Health" Program is sponsoring a workshop/study tour to several European countries this Spring. The travel seminar, scheduled for March 26-April 9, 1977, includes visits with public health leaders at key health facilities in Netherlands, Scandinavia, and Germany. "New and Innovative Practices in Western Europe" is the theme of the two-week study tour. Continuing education credits will be given to participants; approximate cost of the study tour is from $699.00. For further information contact Frederick Hering, EdD, Continuing Professional Education, APHA, 1015 18th St., NW, Washington, DC 20036.

AJPH January, 1977, Vol. 67, No. 1

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Report of the APHA Task Force on Chile.

Association News PICKETT ASSUMES APHA PRESIDENCY; ELLIS NAMED PRESIDENT-ELECT George E. Pickett, MD, MPH, was installed as President of the American P...
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