[U.S. Department of Health, Education, and Welfare, Public Health Service, National Institutes of Health, National Library of Medicine] [Bicentennial of Medicine in the United States, 1776-1976] [Public Health and Preventive Medicine] [John Crayton Snyder, MD, Professor of Population and Public Health, Harvard University School of Public Health] Dr. Martin Cummings: Our next speaker is Dr. John Crayton Snyder, Professor of Population and Public Health at the Harvard University School of Public Health. Dr. Snyder will review public health and preventive medicine. Dr. John Crayton Snyder: To appreciate the changes in public health over the past century we need to remind ourselves what things were like in the 1870s. Many people believed that sickness and misfortunes of all kinds were due to acts of god or they blamed the stars and the planets or the whims of spirit. The great epidemics in the middle ages had left a legacy of fear. Even in the early 19th century people did drastic things when epidemics threatened. A vivid example was the scuttling of the ship Ten Brothers in Boston Harbor by order of the city authorities who hoped thereby to prevent an outbreak of yellow fever. People did know that smallpox spread from person to person and that generous cowpox vaccine provided some protection. Indeed when smallpox threatened the town, vaccination campaigns sometimes were launched as depicted in this scene in Jersey City in 1869. The concept of contagion had its advocates, but many observant, layman and doctors in the early 1870s believed that epidemics originated from noxious substances exhaled into the atmosphere from putrefying animal or vegetable matter. [Image titled Compulsory Vaccination in Jersey City: A Street Scene During the Smallpox Scare, depicting mothers and children crowded around a man who is administering a shot to a child in his mother's arms.] The eminent physician, Dr. Henry Bowditch wrote that the main cause of consumption in Massachusetts was a residence on or near a damp soil. Such ideas were fostered by the appalling living conditions in the 1860s and 70s. Listen to what the inspector said about one part of New York City, quote, "Domestic garbage and filth of every kind is thrown into the streets, covering their surface, filling the gutters, obstructing the sewer coverage, sending forth perineum emanations which must generate pestiforous disease." The refuse of the bedrooms of those sick with typhoid and scarlet fevers and smallpox is frequently thrown into the streets there to contaminate the air and no doubt aid in the spread of these pestilential diseases. The privies are one of the chief features of in salubrity. Nearly all of them are too small in size and too few in number and without ventilation or seat covers. In a single tenement house on Mulberry Street with a trenchant population of 300 persons, there have been 240 cases of fever and 60 deaths in a period of four years. Next slide please. To one artist in 1869, the area around Central Park in New York City looked like this. [Image of raggedly dressed people, rotting structures, and animals languishing in Central Park.] Slide off please. Let's take a look at some other characteristics of the 1870s. There were 40 million people in the United States at that time. Life expectancy at birth was 43 years. Of each 1,000 infants born alive, 188 died before reaching one year of age. Next slide please. The five main causes of death in 1870 were pulmonary tuberculosis, typhoid fevers, diphtheria, measles and smallpox. Lemuel Shattuck in his monumental report of 1850 described in detail ways to remedy such situations and to improve health generally, but his report was ignored for nearly two decades. In 1870, public health and preventive medicine were only gleams in Lemuel Shattuck's eye. Slide off please. There was no concept of a comprehensive national health plan nor any widely held belief that federal or state governments should take responsibility for action in the public interest. The knowledge upon which to plan effective action was simply not available. Even if a comprehensive plan had been conceived, the necessary administrative mechanisms were still to be devised. With the passage of a century remarkable changes occurred. Next slide please. The five communicable diseases that were the chief causes of death in 1870, all disappeared from the list in 1970. In their places we find heart disease, cancer, cerebrovascular diseases, accidents, and influenza. A contrast is equally sharp in the population statistics. Next slide. Next slide please. Now there are five times as many people in the United States as there were 100 years ago. Life expectancy at birth has nearly doubled. Most striking, however,is the contrast in rates of infant deaths. In 1870, there were nine times as many as today. Slide off please. This was a rapid evolution indeed. Changes of this magnitude affecting many millions of people in such a short time span were unknown in previous eras of recorded history. A great burden of mortality from communicable diseases was lifted from the populations of the industrialized countries. To what extent can this rapid evolution be ascribed to advances in science and to the efforts of the health professions? Our colleague Walsh McDermott among others has pointed out that prior to the era of sulfonamides and the antibiotics, the practitioner of medicine could bring only slight if any death-delaying benefits to his patients. Furthermore, death rates in many places began to decrease well before any specific efforts were made to control the chief causes of death. Despites these facts, one can assign a large measure of credit for improvements in health during the past century to combinations of four things: Scientific advances, new concepts, new public policies, and administrative inventions. To illustrate the contributions of American medicine to this rapid evolution, here are few examples selected very arbitrarily. First, we consider scientific advances and new concepts. Theobald Smith and F. L. Kilbourne showed that Texas fever in cattle was transmitted by tics and they were the first to control an arthropod-borne disease by attacking its vector. Then Walter Reed and his associates in Cuba by performing experiments that today no committee on ethics would dare to endorse proved conclusively that the mosquito, Aedes aegypti, transmitted yellow fever from man to man. In the preceding 150 years, yellow fever had been constantly present in the City of Havana. Reed's conclusions pointed so clearly the mosquito control as the practical method of exterminating yellow fever, but the principle was put to test in Havana in February 1902 by William C. Gorgas. The result was as dramatic as the scientific findings. By September of that same year, yellow fever had been completely eradicated from Cuba and it has not reappeared, an epic chapter in the history of preventive medicine and public health. Thirty years later, another new principle was tested against yellow fever. This was a concept that people can be immunized using a virus altered by laboratory manipulations from its natural state of great virulence to a condition [?] virulence. Members of the staff of the Rockefeller Foundation accomplished this feat by a series of steps culminating in the work by Max Theiler and Hugh Smith. Their avirulent 17D strand is now used the world over for protection against both urban and jungle yellow fever. This was a milestone in public health and preventive medicine, the more noteworthy because it was accomplished in the incredibly short period from 1928 to 1937. Another example is poliomyelitis. The early contributions by American scientists include discoveries by Trask, Armstrong, Paul, Bodine, Howe and many others. But the turning point in research on poliomyelitis was the cultivation of polio viruses in non-neuroprimate cells by John Enders, Thomas Weller, and Frederick Robbins in 1949. Their findings were used by Jonas Salk as he developed the formal and inactivated polio virus vaccine and by Albert Sabin as he saw avirulent strains of polio virus suitable for human use. The vaccines sharply reduced the incidence and severity of polio in the United States and in other parts of the world, a benefit to humanity, impossible to quantitate in terms of human misery or of economic loses averted. Furthermore, the work of Enders, Weller, and Robbins prepared the way for many other notable advances in biology, for examples, the discoveries leading to knowledge of cytomegaloviruses and their role in mental retardation and the vaccines against those ubiquitous diseases, measles and rubella. These accomplishments deserve high places in any tabulation of the major advances in public health and preventive medicine. Now we come to some of the new public policies and administrative inventions. There are other prime factors influencing the changes in health since the 1870s. They are to be found not in the advances made by the biological and natural sciences, but rather in the realm of social and political affairs. Eloquent spokesmen like Benthan, Russo and Dickens had voiced the concern of their times over the wretched conditions of much of mankind. Gradually, the conviction spread that something should be done to remedy intolerable situations. In part the concerns stemmed directly from humanitarian motives, and in part it was a recognition by those in political and industrial control that national success depended on manpower and consequently that illness was a national liability. Spurred by the Citizens Association, the New York State legislature enacted a public health bill in 1866. It marked a milestone by assuring the necessary power and administrative machinery. Within a decade, seven other states had taken similar action and by 1918 all had done so. The state legislatures, by creating the state boards of health and providing them with adequate authority, were testing the usefulness of organized community action as a way to attain specific health objectives. People soon learned that the practice of public health required the skills of engineers, chemists, laboratory scientists, physicians, dentists, veterinarians, nurses, pharmacists, educators, nutritionists, entomologists, social workers, experts in law, public affairs, communications, systems analysis and management, each with appropriately trained assistants for [?]. One can summarize this by saying that public health became a mosaic of professions. May I have the next slide please. The mosaic concept greatly enhanced the effectiveness of organized community activity. Its emergence was an essential step in the development of the technique now widely used to deal with complex health problems, whether local, state, national or international. Namely, the mobilizing of appropriate experts for collaboration with community leaders in analyzing problems and developing effective solutions. The technique has had an important part in the major public health advances of the past century and is the established method of public health. Let me cite a current example to illustrate the technique of organized community action. An example where the community is the whole world and the problem is smallpox. Despite the success of Jenner's vaccine, only two decades ago smallpox was still a major threat to the world, afflicting dozens of countries. A lot of money was spent just trying to keep it in check. In our own country, we spent about 100 million dollars yearly. Then in 1958, the world organized itself to get rid of the smallpox. [Zoom in on map of of the world -- titled Smallpox, 1962 -- identifying nations that still had cases of smallpox and were working to eradicate it at that time.] The technique of surveillance and containment was applied with imagination and vigor, especially by the American teams in West Africa. Last year, only four countries had smallpox. Today, only one, Ethiopia. Next slide please. Smallpox virus, the cause of this patient's illness, heads the list of endangered species. [Image of a person's lower legs covered with smallpox lesions.] All of us, environmentalists included, will be pleased when smallpox virus has gone and perhaps it may be gone before this year is over. Now we come to an idea of extraordinary significance and power. The idea took form [?] through times of prosperity and depression, despite wars and their consequences. It continued to grow during civil rights and women's liberation movements. The idea is that every individual has the right to health protection and promotion throughout his or her life. By 1946, a considerable amount of public support had been generated for this idea. It appeared as the basic tenant in the preamble to the constitution of World Health organization. Now the next slide please. The highest attainable standard of health is one of the fundamental rights of every human being. Governments have a responsibility for the provision of adequate health and social measures. Slide off please. The United States formally endorsed the concept along with the majority of the nations of the world. Whether or not the idea is ever completely accepted as the national health policy for the United States, and regardless of whether its implementation is fully financed, surely its influence will continue to be felt far into the future. At this point, we should shift our focus to the voluntary associations that are so characteristic of America. One of the great administrative inventions of the past century was to put voluntary associations to work effectively for the improvement of health. In his essay for this colloquium, Dr. Bowers noted the far-reaching benefits due to one kind of voluntary health, voluntary association, the philanthropic foundation. The other two kinds, professional societies and citizens associations have also made innumerable contributions, but in different ways: prodding the legislatures, educating the public, assembling resources, stimulating professional training, setting standards in the public interest and so on. Our society owes much to the efforts of the whole panorama of voluntary associations from the early Citizens' Association in New York to the American Public Health Association, The Cancer Society, the March of Dimes, the Red Cross and thousands more...sometimes even Ralph Nader. The most recent of the great new concepts is that the world's increasing population pressures have a direct bearing on health. May I have a next slide please? In 1830, there were one billion people in the world, in 1930 two billion, today four billion, in the year 2000, 7.5 billion. The chart shows the expectant geographical distribution of people North and South America, Africa, Europe,Soviet Union, India, China and the remainder of Asia. [Chart showing expected population growth in various countries.] In the United States, the implications of rapid population growth impressed a few individuals early in the 20th century, notably, Margaret Sanger, R. L. Dickinson, and C. J. Gamble. But not until the 1950s did the significance of population growth attain wide consideration. Now population pressures and related environmental issues are recognized as critical for our planet and its limited resources. The health professions after decades of delay have finally begun to realize that they must participate in regulation of population growth and control of human fertility from policy formation to public education to provision of services. There has been an equally important change in the public view about birth control, abortion, sterilization. Likewise, there have been swift advances in the technology of contraception. American scientists contributed most importantly to the development of oral contraceptives and plastic intrauterine devices. Next slide please. The new technology is spreading around the world. The fact that 50 million healthy women are taking oral contraceptives is a wholly new phenomenon. Slide off please. Much more should be said about the relations between health, population growth, and fertility control, but it is time for closing remarks. Extraordinary advances were made during the past century, nearly all of us will agree that there is a great deal yet to be understood and even more to be done before public health and preventive medicine can provide comprehensive health services of high quality throughout this nation in an equitable manner. For the future, with increasing population pressures and diminishing stocks of certain natural resources, I see two tasks of overriding importance for public health. The first is to advance the art and the science of public education. Scientific discoveries that get no farther than the library shelves do not benefit the public health. We need to understand the educational process and to become skillful in motivating large groups of people to use important health measures in their daily lives. The other task no matter how painful the effort is to reorder our national priorities in health soon. Both the public and the members of the health professions face difficult choices. Slide please. The bottom line of this crowded list shows that our government this year is spending 27 billion dollars by the Department of Health, Education, and Welfare. In addition, there are health expenditures in the Veterans Administration, the Department of Defense and of course in the private sector. Slide off. Does this represent the optimum way to spend our money in the effort to improve the nation's health? How much of our financial and intellectual resources should we devote to programs for reducing the effects of common causes of disability and death and how much to the pursuit of expensive and relatively restricted therapeutic procedures? The logical approach to such questions is to concentrate resources on prevention and on the use of many types of auxiliary health workers. This would make the benefits of health measures more widely available and would extend personal health services more evenly through the population. But public health is affected as much by social and political forces as by scientific advances and the pessimists among us say that the logical approach will not be followed. The optimists and activists however hold a different view. Their share this conviction: by means of action, skillfully conceived and executed it is possible to shape the future environment of man, to influence the behavior of man himself and thereby to improve human health and wellbeing to a degree undreamed off today. If the advances of the past century can be extended on a comparable scale and in the appropriate directions over the next 100 years, perhaps events will show that our optimists were right. Dr. Cummings: Our next speaker is Dr. Russell A. Nelson, President Emeritus of the Johns Hopkins Hospital. Dr. Nelson will review the progress in medical care. [Medical Care] [Russell A. Nelson, M.D., President Emeritus, The Johns Hopkins Hospital] Dr. Russell A. Nelson: I want to speak briefly about some of the events in medical care and medical practice, 1876 to 1976. These last 100 years have brought improvement and change in personal medical care at least as profound and spectacular as any century in the history of man. [Russell A. Nelson, M.D.] America has not only participated in these changes, but has been in the vanguard of many of them. 100 years is of course an arbitrary choice of time, but a fortunate one, because in these 100 years changes have been so spectacular. In fact, in the 1870s, the beginning of this century that I speak about, medical practice was not much different from that of the several preceding centuries. Medical treatment was largely empirical, based on a reasonable knowledge of growth structure, little knowledge of function, less so of disease, and relying mostly on compassion and comfort. The changes in our century are the result of the benefits from science and technology. The more one thinks about it, it is as simple as that. As significant as they are, the benefits are not wholly improved knowledge of man and disease. Some think not even primarily, but the general improvement in our lives from better food, housing, education, communication, transportation, and the exploitation of energy into the machine-driven industrial developments. Although these changes in medical practice and medical care have long roots into the past, and progress has been slow and incremental, the medical practices changes occurred more quickly in this century, and mostly in the last 50 years. These are 20th century phenomena. This is not the time, I submit, the place nor the audience, for any attempts, certainly not by me, to document these changes. They are and will continue to be labored and belabored, not so much as the improvements they represent, but more so as the problems they have brought for the future. It seems more interesting to me to discuss just a few medical practice, medical care changes that have developed, in which I believe America has made the significant contribution. First and foremost of course are the tremendous advances in medical research and medical education. All other changes derive from these. Others in the program today and the next few days will make this apparent. I want, in the few minutes I have, to mention just four major medical care developments, largely organizational in nature, that occurred in America during the 20th century of these 100 years. These four are: first, the shift from general medical practice to specialized practice, increasingly by organized groups of physicians; second, the development of the community general hospital; third, the development of the American teaching hospital and academic medical center; and fourth, the growth of hospital and health insurance. Up until the early 1900s, medical practice and medical care was primarily general practice by individual physicians working from their homes and in the homes of their patients. The relatively few surgical specialists are working in the larger hospitals. Though some more-adventurous practitioners who're doing some largely self-taught surgery in simpler setups even in the home. Increasing medical knowledge, and spurred on by the medical and surgical experiences of World War I and its mobilization, led rapidly and progressively to increased specialization. Surgery became sub-specialized, as did the nonsurgical practices, and special diagnostic and treatment procedures proliferated. Medical practice entered irreversibly into the refer-to-a-specialist era. Specialists needed each other for effectiveness and efficiency in practice and particularly in the newer and expanding midwest and western parts of America they associated into groups to achieve this greater effectiveness. The Mayo Clinic, Rochester, Minnesota, became the leader and the template for others, interestingly usually led by surgeons who probably saw the benefits of widely available specialist consultation before their other colleagues. [?], Leahi, Ochsner, Lovelace, [?], are, are familiar national clinic names, but many others were formed, including those in smaller communities widely dispersed in the west and in the south of this country. The older communities of the northeast were and are still slower in developing this clinic group practice method. The clinics developed into more than just a group of doctors and individual practice and important innovation was pulling of income and expense and salary payment for physicians. Administrative organization, training of nonmedical assistance, employment of nurses and various technicians, and providing a host of ancillary services led to the complete- service-available idea. Interestingly, few clinics developed their own hospital relying instead on community institutions. The specialist group practice clinic is one of the outstanding American developments in medical care of the century we speak of. Growth of group practice has been slow but steady, not entirely unexpected in view of the general opposition from the established conservative organized medical profession. As health insurance was developed to meet the increasing cost of medical care and provide a sound, sound financial base for its provision, it was inevitable that somebody would hook together health insurance and group practice. This was started by the Kaiser Industries in the west to meet the special needs of new communities in remote construction areas, but this has long since moved into the general mainstream of American medicine. The new general idea renamed is that of the health maintenance organizations. A federal government-sponsored program, most surely to grow into a basic organization for medical care in the future. Again, our conservative profession is dubious, watchful and reluctant. Advance in medical science with its new technologies required the widespread development of hospitals. America did this in the 1900s with spectacular success. The Hill-Burton Hospital construction program of 1946, enacted, it is believed, as an alternative to the controversial Wagner-Murray-Dingell bill, stimulated an enormous building and modernization activity all over this country, with good and with some not so good consequences. Our hospitals grew not as public governmental institutions so common in other countries, but as private community not -for-profit enterprises, chiefly church related. These hospitals provided the organization the financing, the facilities, and the place for training of health workers, including physicians needed, all needed in the safe care of patients. Our community general hospitals are first class and as a whole not exceeded by those in any other parts of the world. We are the leaders. In addition to providing facilities for patient care and training of personnel, American hospitals with the outstanding, with outstanding leadership from surgeons of the American College of Surgeons, have created effective programs of quality, of care surveillance on a voluntary professional basis. There are a number of significant programs, the best known of which is the accreditation of hospital by the Joint Commission on Hospital Accreditation. This is a unique American contribution. Our hospital story is one of the best of our efforts in medical care in this century. Some of America's great hospitals have always been teaching centers and helped carry the profession of medicine through the dark age of medical education pre-Flexner. As the Flexner reforms proceeded, university, medical schools, and large teaching hospitals united in a commitment to quality in teaching and the creation of standards of patient care conducive to the pursuit and transmission of knowledge. High quality faculty became the medical staffs. Students were included in patient care and laboratory investigation and graduate medical education. The residency system flourished. The spirit of investigation was implanted in the hospital wards and clinics in these teaching centers. Some will say that the Johns Hopkins Hospital and University with Welch, Osler, Halsted, Kelly, and their successors were leaders in these events and I'm not here today to deny this. In any event, this university-hospital partnership has created over time more than 100 university academic medical centers teaching a host of professionals, advancing medical science and providing vast and comprehensive services to the public. But most of all these centers have become the pacesetters for the quality and standards of medical practice. The university academic medical center is a unique American contribution of this century. As medical and hospital care became scientifically and technologically more complex, requiring instrumentation and vastly improved training for professionals, it became increasingly expensive and needed improved financing for both consumer and provider. Some form of insurance to spread the cost was inevitably necessary. Although some form of sickness insurance predates the century we speak, speak of, its modern form derives from Germany of the Bismarck period. It spread into western Europe through workers, plans and voluntary societies of various types. It came later in America and really began during the Great Depression of the 30s with the creation of the non-profit Blue Cross and later Blue Shield plans providing some protection against hospital and medical, chiefly surgical in fact, cost. It saved the day for middle-income people and it saved the day for hospitals. The Blue plans grew slowly until World War II when wage control led labor- management bargaining to non-cash fringe benefits. Tthen it really took off, and growth of both non-profit and private health insurance now covers nearly all of the population, but not fully as far as the benefits are concerned. American health insurance remains largely sickness insurance and hospital surgical protection at that. Medical care was directed into hospitals by this insurance and these hospitals grew and grew, assuming a greater role in the general care not just the care of the bedridden ill. Cost methods of insurance payments to hospitals, thought to be the least expensive way, in fact turned into an escalation force, by removing to some degree restraints on management. Health care costs, the large part being hospital costs soared from around 4 percent of the gross, gross national product to over eight percent, and it's still rising, but millions of people, nearly all of the people, had access to care and relief from some of the cost catastrophe. Ever since the establishment of the federal Social Security program in 1935, there has been pressure for and debate about the national health insurance or national health program for all citizens through a government activity. It is still just around the corner after 40 years. The Medicare and Medicaid programs of 1965 were a breakthrough to provide for this high-risk, low-privately-covered group. From that time on, government has become the dominant force in all health affairs. It is on a course to assure equity for all in access and quality, and to achieve public accountability for performance. The next centennial essay will have to record how all the American people deal with these critical events in providing all its citizens with very high quality health care. Certainly, health insurance and the beginning of public financing and regulation of medical care has to be one of the major events of this century in American health affairs. Like in so many other things in 100 years, 1876-1976 witnessed a veritable revolution in medical practice and medical care in America. The fundamental cause was the science-technology explosion including that in medicine. At least four specialized developments occurred. The beginning of group practice by specialists, some with comprehensive prepaid insurance support. The community general hospital grew to astounding size and effectiveness. University medical education and teaching, and the teaching hospital, formed university academic medical centers of outstanding capacities in teaching, research, community service, and quality setting standards. Voluntary health insurance grew to cover almost all the population, but gaps stubbornly remained leading to the beginning of federal government programs to assure equity for all and public accountability. It was a great medical century, but there is plenty left to do. [Applause] [Public Health and Preventive Medical Care] [Bicentennial of Medicine in the United States, 1776-1976] [Videotaped by: The National Medical Audiovisual Center] [U.S. Department of Health, Education, and Welfare, Public Health Service, National Institutes of Health, National Library of Medicine]