EDITORIALS
involved in a big way. Witness the eager pursuit of public representation on the boards. Witness the major National Association of Counties' push for local government control. And witness some of the existing new coalitions, especially of representatives of rural governments, in the HSA development process. The new HSA does contain a requirement to actually develop a plan. While this may seem trivial and while the first version will clearly contain many compromises, the fact is that we shall have, finally, the beginnings of consensus based upon the beginnings of nationwide criteria. The new HSA is planning around new dollars and will in the foreseeable future have to allocate scarce resourcesprobably with many of the compromises described by Vladek. To do this, however, it must develop mechanisms to make priority decisions among competitive claims for the same pot. In this process, a mechanism may be developed for the longer range and more awesome planning responsibilities of the future, a future when tougher priority decisions about how to distribute the consolidated federal-state-local government
health financing fund under national health insurance will need to be made. At very least the HSA legislation has pumped new local political energy into a planning effort which needed revitalization. With all of its imperfections, this seems a real step forward toward the sixth edition. When we take that next step, perhaps Congress may be ready to return the power to the only agencies we grassroots voters know how to control-state and local governments. Perhaps also by that time, our locally elected general purpose representative governments will be ready to join together to form the regional agencies that can respond to the challenges of planning for the health and welfare of our future.
HUGH H. TILSON, MD REFERENCES 1. Vladek, B. Interest-group representation and the HSAs: Health planning and political theory. Am. J. Pub. Health, 67:23-29, 1977 2. Hammond, J. R. Substate District, HSA and PSRO designations, Am. J. Pub. Health, 66:788-790, 1976.
The Quiet Desperation of Public Health Conscience "How few ever get beyond feeding, clothing, sheltering and warming themselves in this world, and begin to treat themselves as human beings-as intellectual and moral beings."* Professionals and scientists are among those privileged few, in spite of the bad odor they somehow acquired during the 1960s. "The mass of men live lives of quiet desperation." Even in the electronic excitements of the present era, the mass are bound to the monetary rewards of monotonous jobs. The privilege of the professional and scientific few-among whom health workers may be counted-is the intellectual challenge of their work in terms of the creative opportunities it affords and the moral rewards of their role in terms of service to fellow human beings. In the twentieth century this privilege exacts a price. Before the scientific explosion it may have been accurate to state that "it is safest to invest in knowledge, for the probability is that you can carry it with you wherever you go." But today's scientist or professional cannot work in isolation, without tools, without exchange, without access to two-way communication. It may not be inappropriate to compare his or her thrall to that of the nineteenth century rich man, who, "not to make an invidious comparison-is always sold to the institu-
tion which makes him rich. Absolutely speaking, the more money, the less virtue." In many countries of the world today-62 according to Amnesty International'-the scientist who incurs the displeasure of his government, sometimes for utterly trivial reasons, sometimes for voicing his objection to official policies, risks not only imprisonment, death, and physical torture, but also his access to the world of science, his communication with peers, in short an end to his career as a scientist or professional, in or out of prison. He cannot take his knowledge with him wherever he goes because the body of knowledge is no longer fixed. He cannot pursue a life of service because the service is linked to government no matter what the government politics. This is hard. It is even harder for the professional who wants to serve than for Thoreau's "freest of neighbors," about whom he observed, "whatever they may say about the magnitude and seriousness of the question (ed. note: slavery and militant abolitionism) . . . the long and the short of the matter is, that they cannot spare the protection of the existing government, and they dread the consequences to their property and their families of disobedience to it.... this makes it impossible for a man to live honestly, and at the same time comfortably, in outward respects." It is in this context that readers should turrn to the Report of the American Public Health Association's Task
*AIl quotations in this editorial, unless otherwise noted, are taken from the published works of Henry David Thoreau (1817-1862): his book, Walden, or Life in the Woods, his Journals, and his essay, Civil Disobedience.
Force on Chile, published on page 71 of the current issue of the Journal and the APHA policy statement on International Health published on page 97. The Chilean prisoners of conscience and exiles are unusual because so many of them
20
AJPH January, 1977, Vol. 67, No. 1
EDITORIALS
were and are** public health workers. The Chilean National Health Service was unique in the western hemisphere because of its long history, its extensive coverage, its planning efforts, and its broad aspirations. These characteristics have not been well or often described in English language periodicals. The Journal is grateful to the Task Force for providing the historical background which appears on pages 31-36 of the current issue. But is it the business of a national society to criticize the actions of another nation? The question is by no means confined to Chile or to the public health professions. Referring to the case of Sergei Kovalev, an imprisoned Russian biologist, Valentin Truchin, a Russian scientist wrote in an open letter: "You are very proud, my dear colleagues, that you separate science from what you call politics. You do not go in for politics, you say. Neither do we. Dissidents in the Soviet Union do not go in for politics: they struggle for air. What you are separating science from is not politics but mere decency."2 The issues in Chile are also issues of human decency in the treatment of professional colleagues rather than the rhetoric or legitimacy of political differences. It may be taken as a sad commentary on today's world that the need for action by the APHA is by no means unique among the societies which speak for professional and scientific disciplines in the United States. Among other broad based professional societies, comparable to the APHA, the National Association of Social Workers,3 the American Psychological Association,4 the American Physical Society,5 and the American Mathematical Society6 have taken comparable action. Nor is the need for such action confined to Chile, unfortunately. Comparable representations on behalf of the citizens of other countries have been made by several of these and other organizations. The APHA itself in the same year that it first expressed its concern for Chilean colleagues, 1973, expressed similar concerns about the treatment of Soviet scientists.7 The National Academy of Sciences has recently set up an Advisory Committee on Human Rights whose mission is to provide guidelines and advice on an ongoing basis to officers of The Academy, primarily its Foreign Secretary.8 Similar committees have been or are being set up by American Association for the Advancement of Science,9 and other Societies whose role in the past has been purely "scientific." But the need for such actions also has other implica**A member of the APHA Task Force on Chile, Dr. Myron E. Wegman, reports that in 1976 at the University of Concepi6n a public health nurse teaches public health to medical students because there are no physicians available to do so. Dr. Hugo Behm, formerly Dean of the School of Public Health in Santiago is currently a resident of Panama and has been re-elected Vice-President of the APHA for Latin America.
tions. "Public opinion is a weak tyrant compared with our own private opinion" wrote Thoreau, poet, naturalist, and rugged individualist who could afford to "hire and squat somewhere, and raise but a small crop, and eat that soon" and so act, as his conscience dictated. We may be less free to act as our individual consciences dictate, but the very constraints that accompany the privileges of our professional discipline impose their own tyrannies of conscience. As two scientists have recently written: "Because of the international nature of science, its practitioners have a more direct concern-and responsibility-for the human rights of colleagues in other countries." 0o Like human decency itself these tyrannies oblige us to speak out on behalf of those who cannot speak out. To the extent that science and the health professions transcend national boundaries and demand international exchange and communications, our actions, however small, may do more than purge our private or collective conscience. They may even exert a measurable impact on the treatment of our colleagues. For, in the last analysis, as Pablo Neruda, the Chilean Nobel Laureate put it in writing of the violence in Viet Nam: "Pero anlos impuros, la sangre del hombre distante recae en la espuma, nos mancha en la ola, salpica la luna, son nuestros: son nuestros dolores aquellos distantes dolores ..."t
ALFRED YANKAUER, MD, MPH
REFERENCES 1. Amnesty International U.S.A., 2112 Broadway, New York, N.Y. 10023. 2. Federation of American Scientists, Public Interest Report, Vol. 29, No. 2, February, 1976. 3. National Association of Social Workers, 1425 H St. NW, Washington, DC 20005. 4. American Psychological Association, 1200 17 St. NW, Washington, DC 20036. 5. American Physical Society, Panel on Public Affairs, H. Fashbach, Chairman, Mass. Inst. Technol., Cambridge. 6. American Mathematical Society, P.O. Box 6248, Providence, RI 02940. 7. "Treatment of Soviet Scientists" Resolution adopted by APHA Governing Council, 1973. Am. J. Public Health 64:194, 1974. 8. National Academy of Sciences, 2101 Constitution Ave., NW, Washington, DC 20418. 9. American Association for the Advancement of Science, 1515 Massachusetts Ave. NW, Washington, DC 20005. 10. Eisner, T. and Wilson, 0. Sergei Kovalev: A colleague in trouble. Science 194:133, 1976.
t"But our years are tainted, the blood of distant men/ sinks back in the spume, stains us in the wave, spatters the moon:/ those distant agonies are our agonies...." from La Barcarola La Barcarola Termina (1967)
involved in a big way. Witness the eager pursuit of public representation on the boards. Witness the major National Association of Counties' push for local government control. And witness some of the existing new coalitions, especially of representatives of rural governments, in the HSA development process. The new HSA does contain a requirement to actually develop a plan. While this may seem trivial and while the first version will clearly contain many compromises, the fact is that we shall have, finally, the beginnings of consensus based upon the beginnings of nationwide criteria. The new HSA is planning around new dollars and will in the foreseeable future have to allocate scarce resourcesprobably with many of the compromises described by Vladek. To do this, however, it must develop mechanisms to make priority decisions among competitive claims for the same pot. In this process, a mechanism may be developed for the longer range and more awesome planning responsibilities of the future, a future when tougher priority decisions about how to distribute the consolidated federal-state-local government
health financing fund under national health insurance will need to be made. At very least the HSA legislation has pumped new local political energy into a planning effort which needed revitalization. With all of its imperfections, this seems a real step forward toward the sixth edition. When we take that next step, perhaps Congress may be ready to return the power to the only agencies we grassroots voters know how to control-state and local governments. Perhaps also by that time, our locally elected general purpose representative governments will be ready to join together to form the regional agencies that can respond to the challenges of planning for the health and welfare of our future.
HUGH H. TILSON, MD REFERENCES 1. Vladek, B. Interest-group representation and the HSAs: Health planning and political theory. Am. J. Pub. Health, 67:23-29, 1977 2. Hammond, J. R. Substate District, HSA and PSRO designations, Am. J. Pub. Health, 66:788-790, 1976.
The Quiet Desperation of Public Health Conscience "How few ever get beyond feeding, clothing, sheltering and warming themselves in this world, and begin to treat themselves as human beings-as intellectual and moral beings."* Professionals and scientists are among those privileged few, in spite of the bad odor they somehow acquired during the 1960s. "The mass of men live lives of quiet desperation." Even in the electronic excitements of the present era, the mass are bound to the monetary rewards of monotonous jobs. The privilege of the professional and scientific few-among whom health workers may be counted-is the intellectual challenge of their work in terms of the creative opportunities it affords and the moral rewards of their role in terms of service to fellow human beings. In the twentieth century this privilege exacts a price. Before the scientific explosion it may have been accurate to state that "it is safest to invest in knowledge, for the probability is that you can carry it with you wherever you go." But today's scientist or professional cannot work in isolation, without tools, without exchange, without access to two-way communication. It may not be inappropriate to compare his or her thrall to that of the nineteenth century rich man, who, "not to make an invidious comparison-is always sold to the institu-
tion which makes him rich. Absolutely speaking, the more money, the less virtue." In many countries of the world today-62 according to Amnesty International'-the scientist who incurs the displeasure of his government, sometimes for utterly trivial reasons, sometimes for voicing his objection to official policies, risks not only imprisonment, death, and physical torture, but also his access to the world of science, his communication with peers, in short an end to his career as a scientist or professional, in or out of prison. He cannot take his knowledge with him wherever he goes because the body of knowledge is no longer fixed. He cannot pursue a life of service because the service is linked to government no matter what the government politics. This is hard. It is even harder for the professional who wants to serve than for Thoreau's "freest of neighbors," about whom he observed, "whatever they may say about the magnitude and seriousness of the question (ed. note: slavery and militant abolitionism) . . . the long and the short of the matter is, that they cannot spare the protection of the existing government, and they dread the consequences to their property and their families of disobedience to it.... this makes it impossible for a man to live honestly, and at the same time comfortably, in outward respects." It is in this context that readers should turrn to the Report of the American Public Health Association's Task
*AIl quotations in this editorial, unless otherwise noted, are taken from the published works of Henry David Thoreau (1817-1862): his book, Walden, or Life in the Woods, his Journals, and his essay, Civil Disobedience.
Force on Chile, published on page 71 of the current issue of the Journal and the APHA policy statement on International Health published on page 97. The Chilean prisoners of conscience and exiles are unusual because so many of them
20
AJPH January, 1977, Vol. 67, No. 1
EDITORIALS
were and are** public health workers. The Chilean National Health Service was unique in the western hemisphere because of its long history, its extensive coverage, its planning efforts, and its broad aspirations. These characteristics have not been well or often described in English language periodicals. The Journal is grateful to the Task Force for providing the historical background which appears on pages 31-36 of the current issue. But is it the business of a national society to criticize the actions of another nation? The question is by no means confined to Chile or to the public health professions. Referring to the case of Sergei Kovalev, an imprisoned Russian biologist, Valentin Truchin, a Russian scientist wrote in an open letter: "You are very proud, my dear colleagues, that you separate science from what you call politics. You do not go in for politics, you say. Neither do we. Dissidents in the Soviet Union do not go in for politics: they struggle for air. What you are separating science from is not politics but mere decency."2 The issues in Chile are also issues of human decency in the treatment of professional colleagues rather than the rhetoric or legitimacy of political differences. It may be taken as a sad commentary on today's world that the need for action by the APHA is by no means unique among the societies which speak for professional and scientific disciplines in the United States. Among other broad based professional societies, comparable to the APHA, the National Association of Social Workers,3 the American Psychological Association,4 the American Physical Society,5 and the American Mathematical Society6 have taken comparable action. Nor is the need for such action confined to Chile, unfortunately. Comparable representations on behalf of the citizens of other countries have been made by several of these and other organizations. The APHA itself in the same year that it first expressed its concern for Chilean colleagues, 1973, expressed similar concerns about the treatment of Soviet scientists.7 The National Academy of Sciences has recently set up an Advisory Committee on Human Rights whose mission is to provide guidelines and advice on an ongoing basis to officers of The Academy, primarily its Foreign Secretary.8 Similar committees have been or are being set up by American Association for the Advancement of Science,9 and other Societies whose role in the past has been purely "scientific." But the need for such actions also has other implica**A member of the APHA Task Force on Chile, Dr. Myron E. Wegman, reports that in 1976 at the University of Concepi6n a public health nurse teaches public health to medical students because there are no physicians available to do so. Dr. Hugo Behm, formerly Dean of the School of Public Health in Santiago is currently a resident of Panama and has been re-elected Vice-President of the APHA for Latin America.
tions. "Public opinion is a weak tyrant compared with our own private opinion" wrote Thoreau, poet, naturalist, and rugged individualist who could afford to "hire and squat somewhere, and raise but a small crop, and eat that soon" and so act, as his conscience dictated. We may be less free to act as our individual consciences dictate, but the very constraints that accompany the privileges of our professional discipline impose their own tyrannies of conscience. As two scientists have recently written: "Because of the international nature of science, its practitioners have a more direct concern-and responsibility-for the human rights of colleagues in other countries." 0o Like human decency itself these tyrannies oblige us to speak out on behalf of those who cannot speak out. To the extent that science and the health professions transcend national boundaries and demand international exchange and communications, our actions, however small, may do more than purge our private or collective conscience. They may even exert a measurable impact on the treatment of our colleagues. For, in the last analysis, as Pablo Neruda, the Chilean Nobel Laureate put it in writing of the violence in Viet Nam: "Pero anlos impuros, la sangre del hombre distante recae en la espuma, nos mancha en la ola, salpica la luna, son nuestros: son nuestros dolores aquellos distantes dolores ..."t
ALFRED YANKAUER, MD, MPH
REFERENCES 1. Amnesty International U.S.A., 2112 Broadway, New York, N.Y. 10023. 2. Federation of American Scientists, Public Interest Report, Vol. 29, No. 2, February, 1976. 3. National Association of Social Workers, 1425 H St. NW, Washington, DC 20005. 4. American Psychological Association, 1200 17 St. NW, Washington, DC 20036. 5. American Physical Society, Panel on Public Affairs, H. Fashbach, Chairman, Mass. Inst. Technol., Cambridge. 6. American Mathematical Society, P.O. Box 6248, Providence, RI 02940. 7. "Treatment of Soviet Scientists" Resolution adopted by APHA Governing Council, 1973. Am. J. Public Health 64:194, 1974. 8. National Academy of Sciences, 2101 Constitution Ave., NW, Washington, DC 20418. 9. American Association for the Advancement of Science, 1515 Massachusetts Ave. NW, Washington, DC 20005. 10. Eisner, T. and Wilson, 0. Sergei Kovalev: A colleague in trouble. Science 194:133, 1976.
t"But our years are tainted, the blood of distant men/ sinks back in the spume, stains us in the wave, spatters the moon:/ those distant agonies are our agonies...." from La Barcarola La Barcarola Termina (1967)
