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PLANNING FOR COMMUNITY HEALTH
893
immunoglobulin molecules show differences that correlate well with their antigenic properties-e.g., in the Fc fragment, where allotypic differences have been related to
social medicine or public health for some time, the report provides encouragement and support. HEALTH LEGISLATION
definite differences in aminoacid sequences.
In the N-terminal halves of the chains, variability in aminoacid sequences is even more significant, for study of many different myeloma proteins in this respect has shown no two to be alike. Furthermore, antigenic analysis of shows that, besides the homogeneity of myeloma proteins determinants which we have already known antigenic
noted, they display individual antigenic specificities mediated by determinants that are located in these same
regions-the N-terminal halves of both heavy and light chains. Considering the light chain only, we may note that of its 110 or so constituent aminoacids, as many as 30 provide sites at which substitutions may occur to produce variants. This, with a similar variability in the aminoacid sequence in the N-terminal region of heavy chains, makes possible a very large number of different combinations of
aminoacid sequences in the two constituent chains of the Fab fragment; but direct evidence that the specificity of the combining site is in fact determined in this manner is still awaited.
Special
Articles
PLANNING FOR COMMUNITY HEALTH FROM A CORRESPONDENT
PUBLIC-HEALTH services in the United States have been facing critical appraisal. The report of the National Commission on Community Health Services1 disclosed much that was known but not applied. Medical care has been largely unplanned; hence, no doubt, variations in the quantity and quality of care that account, for instance, for the fact that the United States ranks lower than ten or more countries in infant-mortality rate, despite its wealth and technological advancement. The report recommends that community services should be comprehensive, coordinated, and adequately staffed. In the increasing complexity of personal health services, the patient is liable to get lost in the maze. Everyone therefore should have a personal physician, and integration with community care could be brought about through group medical practice that should include public-health nurses, social workers, physiotherapists, and other health personnel. The concept of the community as a unit of practice is not new to public health; but the report did well to re-emphasise the need for planning health resources on an area-wide basis to provide for the needs of groups of people. This is particularly timely in the United States today when, for a number of reasons, hospitals, medical schools, social planners, and politicians are becoming interested in public health. Many of these increasingly " johnny-come-latelies " have been slow to recognise the need for combining preventive with curative services in hospital and outside; for promoting community-wide programmes for a broad range of services; for payment through central sources; and for many other forms of organised social action. For such newcomers, the report will be provocative. For those who have been working in 1. National Commission
Community Health Services. Health is Community Affair. Cambridge, Mass., 1966. on
a
fortuitous that a Citizens’ Commission on Graduate Medical Education,2 appointed by the American Medical Association, was simultaneously at work. The commission was concerned with the need for maintaining the supply of personal physicians. The recently enacted Comprehensive Health Planning and Health Services Law has raised hopes for better use of the nation’s health resources. This Law (P.L. 89-749) states that: It
was
" The purpose
probably
not
Congress declares that fulfillment depends on promoting and assuring
of our national the highest level environment which
of health attainable for every person, in an contributes positively to individual and family
living ..."
To attain this laudable objective, the Law requires the States to bring together the interested parties and provides funds for implementing health-service plans. Again, the enactment, after many years of resistance, of the Social Security Amendments of 1965 (P.L. 89-97, commonly referred to as Medicare and Medicaid) is another indication of the revolution which public health is undergoing. Unlike the British National Health Service, the United States model does not involve the Government in the actual direct provision of services, but only in developing the organisation, setting standards, and paying for services. It remains to be seen whether even the United States can afford the rising costs of care which are sure to follow this contractual arrangement. Another far-reaching Law arose out of the President’s Commission on Heart Disease, Cancer and Stroke. As a consequence of this commission’s report came the Regional Medical Program legislation which aims to foster centres of excellence for the better application of medical knowledge to combat the major killing diseases.3 Across the country, the staffs of medical schools have been thrust into contact with health personnel from official and voluntary agencies, and with representatives of consumer groups for the purpose of planning regional medical programmes. The Anti-Poverty
Program administered through the Opportunity, though basically a broad public-welfare campaign, also has a very substantial health component. Through O.E.O. funds, several comprehensive neighbourhood health centres have been, or are being, established. Though these anti-poverty schemes are under criticism, they are tempting the medical schools out of the teaching hospital into the community. Here, there are opportunities not only for improving the quality of care but also for conducting research on communityhealth services as well as for improving knowledge, attitudes, and skills necessary for future physicians. All these developments emphasise the fact that the United States is undergoing a public-health revolution, Office of Economic
akin to the establishment of the National Health Service in the United Kingdom. There is a display of youthful energy and optimism, with sudden acceptance of social planning and an attempt to combine the resources and energies of many groups. The big question is: How do you persuade independent agencies and individualistic practitioners to sacrifice a part of their autonomy for the benefit of the total group ? on Graduate Medical Education. The Graduate Education of Physicians. Chicago, 1966. 3. See Lancet, 1966, ii, 790.
2. Citizens Commission
immunoglobulin molecules show differences that correlate well with their antigenic properties-e.g., in the Fc fragment, where allotypic differences have been related to
social medicine or public health for some time, the report provides encouragement and support. HEALTH LEGISLATION
definite differences in aminoacid sequences.
In the N-terminal halves of the chains, variability in aminoacid sequences is even more significant, for study of many different myeloma proteins in this respect has shown no two to be alike. Furthermore, antigenic analysis of shows that, besides the homogeneity of myeloma proteins determinants which we have already known antigenic
noted, they display individual antigenic specificities mediated by determinants that are located in these same
regions-the N-terminal halves of both heavy and light chains. Considering the light chain only, we may note that of its 110 or so constituent aminoacids, as many as 30 provide sites at which substitutions may occur to produce variants. This, with a similar variability in the aminoacid sequence in the N-terminal region of heavy chains, makes possible a very large number of different combinations of
aminoacid sequences in the two constituent chains of the Fab fragment; but direct evidence that the specificity of the combining site is in fact determined in this manner is still awaited.
Special
Articles
PLANNING FOR COMMUNITY HEALTH FROM A CORRESPONDENT
PUBLIC-HEALTH services in the United States have been facing critical appraisal. The report of the National Commission on Community Health Services1 disclosed much that was known but not applied. Medical care has been largely unplanned; hence, no doubt, variations in the quantity and quality of care that account, for instance, for the fact that the United States ranks lower than ten or more countries in infant-mortality rate, despite its wealth and technological advancement. The report recommends that community services should be comprehensive, coordinated, and adequately staffed. In the increasing complexity of personal health services, the patient is liable to get lost in the maze. Everyone therefore should have a personal physician, and integration with community care could be brought about through group medical practice that should include public-health nurses, social workers, physiotherapists, and other health personnel. The concept of the community as a unit of practice is not new to public health; but the report did well to re-emphasise the need for planning health resources on an area-wide basis to provide for the needs of groups of people. This is particularly timely in the United States today when, for a number of reasons, hospitals, medical schools, social planners, and politicians are becoming interested in public health. Many of these increasingly " johnny-come-latelies " have been slow to recognise the need for combining preventive with curative services in hospital and outside; for promoting community-wide programmes for a broad range of services; for payment through central sources; and for many other forms of organised social action. For such newcomers, the report will be provocative. For those who have been working in 1. National Commission
Community Health Services. Health is Community Affair. Cambridge, Mass., 1966. on
a
fortuitous that a Citizens’ Commission on Graduate Medical Education,2 appointed by the American Medical Association, was simultaneously at work. The commission was concerned with the need for maintaining the supply of personal physicians. The recently enacted Comprehensive Health Planning and Health Services Law has raised hopes for better use of the nation’s health resources. This Law (P.L. 89-749) states that: It
was
" The purpose
probably
not
Congress declares that fulfillment depends on promoting and assuring
of our national the highest level environment which
of health attainable for every person, in an contributes positively to individual and family
living ..."
To attain this laudable objective, the Law requires the States to bring together the interested parties and provides funds for implementing health-service plans. Again, the enactment, after many years of resistance, of the Social Security Amendments of 1965 (P.L. 89-97, commonly referred to as Medicare and Medicaid) is another indication of the revolution which public health is undergoing. Unlike the British National Health Service, the United States model does not involve the Government in the actual direct provision of services, but only in developing the organisation, setting standards, and paying for services. It remains to be seen whether even the United States can afford the rising costs of care which are sure to follow this contractual arrangement. Another far-reaching Law arose out of the President’s Commission on Heart Disease, Cancer and Stroke. As a consequence of this commission’s report came the Regional Medical Program legislation which aims to foster centres of excellence for the better application of medical knowledge to combat the major killing diseases.3 Across the country, the staffs of medical schools have been thrust into contact with health personnel from official and voluntary agencies, and with representatives of consumer groups for the purpose of planning regional medical programmes. The Anti-Poverty
Program administered through the Opportunity, though basically a broad public-welfare campaign, also has a very substantial health component. Through O.E.O. funds, several comprehensive neighbourhood health centres have been, or are being, established. Though these anti-poverty schemes are under criticism, they are tempting the medical schools out of the teaching hospital into the community. Here, there are opportunities not only for improving the quality of care but also for conducting research on communityhealth services as well as for improving knowledge, attitudes, and skills necessary for future physicians. All these developments emphasise the fact that the United States is undergoing a public-health revolution, Office of Economic
akin to the establishment of the National Health Service in the United Kingdom. There is a display of youthful energy and optimism, with sudden acceptance of social planning and an attempt to combine the resources and energies of many groups. The big question is: How do you persuade independent agencies and individualistic practitioners to sacrifice a part of their autonomy for the benefit of the total group ? on Graduate Medical Education. The Graduate Education of Physicians. Chicago, 1966. 3. See Lancet, 1966, ii, 790.
2. Citizens Commission