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The potential influence of public health measures on adult heart disease
J. &on. Dis. 1965, Vol. 18, pp. 905-913. Pergamon Press Ltd. Printed in Great Britain
THE POTENTIAL INFLUENCE OF PUBLIC HEALTH MEASURES ON ADULT HEART DISEASE
Assistant Commissioner
I. JAY BRIGHTMAN, M.D. for Chronic Disease Services, New York State Department of Health, N.Y.. U.S.A.
THE acceptance of adult heart disease as a public health responsibility, defined in its broadest terms, is well evidenced by the highly developed activities of the U.S. Public Health Service’s National Heart Institute and Heart Disease Control Section in the official domain and the American Heart Association and its numerous state, county, and city affiliates in the voluntary health field. Certainly, the New York Heart Association is an outstanding example of the latter group. The very serious question arises, and must be answered, as to whether these public health programs are well balanced and whether we are making the greatest possible use of our available knowledge. PUBLIC
HEALTH
RESEARCH
the field of laboratory and clinical research we have reached a stage of considerable sophistication. Huge amounts of funds have been made available annually over many years by both the U.S. Public Health Service and the American Heart Association, as well as through their larger state and local counterparts. The major part of these funds is well spent. This is assured by the careful review of grant applications by expert committees at both the initial and renewal stages. These funds have made possible not only the establishment and expansion of cardiovascular research activities in specialized research institutes, in medical school teaching centers, and in other research-oriented hospitals, but also have had the important side-effect of improving the caliber of both graduate and undergraduate teaching programs, which are so significantly influenced by association with dynamic research activities. Yet, several questions do arise. While the desirability of even more funds for research can be well documented, there must be a balance between the amounts of funds appropriated for research and the ability to produce and train qualified research workers to utilize them effectively. Also, we must be ready to answer quite concisely the questions that have arisen as to the possibility of overemphasis on research having an unfavorable effect upon the basic preparation of physicians and paramedical personnel for their chosen fields. Finally, the developing tendency of local health departments and local heart associations to make research funds directly available to local institutions calls for consideration as to whether such allocations assure the same control of quality as research funds administered at higher organizational levels. If not, research provincialism may be diverting funds that might better be spent in other ways. In
905
I. JAY BRIGHTMAN
906
COMMUNITY
HEALTH
SERVICES
Assuming that our research program is well advanced and that we are cognizant of the problems of quantity and quality control, we must look to the other large aspect of public health activity, namely, community health service. Here, we must determine what is the job to be done; what programs are necessary to ascertain that laboratory, clinical, and epidemiologic knowledge which has emanated from the research laboratory is made available to our population with minimal delay; and whether we have the funds, the personnel, and the organization to do what scientific knowledge dictates should be done. Two years ago I assigned to a group of third-year medical students a project to establish or reject the hypothesis that adult heart disease can be favorably influenced by public health measures. Now it might not seem quite fair to ask students to accept such an assignment even with the proviso that they will be marked on the quality of their reasoning and logic rather than on conclusions; after all, the marker did have the title of assistant commissioner of health for chronic disease services and had recently established a bureau of heart disease within his division. Their logic, based on carefully made observations, might have been different, or at least might have been evaluated differently, if their supervisor had been a very conservative president of an Upstate medical society. Nevertheless, it was interesting to see the strong positive side of the hypothesis established by the students, to such an extent in some areas that even I had to disagree with them. The community health phase of public health, whether administered by official or voluntary agencies, may be considered as the sum total of the services necessary to adequately supplement the basic treatment pattern of the physician-patient relationship. In considering this aspect, it is important to utilize the term tre&nent in its comprehensive sense, ranging from prevention of disease and early detection through the provision of adequate medical care and on to rehabilitation. We may look upon community health services in the field of adult heart disease in two categories: first, the application of specific measures; and second, the provision of more general measures that affect patients with potential or actual heart disease, as well as patients with various types of other chronic disorders. Time will not permit a comprehensive review of these. Rather, I would like to discuss some of our major current activities. SERVICES
SPECIFICALLY
FOR
THE
CARDIAC
PATIENT
Public health education We cannot consider it acceptable to state that our lack of knowledge of the specific cause or causes of the most common type of adult heart disease, namely, coronary heart disease, confines our activities entirely to the laboratory and to clinical or epidemiologic research. Certainly, the advances emanating from all research fields have indicated sufficient adverse relationships between excess weight, excess fat intake, excess cigarette smoking, stress, and physical inactivity to warrant available facts being placed before the public and being utilized to motivate such moderation or change in our patterns of living as may be indicated. While we do not have adequate statistical studies to back us up, it seems quite definite that those public health personnel who have been studying these relationships most intently are beginning to take heed themselves. Most public health
The Potential
Influence
of Public Health Measures
on Adult Heart Disease
907
meetings today are characterized by extremely little cigarette smoke, and the silhouettes of many scientists have become very streamlined, sometimes to the point of their appearing somewhat cadaverous. This seems also to be true in general of the medical and related professions, although probably to a lesser extent. It does not appear to have affected many other mature professional groups, though one would think that their sophistication and knowledgeability would have brought them into the fold. If this is true, what can one expect of the general public? Last summer I spent several weeks in western North Carolina on a health survey and observed no curtailment of cigarette smoking there, even among public health personnel. Obviously, other factors are involved here. Getting personal health information across to the public and motivating them to use it are functions that are most difficult to evaluate. The development of special clinics such as the Anticoronary Club in New York City applies education to a limited number of individuals, and the extent to which the publicity emanating from it reaches the general public is largely unknown. In New York State we are now developing a pilot educational program on heart disease. The U.S. Public Health Service has loaned us a special health educator who has been assigned to this particular phase of public health education. Aside from the general analysis of the problem, this educator’s function will be to establish a pilot project in one or two counties, where various methods will be applied and an attempt made to evaluate their effectiveness. Known methods will be utilized, and new tools will be developed to the extent possible. A new position of public information specialist for tobacco education has been established in the New York State Department of Health. With the advice of the department’s Tobacco Education Committee, the public information specialist will attempt to develop methods to get facts across and influence people, particularly young persons. The report of the Surgeon General’s Committee on Smoking and Health makes this activity timely, although we are well aware of the obstacles that face us. The work of this specialist will be done in cooperation with the very active Cigarette Cancer Committee of the Roswell Park Memorial Institute, the State Department of Health’s cancer research hospital in Buffalo. This institute has been pioneering for many years, not only in laboratory and epidemiologic research related to the cigarettexancer association, but in educational methods, withdrawal clinics, and preparation of substitute products. Epidemiologic
research
Concurrent with our educational activities, we must pursue our epidemiologic research to clarify some of the confusing issues that face us at the present time and to gain new information as to the kinds of people that develop chronic heart disease and the causative factors that might be preventable. The cardiovascular Health Center in Albany Medical College, operated jointly with the New York State Department of Health, maintains under observation a group of approximately 1,600 male State employees who were 39 to 55 years of age at the onset of the study in 1953. The Framingham, Massachusetts, project is a continuing epidemiologic study of heart disease in a cross section of a population composed of persons between 30 and 59 years of age on 1 January 1950, and who are followed with biennial
908
I. JAY BRIGHTMAN
examinations. A more recently developed project is one in Tecumseh, Michigan, where the University School of Public Health is attempting to bring an entire population under continued, prolonged, and comprehensive observation. Long-term observational studies are also being conducted by other research groups, particularly at the California State Department of Health, the Columbia University School of Public Health and Administrative Medicine, and the Los Angeles County Department of Health. The Evans County, Georgia, study to identify possible reasons for the marked variations in white and nonwhite cardiac mortality rates is the latest welcome addition. In New York State, a new State Employees Health Service will permit the State Health Department to make limited but long-term observations of a group of over 5,000 persons in the Albany area and thus contribute a considerable supplement to the more intensive studies of the Cardiovascular Health Center. It is from studies such as these, as well as from international investigations, that have come forth the relationships to weight, to fat intake, to blood cholesterol, to hypertension, to physical inactivity, and to smoking which are the basis of our education programs today. Certainly, fascinating stories of clinical findings and dietary patterns are recorded about the Japanese, the Indians in New Delhi, the Yemenites who migrated to Israel, and the Bantu groups in South Africa. Here, interpretation is somewhat more difhcult and has become one of the epidemiologist’s leading indoor sports. Possibly, some studies closer to home might be of more direct interest. It is particularly relevant to us in New York State that we have some of the highest death rates from coronary heart disease of any state in the union. A recent report of deaths from coronary disease for white men aged 45 to 64 years for 163 metropolitan areas in the United States indicated that all but one of New York’s seven major metropolitan areas were in the 25 per cent having the highest rates. Thus, the Albany-Schenectady-Troy area had the 7th highest rate in the country; New York City, the 16th; Rochester, the 19th; Buffalo, the 35th; Binghamton, the 36th; and Syracuse, the 38th. Only the Utica-Rome area was in the lower half of the group, ranking 99th. We know that such statistical data are subject to detailed investigation and that the rates in various areas fluctuate considerably. Yet the differences are worthy of investigation. Whether they are due to differences in sociocultural status and dietary patterns of the population groups or whether they are due to environmental factors is currently under study. Schroeder of Dartmouth has found significant correlations between the mean hardness of finished water and total cardiovascular mortality. These were particularly significant among white men 45 to 64 years of age. Highly significant negative correlations were found between cardiovascular mortality and the presence in water of magnesium, calcium bicarbonate, sulfate, fluoride (a factor that supports the case for fluoridation of water), and dissolved solids. Other mineral elements showed no correlations. There were no correlations of water hardness with noncardiovascular deaths. Morris and his associates in England have confirmed these findings. While Morris believes that a water factor may well be associated with cardiovascular disease, he considers that this probably influences the severity of the disease rather than being a causative factor.
The Potential Influence of Public Health Measures on Adult Heart Disease
909
Cmdiorespiratory resuscitation The field of cardiorespiratory resuscitation is one area where voluntary and public agencies pooled their efforts to get new knowledge into the field at the earliest possible moment. Through the joint efforts of the New York Heart Association, the New York Heart Assembly, the Medical Society of the State of New York, and the New York State and New York City Departments of Health, 187 courses in heart-lung resuscitation were held in the 16 months ending in December 1963. This program reached 6,591 persons, 4,312 of whom were physicians. The aim now is to put this educational program on a continuing basis, so that at least one physician in each hospital is kept expert in this field through graduate training and will be responsible for the training of other physicians, nurses, and other personnel, in accord with a planned community program. Recognizing the need for adeptness in cardiopulmonary resuscitation, it seems essential to evaluate its immediate and long-term results as well as the medical discretion governing its application. We found that our own interests were paralleled by those of the New York Heart Association, and at present Dr. Fred Hiss, Director of our Bureau of Heart Disease, is working with Dr. Louis Orkin, Dr. Jack Yager, and their associates on this matter. The U.S. Public Health Service has indicated its interest in lending its support. Rheumatic fever and rhemmtic heart disease In the field of rheumatic fever and rheumatic heart disease, there are certain preventive measures we can take that are well accepted by the medical profession and by public and voluntary heart associations. Yet a survey by our Bureau of Heart Disease, covering the Upstate heart associations and health departments, indicated a generally haphazard approach to this problem, with little knowledge on the part of the administrative officers as to the effectiveness of the program among those whom the program was reaching and as to the extent of unmet needs. The problem of adults with rheumatic heart disease was generally neglected. A follow-up among 72 physicians who had signed death certificates reporting patients dying from rheumatic heart disease indicated that of 100 deceased patients only 9 had been treated prophylactically. This study was done among physicians in the four-county area of Albany, Rensselaer, Saratoga, and Schenectady and concerned patients who died between 1959 and 1961. The same physicians were asked about their treatment of patients currently under their care. It is interesting that for rheumatic fever patients without cardiac lesions, prophylaxis was generally prescribed, with 82 of 96 such patients receiving penicillin. However, for patients with cardiac lesions, the results were quite different. Out of 415 patients classified as having rheumatic heart disease, only 164 were on prophylaxis. Here we find an important challenge, even though rheumatic heart disease comprises a relatively small percentage of all cardiovascular disorders. This involves guidance and consultation for public or voluntary agencies carrying out these programs, professional education for private physicians, and public education to develop greater acceptance of this phase of prevention. Employment of patients with heart disease AU of us concerned with chronic heart disease are troubled by the problems of employment of persons with these conditions. According to our State Employment
I. JAY BRIGHTMAN
910
Service, there is an over-all problem of placing any person over 45 years of age in a new job; the cardiac patient who has lost his job is even more difficult to place. The challenge is to restore persons to the jobs they had been holding, adjusting the jobs in any way necessary. This calls for a concerted effort involving the patients, their families, and their physicians, as well as the employers, the trade unions, and the community as a whole. The New York State Department of Health has just entered into a contract with the Graduate School of Syracuse University whereby the university’s department of sociology will develop a project designed to identify as clearly as possible the actual barriers that exist in New York State to employment of persons with heart disease or with conditions that increase the risk of developing heart disease. Certainly, this is not the first study of its type. However, it is hoped that such a joint medicalsociologic approach might clarify some of the confusion in this field and help remove some identifiable barriers to the employment of cardiac patients. NONSPECIFIC
COMMUNITY THE
CARDIAC
HEALTH
SERVICES
FOR
PATIENT
The professional groups concerned with adult heart disease should show considerable interest in those programs that develop along broader lines but definitely relate to heart disease. Specifically, these are early detection programs, home-care and homemaker services, improved medical and rehabilitative care in long-term facilities such as nursing homes and infirmaries, and information and referral services. The current inadequacies, both quantitative and qualitative, of these programs are well known and need no further elaboration here. In 1961, the Congress passed the Community Health Services and Facilities Act, the major part of which was designed to improve these community services along noncategorical lines. This program has given a tremendous impetus to the development of community health services for chronically ill patients throughout New York State. Aside from the strengthening of our own staffs for chronic disease and the expansion of the general services in health departments with the formula grant funds given directly to the State, 21 excellent projects have been developed under the special projects branch of this program. Those in New York City include a training program in organized home care by the Montefiore Hospital group: a considerable expansion into the research aspect of the Queensbridge Housing Health Maintenance Program for the Elderly; a special study of armed forces rejectees by the New York City Department of Health: the development of a teaching film on public health nursing care for the chronically ill by the Visiting Nurse Service of New York; a project for home aides for the sick and aged by the same agency; a similar project by the Visiting Nurse Association of Brooklyn; development of a center for advanced training and practice care of the elderly by The Jewish Home and Hospital for Aged; the development of a ‘good companions’ health service, initiated by the Henry Street Settlement, in which healthy elderly persons assist those who are not quite so fortunate: and a project directed at the control of congestive heart failure through a careful follow-up program at St. Luke’s Hospital. In addition to these city projects, several national agencies located in New York City have received major grants for national planning, study, or training purposes.
The Potential
Influence
of Public Health Measures
on Adult Heart Disease
911
These agencies include the American Public Health Association, the National Council on Aging, and The Community Reseach Associates. Yet this progress falls short of what we might have expected, considering our resources. In many instances we receive applications for projects that are not as practical as one would like to see. They call for providing a very high level of care through the so-called ‘team’ approach, utilizing all possible personnel and laboratory resources. This is fine; certainly, no one is against it. Unfortunately, these projects show that little or no consideration has been given to the possibility of providing the same quality of service with a more conservative utilization of funds and personnel; or to the practicality of continuing the program on a long-term basis, to say nothing of extending it to other communities. We are in urgent need of more practical programs and a greater number of them. Voluntary health agencies have not yet made their influence felt in the development of these community projects, possibly because they consider that they are concerned with the problems of a specific disease-heart disease, for example-and therefore would not be concerned with the noncategorical approach. Yet the majority of older patients with a chronic illness, whether in their own homes or in nursing homes, have some form of cardiovascular disease and require improved nursing, physical therapy, and homemaker services, along with better recreational programs and medical social service. The special needs of cardiac patients in nursing homes and home care programs must be stressed by the voluntary heart agencies and the heart disease units of the public health departments; but the over-all provision of these services must be on a general chronic disease basis. We have recently completed a survey designed to project our potential programs in the chronic disease field over the next five years. Of course, it would be a relatively simple matter to state that every community of a given size should have so many persons of various disciplines such as nurses, physical therapists, social workers, and so on, working within one of several organizational patterns. However, we have to recognize that even if funds were to become available, we still have serious shortages of personnel; we do not always have the most enthusiastic govemmental bodies when it comes to putting up new funds; and there is not always the most enthusiastic cooperation from such essential organizations as the medical societies, hospitals, voluntary health agencies concerned, or even from the local public health departments. Analyzing our current inventories of resources in terms of personnel, facilities and services, the expressed interests of communities in developing services, and our own estimation of the potentialities of the individual communities on the basis of past performance, we have projected a program which, at the end of five years, would cost about 10 million dollars per year in combined Federal, State and local funds. It would provide through the State the following new services : 10 multiple disease screening programs; free or low-cost cervical cytologic screening on a Statewide basis; 6 to 12 health maintenance clinics for the aged; 12 to 20 coordinated home-care programs; 12 homemaker programs: improved supervision of nursing homes in New York City and in 20 cities or counties Upstate; and 20 information and referral centers. In addition, considerable augmentation of public health nursing, dental health, nutrition, health education, and medical social services would be included.
I. JAY BRIGHTEN
912
Even this extensive complex of services would not establish comprehensive services for the chronically ill everywhere in New York State, but it constitutes the best blueprint we can draft within the limits of reasonableness at the present time. These projected services would be based on funds under the Community Health Services and Facilities Act being available for initial demonstration periods, with the program coming under either the State aid public health program or the voluntary agency program in the future. Actually, the funds are not yet available to meet what will be required to develop even this limited program, but we would have to do a tremendous amount of basic work if we were to take advantage of such funds, should they become available. VOLUNTARY
AND
PUBLIC
AGENCY
RELATIONSHIPS
In New York State we have had a long history of excellent cooperation and relationships between the official and the voluntary agencies. I am certain that these fine relationships have been characteristic in essentially all of our cities and counties. This is really an extraordinary achievement, because the specific and interdependent roles of the official and voluntary agencies are not easy to define. Until recently, it has been considered that the voluntary health agency should establish demonstration projects to prove the value of a program to the community, with the expectation that the local government would take over the function at an appropriate time, thus freeing the voluntary agency to pursue a new approach. To a certain extent this makes good sense today. However, with the development of chronic illness as the outstanding public health problem of the day, and with heart disease accounting for a major part of this illness, it is not possible to follow any set pattern. Demonstration programs in chronic disease control often call for multidisciplinary approaches, including not only expert knowledge in various aspects of medicine, but also epidemiologic and other techniques to determine the various attributes of the disease by age, sex, cultural group, vocational class, dietary habits, attitudes, and willingness to acknowledge disease and accept service. These are often very expensive to operate and must extend over long periods of time before reliable answers can be obtained. Also, they often cross into other fields. Evaluation requires much collecting of facts and a great deal of statistical study. Thus, whether a demonstration should be initiated by a governmental agency and supplemented by the voluntary agency, or vice versa, will depend on the local interests and resources and the other commitments of each agency. Aside from demonstration service programs, there are continuing programs in public health education, professional education, community service, and research support which are basic functions of both public and voluntary agencies. Again, it is a question of resources, availability of professional personnel, finances, interests, and other commitments that may determine which agency will have the dominant role. The important thing is for the two agencies in any particular field to work closely together, to recognize the resources of the other and their own strengths and limitations, and to develop a joint program for the benefit of the community. SUMMARY
There are many things we can do in regard to heart disease. Broadly speaking, we must support research and we must apply through service, consultation, or
The Potential
Influence
of Public Health Measures
on Adult Heart Disease
913
demonstration programs the practical developments of these research efforts at the earliest possible time. A proper balance of programs for the voluntary and the official agency must be determined, depending on interests, resources, other commitments, and other programs in the community, region, and state. A statement of policy and methodology should be prepared to indicate what the objectives of the program will be, how they will be reached, and how they will be evaluated. Every extra year of productive life made possible by research and service means a great deal to the individual, his family, and the community. For those who are state and national leaders, and particularly for those who are themselves engaged in research, such extra productive years may be of far-reaching significance.
THE POTENTIAL INFLUENCE OF PUBLIC HEALTH MEASURES ON ADULT HEART DISEASE
Assistant Commissioner
I. JAY BRIGHTMAN, M.D. for Chronic Disease Services, New York State Department of Health, N.Y.. U.S.A.
THE acceptance of adult heart disease as a public health responsibility, defined in its broadest terms, is well evidenced by the highly developed activities of the U.S. Public Health Service’s National Heart Institute and Heart Disease Control Section in the official domain and the American Heart Association and its numerous state, county, and city affiliates in the voluntary health field. Certainly, the New York Heart Association is an outstanding example of the latter group. The very serious question arises, and must be answered, as to whether these public health programs are well balanced and whether we are making the greatest possible use of our available knowledge. PUBLIC
HEALTH
RESEARCH
the field of laboratory and clinical research we have reached a stage of considerable sophistication. Huge amounts of funds have been made available annually over many years by both the U.S. Public Health Service and the American Heart Association, as well as through their larger state and local counterparts. The major part of these funds is well spent. This is assured by the careful review of grant applications by expert committees at both the initial and renewal stages. These funds have made possible not only the establishment and expansion of cardiovascular research activities in specialized research institutes, in medical school teaching centers, and in other research-oriented hospitals, but also have had the important side-effect of improving the caliber of both graduate and undergraduate teaching programs, which are so significantly influenced by association with dynamic research activities. Yet, several questions do arise. While the desirability of even more funds for research can be well documented, there must be a balance between the amounts of funds appropriated for research and the ability to produce and train qualified research workers to utilize them effectively. Also, we must be ready to answer quite concisely the questions that have arisen as to the possibility of overemphasis on research having an unfavorable effect upon the basic preparation of physicians and paramedical personnel for their chosen fields. Finally, the developing tendency of local health departments and local heart associations to make research funds directly available to local institutions calls for consideration as to whether such allocations assure the same control of quality as research funds administered at higher organizational levels. If not, research provincialism may be diverting funds that might better be spent in other ways. In
905
I. JAY BRIGHTMAN
906
COMMUNITY
HEALTH
SERVICES
Assuming that our research program is well advanced and that we are cognizant of the problems of quantity and quality control, we must look to the other large aspect of public health activity, namely, community health service. Here, we must determine what is the job to be done; what programs are necessary to ascertain that laboratory, clinical, and epidemiologic knowledge which has emanated from the research laboratory is made available to our population with minimal delay; and whether we have the funds, the personnel, and the organization to do what scientific knowledge dictates should be done. Two years ago I assigned to a group of third-year medical students a project to establish or reject the hypothesis that adult heart disease can be favorably influenced by public health measures. Now it might not seem quite fair to ask students to accept such an assignment even with the proviso that they will be marked on the quality of their reasoning and logic rather than on conclusions; after all, the marker did have the title of assistant commissioner of health for chronic disease services and had recently established a bureau of heart disease within his division. Their logic, based on carefully made observations, might have been different, or at least might have been evaluated differently, if their supervisor had been a very conservative president of an Upstate medical society. Nevertheless, it was interesting to see the strong positive side of the hypothesis established by the students, to such an extent in some areas that even I had to disagree with them. The community health phase of public health, whether administered by official or voluntary agencies, may be considered as the sum total of the services necessary to adequately supplement the basic treatment pattern of the physician-patient relationship. In considering this aspect, it is important to utilize the term tre&nent in its comprehensive sense, ranging from prevention of disease and early detection through the provision of adequate medical care and on to rehabilitation. We may look upon community health services in the field of adult heart disease in two categories: first, the application of specific measures; and second, the provision of more general measures that affect patients with potential or actual heart disease, as well as patients with various types of other chronic disorders. Time will not permit a comprehensive review of these. Rather, I would like to discuss some of our major current activities. SERVICES
SPECIFICALLY
FOR
THE
CARDIAC
PATIENT
Public health education We cannot consider it acceptable to state that our lack of knowledge of the specific cause or causes of the most common type of adult heart disease, namely, coronary heart disease, confines our activities entirely to the laboratory and to clinical or epidemiologic research. Certainly, the advances emanating from all research fields have indicated sufficient adverse relationships between excess weight, excess fat intake, excess cigarette smoking, stress, and physical inactivity to warrant available facts being placed before the public and being utilized to motivate such moderation or change in our patterns of living as may be indicated. While we do not have adequate statistical studies to back us up, it seems quite definite that those public health personnel who have been studying these relationships most intently are beginning to take heed themselves. Most public health
The Potential
Influence
of Public Health Measures
on Adult Heart Disease
907
meetings today are characterized by extremely little cigarette smoke, and the silhouettes of many scientists have become very streamlined, sometimes to the point of their appearing somewhat cadaverous. This seems also to be true in general of the medical and related professions, although probably to a lesser extent. It does not appear to have affected many other mature professional groups, though one would think that their sophistication and knowledgeability would have brought them into the fold. If this is true, what can one expect of the general public? Last summer I spent several weeks in western North Carolina on a health survey and observed no curtailment of cigarette smoking there, even among public health personnel. Obviously, other factors are involved here. Getting personal health information across to the public and motivating them to use it are functions that are most difficult to evaluate. The development of special clinics such as the Anticoronary Club in New York City applies education to a limited number of individuals, and the extent to which the publicity emanating from it reaches the general public is largely unknown. In New York State we are now developing a pilot educational program on heart disease. The U.S. Public Health Service has loaned us a special health educator who has been assigned to this particular phase of public health education. Aside from the general analysis of the problem, this educator’s function will be to establish a pilot project in one or two counties, where various methods will be applied and an attempt made to evaluate their effectiveness. Known methods will be utilized, and new tools will be developed to the extent possible. A new position of public information specialist for tobacco education has been established in the New York State Department of Health. With the advice of the department’s Tobacco Education Committee, the public information specialist will attempt to develop methods to get facts across and influence people, particularly young persons. The report of the Surgeon General’s Committee on Smoking and Health makes this activity timely, although we are well aware of the obstacles that face us. The work of this specialist will be done in cooperation with the very active Cigarette Cancer Committee of the Roswell Park Memorial Institute, the State Department of Health’s cancer research hospital in Buffalo. This institute has been pioneering for many years, not only in laboratory and epidemiologic research related to the cigarettexancer association, but in educational methods, withdrawal clinics, and preparation of substitute products. Epidemiologic
research
Concurrent with our educational activities, we must pursue our epidemiologic research to clarify some of the confusing issues that face us at the present time and to gain new information as to the kinds of people that develop chronic heart disease and the causative factors that might be preventable. The cardiovascular Health Center in Albany Medical College, operated jointly with the New York State Department of Health, maintains under observation a group of approximately 1,600 male State employees who were 39 to 55 years of age at the onset of the study in 1953. The Framingham, Massachusetts, project is a continuing epidemiologic study of heart disease in a cross section of a population composed of persons between 30 and 59 years of age on 1 January 1950, and who are followed with biennial
908
I. JAY BRIGHTMAN
examinations. A more recently developed project is one in Tecumseh, Michigan, where the University School of Public Health is attempting to bring an entire population under continued, prolonged, and comprehensive observation. Long-term observational studies are also being conducted by other research groups, particularly at the California State Department of Health, the Columbia University School of Public Health and Administrative Medicine, and the Los Angeles County Department of Health. The Evans County, Georgia, study to identify possible reasons for the marked variations in white and nonwhite cardiac mortality rates is the latest welcome addition. In New York State, a new State Employees Health Service will permit the State Health Department to make limited but long-term observations of a group of over 5,000 persons in the Albany area and thus contribute a considerable supplement to the more intensive studies of the Cardiovascular Health Center. It is from studies such as these, as well as from international investigations, that have come forth the relationships to weight, to fat intake, to blood cholesterol, to hypertension, to physical inactivity, and to smoking which are the basis of our education programs today. Certainly, fascinating stories of clinical findings and dietary patterns are recorded about the Japanese, the Indians in New Delhi, the Yemenites who migrated to Israel, and the Bantu groups in South Africa. Here, interpretation is somewhat more difhcult and has become one of the epidemiologist’s leading indoor sports. Possibly, some studies closer to home might be of more direct interest. It is particularly relevant to us in New York State that we have some of the highest death rates from coronary heart disease of any state in the union. A recent report of deaths from coronary disease for white men aged 45 to 64 years for 163 metropolitan areas in the United States indicated that all but one of New York’s seven major metropolitan areas were in the 25 per cent having the highest rates. Thus, the Albany-Schenectady-Troy area had the 7th highest rate in the country; New York City, the 16th; Rochester, the 19th; Buffalo, the 35th; Binghamton, the 36th; and Syracuse, the 38th. Only the Utica-Rome area was in the lower half of the group, ranking 99th. We know that such statistical data are subject to detailed investigation and that the rates in various areas fluctuate considerably. Yet the differences are worthy of investigation. Whether they are due to differences in sociocultural status and dietary patterns of the population groups or whether they are due to environmental factors is currently under study. Schroeder of Dartmouth has found significant correlations between the mean hardness of finished water and total cardiovascular mortality. These were particularly significant among white men 45 to 64 years of age. Highly significant negative correlations were found between cardiovascular mortality and the presence in water of magnesium, calcium bicarbonate, sulfate, fluoride (a factor that supports the case for fluoridation of water), and dissolved solids. Other mineral elements showed no correlations. There were no correlations of water hardness with noncardiovascular deaths. Morris and his associates in England have confirmed these findings. While Morris believes that a water factor may well be associated with cardiovascular disease, he considers that this probably influences the severity of the disease rather than being a causative factor.
The Potential Influence of Public Health Measures on Adult Heart Disease
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Cmdiorespiratory resuscitation The field of cardiorespiratory resuscitation is one area where voluntary and public agencies pooled their efforts to get new knowledge into the field at the earliest possible moment. Through the joint efforts of the New York Heart Association, the New York Heart Assembly, the Medical Society of the State of New York, and the New York State and New York City Departments of Health, 187 courses in heart-lung resuscitation were held in the 16 months ending in December 1963. This program reached 6,591 persons, 4,312 of whom were physicians. The aim now is to put this educational program on a continuing basis, so that at least one physician in each hospital is kept expert in this field through graduate training and will be responsible for the training of other physicians, nurses, and other personnel, in accord with a planned community program. Recognizing the need for adeptness in cardiopulmonary resuscitation, it seems essential to evaluate its immediate and long-term results as well as the medical discretion governing its application. We found that our own interests were paralleled by those of the New York Heart Association, and at present Dr. Fred Hiss, Director of our Bureau of Heart Disease, is working with Dr. Louis Orkin, Dr. Jack Yager, and their associates on this matter. The U.S. Public Health Service has indicated its interest in lending its support. Rheumatic fever and rhemmtic heart disease In the field of rheumatic fever and rheumatic heart disease, there are certain preventive measures we can take that are well accepted by the medical profession and by public and voluntary heart associations. Yet a survey by our Bureau of Heart Disease, covering the Upstate heart associations and health departments, indicated a generally haphazard approach to this problem, with little knowledge on the part of the administrative officers as to the effectiveness of the program among those whom the program was reaching and as to the extent of unmet needs. The problem of adults with rheumatic heart disease was generally neglected. A follow-up among 72 physicians who had signed death certificates reporting patients dying from rheumatic heart disease indicated that of 100 deceased patients only 9 had been treated prophylactically. This study was done among physicians in the four-county area of Albany, Rensselaer, Saratoga, and Schenectady and concerned patients who died between 1959 and 1961. The same physicians were asked about their treatment of patients currently under their care. It is interesting that for rheumatic fever patients without cardiac lesions, prophylaxis was generally prescribed, with 82 of 96 such patients receiving penicillin. However, for patients with cardiac lesions, the results were quite different. Out of 415 patients classified as having rheumatic heart disease, only 164 were on prophylaxis. Here we find an important challenge, even though rheumatic heart disease comprises a relatively small percentage of all cardiovascular disorders. This involves guidance and consultation for public or voluntary agencies carrying out these programs, professional education for private physicians, and public education to develop greater acceptance of this phase of prevention. Employment of patients with heart disease AU of us concerned with chronic heart disease are troubled by the problems of employment of persons with these conditions. According to our State Employment
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Service, there is an over-all problem of placing any person over 45 years of age in a new job; the cardiac patient who has lost his job is even more difficult to place. The challenge is to restore persons to the jobs they had been holding, adjusting the jobs in any way necessary. This calls for a concerted effort involving the patients, their families, and their physicians, as well as the employers, the trade unions, and the community as a whole. The New York State Department of Health has just entered into a contract with the Graduate School of Syracuse University whereby the university’s department of sociology will develop a project designed to identify as clearly as possible the actual barriers that exist in New York State to employment of persons with heart disease or with conditions that increase the risk of developing heart disease. Certainly, this is not the first study of its type. However, it is hoped that such a joint medicalsociologic approach might clarify some of the confusion in this field and help remove some identifiable barriers to the employment of cardiac patients. NONSPECIFIC
COMMUNITY THE
CARDIAC
HEALTH
SERVICES
FOR
PATIENT
The professional groups concerned with adult heart disease should show considerable interest in those programs that develop along broader lines but definitely relate to heart disease. Specifically, these are early detection programs, home-care and homemaker services, improved medical and rehabilitative care in long-term facilities such as nursing homes and infirmaries, and information and referral services. The current inadequacies, both quantitative and qualitative, of these programs are well known and need no further elaboration here. In 1961, the Congress passed the Community Health Services and Facilities Act, the major part of which was designed to improve these community services along noncategorical lines. This program has given a tremendous impetus to the development of community health services for chronically ill patients throughout New York State. Aside from the strengthening of our own staffs for chronic disease and the expansion of the general services in health departments with the formula grant funds given directly to the State, 21 excellent projects have been developed under the special projects branch of this program. Those in New York City include a training program in organized home care by the Montefiore Hospital group: a considerable expansion into the research aspect of the Queensbridge Housing Health Maintenance Program for the Elderly; a special study of armed forces rejectees by the New York City Department of Health: the development of a teaching film on public health nursing care for the chronically ill by the Visiting Nurse Service of New York; a project for home aides for the sick and aged by the same agency; a similar project by the Visiting Nurse Association of Brooklyn; development of a center for advanced training and practice care of the elderly by The Jewish Home and Hospital for Aged; the development of a ‘good companions’ health service, initiated by the Henry Street Settlement, in which healthy elderly persons assist those who are not quite so fortunate: and a project directed at the control of congestive heart failure through a careful follow-up program at St. Luke’s Hospital. In addition to these city projects, several national agencies located in New York City have received major grants for national planning, study, or training purposes.
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These agencies include the American Public Health Association, the National Council on Aging, and The Community Reseach Associates. Yet this progress falls short of what we might have expected, considering our resources. In many instances we receive applications for projects that are not as practical as one would like to see. They call for providing a very high level of care through the so-called ‘team’ approach, utilizing all possible personnel and laboratory resources. This is fine; certainly, no one is against it. Unfortunately, these projects show that little or no consideration has been given to the possibility of providing the same quality of service with a more conservative utilization of funds and personnel; or to the practicality of continuing the program on a long-term basis, to say nothing of extending it to other communities. We are in urgent need of more practical programs and a greater number of them. Voluntary health agencies have not yet made their influence felt in the development of these community projects, possibly because they consider that they are concerned with the problems of a specific disease-heart disease, for example-and therefore would not be concerned with the noncategorical approach. Yet the majority of older patients with a chronic illness, whether in their own homes or in nursing homes, have some form of cardiovascular disease and require improved nursing, physical therapy, and homemaker services, along with better recreational programs and medical social service. The special needs of cardiac patients in nursing homes and home care programs must be stressed by the voluntary heart agencies and the heart disease units of the public health departments; but the over-all provision of these services must be on a general chronic disease basis. We have recently completed a survey designed to project our potential programs in the chronic disease field over the next five years. Of course, it would be a relatively simple matter to state that every community of a given size should have so many persons of various disciplines such as nurses, physical therapists, social workers, and so on, working within one of several organizational patterns. However, we have to recognize that even if funds were to become available, we still have serious shortages of personnel; we do not always have the most enthusiastic govemmental bodies when it comes to putting up new funds; and there is not always the most enthusiastic cooperation from such essential organizations as the medical societies, hospitals, voluntary health agencies concerned, or even from the local public health departments. Analyzing our current inventories of resources in terms of personnel, facilities and services, the expressed interests of communities in developing services, and our own estimation of the potentialities of the individual communities on the basis of past performance, we have projected a program which, at the end of five years, would cost about 10 million dollars per year in combined Federal, State and local funds. It would provide through the State the following new services : 10 multiple disease screening programs; free or low-cost cervical cytologic screening on a Statewide basis; 6 to 12 health maintenance clinics for the aged; 12 to 20 coordinated home-care programs; 12 homemaker programs: improved supervision of nursing homes in New York City and in 20 cities or counties Upstate; and 20 information and referral centers. In addition, considerable augmentation of public health nursing, dental health, nutrition, health education, and medical social services would be included.
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Even this extensive complex of services would not establish comprehensive services for the chronically ill everywhere in New York State, but it constitutes the best blueprint we can draft within the limits of reasonableness at the present time. These projected services would be based on funds under the Community Health Services and Facilities Act being available for initial demonstration periods, with the program coming under either the State aid public health program or the voluntary agency program in the future. Actually, the funds are not yet available to meet what will be required to develop even this limited program, but we would have to do a tremendous amount of basic work if we were to take advantage of such funds, should they become available. VOLUNTARY
AND
PUBLIC
AGENCY
RELATIONSHIPS
In New York State we have had a long history of excellent cooperation and relationships between the official and the voluntary agencies. I am certain that these fine relationships have been characteristic in essentially all of our cities and counties. This is really an extraordinary achievement, because the specific and interdependent roles of the official and voluntary agencies are not easy to define. Until recently, it has been considered that the voluntary health agency should establish demonstration projects to prove the value of a program to the community, with the expectation that the local government would take over the function at an appropriate time, thus freeing the voluntary agency to pursue a new approach. To a certain extent this makes good sense today. However, with the development of chronic illness as the outstanding public health problem of the day, and with heart disease accounting for a major part of this illness, it is not possible to follow any set pattern. Demonstration programs in chronic disease control often call for multidisciplinary approaches, including not only expert knowledge in various aspects of medicine, but also epidemiologic and other techniques to determine the various attributes of the disease by age, sex, cultural group, vocational class, dietary habits, attitudes, and willingness to acknowledge disease and accept service. These are often very expensive to operate and must extend over long periods of time before reliable answers can be obtained. Also, they often cross into other fields. Evaluation requires much collecting of facts and a great deal of statistical study. Thus, whether a demonstration should be initiated by a governmental agency and supplemented by the voluntary agency, or vice versa, will depend on the local interests and resources and the other commitments of each agency. Aside from demonstration service programs, there are continuing programs in public health education, professional education, community service, and research support which are basic functions of both public and voluntary agencies. Again, it is a question of resources, availability of professional personnel, finances, interests, and other commitments that may determine which agency will have the dominant role. The important thing is for the two agencies in any particular field to work closely together, to recognize the resources of the other and their own strengths and limitations, and to develop a joint program for the benefit of the community. SUMMARY
There are many things we can do in regard to heart disease. Broadly speaking, we must support research and we must apply through service, consultation, or
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demonstration programs the practical developments of these research efforts at the earliest possible time. A proper balance of programs for the voluntary and the official agency must be determined, depending on interests, resources, other commitments, and other programs in the community, region, and state. A statement of policy and methodology should be prepared to indicate what the objectives of the program will be, how they will be reached, and how they will be evaluated. Every extra year of productive life made possible by research and service means a great deal to the individual, his family, and the community. For those who are state and national leaders, and particularly for those who are themselves engaged in research, such extra productive years may be of far-reaching significance.