The Poverty
of
Affluence
LORIN E. KERR, MD, MSPH For the flrst time in the American Public Health Association's 103-year history, our Annual Meeting is primarily concemed with the health of minorities. As evidenced by programs over the last quarter of a century, past presentations on this subject have been sporadic. Last year APHA responded-through its Goveming Council-to a minority confrontation by directing that the theme of this 1974 meeting should be the "Health of Non-White and Poor Americans." It is more than passing rhetoric that a confrontation was obviously necessary before we could ever get to this theme and point of conscience. The direction of this Presidential Address is thus mandated. I believe it is also significant that in reviewing all of the well conceived previous Presidential Addresses, it is apparent to me that there has been no such proscription before now. I am pleased that I can direct my remarks to this mandate. American society has exacerbated the health problems which are acute and startling in the minorities-problems of midst of the abundance surrounding us. Any downtum in the economy such as we are now experiencing worsens already acute problems. It is our national opulence which has produced a paucity of ethical and committed social concern for the shocking state of the health of all minorities throughout the nation-a nation which is truly poverty stricken in the midst of affluence. This concept is reemphasized by many of the societal issues which undermine health status-inflation, unemployment, inadequate housing, poor nutrition, and the lack of upward mobility in education and employment-yes, even by the lack of any kind of guaranteed benefits in our "voluntary
American suburbia grows more white. Central cities tend to decay; suburbs to flourish. Our national rhetoric states that "Health is a Right," but this has had little or no effect on attitudes, social concepts, or legislation. In fact, this adherence to the status quo continues to accentuate the differences of health status between the majority and the minorities. Were this not true, our theme would not be relevant. The etiology and resolution of these group differences are primarily sociopolitical. Let us remember that public health originated as a broad movement of socio political reform; let APHA record and act upon the declaration that "Health is an Equal
Right."
health system." The recorded constitutional history of the United States expounds exemplary criteria which raise our expectations-yet we daily follow other practices which frequently are diametrically opposed to these tenets. Today, the universal attitude toward minorities is little different from the treatment of the Indians and black people by the Founding Fathers. The recently published report of a 2-year study by the U.S. Commission on Civil Rights, entitled Equal Opportunity in Suburbia, documents that Amerincan central cities are growing more black, while
As this meeting will verify, the basic health needs of minorities are essentially the same as those of the white majority. However, the magnitude of the unmet needs of minorities is far greater, because of two centuries of malign attention and benign neglect-neglect which will probably receive little public attention when American celebrates its bicentennial and underscores its own apathy. Moreover, this neglect has further intensified the complexity of the needs. Some of our colleagues have voiced their concern that a presentation of facts and the focus of attention on these facts by health workers would polarize this Association-a concern which I do not share. In light of the myriad problems in our total American society, this meeting is, hopefully, a minimal first effort directed toward the ultimate elimination of the double standard in health. When remediable health problems affect the majority, remedial action is usually possible. But among the minorities and the often overlooked poor, corrective action is usually impossible-even when high quality medical advice is available. Such things as unemployment, low wages, seasonal work, illiteracy in the English language, and the high cost of medical services are very real problems and effective barriers to the application and use of sound health information. Also, the frustration of simply surviving and coping with family needs in a nonresponsive and laissezfaire society can produce serious mental health problems which, in tum, are often reflected in elevated crime rates and other substantive costs. Gunnar Myrdal succinctly expressed it this way in his recent book Against the Stream:
This Presidential Address was presented at the 102nd Annual Meeting, American Public Health Association, New Orleans, Louisiana, October 21, 1974. Dr. Kerr is President, American Public Health Association, 1973-1974. He is Director, Department of Occupational Health, United Mine Workers of America, Washington, DC.
"The United States is that country among the rich countries that has the most and worst slums, the and highest rate of unemployed and unemployables,most the least developed health services, and that is [miserly] toward its old people and its poor children who are so many, as well as being the country that leads the whole Western world in violence, crime and corruption in high places."' PRESIDENTIAL ADDRESS
17
APHA is the only multidiscipline organization in this country primarily devoted to protecting and enhancing the health of the nation. To this end, we are, and should be, constantly seeking to improve and refine epidemiological, laboratory, and statistical techniques. Likewise, we are constantly striving to implement preventive health services, and to improve the education and use of health workers. These and numerous other endeavors constitute our professional and scientific responsibilities. There are those among us who feel this should be the sum total of our organizational responsibilities. There are others who feel that compliance with APHA's long standing commitment to "Serving Society-Protecting Health" calls for an actionoriented organization. Some organizational conflict has thus developed. I am convinced that APHA's goal of protecting and preserving the health of the nation requires both missions. They can coexist-there will be times when science takes priority but, equally important, there will also be those occasions when action must take precedence. This dual mission is best implemented when it involves our daily activities-those for which we are paid and those in which we are involved, or should be, as concerned persons. How does one change the 200-year-old American bias so that we can treat a black patient with cardiac arrest? We have the technology and mechanics of heart treatment even to the point of energizing emergency air-ground transportation. However, I have failed to observe any feeling of urgency in this country to implement getting our highly scientific mechanisms to places in the United States where the bulk of the population is poor and black, brown, red, Asian, or white. Moreover, I fail to observe any tangible urgency to wipe out existing minority segregation and bias in health care. There is also a shameful lack of minority health workers in America-especially in the professions. Affirnative programs and methods must be found and implemented to assure that each institution and organization in the health field makes certain that members of minority groups are constantly being trained and educated in significant and equitable numbers to fill this gap. We are all aware that critical manpower shortages exist in most health disciplines here and in many other parts of the world. The concept of good public health must never be isolationist. What good we do here should benefit all mankind. Today, America is confronted with the absence of a functioning official federal public health agency. In his recent book, Go East, Young Man, Justice William 0. Douglas states that the U.S. Public Health Service became so closely identified with the interests they were supposed to regulate that they were eventually transformed into spokesmen for those interest groups. He felt that this happened as the PHS became a satellite of state public health agencies which in turn were controlled by the industrial polluters and other members of the Establishment. There may well be some disagreement with Douglas's assessment. However, there can be little argument that the federal government's failure to respond to expanding demands in public health and personal health services, 18
AJPH JANUARY, 1975, Vol. 65, No. 1
despite interminable reorganizations, has been largely responsible for the thrust of this meeting. The present health crisis in America is a crisis not of technical information but of public policy. Myron E. Wegman's 1969 query, "Who Will Lead This Nation's Health Effort?"2 still remains unanswered 5 years later. This lack of concerned direction and leadership has had such a devastating impact on state and local health departments that they have become fragmented and impotent. Schools of public health have continued for so long to be "the underprivileged group of graduate institutions" that their viability is now in question. Supporters of this mindless destructive public policy point accusatory fingers at all levels of health department personnel when queried about the reasons for these actions. However, I am reminded of the truism that we don't tear down good buildings merely because we disagree with the tenants. The pressing need for the national availability of an organized body trained and equipped to provide services and leadership of specialists, in all aspects of public health, demands concerted action of all health personnel. In the words of Charles C. Edwards, Assistant Secretary for Health, "Unfortunately, we have had too many instances of health policy being made by business school graduates who have had no experience in the health field."3 The early detection and prevention of disease, long the undisputed arena of public health, is today conspicuous by its absence. What have we done-each of us-to reduce the incidence of venereal diseases-or to reverse the frightening low level trends of immunization of children against measles, polio, diphtheria, pertussis, and tetanus? Last year we were given the details on an epidemic of diphtheria which had occurred among Chicanos. The local medical society, in retaliation against the physicians who initiated an immunizing campaign, literally drove them out of town-and what did we do? Not too long ago were also treated to the spectacle of a typhoid outbreak in a large migratory agricultural workers' camp. Where were we or our Affiliates? In the same vein, more recently we have become increasingly aware of the occupational diseases of which there is no accurate national accounting. Although we are learning of the shocking number of coal miners killed and disabled by the chronic respiratory diseases occurring among them, we still have no knowledge of the number of workers with silicosis, byssinosis, or asbestosis, just to mention a few of the more highly publicized man-made dust diseases. The same deplorable lack of statistics is true of all job-related illnesses-such as impaired hearing; cancers of the lung, bladder, and liver; and lead poisoning, to name a few. In addition, we are confronted with the unmeasured impact of highly mechanized jobs on the physical and mental health of the worker. The prevention of this frightening toll of dead and disabled workers will yield more startling results than can be attributed to the virtual elimination of the communicable diseases. It would also contribute enormously to the containment of medical care costs. The success of this program demands the development of a personal health delivery system in which the prevention, diagnosis, treatment, and rehabilitation of
occupational illness and injury will be coordinated and integrated with all of the health services provided for the worker and his family. No longer can we tolerate programs which fragment and isolate the worker and his health needs. Lest we forget, there is a far higher percentage of minorities employed in the hazardous industries than occurs in the banking, insurance, or health industries. APHA has a major role to play in the development of a national consciousness of the many overt and covert problems affecting the health status and difficulties of Americans in minority groups. Our individual self-awareness of this problem is imperative before APHA can have a meaningful constructive impact on the private sector of the economy, voluntary public agencies, or the local, state, or federal branches of government. For example, we have been mute on the increase of deductibles and coinsurance in the Medicare law. Today only 37 per cent of the medical care costs of the aged are being paid by the Social Security Administration. As a result, the elderly are forced to pay 63 per cent of the costs out of pocket-if they receive care. This is indeed a sharp rise from the initially planned percentage. In addition, there are still some elderly who are not even eligible for Medicare. Thus, increased costs and lack of eligibility have worked a double-barreled hardship particularly on minorities, since these are the people most likely to be ineligible and least able to pay coinsurance and noncovered costs. To further underscore the magnitude of this problem among the aged, preventive services are not even covered by the Medicare law. There is still another role we must play in getting educational and advisory material before the legislative branches of government. We must use our personal resources of knowledge on those agencies with whom we are associated either as employers or as employees. This involvement runs the gamut from school boards-public and private-churches, hospitals, public and voluntary health agencies, to industrial corporations where we may be a worker or a stockholder, and to consumer organizations, which in effect covers all facets of our daily living. We must speak out in our professional societies, our personal associations, and to those whom we may be teaching or supervising. If we are really committed to good health for all persons, the members of APHA must make all America aware of the critical lag in the provision of good health care for minorities and the poor. We must lead an overt and active role of advocacy. The Association's leadership potential has been frequently undercut by the lack of personal commitment among health personnel to the total well-being of any individual regardless of color, ethnic background, or socioeconomic status. Closely associated is a lack of concern with local community health problems and their resolution-a situation frequently encountered in both the Association and the Affiliates. Moreover, APHA Section programs are all too often devoid of planned implementation. Leadership will flow, however, from a resolution of these problems and an amalgam of the resultant initiatives will answer most questions. APHA must also continue the democratization of its own organization initiated a few years ago. One further step
I strongly recommend is that the entire membership of the Association should vote for all APHA officers. This responsibility should no longer rest solely with the Governing Council. All that I have said thus far leads me to believe that we must now devote our energies to rebuilding our health departments to be viable and responsive to current needs and demands. Achievement of this goal can be accomplished when the electorate of local, county, state, and federal bodies puts health needs high on its list of priorities. All too often, public health is permitted to appear as a nebulous term, the cost of which is difficult for the general public to equate with the cost of a piece of fire equipment-or a monument. According to David B. Wamrrn4 -and I agree-it will be necessary to alert health departments that they have a fiduciary responsibility for the health of the community and may, in fact, be held legally accountable for the community health in ways not previously contemplated. This responsibility may reach to new boundaries of public accountability for health officials. Before we vote for a state legislator or a Congressman, we must make it our business to know his or her stand on health needs-including personal health services. And, because health needs are only one segment of the body politic's concern, we should also know the attitude of all appointed and elected representatives from dogcatcher to President. This includes their concern for the rights and
needs of minorities. Nearly half-a-century ago, C.-E. A. Winslow, in his Presidential Address,5 questioned whether there was ever a point at which social responsibility for individual health ceases. Most of his remarks, however, were devoted to what he felt then was an urgent need to include medical care in health department programs. He predicted that "Some form or forms of organized community medical service are coming as surely as the sun will rise tomorrow." In addition, he said: "It is only through the leadership of the health officer as an agent of the public solemnly charged with the duty of preventing disease and promoting health in every form, and through the thoughtful and broad-minded cooperation of the medical profession, that the legitimate demand for an organized preventive medical service can be wisely met."
He then warned that, "If we place our heads in the sand like the ostrich, or if we emulate King Canute and order back the tides, the inevitable will still occur; but its form and its direction we can govern if we will."
Looking to the immediate future, there should be active support of the proposal recently made by Nathan Sinai, Emeritus Professor of Public Health, University of Michigan, that health department personnel should be retrained in the intricacies of medical care administration.6 He is concemed that, at most, there are only about 18 months in which to ready this nationwide network of health personnel before the country will be swamped with the demand for such expertise following the passage of a PRESIDENTIAL ADDRESS
19
national health plan. Equally important should be the inclusion of environmental health as part of the preventive system in this training. The early warnings of Winslow, augmented by the sagacity of Ray Lyman Wilbur's summary of the report by the Committee on the Costs of Medical Care in 1932 and the report of the 1938 National Health Conference, support Sinai's contention. In fact, there is good reason to believe that we in public health have been given another chance to respond to the APHA commitment to "Serving Society-Protecting Health." Failure to do so assures our early demise. In conclusion, I would like to return to the title of this address-"The Poverty of Affluence." Each of the points I have covered is a problem of long standing which, with the passage of time, has worsened. This is due, in part, to national priorities which have permitted the expenditure of billions of dollars for precision lunar landings and billions more for precise and wanton destruction in many parts of the world. Despite the plethora of skills, talents, and money devoted to such awesome precision, our health needs continue to go unmet. Lately I have been haunted by the thought that this dichotomy may be due to the deadening impact on ethical precepts by these and other billions of dollars. Ours is an ethical profession with dedicated commitments to the individual, the community, the nation, and itself. It is worrisome, however, to think that the community of which we are also a product has fragmented our actions and ethics, thereby separating us from those in
need of our skills and leaming. Ethically we may be poverty-stricken because we have abjured our responsibilities in the community and in the nation, and have not sufficiently shared both the hopes and pains of others. I hope, as a result of this 102nd Annual Meeting with its focus on the health problems of all minorities and the poor, that the entire structure and membership of the American Public Health Association will become totally committed to an early resolution of infinite, chronic-and worsening-problems of health and health care.
References 1. Myrdal, G. Against the Stream. Pantheon, New York, 1973 2. Wegman, M. E. Who Will Lead This Nation's Health Effort? (Editorial). N. Engl. J. Med. 281:959, 1969. 3. Edwards, C. C. The U.S. Public Health Service. Hosp. Formul. Management 9:8, 1974. 4. Warren, D. G. Legal Obstacles in NOT Developing New Roles for Local Health Departments. Presented at meeting for North Carolina Health Directors, School of Public Health, University of North Carolina, Chapel Hill, March 6, 1974. 5. Winslow, C.-E. A. Public Health at the Crossroads. Am. J. Public Health 16:1075, 1926. 6. Sinai, N. National Health Plans: The Challenge of Management. Presented at a symposium-tribute honoring Dr. Nathan Sinai, University of California at Los Angeles, May 11, 1974.
NEW APHA 40-YEAR MEMBERS 1974 Mrs. R. W. Arfsten Claude H. Ballard J. Lloyd Barron Kenneth L. Burdon, PhD Anselmo F. Dappert Floyd M. Feldmann, MD, DrPH Alice L. Fisher, RN, MSPH Archie B. Freeman John F. Gordon, MD Russell Gottshall, PhD Francois Guimont, MD, DPH Ernest B. Hanan, MD
20
AJPH JANUARY, 1975, Vol. 65, No. 1
Marie C. Harrington Harold M. Kelso, MD, MPH Louise Knapp, RN James H. LeVan Aaron Leifer, MD, MSPH Anne S. Loop, PhD Herbert H. Marks Lucy S. Morgan, PhD Clyde R. Newell James E. Perkins, MD, DrPH Julius Pincus, MD Dr. Bettie F. Rogerson
Hernan Romero, MD Ernest L. Stebbins, MD, MPH Marion E. Stroud Fred H. Stutz Richard M. Taylor, MD, DPH H. R. Thornton, PhD Victoria M. Trasko David B. Treat Louis S. Welty, MD, MPH George J. Wherrett, MD Muriel B. Wilbur, PhD, MPH
of
Affluence
LORIN E. KERR, MD, MSPH For the flrst time in the American Public Health Association's 103-year history, our Annual Meeting is primarily concemed with the health of minorities. As evidenced by programs over the last quarter of a century, past presentations on this subject have been sporadic. Last year APHA responded-through its Goveming Council-to a minority confrontation by directing that the theme of this 1974 meeting should be the "Health of Non-White and Poor Americans." It is more than passing rhetoric that a confrontation was obviously necessary before we could ever get to this theme and point of conscience. The direction of this Presidential Address is thus mandated. I believe it is also significant that in reviewing all of the well conceived previous Presidential Addresses, it is apparent to me that there has been no such proscription before now. I am pleased that I can direct my remarks to this mandate. American society has exacerbated the health problems which are acute and startling in the minorities-problems of midst of the abundance surrounding us. Any downtum in the economy such as we are now experiencing worsens already acute problems. It is our national opulence which has produced a paucity of ethical and committed social concern for the shocking state of the health of all minorities throughout the nation-a nation which is truly poverty stricken in the midst of affluence. This concept is reemphasized by many of the societal issues which undermine health status-inflation, unemployment, inadequate housing, poor nutrition, and the lack of upward mobility in education and employment-yes, even by the lack of any kind of guaranteed benefits in our "voluntary
American suburbia grows more white. Central cities tend to decay; suburbs to flourish. Our national rhetoric states that "Health is a Right," but this has had little or no effect on attitudes, social concepts, or legislation. In fact, this adherence to the status quo continues to accentuate the differences of health status between the majority and the minorities. Were this not true, our theme would not be relevant. The etiology and resolution of these group differences are primarily sociopolitical. Let us remember that public health originated as a broad movement of socio political reform; let APHA record and act upon the declaration that "Health is an Equal
Right."
health system." The recorded constitutional history of the United States expounds exemplary criteria which raise our expectations-yet we daily follow other practices which frequently are diametrically opposed to these tenets. Today, the universal attitude toward minorities is little different from the treatment of the Indians and black people by the Founding Fathers. The recently published report of a 2-year study by the U.S. Commission on Civil Rights, entitled Equal Opportunity in Suburbia, documents that Amerincan central cities are growing more black, while
As this meeting will verify, the basic health needs of minorities are essentially the same as those of the white majority. However, the magnitude of the unmet needs of minorities is far greater, because of two centuries of malign attention and benign neglect-neglect which will probably receive little public attention when American celebrates its bicentennial and underscores its own apathy. Moreover, this neglect has further intensified the complexity of the needs. Some of our colleagues have voiced their concern that a presentation of facts and the focus of attention on these facts by health workers would polarize this Association-a concern which I do not share. In light of the myriad problems in our total American society, this meeting is, hopefully, a minimal first effort directed toward the ultimate elimination of the double standard in health. When remediable health problems affect the majority, remedial action is usually possible. But among the minorities and the often overlooked poor, corrective action is usually impossible-even when high quality medical advice is available. Such things as unemployment, low wages, seasonal work, illiteracy in the English language, and the high cost of medical services are very real problems and effective barriers to the application and use of sound health information. Also, the frustration of simply surviving and coping with family needs in a nonresponsive and laissezfaire society can produce serious mental health problems which, in tum, are often reflected in elevated crime rates and other substantive costs. Gunnar Myrdal succinctly expressed it this way in his recent book Against the Stream:
This Presidential Address was presented at the 102nd Annual Meeting, American Public Health Association, New Orleans, Louisiana, October 21, 1974. Dr. Kerr is President, American Public Health Association, 1973-1974. He is Director, Department of Occupational Health, United Mine Workers of America, Washington, DC.
"The United States is that country among the rich countries that has the most and worst slums, the and highest rate of unemployed and unemployables,most the least developed health services, and that is [miserly] toward its old people and its poor children who are so many, as well as being the country that leads the whole Western world in violence, crime and corruption in high places."' PRESIDENTIAL ADDRESS
17
APHA is the only multidiscipline organization in this country primarily devoted to protecting and enhancing the health of the nation. To this end, we are, and should be, constantly seeking to improve and refine epidemiological, laboratory, and statistical techniques. Likewise, we are constantly striving to implement preventive health services, and to improve the education and use of health workers. These and numerous other endeavors constitute our professional and scientific responsibilities. There are those among us who feel this should be the sum total of our organizational responsibilities. There are others who feel that compliance with APHA's long standing commitment to "Serving Society-Protecting Health" calls for an actionoriented organization. Some organizational conflict has thus developed. I am convinced that APHA's goal of protecting and preserving the health of the nation requires both missions. They can coexist-there will be times when science takes priority but, equally important, there will also be those occasions when action must take precedence. This dual mission is best implemented when it involves our daily activities-those for which we are paid and those in which we are involved, or should be, as concerned persons. How does one change the 200-year-old American bias so that we can treat a black patient with cardiac arrest? We have the technology and mechanics of heart treatment even to the point of energizing emergency air-ground transportation. However, I have failed to observe any feeling of urgency in this country to implement getting our highly scientific mechanisms to places in the United States where the bulk of the population is poor and black, brown, red, Asian, or white. Moreover, I fail to observe any tangible urgency to wipe out existing minority segregation and bias in health care. There is also a shameful lack of minority health workers in America-especially in the professions. Affirnative programs and methods must be found and implemented to assure that each institution and organization in the health field makes certain that members of minority groups are constantly being trained and educated in significant and equitable numbers to fill this gap. We are all aware that critical manpower shortages exist in most health disciplines here and in many other parts of the world. The concept of good public health must never be isolationist. What good we do here should benefit all mankind. Today, America is confronted with the absence of a functioning official federal public health agency. In his recent book, Go East, Young Man, Justice William 0. Douglas states that the U.S. Public Health Service became so closely identified with the interests they were supposed to regulate that they were eventually transformed into spokesmen for those interest groups. He felt that this happened as the PHS became a satellite of state public health agencies which in turn were controlled by the industrial polluters and other members of the Establishment. There may well be some disagreement with Douglas's assessment. However, there can be little argument that the federal government's failure to respond to expanding demands in public health and personal health services, 18
AJPH JANUARY, 1975, Vol. 65, No. 1
despite interminable reorganizations, has been largely responsible for the thrust of this meeting. The present health crisis in America is a crisis not of technical information but of public policy. Myron E. Wegman's 1969 query, "Who Will Lead This Nation's Health Effort?"2 still remains unanswered 5 years later. This lack of concerned direction and leadership has had such a devastating impact on state and local health departments that they have become fragmented and impotent. Schools of public health have continued for so long to be "the underprivileged group of graduate institutions" that their viability is now in question. Supporters of this mindless destructive public policy point accusatory fingers at all levels of health department personnel when queried about the reasons for these actions. However, I am reminded of the truism that we don't tear down good buildings merely because we disagree with the tenants. The pressing need for the national availability of an organized body trained and equipped to provide services and leadership of specialists, in all aspects of public health, demands concerted action of all health personnel. In the words of Charles C. Edwards, Assistant Secretary for Health, "Unfortunately, we have had too many instances of health policy being made by business school graduates who have had no experience in the health field."3 The early detection and prevention of disease, long the undisputed arena of public health, is today conspicuous by its absence. What have we done-each of us-to reduce the incidence of venereal diseases-or to reverse the frightening low level trends of immunization of children against measles, polio, diphtheria, pertussis, and tetanus? Last year we were given the details on an epidemic of diphtheria which had occurred among Chicanos. The local medical society, in retaliation against the physicians who initiated an immunizing campaign, literally drove them out of town-and what did we do? Not too long ago were also treated to the spectacle of a typhoid outbreak in a large migratory agricultural workers' camp. Where were we or our Affiliates? In the same vein, more recently we have become increasingly aware of the occupational diseases of which there is no accurate national accounting. Although we are learning of the shocking number of coal miners killed and disabled by the chronic respiratory diseases occurring among them, we still have no knowledge of the number of workers with silicosis, byssinosis, or asbestosis, just to mention a few of the more highly publicized man-made dust diseases. The same deplorable lack of statistics is true of all job-related illnesses-such as impaired hearing; cancers of the lung, bladder, and liver; and lead poisoning, to name a few. In addition, we are confronted with the unmeasured impact of highly mechanized jobs on the physical and mental health of the worker. The prevention of this frightening toll of dead and disabled workers will yield more startling results than can be attributed to the virtual elimination of the communicable diseases. It would also contribute enormously to the containment of medical care costs. The success of this program demands the development of a personal health delivery system in which the prevention, diagnosis, treatment, and rehabilitation of
occupational illness and injury will be coordinated and integrated with all of the health services provided for the worker and his family. No longer can we tolerate programs which fragment and isolate the worker and his health needs. Lest we forget, there is a far higher percentage of minorities employed in the hazardous industries than occurs in the banking, insurance, or health industries. APHA has a major role to play in the development of a national consciousness of the many overt and covert problems affecting the health status and difficulties of Americans in minority groups. Our individual self-awareness of this problem is imperative before APHA can have a meaningful constructive impact on the private sector of the economy, voluntary public agencies, or the local, state, or federal branches of government. For example, we have been mute on the increase of deductibles and coinsurance in the Medicare law. Today only 37 per cent of the medical care costs of the aged are being paid by the Social Security Administration. As a result, the elderly are forced to pay 63 per cent of the costs out of pocket-if they receive care. This is indeed a sharp rise from the initially planned percentage. In addition, there are still some elderly who are not even eligible for Medicare. Thus, increased costs and lack of eligibility have worked a double-barreled hardship particularly on minorities, since these are the people most likely to be ineligible and least able to pay coinsurance and noncovered costs. To further underscore the magnitude of this problem among the aged, preventive services are not even covered by the Medicare law. There is still another role we must play in getting educational and advisory material before the legislative branches of government. We must use our personal resources of knowledge on those agencies with whom we are associated either as employers or as employees. This involvement runs the gamut from school boards-public and private-churches, hospitals, public and voluntary health agencies, to industrial corporations where we may be a worker or a stockholder, and to consumer organizations, which in effect covers all facets of our daily living. We must speak out in our professional societies, our personal associations, and to those whom we may be teaching or supervising. If we are really committed to good health for all persons, the members of APHA must make all America aware of the critical lag in the provision of good health care for minorities and the poor. We must lead an overt and active role of advocacy. The Association's leadership potential has been frequently undercut by the lack of personal commitment among health personnel to the total well-being of any individual regardless of color, ethnic background, or socioeconomic status. Closely associated is a lack of concern with local community health problems and their resolution-a situation frequently encountered in both the Association and the Affiliates. Moreover, APHA Section programs are all too often devoid of planned implementation. Leadership will flow, however, from a resolution of these problems and an amalgam of the resultant initiatives will answer most questions. APHA must also continue the democratization of its own organization initiated a few years ago. One further step
I strongly recommend is that the entire membership of the Association should vote for all APHA officers. This responsibility should no longer rest solely with the Governing Council. All that I have said thus far leads me to believe that we must now devote our energies to rebuilding our health departments to be viable and responsive to current needs and demands. Achievement of this goal can be accomplished when the electorate of local, county, state, and federal bodies puts health needs high on its list of priorities. All too often, public health is permitted to appear as a nebulous term, the cost of which is difficult for the general public to equate with the cost of a piece of fire equipment-or a monument. According to David B. Wamrrn4 -and I agree-it will be necessary to alert health departments that they have a fiduciary responsibility for the health of the community and may, in fact, be held legally accountable for the community health in ways not previously contemplated. This responsibility may reach to new boundaries of public accountability for health officials. Before we vote for a state legislator or a Congressman, we must make it our business to know his or her stand on health needs-including personal health services. And, because health needs are only one segment of the body politic's concern, we should also know the attitude of all appointed and elected representatives from dogcatcher to President. This includes their concern for the rights and
needs of minorities. Nearly half-a-century ago, C.-E. A. Winslow, in his Presidential Address,5 questioned whether there was ever a point at which social responsibility for individual health ceases. Most of his remarks, however, were devoted to what he felt then was an urgent need to include medical care in health department programs. He predicted that "Some form or forms of organized community medical service are coming as surely as the sun will rise tomorrow." In addition, he said: "It is only through the leadership of the health officer as an agent of the public solemnly charged with the duty of preventing disease and promoting health in every form, and through the thoughtful and broad-minded cooperation of the medical profession, that the legitimate demand for an organized preventive medical service can be wisely met."
He then warned that, "If we place our heads in the sand like the ostrich, or if we emulate King Canute and order back the tides, the inevitable will still occur; but its form and its direction we can govern if we will."
Looking to the immediate future, there should be active support of the proposal recently made by Nathan Sinai, Emeritus Professor of Public Health, University of Michigan, that health department personnel should be retrained in the intricacies of medical care administration.6 He is concemed that, at most, there are only about 18 months in which to ready this nationwide network of health personnel before the country will be swamped with the demand for such expertise following the passage of a PRESIDENTIAL ADDRESS
19
national health plan. Equally important should be the inclusion of environmental health as part of the preventive system in this training. The early warnings of Winslow, augmented by the sagacity of Ray Lyman Wilbur's summary of the report by the Committee on the Costs of Medical Care in 1932 and the report of the 1938 National Health Conference, support Sinai's contention. In fact, there is good reason to believe that we in public health have been given another chance to respond to the APHA commitment to "Serving Society-Protecting Health." Failure to do so assures our early demise. In conclusion, I would like to return to the title of this address-"The Poverty of Affluence." Each of the points I have covered is a problem of long standing which, with the passage of time, has worsened. This is due, in part, to national priorities which have permitted the expenditure of billions of dollars for precision lunar landings and billions more for precise and wanton destruction in many parts of the world. Despite the plethora of skills, talents, and money devoted to such awesome precision, our health needs continue to go unmet. Lately I have been haunted by the thought that this dichotomy may be due to the deadening impact on ethical precepts by these and other billions of dollars. Ours is an ethical profession with dedicated commitments to the individual, the community, the nation, and itself. It is worrisome, however, to think that the community of which we are also a product has fragmented our actions and ethics, thereby separating us from those in
need of our skills and leaming. Ethically we may be poverty-stricken because we have abjured our responsibilities in the community and in the nation, and have not sufficiently shared both the hopes and pains of others. I hope, as a result of this 102nd Annual Meeting with its focus on the health problems of all minorities and the poor, that the entire structure and membership of the American Public Health Association will become totally committed to an early resolution of infinite, chronic-and worsening-problems of health and health care.
References 1. Myrdal, G. Against the Stream. Pantheon, New York, 1973 2. Wegman, M. E. Who Will Lead This Nation's Health Effort? (Editorial). N. Engl. J. Med. 281:959, 1969. 3. Edwards, C. C. The U.S. Public Health Service. Hosp. Formul. Management 9:8, 1974. 4. Warren, D. G. Legal Obstacles in NOT Developing New Roles for Local Health Departments. Presented at meeting for North Carolina Health Directors, School of Public Health, University of North Carolina, Chapel Hill, March 6, 1974. 5. Winslow, C.-E. A. Public Health at the Crossroads. Am. J. Public Health 16:1075, 1926. 6. Sinai, N. National Health Plans: The Challenge of Management. Presented at a symposium-tribute honoring Dr. Nathan Sinai, University of California at Los Angeles, May 11, 1974.
NEW APHA 40-YEAR MEMBERS 1974 Mrs. R. W. Arfsten Claude H. Ballard J. Lloyd Barron Kenneth L. Burdon, PhD Anselmo F. Dappert Floyd M. Feldmann, MD, DrPH Alice L. Fisher, RN, MSPH Archie B. Freeman John F. Gordon, MD Russell Gottshall, PhD Francois Guimont, MD, DPH Ernest B. Hanan, MD
20
AJPH JANUARY, 1975, Vol. 65, No. 1
Marie C. Harrington Harold M. Kelso, MD, MPH Louise Knapp, RN James H. LeVan Aaron Leifer, MD, MSPH Anne S. Loop, PhD Herbert H. Marks Lucy S. Morgan, PhD Clyde R. Newell James E. Perkins, MD, DrPH Julius Pincus, MD Dr. Bettie F. Rogerson
Hernan Romero, MD Ernest L. Stebbins, MD, MPH Marion E. Stroud Fred H. Stutz Richard M. Taylor, MD, DPH H. R. Thornton, PhD Victoria M. Trasko David B. Treat Louis S. Welty, MD, MPH George J. Wherrett, MD Muriel B. Wilbur, PhD, MPH
