Setting Prioriti es in Health Services HAROLD J. WERSHOW
A growing recognition that our resources are not limitless has made it necessary for us to abandon the concept of unlimited production and consumption and to set priorities among the goods and services that society is to provide. The author argues that determining priorities in the area of health services should be done on a rational basis, with increased emphasis on primary prevention.
A
LTHOUGH PAINFUL IF NOT TRAUMATIC to face, the problem of setting priorities in providing human services is upon us and cannot be ignored. It has been an article of faith ever since the beginning of the New Deal that an ever growing economy and increasingly progressive tax structure would, for the foreseeable future, enable expansion of health and welfare services to be limited only by the appropriations that could be obtained. However, the time has come to entertain the heretical belief that there are limits to the growth of the economy as a whole. Even now, all the services regarded as possible and desirable cannot be provided. The social work profession should participate in the process—of necessity political in nature—of setting HEALTH AND SOCIAL WORK, Vol. 2, No. 4, November 1977
7
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priorities and not let them be set entirely by others while it merely kicks and screams in blind opposition. A determined effort on the part of social workers to become involved in the inevitable decision-making is necessary, and that effort should be as rational and as based in reality as possible. The constraints on economie growth are increasingly evident today. Those living in the affluent countries of the West are no longer able to consume energy, food, and minerals in the amounts and at the prices to which they have become accustomed. It will certainly become more expensive to produce food and manufactured materials in a manner that respects the environment instead of, further polluting it. Furthermore, there will be more people alive in the world, if not in the United States (although the much vaunted short-term decline in this country's birthrate may prove in the long run to be illusory), to share fewer and more expensive products.' These problems are compounded by a taxpayers' revolt that is taking place on a worldwide basis and affecting even the social democracies of Western Europe, New Zealand, and Australia that have until recently been relatively generous and humane in the provision of services. It would seem that when taxes reach a certain proportion of income they are perceived by a population as confiscatory and represent the limit of taxation that will be accepted. This limit may be as high as 50 percent in Europe; it seems to be less in the United States. 2 Although taxes in this country could be equalized and made more progressive than they are, it seems that the end of capital gains, oil depletion allowances, tax-free municipal bonds, and deductions for payments of home mortgage interest and property taxes
PRIORITIES IN HEALTH SERVICES
9
(and attempts to abolish these deductions would be politically explosive) would not yield substantial additional revenues. 3 Nor can it be glibly stated that x amount of health and welfare services costs less thán, say, an aircraft carrier. Neither common prudence nor the consensus in the United States will permit a substantial lowering of defense expenditures. Finally and incontrovertibly, nothing can grow exponeritially without end; social workers have an Mescapable obligation to begin working toward a professional consensus about planning and the setting of priorities in health and welfare services. The author hopes that this article is a step toward a discussion leading to that consensus. PUTTING FIRST THINGS FIRST
Because cost-benefit estimates and measurement of outcomes of rendered services are simpler with regard to health services, as a heuristic device they will be emphasized in the discussion that follows. When it comes to expensive and dramatic heroics in medicine, the United States leads the world. More coronary bypasses and other forms of open-heart surgery, kidney dialyses, organ transplants, and other medical and surgical procedures that are on the cutting edge of "progress" are undertaken in this country than in all the rest of the world combined. Nevertheless, assured access to a primary-care physician is more difficult to achieve here than it is in any other advanced society. Family practice has been neglected by medical schools in the United States to the extent that before recent efforts to rejuvenate that area of medicine were undertaken, the family physician was fast becoming a member of a vanishing species. The channeling of effort, research, and funds
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into areas that, although laudable, serve relatively few patients at great expense and the neglect of other areas that may be undramatic, even routine in nature, yet serve many people at low cost must be questioned. 4 A clear example of the former are efforts regarding kidney dialysis and transplantation which at any one time serve 12,000 to 15,000 patients with end-stage renal failure at a current cost of $400 million a year. These costs, furthermore, will probably stabilize at a figure three or four times greater than present levels. (This estimate covers only those medical expenses paid by Medicare and not disability or care costs.) Many kidney patients, especially the elderly, have severe diabetes or arteriosclerosis. Through dialysis or transplantation, most of them will gain about six more months of lif e that will constitute a dragged-out and debilitated rather than vital and zestful existence. Some nephrologists see little sense in treating them as opposed to patients of any age whose kidneys have been destroyed by infection or trauma but whose other organs and systems have not been involved—but they must do so in the absence of authority to deny treatment. Disability for black lung disease has recently been included in Medicare coverage, and treatment costs for cancer and hemophilia may soon be included in that program. This may be commendable, but the question remains: What portion of this country's resources, not only money but also scarce, trained manpower, should be devoted to high-cost, low-yield efforts, and what portion should be devoted to others? WEIGHING COSTS
To what extent will this country's medical resources be strained if a major technological breakthrough occurs?
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11
What if an artificial heart were invented, the production and installation of which might well cost approximately $30,000 per case? Assuming that only 50 percent of the half million people in this country who die each year of coronary disease can benefit from this procedure, the additional load on the medical care system (which already absorbs over 8 percent of the gross national product, or GNP) that it would represent would be $7.5 billion, or almost 10 percent of the total present outlay for medical care in the United States. 5 Does this scenario depict the wisest use of resources? Wise or not, it will occur, for the pursuit of technological "miracles" brings rewards. High status in the medical fraternity, the kind of praise and publicity relished by most individuals, the Nobel prize—all these come to the so-called miracle workers. Approbation on this scale is withheld from those who spend their professional careers performing such prosaic, mundane, and even boring primary-prevention tasks as bringing all children up to date in their immunization inoculations, providing health services to the inner-city and rural poor, and making dental, optometric, and podiatric services readily available. A large majority of people in the United States remain unserved in these last areas. Moreover, old people in this country are left to languish in neglect and hunger in what are euphemistically called single-room occupancies but are in reality wretched firetraps equipped with one-burner hot plates. Similarly, people who have spent many years in mental hospitals and institutions for the retarded are released by the thousands into "the community" without adequate supervision. They huddle in nursing homes without professional direction and in boarding homes without supervision, often without being protected by
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the minimal health standards required by licensing regulations. 6 By what logic or sense of decency do we in this country offer expensive medical services to relatively few and deprive so many of bread and the opportunity to be reintegrated into the society that put them away in the first place? How many hot "meals on wheels" can be bought for the cost of one kidney transplant? The cost of one open-heart surgical procedure could pay the annual salary of two social workers to supervise patients discharged from mental hospitals. How can one need be weighed against the other? To what extent should one need be met as compared with the other? In the long ,run, there is only one relatively inelastic source to pay for everything needed or wanted in this country—the GNP, or the sum of goods and services produced. Its total can increase by a few percent a year if sufficient capital is invested, but investment of this kind of necessity takes place at the expense of investments in other areas. Offering more of some goods and services entails the decision to offer less of others. Social work as a profession has not yet absorbed the full significance of this. It can mean that no one is entitled to more than two kidney transplants (on the grounds that any further transplants are too likely to be rejected) and that there are limits to the number of times medical resources will be used to treat an alcoholic for d.t.'s or a diabetic for coma (on the same grounds, namely, that the state of the art is such that chances for success are slim and, further, that people are responsible for their own bodies and what they do to them). Health and welfare services, then, must not only compete among themselves for limited resources but must also compete with pressing needs in other problem areas. In addition
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to health care, such concerns as education, reform of the criminal justice system, cleaning up the rivers and air, and providing new homes for the next generation are crying for attention, funds, and personnel. Each of these needs could easily absorb $100 billion in the next decade. UNNECESSARY SERVICES In addition, it must be stressed that full provision of medical services will have a marginal effect on the life span of individuals in all but the most deprived groups. For example, although the number of deaths among children in this country is not as low as it might be, so few young children die that rare diseases such as leukemia and other forms of cancer are among the major causes of death in children. 7 A large proportion of childhood deaths, moreover, can be attributed to matters of life-style rather than to medical problems, for many of them are caused by firearms, automobiles, fires, drowning, various other accidents, and suicide (a major cause of death in white people as young as ages 10 to 14). 8 Indeed, increasing the number of physicians, nurses, and hospitals three- or fourfold would change patterns of illness and death minimally. The death rate among young people is so low, in fact, that if no one ever died before reaching the age of 35, average life expectancy would be increased by no more than 3.7 years. 9 Also arguing against the wholesale proliferation of medical services is the fact that the great decline in mortality rates that took place in the Jatter half of the 18th century was due more to improvements in sanitation and a general increase in standards of living than to better medical care. The declining death rates were
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specifically attributable to decreases in the incidente of tuberculosis (which accounted for approximately 50 percent of the decline), cholera, typhus, typhoid, dysentery, diarrhea (which accounted for 30 percent of the decline), and smallpox (which accounted for 5 percent)." The only medical advance associated with the drop in mortality ratel was the more widespread use of vaccination—a preventive public health measure, not a treatment measure. The improvement in public health stemmed in large measure from better separation of clean water from sewage, availability of a better diet, and availability of more frequent washing. Today, the major health dangers to adults are posed by smoking, drug abuse (legal and illegal), lack of exercise, excess star ch and animal fat in the diet, air (and possibly water) pollution, careless driving without seat beits or under the influence of ethanol, and the possibility of being shot by their best friends, relatives, neighbors, or themselves. 11 It is likely that the greatest improvement in public health would come about from nonmedical innovations, such as a tar-free cigarette or a pilt that would benefit overfed middle-class citizens by coating half the fond ingested by an individual to prevent its being absorbed in the small intestines. The provision of high-quality emergency medical care by fire medics and other technicians is another service whose implementation would be beneficial and would involve nothing more than doing better what the medical care system already knows how to do. The author rejects the notion that some of the measures discussed merely "attack symptoms and do not get down to causes." In situations in which causes are often unknown, multifactorial, or difficult or impossible to control, relieving symptoms may be all that can be
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done. Besides, why should difficult and expensive solutions of a definitive nature be insisted on when simpler and cheaper ones are available? 12 Striking at the root of the problem in this instante means attending to health education, which at present is primitive, ineffective, and as ignored in terms of medical priorities and prestige as are other aspects of primary prevention and care. At this point a note of cautious realism is in order: the proliferation of the best health practices will not lower the cost of medical care for long. Those who live for a longer time are more likely to succumb to the debilitating, long drawn-out, and degenerative diseases of aging that are expensive to treat. Therefore, no matter to what extent effective care is expanded by the use of such resources as physicians' assistants, nurse practitioners, and health maintenance organizations and no matter how well other available resources and knowledge are employed, the long-term trend toward increasing costs for medical care should not be expected to abate. LESS IS BETTER
The use of early detection devices such as annual physical examinations and mass screenings do not do as much good as is of ten claimed. Annual physical checkups yield few benefits at the cost of great travail. Perhaps these annual examinations should be limited to a detailed history (much of which can be computerized) that is supplemented by tests pertaining to visual acuity, glaucoma, hypertension, dentition, the checking of height and weight, laboratory analyses of blood and urine, and Pap smears for females. These procedures
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may be about all that is useful, and they can be done by people other than physicians. Much more important than medical examinations or anything medical science can do about mortality and morbidity is the taking of responsibility by individuals for their own health. This includes such matters as recognizing the danger signals of serious illnesses (such as the seven warning signals of cancer) and developing the knowledge and confidence to do elementary triage for one's own family. Undertaking triage requires knowing which symptoms and discomforts are likely to be self-limited and may therefore be ignored or treated with home or over-the-counter remedies, which should be observed for a few days before calling a doctor, and which should send one speeding to •the nearest hospital's emergency room. 13 The notion that only physicians can treat illness is no longer defensible. This ideology must be changed so that people will attain knowledge of and assume responsibility for the care of their own bodies. If physicians cannot help their patients achieve this state, then perhaps a different group of professionals will arise to meet the need. EARLY SCREENING Certain screening procedures having great popular appeal are of doubtful value, such as phenylketonuria (PKU) screening, which is mandatory for all newborn children in 39 states. Not only does this procedure fail to identify many babies who are affected by the inability to metabolize the protein in question, but some babies with high blood concentrations of phenylpyruvic acid do not in fact become retarded. If these children are placed on the diet traditionally used in the face of PKU, they
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"Offering more of some goods and services entails the decision to offer less of others. Social work as a profession has not yet absorbed the full significance of this."
fail to thrive. In addition, the effectiveness of the standard treatment for PKU even when appropriately used is in question. The screening and treatment program involved was made available to the public prematurely as a result of pressure by parents of retarded children, with less than great enthusiasm by biochemists and others involved in relevant research." Other groups have in turn clamored for mass screening for other defects and conditions, largely on the assumption that their particular group has been denied its place in the sun. Such screening, principally for sickle-cell trait and Tay-Sachs disease, is presently receiving its share of notoriety. However, no useful treatment is possible for these diseases, and the identification of individuals as carriers of a hereditary disease may subject them to lifelong stigmatization and emotional strain." What may really be needed is a program of premarital genetic counseling for members of those few families with a history of metabolic defects. A great many more black people suffer from hypertension than the approximately 340 who die annually of sickle-cell anemia, and a great many more Jewish people suffer from diabetes than the approximately 50 who die of Tay-Sachs disease." Screening programs for hypertension and diabetes rather than for sickle-cell trait or Tay-Sachs disease would therefore seem to have much greater relevance and benefit for blacks and Jews. The
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questionable value of various screening programs for genetic conditions indicates that certain services should not necessarily be undertaken merely because medical science knows how to do so. PRIMARY PREVENTION
Major health problems do not stem from strictly medical causes but rather are related to the tendency of individuals and societies to cope with stress by using dysfunctional mechanisms. Similarly, life-styles that lead to social malfunctioning are the results of the anomic, life-cramping relationships prevalent in modern industrial society. 17 Illness may often be one variety of such malfunctioning; in f act, social and physical malfunctioning are interrelated. Some means of reducing such malfunctions readily suggest themselves. American society has set its priorities willy-nilly, without thought or planning. For example, it has failed to create useful employment in a federally guaranteed iob program for those needing such a program. Among the consequences of this choice may be the necessity for a carefully controlled lower minimum wage for teenagers and an income subsidy for single-parent househoids. Implementation of adequate job programs, then, may be one way in which social malfunctioning can be reduced. Another element of a basic preventive program for social problems is the abolition in the schools of promotion for social rather than academic reasons. Whatever the cost in terms of special teachers, classes that have to be repeated, and research and development of new and effective programs, no one should be allowed to complete elementary school without being able to
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read with sufficient facility to enjoy doing so. Despite everything written about the demise of reading as a means of learning, in the opinion of the author, books are still the cheapest, most available, and most easily operated teaching machines. People who cannot read well are less capable of processing information in an orderly manner about the world in which they live, are less likely to speak and write in standard English or to have a rich vocabulary, and are less able to express complex ideas. In short, ending the practice of "social" promotions, exerting concerted effort to determine how best to teach young people to read well, and instituting programs for full employment and minimum family income may be primary-prevention items of the highest priority to ensure general physical and psychosocial well-being. A more controversial element to be included in a primaryprevention program for social problems might be a compulsory (as yet undeveloped) long-term contraceptive such as an intramuscular hormonal implant for use by all unmarried teenagers. Programs like these might be considered essential elements of a national effort to reduce the prevalence of delinquency, child abuse, illegitimacy, the stigma associated with public assistance, and other social problems." Implementing them would not eliminate the need for social services but would reduce it. This in turn would allow the social work profession to exercise its skills in areas that are not dominated by economic forces and unassailable in terms of social work efforts. Only then can social work begin to develop tasks that can be realized. These might include development of mass-screening instruments, nonstigmatizing in effect, in the area of psychosocial functioning, continuation of efforts to delineate
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the division of tasks between various levels of professional skills, and detection of prodromal signs of social malfunctioning and development of early treatment methods. ARRIVING AT ADEQUATE CHOICES
In briefly outlining some elements of the priority-setting process, it should be stated that some programs, such as library services and primary and secondary education, are so vital that they ought to be offered as a right to all, by universal provision, and with no qualifying requirements or payment demanded. In the author's opinion, the programs discussed previously are of this category and would appear to be part of the infrastructure of a sane society,. Services given next highest priority would include programs that are perhaps as necessary and vital but might, because of expense or the possibility of use beyond necessity, require a measure of copayment for those with requisite incomes and subsidy for those who would otherwise be denied access to service systems. National health insurance would be the major item in this category. The more usual social services to individuals, groups, and communities would be included in the next category of priorities. Self-help groups should be encouraged to provide some of these services, with an appropriate measure of professional consultation. Programs in the areas of drug treatment, rape prevention, and counseling for mastectomy and ostomy patients come under this category. Integral to the intelligent ordering of priorities is clarification of the appropriate use of various levels of paid professional staff. In this regard, the widest possible use of volunteers is desirable, and not for pur-
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poses of cost reduction alone. Channels for the expression of impulses toward voluntarism and altruism are basic components in democratie societies." Encouraging people to avail themselves of these channels is the most effective way to secure citizen understanding and to prompt concern and social action among the general public. In addition, certain sorely needed services can only be provided by volunteers. Another area requiring clarification is the proper role of social work in social welfare. If social workers can eschew the temptation to claim the impossible, they can establish their competence to seek limited, attainable goals. 2 ° Each field in social work must then decide on its own priorities. For example, in the area of family and children's services, what portion of giffort and resources should be devoted to crisis intervention, shortterm counseling, longer-term therapies, and foster care? Similarly, certain services to the aged should, at present, be considered experimental research programs at best and not as treatment programs to be widely used. 21 As a final consideration, it should be remembered that the profession of social work will contribute to, not decide on, the proper mix of services and service providers. Social workers would therefore do well to enlist the best minds in appropriate disciplines to assist them in making their most thoughtful contribution to this process. Among those to be consulted are economists who can calculate cost-benefit ratios to the extent that such calculations are possible and political scientists who can help device the least baffling, most responsive institutions for the delivery of services. The social work profession must also seek to form the widest possible coalitions with groups and organizations regarding different aspects of the total configuration of services.
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There will never be an end to this process, which will not be dominated by the National Association of Social Workers, a distinguished commission, or any series of legislative acts but by the never ending interaction of forces in the socio-economic-political arena. This country should strive to involve all its people in setting priorities in health and welfare services in the ceaseless process of forming a more perfect union. However far from perfection its present state may be, when compared to any other country, the United States is not doing all that badly. In summary, the allocating of resources involves a series of compromises in which fewer resources are devoted to some ,services and more are devoted to others. At any point in time, the number of resources available is smaller than that required by the needs and desires of society, and choices must be made. The author has argued that these choices should be made rationally on the basis of emphasizing fundamental community-wide services to support and strengthen individual and group functioning, instead of on the present basis, which stresses the provision of individual and often esoteric treatment, most of which is expensive, of benefit to few people, or of questionable benefit to anyone.
About the Author Harold J. Wershow, DSW, is Professor, Department of Sociology, University of Alabama in Birmingham, and is currently Fulbright-Hays Lecturer, School of Social Work, Haif a University, Israel. A version of this article was presented at the Sixth Annual Conference on Aging of the University of Alabama School of Social Work, Tuscaloosa, Alabama, March 1977.
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Notes and References 1. Paul Ehrlich and Anne H. Ehrlich, The End of Afiluence (New York: Balantine Books, 1974); Harold J. Wershow, "Man, A Maladapted Species?" Ecology of Foods and Nutrition, 2 (December 1973), pp. 69-72; and Donella H. Meadows et al., The Limits to Growth: A Report for the Club of Rome's Project on the Predicament of Mankind (New York: Universe Books, 1972). 2. Harold J. Wershow, "The Outer Limits of the Welfare State." To be published in the International Journal of Aging and Human Development.
3. Harold J. Wershow, "A World Worth Living In," Social Work, 20 (May 1975), pp. 175-178; and Phillip M. Stem, The Rape of the Taxpayer (New York: Vintage
Books, 1974). 4. For further discussion of this point, see Victor R. Fuchs, Who Shall Live? Health, Economics and Social Choice (New York: Basic Books, 1974). 5. Nathan Glazer, "Paradoxes of Health Care," The Public Interest, No. 22 (Winter 1971), pp. 62-77. 6. Special Committee on Aging, U.S. Senate, The Role of Nursing Homes in Caring for Discharged Mental Patients and the Birth of a For-Profit Boarding Home Industry, Supporting Paper No. 7 (Washington, D.C.: U.S.
Government Printing Office, 1976). 7. National Center for Health Statistics, Monthly Vital Statistics Reports: Annual Summary for the U.S., 1975
(Washington, D.C.: U.S. Government Printing Office, 1976). 8. Keith W. Sohnert and Howard Eisenberg, How to Be Your Own Doctor (Sometimes) (New York: Grosset & Dunlap, 1976). 9. Personal communication, Dr. George Reinhart IV, demographer. 10. David Mechanic, Medical Sociology: A Selective View (New York: Free Press, 1968), p. 237. 11. Fuchs, op. cit., pp. 119-120; and Nathan Glazer,
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op. cit., pp. 62-77. 12. Amitai Etzioni, "Shortcuts to Social Change," The Public Interest, No. 12 (Summer 1968), pp. 40-51. 13. Sohnert and Eisenberg, op. cit. 14. Samuel P. Bessman and Judith P. Swazey, "Phenylketonuria: A Study of Biomedical Legislation," in Everett Mendelson, Judith P. Swazey, and Irene Taviss, eds., Human Aspects of Biomedical Innovation (Cambridge, Mass.: Harvard University Press, 1971). 15. "Sickle Cell Anemia: The Route from Obscurity to Prominence," Science, 178 (October 13, 1972), p. 140; and "Sickle Cell Anemia: National Program Raises Problems as Well as Hopes," Science, 178 (October 20, 1972), pp. 283-286. 16. National Center for Health Statistics, Vital Health Statistics of the 'United States, 1972 (Washington, D.C.: U.S. Government Printing Office, 1976), and M. M. Keback and R. S. Zeiger, "The John F. Kennedy Institute Tay-Sachs Program: Practical Issues in an Adult Genetic Screening Program," in B. Hilton et al., eds., Ethical Issues in Human Genetics (New York: Plenum Press, 1973). 17. Matthew P. Dumont, The Absurd Healer: Perspectives of a Community Psychiatrist (New York: Viking Press, 1968). 18. For a discussion of services for strengthening and supporting social functioning, see Alfred J. Kahn and
Sheila B. Kamerman, Not for the Poor Alone: European Social Services (Philadelphia: Temple University Press, 1975). 19. Richard M. Titmuss, The Gift Relationship (London, England: George Allen & Unwin, 1971). 20. Joel Fischer, "Is Casework Effective? A Review," Social Work, 18 (January 1973), pp. 5-22; and Wershow, "A World Worth Living In," pp. 175-177. 21. Harold J. Wershow, "Reality Orientation for Gerontologists," The Gerontologist, 17 (August 1977).
A growing recognition that our resources are not limitless has made it necessary for us to abandon the concept of unlimited production and consumption and to set priorities among the goods and services that society is to provide. The author argues that determining priorities in the area of health services should be done on a rational basis, with increased emphasis on primary prevention.
A
LTHOUGH PAINFUL IF NOT TRAUMATIC to face, the problem of setting priorities in providing human services is upon us and cannot be ignored. It has been an article of faith ever since the beginning of the New Deal that an ever growing economy and increasingly progressive tax structure would, for the foreseeable future, enable expansion of health and welfare services to be limited only by the appropriations that could be obtained. However, the time has come to entertain the heretical belief that there are limits to the growth of the economy as a whole. Even now, all the services regarded as possible and desirable cannot be provided. The social work profession should participate in the process—of necessity political in nature—of setting HEALTH AND SOCIAL WORK, Vol. 2, No. 4, November 1977
7
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HEALTH AND SOCIAL WORK
priorities and not let them be set entirely by others while it merely kicks and screams in blind opposition. A determined effort on the part of social workers to become involved in the inevitable decision-making is necessary, and that effort should be as rational and as based in reality as possible. The constraints on economie growth are increasingly evident today. Those living in the affluent countries of the West are no longer able to consume energy, food, and minerals in the amounts and at the prices to which they have become accustomed. It will certainly become more expensive to produce food and manufactured materials in a manner that respects the environment instead of, further polluting it. Furthermore, there will be more people alive in the world, if not in the United States (although the much vaunted short-term decline in this country's birthrate may prove in the long run to be illusory), to share fewer and more expensive products.' These problems are compounded by a taxpayers' revolt that is taking place on a worldwide basis and affecting even the social democracies of Western Europe, New Zealand, and Australia that have until recently been relatively generous and humane in the provision of services. It would seem that when taxes reach a certain proportion of income they are perceived by a population as confiscatory and represent the limit of taxation that will be accepted. This limit may be as high as 50 percent in Europe; it seems to be less in the United States. 2 Although taxes in this country could be equalized and made more progressive than they are, it seems that the end of capital gains, oil depletion allowances, tax-free municipal bonds, and deductions for payments of home mortgage interest and property taxes
PRIORITIES IN HEALTH SERVICES
9
(and attempts to abolish these deductions would be politically explosive) would not yield substantial additional revenues. 3 Nor can it be glibly stated that x amount of health and welfare services costs less thán, say, an aircraft carrier. Neither common prudence nor the consensus in the United States will permit a substantial lowering of defense expenditures. Finally and incontrovertibly, nothing can grow exponeritially without end; social workers have an Mescapable obligation to begin working toward a professional consensus about planning and the setting of priorities in health and welfare services. The author hopes that this article is a step toward a discussion leading to that consensus. PUTTING FIRST THINGS FIRST
Because cost-benefit estimates and measurement of outcomes of rendered services are simpler with regard to health services, as a heuristic device they will be emphasized in the discussion that follows. When it comes to expensive and dramatic heroics in medicine, the United States leads the world. More coronary bypasses and other forms of open-heart surgery, kidney dialyses, organ transplants, and other medical and surgical procedures that are on the cutting edge of "progress" are undertaken in this country than in all the rest of the world combined. Nevertheless, assured access to a primary-care physician is more difficult to achieve here than it is in any other advanced society. Family practice has been neglected by medical schools in the United States to the extent that before recent efforts to rejuvenate that area of medicine were undertaken, the family physician was fast becoming a member of a vanishing species. The channeling of effort, research, and funds
I0
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into areas that, although laudable, serve relatively few patients at great expense and the neglect of other areas that may be undramatic, even routine in nature, yet serve many people at low cost must be questioned. 4 A clear example of the former are efforts regarding kidney dialysis and transplantation which at any one time serve 12,000 to 15,000 patients with end-stage renal failure at a current cost of $400 million a year. These costs, furthermore, will probably stabilize at a figure three or four times greater than present levels. (This estimate covers only those medical expenses paid by Medicare and not disability or care costs.) Many kidney patients, especially the elderly, have severe diabetes or arteriosclerosis. Through dialysis or transplantation, most of them will gain about six more months of lif e that will constitute a dragged-out and debilitated rather than vital and zestful existence. Some nephrologists see little sense in treating them as opposed to patients of any age whose kidneys have been destroyed by infection or trauma but whose other organs and systems have not been involved—but they must do so in the absence of authority to deny treatment. Disability for black lung disease has recently been included in Medicare coverage, and treatment costs for cancer and hemophilia may soon be included in that program. This may be commendable, but the question remains: What portion of this country's resources, not only money but also scarce, trained manpower, should be devoted to high-cost, low-yield efforts, and what portion should be devoted to others? WEIGHING COSTS
To what extent will this country's medical resources be strained if a major technological breakthrough occurs?
PRIORITIES IN HEALTH SERVICES
11
What if an artificial heart were invented, the production and installation of which might well cost approximately $30,000 per case? Assuming that only 50 percent of the half million people in this country who die each year of coronary disease can benefit from this procedure, the additional load on the medical care system (which already absorbs over 8 percent of the gross national product, or GNP) that it would represent would be $7.5 billion, or almost 10 percent of the total present outlay for medical care in the United States. 5 Does this scenario depict the wisest use of resources? Wise or not, it will occur, for the pursuit of technological "miracles" brings rewards. High status in the medical fraternity, the kind of praise and publicity relished by most individuals, the Nobel prize—all these come to the so-called miracle workers. Approbation on this scale is withheld from those who spend their professional careers performing such prosaic, mundane, and even boring primary-prevention tasks as bringing all children up to date in their immunization inoculations, providing health services to the inner-city and rural poor, and making dental, optometric, and podiatric services readily available. A large majority of people in the United States remain unserved in these last areas. Moreover, old people in this country are left to languish in neglect and hunger in what are euphemistically called single-room occupancies but are in reality wretched firetraps equipped with one-burner hot plates. Similarly, people who have spent many years in mental hospitals and institutions for the retarded are released by the thousands into "the community" without adequate supervision. They huddle in nursing homes without professional direction and in boarding homes without supervision, often without being protected by
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the minimal health standards required by licensing regulations. 6 By what logic or sense of decency do we in this country offer expensive medical services to relatively few and deprive so many of bread and the opportunity to be reintegrated into the society that put them away in the first place? How many hot "meals on wheels" can be bought for the cost of one kidney transplant? The cost of one open-heart surgical procedure could pay the annual salary of two social workers to supervise patients discharged from mental hospitals. How can one need be weighed against the other? To what extent should one need be met as compared with the other? In the long ,run, there is only one relatively inelastic source to pay for everything needed or wanted in this country—the GNP, or the sum of goods and services produced. Its total can increase by a few percent a year if sufficient capital is invested, but investment of this kind of necessity takes place at the expense of investments in other areas. Offering more of some goods and services entails the decision to offer less of others. Social work as a profession has not yet absorbed the full significance of this. It can mean that no one is entitled to more than two kidney transplants (on the grounds that any further transplants are too likely to be rejected) and that there are limits to the number of times medical resources will be used to treat an alcoholic for d.t.'s or a diabetic for coma (on the same grounds, namely, that the state of the art is such that chances for success are slim and, further, that people are responsible for their own bodies and what they do to them). Health and welfare services, then, must not only compete among themselves for limited resources but must also compete with pressing needs in other problem areas. In addition
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to health care, such concerns as education, reform of the criminal justice system, cleaning up the rivers and air, and providing new homes for the next generation are crying for attention, funds, and personnel. Each of these needs could easily absorb $100 billion in the next decade. UNNECESSARY SERVICES In addition, it must be stressed that full provision of medical services will have a marginal effect on the life span of individuals in all but the most deprived groups. For example, although the number of deaths among children in this country is not as low as it might be, so few young children die that rare diseases such as leukemia and other forms of cancer are among the major causes of death in children. 7 A large proportion of childhood deaths, moreover, can be attributed to matters of life-style rather than to medical problems, for many of them are caused by firearms, automobiles, fires, drowning, various other accidents, and suicide (a major cause of death in white people as young as ages 10 to 14). 8 Indeed, increasing the number of physicians, nurses, and hospitals three- or fourfold would change patterns of illness and death minimally. The death rate among young people is so low, in fact, that if no one ever died before reaching the age of 35, average life expectancy would be increased by no more than 3.7 years. 9 Also arguing against the wholesale proliferation of medical services is the fact that the great decline in mortality rates that took place in the Jatter half of the 18th century was due more to improvements in sanitation and a general increase in standards of living than to better medical care. The declining death rates were
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specifically attributable to decreases in the incidente of tuberculosis (which accounted for approximately 50 percent of the decline), cholera, typhus, typhoid, dysentery, diarrhea (which accounted for 30 percent of the decline), and smallpox (which accounted for 5 percent)." The only medical advance associated with the drop in mortality ratel was the more widespread use of vaccination—a preventive public health measure, not a treatment measure. The improvement in public health stemmed in large measure from better separation of clean water from sewage, availability of a better diet, and availability of more frequent washing. Today, the major health dangers to adults are posed by smoking, drug abuse (legal and illegal), lack of exercise, excess star ch and animal fat in the diet, air (and possibly water) pollution, careless driving without seat beits or under the influence of ethanol, and the possibility of being shot by their best friends, relatives, neighbors, or themselves. 11 It is likely that the greatest improvement in public health would come about from nonmedical innovations, such as a tar-free cigarette or a pilt that would benefit overfed middle-class citizens by coating half the fond ingested by an individual to prevent its being absorbed in the small intestines. The provision of high-quality emergency medical care by fire medics and other technicians is another service whose implementation would be beneficial and would involve nothing more than doing better what the medical care system already knows how to do. The author rejects the notion that some of the measures discussed merely "attack symptoms and do not get down to causes." In situations in which causes are often unknown, multifactorial, or difficult or impossible to control, relieving symptoms may be all that can be
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done. Besides, why should difficult and expensive solutions of a definitive nature be insisted on when simpler and cheaper ones are available? 12 Striking at the root of the problem in this instante means attending to health education, which at present is primitive, ineffective, and as ignored in terms of medical priorities and prestige as are other aspects of primary prevention and care. At this point a note of cautious realism is in order: the proliferation of the best health practices will not lower the cost of medical care for long. Those who live for a longer time are more likely to succumb to the debilitating, long drawn-out, and degenerative diseases of aging that are expensive to treat. Therefore, no matter to what extent effective care is expanded by the use of such resources as physicians' assistants, nurse practitioners, and health maintenance organizations and no matter how well other available resources and knowledge are employed, the long-term trend toward increasing costs for medical care should not be expected to abate. LESS IS BETTER
The use of early detection devices such as annual physical examinations and mass screenings do not do as much good as is of ten claimed. Annual physical checkups yield few benefits at the cost of great travail. Perhaps these annual examinations should be limited to a detailed history (much of which can be computerized) that is supplemented by tests pertaining to visual acuity, glaucoma, hypertension, dentition, the checking of height and weight, laboratory analyses of blood and urine, and Pap smears for females. These procedures
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may be about all that is useful, and they can be done by people other than physicians. Much more important than medical examinations or anything medical science can do about mortality and morbidity is the taking of responsibility by individuals for their own health. This includes such matters as recognizing the danger signals of serious illnesses (such as the seven warning signals of cancer) and developing the knowledge and confidence to do elementary triage for one's own family. Undertaking triage requires knowing which symptoms and discomforts are likely to be self-limited and may therefore be ignored or treated with home or over-the-counter remedies, which should be observed for a few days before calling a doctor, and which should send one speeding to •the nearest hospital's emergency room. 13 The notion that only physicians can treat illness is no longer defensible. This ideology must be changed so that people will attain knowledge of and assume responsibility for the care of their own bodies. If physicians cannot help their patients achieve this state, then perhaps a different group of professionals will arise to meet the need. EARLY SCREENING Certain screening procedures having great popular appeal are of doubtful value, such as phenylketonuria (PKU) screening, which is mandatory for all newborn children in 39 states. Not only does this procedure fail to identify many babies who are affected by the inability to metabolize the protein in question, but some babies with high blood concentrations of phenylpyruvic acid do not in fact become retarded. If these children are placed on the diet traditionally used in the face of PKU, they
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"Offering more of some goods and services entails the decision to offer less of others. Social work as a profession has not yet absorbed the full significance of this."
fail to thrive. In addition, the effectiveness of the standard treatment for PKU even when appropriately used is in question. The screening and treatment program involved was made available to the public prematurely as a result of pressure by parents of retarded children, with less than great enthusiasm by biochemists and others involved in relevant research." Other groups have in turn clamored for mass screening for other defects and conditions, largely on the assumption that their particular group has been denied its place in the sun. Such screening, principally for sickle-cell trait and Tay-Sachs disease, is presently receiving its share of notoriety. However, no useful treatment is possible for these diseases, and the identification of individuals as carriers of a hereditary disease may subject them to lifelong stigmatization and emotional strain." What may really be needed is a program of premarital genetic counseling for members of those few families with a history of metabolic defects. A great many more black people suffer from hypertension than the approximately 340 who die annually of sickle-cell anemia, and a great many more Jewish people suffer from diabetes than the approximately 50 who die of Tay-Sachs disease." Screening programs for hypertension and diabetes rather than for sickle-cell trait or Tay-Sachs disease would therefore seem to have much greater relevance and benefit for blacks and Jews. The
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questionable value of various screening programs for genetic conditions indicates that certain services should not necessarily be undertaken merely because medical science knows how to do so. PRIMARY PREVENTION
Major health problems do not stem from strictly medical causes but rather are related to the tendency of individuals and societies to cope with stress by using dysfunctional mechanisms. Similarly, life-styles that lead to social malfunctioning are the results of the anomic, life-cramping relationships prevalent in modern industrial society. 17 Illness may often be one variety of such malfunctioning; in f act, social and physical malfunctioning are interrelated. Some means of reducing such malfunctions readily suggest themselves. American society has set its priorities willy-nilly, without thought or planning. For example, it has failed to create useful employment in a federally guaranteed iob program for those needing such a program. Among the consequences of this choice may be the necessity for a carefully controlled lower minimum wage for teenagers and an income subsidy for single-parent househoids. Implementation of adequate job programs, then, may be one way in which social malfunctioning can be reduced. Another element of a basic preventive program for social problems is the abolition in the schools of promotion for social rather than academic reasons. Whatever the cost in terms of special teachers, classes that have to be repeated, and research and development of new and effective programs, no one should be allowed to complete elementary school without being able to
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read with sufficient facility to enjoy doing so. Despite everything written about the demise of reading as a means of learning, in the opinion of the author, books are still the cheapest, most available, and most easily operated teaching machines. People who cannot read well are less capable of processing information in an orderly manner about the world in which they live, are less likely to speak and write in standard English or to have a rich vocabulary, and are less able to express complex ideas. In short, ending the practice of "social" promotions, exerting concerted effort to determine how best to teach young people to read well, and instituting programs for full employment and minimum family income may be primary-prevention items of the highest priority to ensure general physical and psychosocial well-being. A more controversial element to be included in a primaryprevention program for social problems might be a compulsory (as yet undeveloped) long-term contraceptive such as an intramuscular hormonal implant for use by all unmarried teenagers. Programs like these might be considered essential elements of a national effort to reduce the prevalence of delinquency, child abuse, illegitimacy, the stigma associated with public assistance, and other social problems." Implementing them would not eliminate the need for social services but would reduce it. This in turn would allow the social work profession to exercise its skills in areas that are not dominated by economic forces and unassailable in terms of social work efforts. Only then can social work begin to develop tasks that can be realized. These might include development of mass-screening instruments, nonstigmatizing in effect, in the area of psychosocial functioning, continuation of efforts to delineate
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the division of tasks between various levels of professional skills, and detection of prodromal signs of social malfunctioning and development of early treatment methods. ARRIVING AT ADEQUATE CHOICES
In briefly outlining some elements of the priority-setting process, it should be stated that some programs, such as library services and primary and secondary education, are so vital that they ought to be offered as a right to all, by universal provision, and with no qualifying requirements or payment demanded. In the author's opinion, the programs discussed previously are of this category and would appear to be part of the infrastructure of a sane society,. Services given next highest priority would include programs that are perhaps as necessary and vital but might, because of expense or the possibility of use beyond necessity, require a measure of copayment for those with requisite incomes and subsidy for those who would otherwise be denied access to service systems. National health insurance would be the major item in this category. The more usual social services to individuals, groups, and communities would be included in the next category of priorities. Self-help groups should be encouraged to provide some of these services, with an appropriate measure of professional consultation. Programs in the areas of drug treatment, rape prevention, and counseling for mastectomy and ostomy patients come under this category. Integral to the intelligent ordering of priorities is clarification of the appropriate use of various levels of paid professional staff. In this regard, the widest possible use of volunteers is desirable, and not for pur-
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poses of cost reduction alone. Channels for the expression of impulses toward voluntarism and altruism are basic components in democratie societies." Encouraging people to avail themselves of these channels is the most effective way to secure citizen understanding and to prompt concern and social action among the general public. In addition, certain sorely needed services can only be provided by volunteers. Another area requiring clarification is the proper role of social work in social welfare. If social workers can eschew the temptation to claim the impossible, they can establish their competence to seek limited, attainable goals. 2 ° Each field in social work must then decide on its own priorities. For example, in the area of family and children's services, what portion of giffort and resources should be devoted to crisis intervention, shortterm counseling, longer-term therapies, and foster care? Similarly, certain services to the aged should, at present, be considered experimental research programs at best and not as treatment programs to be widely used. 21 As a final consideration, it should be remembered that the profession of social work will contribute to, not decide on, the proper mix of services and service providers. Social workers would therefore do well to enlist the best minds in appropriate disciplines to assist them in making their most thoughtful contribution to this process. Among those to be consulted are economists who can calculate cost-benefit ratios to the extent that such calculations are possible and political scientists who can help device the least baffling, most responsive institutions for the delivery of services. The social work profession must also seek to form the widest possible coalitions with groups and organizations regarding different aspects of the total configuration of services.
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There will never be an end to this process, which will not be dominated by the National Association of Social Workers, a distinguished commission, or any series of legislative acts but by the never ending interaction of forces in the socio-economic-political arena. This country should strive to involve all its people in setting priorities in health and welfare services in the ceaseless process of forming a more perfect union. However far from perfection its present state may be, when compared to any other country, the United States is not doing all that badly. In summary, the allocating of resources involves a series of compromises in which fewer resources are devoted to some ,services and more are devoted to others. At any point in time, the number of resources available is smaller than that required by the needs and desires of society, and choices must be made. The author has argued that these choices should be made rationally on the basis of emphasizing fundamental community-wide services to support and strengthen individual and group functioning, instead of on the present basis, which stresses the provision of individual and often esoteric treatment, most of which is expensive, of benefit to few people, or of questionable benefit to anyone.
About the Author Harold J. Wershow, DSW, is Professor, Department of Sociology, University of Alabama in Birmingham, and is currently Fulbright-Hays Lecturer, School of Social Work, Haif a University, Israel. A version of this article was presented at the Sixth Annual Conference on Aging of the University of Alabama School of Social Work, Tuscaloosa, Alabama, March 1977.
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Notes and References 1. Paul Ehrlich and Anne H. Ehrlich, The End of Afiluence (New York: Balantine Books, 1974); Harold J. Wershow, "Man, A Maladapted Species?" Ecology of Foods and Nutrition, 2 (December 1973), pp. 69-72; and Donella H. Meadows et al., The Limits to Growth: A Report for the Club of Rome's Project on the Predicament of Mankind (New York: Universe Books, 1972). 2. Harold J. Wershow, "The Outer Limits of the Welfare State." To be published in the International Journal of Aging and Human Development.
3. Harold J. Wershow, "A World Worth Living In," Social Work, 20 (May 1975), pp. 175-178; and Phillip M. Stem, The Rape of the Taxpayer (New York: Vintage
Books, 1974). 4. For further discussion of this point, see Victor R. Fuchs, Who Shall Live? Health, Economics and Social Choice (New York: Basic Books, 1974). 5. Nathan Glazer, "Paradoxes of Health Care," The Public Interest, No. 22 (Winter 1971), pp. 62-77. 6. Special Committee on Aging, U.S. Senate, The Role of Nursing Homes in Caring for Discharged Mental Patients and the Birth of a For-Profit Boarding Home Industry, Supporting Paper No. 7 (Washington, D.C.: U.S.
Government Printing Office, 1976). 7. National Center for Health Statistics, Monthly Vital Statistics Reports: Annual Summary for the U.S., 1975
(Washington, D.C.: U.S. Government Printing Office, 1976). 8. Keith W. Sohnert and Howard Eisenberg, How to Be Your Own Doctor (Sometimes) (New York: Grosset & Dunlap, 1976). 9. Personal communication, Dr. George Reinhart IV, demographer. 10. David Mechanic, Medical Sociology: A Selective View (New York: Free Press, 1968), p. 237. 11. Fuchs, op. cit., pp. 119-120; and Nathan Glazer,
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op. cit., pp. 62-77. 12. Amitai Etzioni, "Shortcuts to Social Change," The Public Interest, No. 12 (Summer 1968), pp. 40-51. 13. Sohnert and Eisenberg, op. cit. 14. Samuel P. Bessman and Judith P. Swazey, "Phenylketonuria: A Study of Biomedical Legislation," in Everett Mendelson, Judith P. Swazey, and Irene Taviss, eds., Human Aspects of Biomedical Innovation (Cambridge, Mass.: Harvard University Press, 1971). 15. "Sickle Cell Anemia: The Route from Obscurity to Prominence," Science, 178 (October 13, 1972), p. 140; and "Sickle Cell Anemia: National Program Raises Problems as Well as Hopes," Science, 178 (October 20, 1972), pp. 283-286. 16. National Center for Health Statistics, Vital Health Statistics of the 'United States, 1972 (Washington, D.C.: U.S. Government Printing Office, 1976), and M. M. Keback and R. S. Zeiger, "The John F. Kennedy Institute Tay-Sachs Program: Practical Issues in an Adult Genetic Screening Program," in B. Hilton et al., eds., Ethical Issues in Human Genetics (New York: Plenum Press, 1973). 17. Matthew P. Dumont, The Absurd Healer: Perspectives of a Community Psychiatrist (New York: Viking Press, 1968). 18. For a discussion of services for strengthening and supporting social functioning, see Alfred J. Kahn and
Sheila B. Kamerman, Not for the Poor Alone: European Social Services (Philadelphia: Temple University Press, 1975). 19. Richard M. Titmuss, The Gift Relationship (London, England: George Allen & Unwin, 1971). 20. Joel Fischer, "Is Casework Effective? A Review," Social Work, 18 (January 1973), pp. 5-22; and Wershow, "A World Worth Living In," pp. 175-177. 21. Harold J. Wershow, "Reality Orientation for Gerontologists," The Gerontologist, 17 (August 1977).
