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Heart disease and public health
HEART
DISEASE
AND
PUBLIC
HEALTH
CURRENT TRENDS AND PROSPECTS LOUIS I. I>UBI,IN,++ PH.D.
NEW YORK, N. 1’.
A
S I am to discuss heart diseaseand public health, it will avoid misunderstanding if at the outset I attempt to define what we mean by public health. It is that branch of medicine which concerns itself with the prevention and control of disease from the point of view of the community as a whole. In contrast with the practicing physician, the health officer has the people of the city, county, state, or nation as his patients, and he utilizes the resources of the community in his effort. We all know that, under modern conditions, the individual patient and the individual doctor are often helpless in combatting the spread of infection, as, for example, in controlling yellow fever, typhoid fever, or malaria. It takes the resources of the state to do that. Even in relation to such diseasesas tuberculosis and syphilis, it has become a well-established principle, learned through sad experience, that not only prevention, but treatment, is properly a public health function. The individual patient, in many instances, is unable to provide himself with the care which he needs, and the community is to that extent endangered. The public interest, therefore, demands that the necessary treatment be given, even if at public expense. In all this, there is no real conflict between the public health officer and the individual practicing physician. There are broad areas of mutual interest. The wise health officer will attempt to make all practicing physicians his associates, and all good doctors will look to their health officer for guidance and support in helping them with their patienm. These general principles are gradually being evolved, although they have not yet been completely crystallized. The functions of the health officer, on the one hand, and of the practicing physician, on the other, are being worked out in the light of experience and of changing conditions, and the public interest, in the last analysis, determines their mutual responsibilities. What are the most important problems in heart disease, and what is or should be the relationship of the public health officer to them? Heart disease is the outstanding feature of the medical picture, and will be increasingly so in the future. Clearly, the health officer cannot ignore a field so wide in extent and affecting the public health so vitally. EssenPresented before the Annual Meeting of the American Heart Association, Cleveland, Ohio, May 80. 1941. Received for publication June 9. 1941. *Third Vice-President and Statistician, Metropolitan Life Insurance Company, New York.
I.6
DUBLIN
:
HEART
DISEASE
AND
PUBLIC
17
HEALTH
tially, his problems in this field are the same as those of the practicing physician, although his approach and functions are necessarily different. As I have already indicated, the health officer must concern himself with those phases of heart disease in which large-scale prevention or measures of control are attainable. The well-recognized public health procedures are clearly applicable to the control of rheumatic fever and syphilis. The control of premature hypertensive and arteriosclerotic heart disease has to date received scarcely any attention from health officers. Imperceptibly shading off from the last category is the numerically most important group, which comprises cardiac disease in old people. To a greater or lesser degree, the health officer, as we shall see, can function to advantage in all of these four phases. Rheumatic fever is today one of the foremost health problems of childhood. Between the ages of 5 and 9, deaths from it are outnumbered only by those from the four principal communicable diseases of childhood, as a group, and by pneumonia .I At the ages of 10 to 14, it is the leading cause of death. Between the ages of 15 and 25, it is second only to tuberculosis. Although it is true that the mortality from rheumatic fever has declined, the rate of fall is less than that from other diseases, so that the proportion of deaths from rheumatic fever to the total number of deaths among persons under the age of 25 has increased. By its very nature, rheumatic fever is a disease in every phase of which the health officer can be of great help, but he has done comparatively little. He may actively participate in a case-finding program. He can take over or amplify facilities for the treatment and care of children with the disease. Practically nowhere are these facilities commensurate with the needs. His laboratory can function in research in rheumatic fever, the cause of which has thus far eluded scientific investigation, and his records may help to unravel the complex epidemiology of the disease. He can provide convalescent and sanatorium care in suitable types of institutions. In certain parts of the country he can make use of facilities built for other purposes, but which are not fully used, particularly the tuberculosis sanatoriums. Furthermore, since nonspecific factors seem to be responsible for most of the decline in rheumatic fever, public health officials can actively promote improvement in certain matters which come under their aegis or in which they have some influence, as, for example, in housing and in popular education in health and nutrition. In the control of syphilis, the health officer has already contributed a great deal. In fact, the progress that has been made reflects the degree to which health officers have been willing and able to take responsibility, not only in finding cases but also in treatment. In the Scandinavian countries, where syphilis has been largely controlled, it has -*Since rheumatic
this Paper fever.
was
Written,
mortality
from
pneumonia
has
fallen
below
that
for
18
THE
AMERICAK
HEART
JOURKAL
been the public health service which has carried the brunt of the work. If in our country some progress in this direction has been made, there is no denying the fact that in the present national emergency, with huge numbers of young men concentrated in camps and in defense industries, and with no correspondingly increased facilities for handling the case load, we may lose the gains of the last ten years. The task of the health officer is manyfold-finding the victims of the disease, and providing adequate facilities for treatment and seeing that they are used. He needs a broad concept of his job and resourcefulness in dealing with it. The most difficult aspect of the problem in heart disease, both for medicine and for public healt,h, is constituted by the relatively large numbers of persons in the prime of life who fall prey to early and sometimes preventable heart and coronary artery diseases of other etiologic The root of much of this problem is types. They affect. men chiefly. probably related to the process of aging of the human organism, the study of which has been scarcely begun. Fortunately, there is increasing awareness of the necessity for research on the fundamental problems involved, and a number of medical men and other scientists and public agencies are already engaging in this work. Notable is the work being done in one public institution, the Research Unit of New York City’s Hospital for Chronic Diseases, and in several other places. But a greater part of our public medical resources can and should be devoted to this field. Apart from this, however-and the wide difference between the death rate of the t,wo sexes is, in my judgment,, a good indication-a large number of early deaths from heart disease can be avoided or postponed. Many are proba,bly due to faulty living habits with respect to the routine of daily life, or to lack of attention to infections. Intensive research and popular health education, both of which are important functions of modern public health organizations, can do a great deal in this regard. For one thing, the health officer can help in the early detection of incipient heart disease by popularizing the periodic medical examination. In this matter a more receptive attitude on the part of the medical profession generally is much to be desired. It is admittedly true that symptoms of early heart disease are often hard, sometimes impossible, to detect, but too many patients receive little or no medical supervision until long after the disease has progressed. It may not be too early for the two professions to consider the desirability of providing public clinics for the periodic medical examination of certain groups of the population that cannot themselves afford such service. The public health officer should consider in what ways, efficient and economical, he can utilize available medical resources in cases of early heart disease, or in acute attacks of chronic disease. For example, do we not all know of working men and women with cardiac disease who
DUBLIN:
HEART DISEASE AND PUBLIC HEALTH
19
would benefit from relatively short periods of sanatorium care, where prescribed rest and other measures would be carried out under suitable conditions, and where re-education of the patient in his way of life could be carried out better than in the atmosphere of worry and strain of the home and work place? In a few places, the overbuilt sanatorium facilities for tuberculosis, or other hospitals now unutilized, could be devoted to this purpose. The health officer can make increasing use of the visiting nurse services under his supervision for chronic cardiac disease and, when such services are lacking, can develop or amplify them. Visiting nurses now operating very widely all over the country are of value not merely in actual bedside care, but in the broader fields of psychologic adjustment of the patient or his family, and in interpreting the doctor’s instructions to them. These phases are often neglected because they take more time than the busy physician can give them. But they can be handled well by visiting nurses, particularly if nurses are given special training. Old people with cardiovascular disease present a somewhat different set of problems which are much more difficult in character and limited in scope. The chief needs are for additional clinic facilities, for more home care, and for institutional care of the semihospital type. The numbers of aged cardiac patients are already so great and so rapidly increasing that there is urgent need for a long range program for their care. The very nature of the situation is such that a major part of the financial burden must be borne by public funds. Public health officers must recognize their responsibility here and seek the help and guidance of the whole medical profession in developing programs that are consonant with the welfare of the patients, the public, and the doctors, We cannot safely add to the burdens of voluntary hospital clinics if they are to continue to do good work. A larger number of public clinics, run by full-time men, is the only desirable solution for impoverished ambulant patients. When such patients are confined at home, public medical service may be necessary, but the work of physicians may be lightened and rendered more efficient by the proper use of visiting nurses and, in selected cases, of medical social workers. Increasing numbers may best be handled in institutions, but these cannot and need not be elaborate and costly hospitals. Heart disease, then, presents many different tasks, responsibilities, and opportunities for public health officers. But before any large-scale advance can be made, both they and the medical profession as a whole must accept the view that heart disease is a proper field of work for the health officer. They need also to agree on the respective roles of the private and public physician. In this respect, the problem of heart disease reminds one of the situation which prevailed in tuberculosis about thirty years ago. At that time health officers were just beginning to recognize that the problem
of the tuberculous patients was largely one for them to solve. ThWC! was colClcrablc licsitation in cntcring llic field, and uncertainty in developing the necessary technique and l~ro~dures. They lacked diagnostic classifications and standards, staffs trained in the special treatment of the disease, and snfiicient diagnostic and sanatorium facilities for the care of patients. What a change t.hirty years has brought about, thanks to the increasingly better understanding of the basic factors of the situation by both practicing physicians and the growing profession of health officers. Once it was realized that a disease so widespread, yet everywhere so concentrated among poor people, was the province of the public authorities, construct.ive steps, one after another, were taken by health ofiiceis and physicians in developing new procedures, with the result that, within a single generation, prodigious advances were made, not only in cutting down the ravages of the disease, and in proi.ecting persons against it, but also in developing an understanding of the nature of the disease itself. I am bold enough today to stress this analogy with reference to heart disease. I appreciate, of course, inherent and fundamental differences between the one disease which stems from an invasion of the body by a bacillus, and the other disease or group of diseases, the bulk of which represents seyuelae of many factors, both exogenous and endogenous in nature, in the aging patient. Prevention of tuberculosis did not prove a hard nut to crack once the nature of the problem was understood and properly organized efforts were brought to bear. Prevention of heart disease will be a very different, proposition because so large a part of it is the end result of accumulated insults incidental to the functioning of the body. On the other hand, there are enough phases of heart disease in which prevention is possible to excit.e the health officer with t,he real job he can do in this field. But my major interest is the idea that the field of heart disease is fundamentally one in which the health officer can function and bear a major responsibility. There is every reason why the organized official and voluntary public health agencies should participate in the work to be done. Health officers have a tremendous contribution to make in supplementing and strengthening the efforts of the medical profession and in developing appropriate administrative procedures for the pracFor this disease, the most common in adult tical care of patients. life, involves such long periods of disability that the medical costs are far beyond the resources of most of its victims. The very economics of the situation make it impossible for the ordinary relationships of physiThus far this situation cian and private patient to be fully effective. has been met by the establishment of free or low-cost outpatient clinics in public and private hospitals, in which much of the service of the physician is rendered without compensation. Patients either cannot be
DUBLIN
:
HEART
DISEASE
AND
PUBLIC
HEALTH
21
seen sufficiently often or are treated too superficially because of the crowded conditions of most of the clinics. This situation will get worse, rather than better. Obviously, we must think in terms of modifying our present types of organizat,ion and medical care for these people. Leaders in medicine and public health must face frankly a situation as patent as this, and take the necessary steps for integrating the care of those suffering from heart disease into a general scheme, in which the proper share is borne by public funds, under the administration of the health officer, just as has been done in the case of tuberculosis. I have no illusions that this scheme can be developed overnight. The tuberculosis problem, which was simpler, took decades to get under way toward solution. But the important and first step is the acceptance by physicians and health officers of the concept that heart disease is a suitable field for similar exploitation. Then, in good will, all interested parties can get together in planning their respective parts of the job, on ways of effective cooperation, and on the sequence of steps which would be most likely to assure progress and win the support of the community.
DISEASE
AND
PUBLIC
HEALTH
CURRENT TRENDS AND PROSPECTS LOUIS I. I>UBI,IN,++ PH.D.
NEW YORK, N. 1’.
A
S I am to discuss heart diseaseand public health, it will avoid misunderstanding if at the outset I attempt to define what we mean by public health. It is that branch of medicine which concerns itself with the prevention and control of disease from the point of view of the community as a whole. In contrast with the practicing physician, the health officer has the people of the city, county, state, or nation as his patients, and he utilizes the resources of the community in his effort. We all know that, under modern conditions, the individual patient and the individual doctor are often helpless in combatting the spread of infection, as, for example, in controlling yellow fever, typhoid fever, or malaria. It takes the resources of the state to do that. Even in relation to such diseasesas tuberculosis and syphilis, it has become a well-established principle, learned through sad experience, that not only prevention, but treatment, is properly a public health function. The individual patient, in many instances, is unable to provide himself with the care which he needs, and the community is to that extent endangered. The public interest, therefore, demands that the necessary treatment be given, even if at public expense. In all this, there is no real conflict between the public health officer and the individual practicing physician. There are broad areas of mutual interest. The wise health officer will attempt to make all practicing physicians his associates, and all good doctors will look to their health officer for guidance and support in helping them with their patienm. These general principles are gradually being evolved, although they have not yet been completely crystallized. The functions of the health officer, on the one hand, and of the practicing physician, on the other, are being worked out in the light of experience and of changing conditions, and the public interest, in the last analysis, determines their mutual responsibilities. What are the most important problems in heart disease, and what is or should be the relationship of the public health officer to them? Heart disease is the outstanding feature of the medical picture, and will be increasingly so in the future. Clearly, the health officer cannot ignore a field so wide in extent and affecting the public health so vitally. EssenPresented before the Annual Meeting of the American Heart Association, Cleveland, Ohio, May 80. 1941. Received for publication June 9. 1941. *Third Vice-President and Statistician, Metropolitan Life Insurance Company, New York.
I.6
DUBLIN
:
HEART
DISEASE
AND
PUBLIC
17
HEALTH
tially, his problems in this field are the same as those of the practicing physician, although his approach and functions are necessarily different. As I have already indicated, the health officer must concern himself with those phases of heart disease in which large-scale prevention or measures of control are attainable. The well-recognized public health procedures are clearly applicable to the control of rheumatic fever and syphilis. The control of premature hypertensive and arteriosclerotic heart disease has to date received scarcely any attention from health officers. Imperceptibly shading off from the last category is the numerically most important group, which comprises cardiac disease in old people. To a greater or lesser degree, the health officer, as we shall see, can function to advantage in all of these four phases. Rheumatic fever is today one of the foremost health problems of childhood. Between the ages of 5 and 9, deaths from it are outnumbered only by those from the four principal communicable diseases of childhood, as a group, and by pneumonia .I At the ages of 10 to 14, it is the leading cause of death. Between the ages of 15 and 25, it is second only to tuberculosis. Although it is true that the mortality from rheumatic fever has declined, the rate of fall is less than that from other diseases, so that the proportion of deaths from rheumatic fever to the total number of deaths among persons under the age of 25 has increased. By its very nature, rheumatic fever is a disease in every phase of which the health officer can be of great help, but he has done comparatively little. He may actively participate in a case-finding program. He can take over or amplify facilities for the treatment and care of children with the disease. Practically nowhere are these facilities commensurate with the needs. His laboratory can function in research in rheumatic fever, the cause of which has thus far eluded scientific investigation, and his records may help to unravel the complex epidemiology of the disease. He can provide convalescent and sanatorium care in suitable types of institutions. In certain parts of the country he can make use of facilities built for other purposes, but which are not fully used, particularly the tuberculosis sanatoriums. Furthermore, since nonspecific factors seem to be responsible for most of the decline in rheumatic fever, public health officials can actively promote improvement in certain matters which come under their aegis or in which they have some influence, as, for example, in housing and in popular education in health and nutrition. In the control of syphilis, the health officer has already contributed a great deal. In fact, the progress that has been made reflects the degree to which health officers have been willing and able to take responsibility, not only in finding cases but also in treatment. In the Scandinavian countries, where syphilis has been largely controlled, it has -*Since rheumatic
this Paper fever.
was
Written,
mortality
from
pneumonia
has
fallen
below
that
for
18
THE
AMERICAK
HEART
JOURKAL
been the public health service which has carried the brunt of the work. If in our country some progress in this direction has been made, there is no denying the fact that in the present national emergency, with huge numbers of young men concentrated in camps and in defense industries, and with no correspondingly increased facilities for handling the case load, we may lose the gains of the last ten years. The task of the health officer is manyfold-finding the victims of the disease, and providing adequate facilities for treatment and seeing that they are used. He needs a broad concept of his job and resourcefulness in dealing with it. The most difficult aspect of the problem in heart disease, both for medicine and for public healt,h, is constituted by the relatively large numbers of persons in the prime of life who fall prey to early and sometimes preventable heart and coronary artery diseases of other etiologic The root of much of this problem is types. They affect. men chiefly. probably related to the process of aging of the human organism, the study of which has been scarcely begun. Fortunately, there is increasing awareness of the necessity for research on the fundamental problems involved, and a number of medical men and other scientists and public agencies are already engaging in this work. Notable is the work being done in one public institution, the Research Unit of New York City’s Hospital for Chronic Diseases, and in several other places. But a greater part of our public medical resources can and should be devoted to this field. Apart from this, however-and the wide difference between the death rate of the t,wo sexes is, in my judgment,, a good indication-a large number of early deaths from heart disease can be avoided or postponed. Many are proba,bly due to faulty living habits with respect to the routine of daily life, or to lack of attention to infections. Intensive research and popular health education, both of which are important functions of modern public health organizations, can do a great deal in this regard. For one thing, the health officer can help in the early detection of incipient heart disease by popularizing the periodic medical examination. In this matter a more receptive attitude on the part of the medical profession generally is much to be desired. It is admittedly true that symptoms of early heart disease are often hard, sometimes impossible, to detect, but too many patients receive little or no medical supervision until long after the disease has progressed. It may not be too early for the two professions to consider the desirability of providing public clinics for the periodic medical examination of certain groups of the population that cannot themselves afford such service. The public health officer should consider in what ways, efficient and economical, he can utilize available medical resources in cases of early heart disease, or in acute attacks of chronic disease. For example, do we not all know of working men and women with cardiac disease who
DUBLIN:
HEART DISEASE AND PUBLIC HEALTH
19
would benefit from relatively short periods of sanatorium care, where prescribed rest and other measures would be carried out under suitable conditions, and where re-education of the patient in his way of life could be carried out better than in the atmosphere of worry and strain of the home and work place? In a few places, the overbuilt sanatorium facilities for tuberculosis, or other hospitals now unutilized, could be devoted to this purpose. The health officer can make increasing use of the visiting nurse services under his supervision for chronic cardiac disease and, when such services are lacking, can develop or amplify them. Visiting nurses now operating very widely all over the country are of value not merely in actual bedside care, but in the broader fields of psychologic adjustment of the patient or his family, and in interpreting the doctor’s instructions to them. These phases are often neglected because they take more time than the busy physician can give them. But they can be handled well by visiting nurses, particularly if nurses are given special training. Old people with cardiovascular disease present a somewhat different set of problems which are much more difficult in character and limited in scope. The chief needs are for additional clinic facilities, for more home care, and for institutional care of the semihospital type. The numbers of aged cardiac patients are already so great and so rapidly increasing that there is urgent need for a long range program for their care. The very nature of the situation is such that a major part of the financial burden must be borne by public funds. Public health officers must recognize their responsibility here and seek the help and guidance of the whole medical profession in developing programs that are consonant with the welfare of the patients, the public, and the doctors, We cannot safely add to the burdens of voluntary hospital clinics if they are to continue to do good work. A larger number of public clinics, run by full-time men, is the only desirable solution for impoverished ambulant patients. When such patients are confined at home, public medical service may be necessary, but the work of physicians may be lightened and rendered more efficient by the proper use of visiting nurses and, in selected cases, of medical social workers. Increasing numbers may best be handled in institutions, but these cannot and need not be elaborate and costly hospitals. Heart disease, then, presents many different tasks, responsibilities, and opportunities for public health officers. But before any large-scale advance can be made, both they and the medical profession as a whole must accept the view that heart disease is a proper field of work for the health officer. They need also to agree on the respective roles of the private and public physician. In this respect, the problem of heart disease reminds one of the situation which prevailed in tuberculosis about thirty years ago. At that time health officers were just beginning to recognize that the problem
of the tuberculous patients was largely one for them to solve. ThWC! was colClcrablc licsitation in cntcring llic field, and uncertainty in developing the necessary technique and l~ro~dures. They lacked diagnostic classifications and standards, staffs trained in the special treatment of the disease, and snfiicient diagnostic and sanatorium facilities for the care of patients. What a change t.hirty years has brought about, thanks to the increasingly better understanding of the basic factors of the situation by both practicing physicians and the growing profession of health officers. Once it was realized that a disease so widespread, yet everywhere so concentrated among poor people, was the province of the public authorities, construct.ive steps, one after another, were taken by health ofiiceis and physicians in developing new procedures, with the result that, within a single generation, prodigious advances were made, not only in cutting down the ravages of the disease, and in proi.ecting persons against it, but also in developing an understanding of the nature of the disease itself. I am bold enough today to stress this analogy with reference to heart disease. I appreciate, of course, inherent and fundamental differences between the one disease which stems from an invasion of the body by a bacillus, and the other disease or group of diseases, the bulk of which represents seyuelae of many factors, both exogenous and endogenous in nature, in the aging patient. Prevention of tuberculosis did not prove a hard nut to crack once the nature of the problem was understood and properly organized efforts were brought to bear. Prevention of heart disease will be a very different, proposition because so large a part of it is the end result of accumulated insults incidental to the functioning of the body. On the other hand, there are enough phases of heart disease in which prevention is possible to excit.e the health officer with t,he real job he can do in this field. But my major interest is the idea that the field of heart disease is fundamentally one in which the health officer can function and bear a major responsibility. There is every reason why the organized official and voluntary public health agencies should participate in the work to be done. Health officers have a tremendous contribution to make in supplementing and strengthening the efforts of the medical profession and in developing appropriate administrative procedures for the pracFor this disease, the most common in adult tical care of patients. life, involves such long periods of disability that the medical costs are far beyond the resources of most of its victims. The very economics of the situation make it impossible for the ordinary relationships of physiThus far this situation cian and private patient to be fully effective. has been met by the establishment of free or low-cost outpatient clinics in public and private hospitals, in which much of the service of the physician is rendered without compensation. Patients either cannot be
DUBLIN
:
HEART
DISEASE
AND
PUBLIC
HEALTH
21
seen sufficiently often or are treated too superficially because of the crowded conditions of most of the clinics. This situation will get worse, rather than better. Obviously, we must think in terms of modifying our present types of organizat,ion and medical care for these people. Leaders in medicine and public health must face frankly a situation as patent as this, and take the necessary steps for integrating the care of those suffering from heart disease into a general scheme, in which the proper share is borne by public funds, under the administration of the health officer, just as has been done in the case of tuberculosis. I have no illusions that this scheme can be developed overnight. The tuberculosis problem, which was simpler, took decades to get under way toward solution. But the important and first step is the acceptance by physicians and health officers of the concept that heart disease is a suitable field for similar exploitation. Then, in good will, all interested parties can get together in planning their respective parts of the job, on ways of effective cooperation, and on the sequence of steps which would be most likely to assure progress and win the support of the community.