EDITORIALS

organizational factors that might be implicated." Their report demonstrates what an institution serving the underprivileged can do to adapt its own behavior to the needs of those it serves. The versatility of science astounds: using the same methods and the same language, it can help solve problems or it can shield problems from solution. For years, researchers have happily studied and described the ethnic, age, or sex groups that are the most or least reliable in keeping appointments instead of asking what makes an appointment likely to be kept. By asking better questions, Hertz and Stamps found out that the institution's behavior had a lot to do with the problem. The same may be said of many other current health problems. Thus, in the general effort to reduce the escalation of health care costs, providers and government are quick to blame patients for overuse of medical services or prescription drugs. There seems to be less enthusiasm for looking seriously at price-gouging, monopoly control, drug pushing by drug companies, fainthearted regulation, agency capture by regulatees, and other "organizational factors which may be implicated" in the problem of health care costs. Whether or not the victim is actually blamed or merely identified as having the "relevant" age, sex, or ethnicity

makes very little difference. In either case, the practical effect of focusing attention on the victim instead of the problem is to permit health care institutions, government, and the people in charge to evade responsibility for their own actions. There is certainly nothing wrong with efforts of health care providers and institutions to help individuals to make the best use of their own lives. Yet clearly those of us who work in institutions that deliver or regulate health care must also continue to pressure those institutions to look critically at themselves and shoulder those responsibilities which are rightly theirs rather than those of their clients.

RUTH B. GALANTER, MCP Address reprint requests to Ruth B. Galanter, MCP, Editor, Health Law Newsletter, National Health Law Program, 2401 Main Street, Santa Monica, CA 90405. Ms. Galanter is a member of the Journal Editorial Board.

REFERENCES 1. "Court Alters Controversial Rape Decision". Los Angeles Times, Aug. 9, 1977, Pt. II, P. 1. 2. Hertz, Philip, and Stamps, Paula L. Appointment-keeping behavior re-evaluated. Am. J. Public Health 67:1033-1036, 1977.

Strategy for Prevention Half a century ago, the Massachusetts Department of Public Health pioneered in tuberculosis and cancer control. Cautiously but unmistakably, as indicated in Dr. Fielding's commentary in this issue, the Department is now moving into the new areas of prevention discovered in the second epi-

demiologic revolution.I A variety of approaches have been taken by the Department. Among the most important is the proposal to collect and disseminate cost-benefit data for preventive measures, an approach that health officers used effectively in the past to gain public support and public funds for the control of infectious diseases. The suggestion that insurance premiums take self-imposed health risks into account is favored, but the difficulty in identifying risks is recognized, as well as the possibility that national health insurance will reverse any progress made in this direction. This need not be the case, however; the financing of a national health care program by a variety of tax funds should properly include the revenues from substantial taxation of cigarettes and alcohol. Recommendations are made in the article for economic incentives to hospitals to develop preventive programs; for an educational program for primary care practitioners so they may explain health risks to their patients; and for giving prevention a high priority in the plans of the Health Systems Agencies. Although these are attractive proposals, they will 1026

be difficult to achieve without the availability of substantial funds earmarked for specific preventive programs. Such funds will not be forthcoming in the absence of extensive public education. The Massachusetts Department of Public Health not only favors a strengthened health education curriculum in the schools, but cosponsors demonstration projects for prevention with various civic groups and is involved in cooperative agreements with radio and television stations for programs on smoking, alcohol and other health risks. These are elements of what should become a manypronged, sustained and vigorous educational campaign by all health departments-local, state and federal-to inform the public of the findings of our epidemiologic colleagues. Without the support of an informed public, progress in the new areas of public health will be difficult indeed. Dr. Fielding favors adoption of a taxation policy that provides disincentives for use of harmful products and provides funds to promote their non-use, citing bills taxing alcohol and cigarettes that have been introduced into the Massachusetts State Legislature. His overall view is a realistic one, stating that "in order for these strategies to work, we need to build a consensus for change that includes the use of legislative and financial levers." This is a far different emphasis than that of the currently fashionable "life-style" approach which reduces behavior to the individual level and, by ignoring the social environment which creates life-styles, avoids AJPH November 1977, Vol. 67, No. 11

EDITORIALS

confrontation with powerful interests that promote the lifestyles that are injurious to health. Tentative as some of Dr. Fielding's approaches may be, they represent a serious effort to explore the newer, more important areas of prevention: heart disease, cancer, stroke, accidents, chronic obstructive lung disease and cirrhosis of the liver. In all of these, thanks to the work of the epidemiologists, known measures of prevention now exist. It has been conservatively estimated that application of these measures could save each year in the United States at least 400,000 lives and $20 billion.2 This great endeavor needs to be made the first priority of every health department. It is a difficult task, fraught with complexities and potential antagonisms. Yet just as Hermann Biggs, Charles V. Chapin, and other health officers surmounted the complexities and antagonisms of the struggle against infectious diseases early in this century, so will the new generation of health officers win their coming compaigns against the non-infectious diseases. Dr. Fielding

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is a member of this new generation of state and local health officers who are young, dedicated, unwilling to continue in the old ways, and unswerving in their conviction that the primary role of every health department-and every public health worker-is to prevent the disease and trauma which bring sickness and death in their wake.

MILTON TERRIS, MD Address reprint requests to Dr. Milton Terris, Professor and Chairman, Department of Community and Preventive Medicine, New York Medical College, Fifth Avenue and 106th Street, New York, NY 10029

REFERENCES 1. Fielding, Jonathan E. Health promotion-some notions in search of a constituency. Commentary, Am. J. Public Health 67:10821085, 1977. 2. Terris, M. Costs and Benefits of Prevention: The Challenge to National Policy. Presented at the Annual Meeting of the American Public Health Association, October 1976.

Measles Rampant

Early in 1875, Cakobau, king of the Fiji Islands, came back from a visit to Australia with a case of measles-a disease not usually fatal elsewhere but totally unknown in the Fijis. In a matter of weeks Cakobau's illness became an epidemic. Not having any natural resistance to the contagion, 40,000 natives died of the new disease. LIFE Magazine, July 4, 1969, p. 50.

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Strategy for prevention.

EDITORIALS organizational factors that might be implicated." Their report demonstrates what an institution serving the underprivileged can do to adap...
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