are Par foe ae iin. Cn Panel f ei en Se ial foo _ < EDUC H.- . rae DEPARTMENT OF ee le REPORT Surgeon General’s Workshop on Prevention of Disability from Arthritis U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Division of Chronic Diseases Diabetes and Arthritis Program Washington, D.C. 20201 WE Buu Soblrw (5 NATIONAL LIBRARY OF MEDICINE “—\. BETHESDA 14, MD. Background of the Conference The need for a national conference on the prevention of disability from arthritis was first described in a long-range plan- ning document that was prepared in the fall of 1963 by the staff of the Diabetes and Arthritis Program, Division of Chronic Diseases, U. S. Public Health Service (PHS). The document noted that, although arthritis is a major public health problem, the dimensions of the problem are not widely recognized. And it stressed that, al- though therapeutic measures for dealing with the problem are far from ideal, pro- cedures that diminish disability, particu- larly when applied in a timely fashion, have been devised and should be made available to the millions of Americans who suffer from disabling arthritis. In June 1964, representatives of the Arthritis and Rheumatism Foundation (now, The Arthritis Foundation), the National Foundation, the American Rheu- matism Association, the National Insti- tute of Arthritis and Metabolic Diseases (PHS), and the Diabetes and Arthritis Program (PHS) met in San Fran- cisco to give further consideration to the need for a national conference on arth- ritis. At the conclusion of this meeting, it was the consensus of the group that such a conference was vitally needed. Participants submitted a recommendation to this effect to the Surgeon General and offered to serve as a steering committee to plan the confer- ence. On the basis of this recommendation, the Surgeon General agreed that a confer- ence should be held and accepted the par- ticipants’ offer to serve as a Steering Com- mittee. This Committee, later enlarged, met several times during 1964. In these subsequent meetings, the Steer- ing Committee determined that the empha- sis of the deliberations should be on com- munity health services, as opposed to basic research. Therefore, the title of the Con- ference, THE SURGEON GENERAL'S WORKSHOP ON PREVENTION OF DIS- ABILITY FROM ARTHRITIS, reflected this emphasis on prevention. The Steering Committee also determined that the objec- tives of the conference should be to: 1. Assess the problem 2. Assess the resources to meet the prob- lem 3. Determine gaps between needs and resources 4. Recommend action to close the gaps The Workshop was held May 5-8, 1965, at Airlie House, Warrenton, Virginia. About 100 persons participated. Repre- sented were every: health profession, medi- cal economics, science writing, health and medical insurance, and other specialties. To accomplish intensive discussion, the total group was divided into seven Work- shops: Public Education and Information Diagnosis and Treatment Facilities Long-Term Control and Management Professional Education Clinical Investigation and Training Voluntary and Public Agency Activ- ities and Programs 7. Socioeconomic Aspects (Financial Aan PwnNr Resources) Each Workshop reported back to the total group and each report was discussed by the total group. This report is a summary of the Work- shop reports. Although it represents a con- sensus of the total group, no individual participant or agency is necessarily in agreement with the total report; and it should not be inferred that any individual participant identifies himself with the report. Conference Participants WORKSHOP 1 William S. Clark, M.D., Chairman -WORKSHOP 2 Ephraim P. Engleman, M.D., Chairman WORKSHOP 3 Currier McEwen, M.D., Chairman WORKSHOP 4 Howard F. Polley, M.D., Chairman WORKSHOP 5 John L. Decker, M.D., Chairman WORKSHOP 6 William D. Robinson, M.D., Chairman WORKSHOP 7 Ronald W. Lamont-Havers, M.D., Chairman REVIEW WORKSHOPS 1-7 Cornelius Traeger, M.D. Workshop 1 PUBLIC EDUCATION AND INFORMATION William S. Clark, M.D., CHAIRMAN President The Arthritis Foundation 1212 Avenue of the Americas New York, New York Helen C. Anderson, R.N. Associate Editor American Journal of Nursing 10 Columbus Circle New York, New York Theodore B. Bayles, M.D. Director of Research Robert B. Brigham Hospital 125 Parker Hill Avenue Boston, Massachusetts Adelia M. Beeuwkes Professor, Public Health Nutrition School of Public Health The University of Michigan Ann Arbor, Michigan James L. Curran Director, Dept. of Public Information The Arthritis Foundation 1212 Avenue of the Americas New York, New York Mr. Pierre C. Fraley Chester Springs Pennsylvania Harold T. Fuerst, M.D. Assistant Commissioner for Preventable and Chronic Diseases Department of Health, City of New York 125 Worth Street New York, New York Mr. Charles E. Hovorka Executive Director, The Arthritis Foundation Southern California Chapter 8576 Wilshire Boulevard Beverly Hills, California J. Stewart Hunter Assistant to the Surgeon General for Information U.S. Public Health Service Washington, D.C. Ralph F. Jacox, M.D. Department of Medicine School of Medicine and Dentistry The University of Rochester 260 Crittenden Boulevard Rochester, New York Mr. David R. Preston 8 Washington Avenue Westport, Connecticut Elam C. Toone, Jr., M.D. Department of Medicine Medical College of Virginia Richmond, Virginia Hiawatha B, Walker, Ph. D. Associate Professor, Department of Health Education School of Public Health University of North Carolina Chapel Hill, North Carolina Mr. Victor Wartofsky Information Officer, National Institute of Arthritis and Metabolic Diseases National Institutes of Health (PHS) Bethesda, Maryland Thomas E. Weiss, M.D. Department of Internal Medicine Ochsner Clinic 1514 Jefferson Highway New Orleans, Louisiana Workshop 2 DIAGNOSIS AND TREATMENT FACILITIES Ephraim P. Engleman, M.D., CHAIRMAN Head, Arthritis Clinical Study Center and Rheumatic Disease Group University of California Medical Center San Francisco, California Roy M. Acheson, D.M., Sc.D. Professor of Epidemiology and M edicine Department of Epidemiology and Public Health Yale University School of Medicine New Haven, Connecticut Mrs. H. Marie Callender (R.N.) Associate Director, Division of Chronic Disease and Adult Health County of Westchester, Dept. of Health County Office Building White Plains, New York Morris F. Collen, M.D. Director, Medical Methods Research The Permanente Medical Group 1924 Broadway Oakland, California Miss Mary E. Davis Staff Associate American Public Welfare Association 1313 East 60th Street Chicago, Illinois David J. Hamerman, M.D. Department of Medicine Albert Einstein College of Medicine Yeshiva University Bronx, New York Dr. Irvin E. Hendryson 1750 Race Street Denver, Colorado Miss Mary L. Hemmy Executive Director The Benjamin Rose Institute Cleveland, Ohio Charles Ragan, M.D. First Medical Division Bellevue Hospital 462 First Avenue New York, New York Guy F. Robbins, M.D. Memorial Center for Cancer and Allied Diseases 444 East 68th Street New York, New York Cecil G. Sheps, M.D. General Director Beth Israel Medical Center 10 Nathan D. Perlman Place New York, New York Ralph J. Wedgwood, M.D. Professor and Chairman, Department of Pediatrics University of Washington Seattle, Washington Workshop 3 LONG-TERM CONTROL AND MANAGEMENT Currier McEwen, M.D., CHAIRMAN Department of Medicine New York Univ. Medical Center 550 First Avenue New York, New York Martin H. Acker, Ph. D. Associate Professor and Coordinator, Counselor Training School of Education University of Oregon Eugene, Oregon Sterling B. Brinkley, M.D. Program Services Vocational Rehabilitation Administration Dept. of Health, Education, and Welfare Washington, D.C. Mrs. Louise Broderick Regional Vice President American Nursing Home Association 2445 Broadway San Diego, California Mrs. Joy C. Cordery American Occupational Therapy Assoc. Hospital of the Medical Research Center Brookhaven National Laboratory Upton, New York Edward F. Delagi, M.D. Associate Professor Department of Rehabilitation Medicine Albert Einstein College of Medicine Yeshiva University New York, New York Robert B. Duthie, M.D. Professor of Orthopaedic Surgery and Orthopaedic Surgeon-in-Chief Strong Memorial Hospital Univ. of Rochester School of Medicine Rochester, New York Leonard D. Fenninger, M.D. Medical Director Strong Memorial Hospital Univ. of Rochester School of Medicine Rochester, New York Miss Evelyn M. McNamera Chief Social W ork Consultant The National Foundation 800 Second Avenue New York, New York Miss Catherine Nelson Department of Nursing Education Teachers College, Columbia University 121st Street and Amsterdam Avenue New York, New York Mrs. Beth Loggins Roberts 1515 Redondo Drive Killeen, Texas Harold S. Robinson, M.D. Medical Director, Medical Centre Canadian Arthritis and Rheumatism Society 900 West 27th Avenue Vancouver, British Columbia Clarence A. Tinsman, M.D. Chief, Heart and Metabolic Diseases Section Division of Chronic Diseases Bureau of Special Health Services Pennsylvania Department of Health Harrisburg, Pennsylvania G. Donald Whedon, M.D. Director, National Institute of Arthritis and Metabolic Diseases National Institutes of Health (PHS) Bethesda, Maryland Workshop 4 PROFESSIONAL EDUCATION Howard F. Polley, M.D., CHAIRMAN President, American Rheumatism Association The Mayo Clinic Rochester, Minnesota John H. Bland, M.D. Director, Rheumatism Research Unit Department of Medicine Univ. of Vermont College of Medicine Burlington, Vermont Alfred Jay Bollet, M.D. Associate Professor, Department of Preventive Medicine Univ. of Virginia School of Medicine Charlottesville, Virginia Alfred A. Burr, Jr., R.P.T. Department of Medicine New York Univ, School of Medicine New York, New York Evan Calkins, M.D. Buffalo General Hospital 100 High Street Buffalo, New York John L. Caughey, Jr., M.D. Associate Dean, School of Medicine Western Reserve University Cleveland, Ohio Lillian E. Chabala, R.P.T. Consultant, Division of Professional Service American Physical Therapy Association New York, New York Sidney Cleveland, Ph.D. Chie], Psychology Service Veterans Administration Hospital Houston. Texas N. L. Gault, Jr., M.D. Associate Dean, College of Medical Sciences University of Minnesota Minneapolis, Minnesota Amos N. Johnson, M.D. President-elect American Academy of General Practice Garland, North Carolina Phil R. Manning, M.D. Associate Dean, Postgraduate Medical Education University of Southern California Los Angeles, California Miss Martha E. Schnebly (O.T.R.) Director of Occupational Therapy Institute of Physical Medicine and Rehabilitation New York University Medical Center New York, New York Gladys E. Sorensen, Ed.D. Professor of Nursing College of Nursing University of Arizona Tucson, Arizona Mrs. Dorothea F. Turner Editor, Journal of the American Dietetic Association 620 North Michigan Avenue Chicago, Illinois John Robert Ward, M.D. Associate Professor of Medicine Chief, Arthritis Division Salt Lake County General Hospital Salt Lake City, Utah Morris Ziff, M.D. Department of Internal Medicine Southwestern Medical School The University of Texas Dallas, Texas Workshop 5 CLINICAL INVESTIGATION AND TRAINING John L. Decker, M.D., CHAIRMAN Chief, Arthritis & Rheumatism Branch National Institute of Arthritis & Metabolic Diseases National Institutes of Health (PHS) Bethesda, Maryland Earl J. Brewer, Jr., M.D. Assistant Professor of Pediatrics Baylor University College of Medicine Director, Arthritis Clinic Texas Children’s Hospital Texas Medical Center Houston, Texas Alan S. Cohen, M.D. Associate Professor of Medicine Director, Arthritis and Connective Tissue Disease Section Boston University Medical Center Boston, Massachusetts Alexander B. Gutman, M.D. Director, Department of Medicine The Mount Sinai Hospital New York, New York Donald Mainland, M.D. Professor of Medical Statistics New York University College of Medicine 112 East 19th Street New York, New York Alfonse T. Masi, M.D. Assistant Professor Department of Epidemiology The Johns Hopkins University School of Hygiene and Public Health Baltimore, Maryland Sanford Meyerowitz, M.D. Department of Psychiatry University of Rochester School of Medicine and Dentistry 260 Crittenden Boulevard Rochester, New York William M. Mikkelson, M.D. Department of Internal Medicine University of Michigan Medical Center Ann Arbor, Michigan Robert L. Preston, M.D. Clinical Professor of Orthopedic Surgery Rheumatic Diseases Study Group New York University College of Medicine New York, New York Robert D. Ray, M.D. Department of Orthopaedic Surgery University of Illinois Medical Center Chicago, Illinois John B. Redford, M.D. Chairman, Department of Physical Medicine and Rehabilitation Medical College of Virginia Richmond, Virginia Robert Rosengarten, M.D. Department of Medicine New York Univ. College of Medicine New York, New York Lawrence E. Shulman, M.D. Associate Professor of Medicine The Johns Hopkins Hospital 725 North Wolfe Street Baltimore, Maryland Gene H. Stollerman, M.D. Professor and Chairman Department of Medicine University of Tennessee Memphis, Tennessee Workshop 6 VOLUNTARY AND PUBLIC AGENCY ACTIVITIES AND PROGRAMS William D. Robinson, M.D., CHAIRMAN | Professor and Chairman Department of Internal Medicine University Hospital University of Michigan Medical Center Ann Arbor, Michigan Paul J. Bilka, M.D. 500 Physicians and Surgeons Building Minneapolis, Minnesota Benjamin T. Burton, Ph, D Associate Director for Program Analysis and Scientific Communication National Institute of Arthritis and Metabolic Diseases National Institutes of Health (PHS) Bethesda, Maryland Mr. James M. Ensign Director of Professional Relations Blue Cross Association 840 North Lake Shore Drive Chicago, Illinois Mr. Benjamin Fogel The Arthritis Foundation 1212 Avenue of the Americas New York, New York Richard H. Freyberg, M.D. Director, Department of Rheumatic Diseases Hospital for Special Surgery Cornell University Medical College New York, New York Mr. Thomas E. Hanrahan Secretary, Council on Voluntary Health Agencies American Medical Association 535 North Dearborn Chicago, Illinois Robert F. Hansen, M.D. Regional Chronic Disease Consultant, IV Public Health Service 50 Seventh Street, N. E. Atlanta, Georgia William S. Jordan, Jr., M.D. Professor and Chairman, Department of Preventive Medicine Univ. of Virginia School of Medicine Charlottesville, Virginia _ Mr. Alfred Moran Executive Director New York Chapter, Arthritis Foundation 432 Park Avenue South New York, New York John S. Neill, M.D. Director, Hillsborough County Health Department Tampa, Florida Mildred C. J. Pfeiffer, M.D. Director, Division of Planning Bureau of Planning, Evaluation and Research Pennsylvania Department of Health Harrisburg, Pennsylvania Mack I. Shanholtz, M.D. State Health Commissioner Department of Health Richmond, Virginia Morton Thompson, Ed. D. Director, Consulting Service on Recreation for the Ill and Handicapped National Recreation Association 8 West Eighth Street New York, New York Miss Sarah Van Buskirk (R.N.) Executive Director Visiting Nurse Association of the District of Columbia Washington, D.C. Workshop 7 SOCIOECONOMIC ASPECTS (FINANCIAL RESOURCES) Ronald W. Lamont-Havers, M.D., CHAIRMAN Associate Director, Extramural Programs National Institute of Arthritis and Metabolic Diseases National Institutes of Health (PHS) Bethesda, Maryland Mrs, Edith S. Alt Director, Division of Community Resources Health Insurance Plan of Greater New York 625 Madison Avenue New York, New York Mrs. Dorothy P. Rice Health Economics Branch Division of Community Health Services U.S, Public Health Service Washington, D.C Glenn M, Clark, M.D. Dean of Hospital Affairs Univ. of Tennessee Medical School 860 Madison Avenue Memphis, Tennessee Donald F. Hill, M.D., F.A.C.P. President, South Western Clinic and Research Institute, Inc. Tucson, Arizona Mrs. Susan K. Kinoy Project Director, Kingsbridge Neighborhood Project on Aging 900 Grand Concourse, Suite 201 Bronx, New York Robert H. Manheimer, M.D. Medical Director, New York Chapter Arthritis Foundation 432 Park Avenue, South New York, New York A. B. Price, M.D. Head, Section of Health Facilities Division of Health Services State Department of Health Olympia, Washington Milton I. Roemer, M.D. Projessor of Public Health School of Public Health University of California at Los Angeles Los Angeles, California Jean Stair, Ed. D. Professor of Public Health Nursing Western Reserve University 2063 Adelbert Road Cleveland, Ohio J. Sydney Stillman, M.D. Robert Breck Brigham Hospital 125 Parker Hill Avenue Boston, Massachusetts Mr. Thomas M. Tierney Executive Vice-President Colorado Blue Cross 244 University Boulevard Denver, Colorado Mr. Elijah L. White Assistant Chief, Division of Health Interview Statistics National Center for Health Statistics U.S, Public Health Service Washington, D. C. The Problem of Preventing Disability from Arthritis The crippling effect of arthritis on the citizens of this country has created an eco- nomic and sociologic problem that can no longer be ignored. Arthritis is the number one crippler in the United States. And the National Center for Health Statistics (PHS) recently reported that arthritis ranks second only to heart disease as the leading cause of limitation of activity for persons who suffer from chronic disability. The physical ravages of arthritis impose great economic and social burdens on all members of society. Arthritis gradually withdraws from productive activity large numbers of otherwise capable people. The latest estimate of the number of persons in the United States who report that they have arthritis or rheumatism is now 12,668,000. A more dramatic indication of the physi- cal waste from arthritis appears in data that show that 3,300,000 arthritics in this country maintain, during home interview, that they suffer limitation of activity be- cause of arthritis, About 700,000 report that they are unable to work, keep house, go to school or engage in most recreational activities (see Table A, page 10). Economic Problem. The total cost of arthritis to the public has not been deter- mined. That it is substantial is indicated, in part, by a 1962-63 survey of recipients of public assistance under the program of aid to the permanently and totally disabled. Of the more than 500,000 persons who were receiving aid under this program, an estimated 33,000, or 6.6 percent, had ar- thritis as their primary impairment. At least 17,000 additional recipients had arthritis as their secondary impairment, for a total of 50,000 recipients with primary or sec- ondary impairment. Since the average payment in this program is approximately $78.00 per month, or $948 per year, a total of $47 million was paid annually to the 50,000 recipients. To compound this economic tragedy, arthritis accounts for over 12 million work- 10 loss days per year. In terms of productiv- : ity, the loss to the economy is estimated to be $520 million a year. Loss of earning power, coupled with the Table A Number and percent distribution of persons with arthritis or rheumatism, by type of usual activity status, and by degree of activity limitation, United States, July 1961-June 1963. (civilian noninstitutional population) Type of usual activity and degree Number persons Percent of activity limitation (in thousands) distribution Total. 0. =~ «12,668 100.0 Usual activity status: Preschool or school age 57 0.4 Working 0. 4,078 32.2 Keeping house .... .. 5,926 46.8 Retired on, 1,991 15.7 Other or unknown . 615 49 Degree of activity limitation due to arthritis: Limited, total... 3,300 26.0 Unable to carry on major’ activity ...... 697 5.5 Limited in major activity 1,888 149 Not limited in major activity, but other- wise limited | ............. 714 5.6 None, total .......... 9,368 74.0 1 Refers to ability to work, keep house, or engage in school or pre-school activities. Note: Does not include persons in nursing homes. Source: Unpublished data, and Chronic conditions and activity limitation, United States, July 1961-June 1963. Estimated annual average. U. $. Depart- ment of Health, Education, and Welfare, Public Health Service Publication No. 1000-Series 10, No. 17, May 1965. Wash- ington: U.S. Government Printing Office. high costs of treatment and care, often leads the victim of arthritis to economic dependence upon other members of the family or upon community agencies. This Table B_ Estimated annual work productivity losses, benefit payments, and expenditures due to arthritis, Total... $1,297,000,000 Work productivity floss, total = $ 520,000,000 Among arthritics who work, but lose time because of the arthritis... Among arthritics who are unable to work and who re- ceive disability bene- fits... (minimal) $300,000,000 Benefit payments to arthritics, total... (minimal) $ 132,000,000 From Old-Age, Sur- vivors, and Disabil- ity Insurance, Social Security Adminis- tration ... $ 85,000,000 From Aid to the Permanently and Totaily Disabled, Welfare Administra- tion $ 47,000,000 Nonprescription drugs (except aspirin) $ 435,000,000 Physicians’ visits ........ $ 150,000,000 Hospitalization $ 60,000,000 Other: Prescription drugs Aspirin ee Physical therapy ae Certain services in doctors’ offices Nursing home care . coueeee Care in private homes __. Private insurance benefits . Federal, State, and local income taxes lost a . ? $220,000,000 TR Dy ea a costs the public money. Although the true figure is not known, arthritis is estimated to cost the U.S. economy over a billion dollars a year. Not counted in this figure Table € Number of persons per 1,000 civilian non- institutional population with activity limitation due to arthritis or rheumatism, by family income and age, United States, July 1961-June 1963. Persons with activity limitation due to Total arthritis or rheumatism Annual tamily population Number Per 1,000 income and age (in thousands) (in thousands) population Total ... .. ..... 181,964 3,300 18.1 Under 45 years 128,658 327 2.5 45 years and over... 53,306 2,973 55.8 Under $4,000 56,390 2,033 36.1 Under 45 years 34,897 114 3.3 45 years and over oe 21,493 1,919 89.3 $4,000 and over 115,056 1,083 9.4 Under 45 years 87,299 200 2.3 45 years and over 27,757 883 31.8 Income unknown 10,518 184 17.5 Under 45 years 6,463 13 2.0 45 years and over... 4,055 171 42.2 Source: Chronic conditions and activity limitations, United States, July 1961-June 1963. Estimated annual average. U.S. Department of Health, Education, and Welfare, Public Health Service Publication No. 1000-Series 10. No. 17, May 1965. Washington: U.S. Government Printing Office. are the costs of prescription drugs, aspirin, certain services in doctor’s offices, nurs- ing home care, care in private homes, pri- vate insurance benefits, and Federal, State, and local income tax losses (see Table B, page 10). Of the $435 million that is spent annually for medications for arthritis, $250 million is wasted by arthritics on products that are falsely advertised or grossly misrepre- sented. Frequently, quackery flourishes because the physician who first sees the arthritis patient is not trained to cope adequately with the problem. In addition, public and private organizations do not have the resources to counter the promo- tion of fraudulent remedies. In lieu of con- crete information about arthritis, the suf- ferer, believing that nothing can be done, wanders aimlessly into the pit of quackery. When he does seek the aid of a knowledge- . able physician, his disease may have pro- gressed beyond the point at which effective measures might have been applied. Growing Problem. Since arthritis lacks the virulence to kill, prevalence rises with age. Victims of arthritis may become crippled, disabled, and wracked with pain, but they continue to live. Arthritis has its greatest impact on the lower income groups. As family income goes down, the percentage of arthritis and, the percentage of arthritics in the disabled group, goes up. A comparison of persons with limitation of activity by family income and age in- dicates that arthritics who are over 40 years of age with family incomes under $4,000 have even more limitation of activity than those who are over 45 years of age with incomes over $4,000 (see Table C, page 10). It can be said that arthritis is asso- ciated with lower income, regardless of age, although it is also associated with in- creasing age. Psychological and Sociological Im- pact. While our society manifests a strong consciousness of responsibility for the handicapped and disabled, it nevertheless places emphasis on youth, activity, and achievement—values that are hardly com- patible with a long-term crippling disease. When crippling arthritis strikes, the psy- chological and sociological stresses that twist and tear at the patient and at all who must suffer with him are so great, both in magnitude and in duration, that they defy quantitative measurement. The battle that the crippled arthritic must wage to maintain his levels of reserve and adaptability against the onslaught of his disease has profound meaning for all responsible members of society. Something Can Be Done. The princi- pal problem in preventing disability from arthritis is that of decreasing the interval of time between the patient’s first symp- toms and the initiation of comprehensive treatment and care. Decreasing this inter- val is, in part, a matter of patient and public education. Delay in seeking proper care speeds crippling; the informed patient will not delay. Of perhaps more significance, however, is the related problem of making the pa- tient’s first medical contact more effective in leading him to prompt and adequate care. This involves the basic training of the physician and the postgraduate efforts that must be made if the practicing physi- cian is to be kept up-to-date in the field of arthritis. Also, it implies the availability of resources for early and accurate diag- nosis and the adequacy of facilities that will provide total or comprehensive medi- cal care that is adapted to the needs of the individual patient. ll 12 Unfortunately, public education activ- ities, professional training programs, diag. nostic resources, and adequate care facilities are, at present, insufficient. This must change. Something can be done for the arthritic. It can be done now, if society is willing to undertake the task. In the prevention of disability from arthritis, there is one fact that has been repeatedly demonstrated; there is one point on which virtually all workers in the field agree: The early initiation of comprehen- sive treatment and care activities, including hospitalization, when necessary, and em- bodying subsequent and continuing med- ical and social support, is essential to the prevention of disability from arthritis. Severe crippling can be prevented. In seven out of ten cases, victims of rheuma- toid arthritis can be kept out of the bed or wheelchair. They can be helped to lead a useful and productive life. For this reason, it is of vital importance that com- munity resources be augmented substan- tially and that they be brought to bear early in the course of the disease, rather than later, as is too often the case at the present time. Chronic Cripplers Excluded. For too long, the public, professional health work- ers, and statesmen have been concerned with diseases that kill, to the exclusion of the chronic crippling diseases. As a result, much progress needs to be made. The ex- cellence of current, short-term, inpatient, acute-problem studies has not been dupli- cated in outpatient work with chronic dis- eases, Clinical work and planning, which could include a comprehensive program of patient education, is inadequate at many of our better medical schools. Facilities for early hospitalization for patients who would benefit from such care are fre. quently inadequate. There are too few comprehensive care programs, which could serve as models of educational training of medical students, physicians, and other professional personnel, too few clinics, too few general hospitals, nursing homes, and home care programs, which are capable of dealing with the specific needs of the arthritic, and too few interested health professionals, With respect to professional education, recruitment, support, and training of both medical and allied health professionals is inadequate. The sparse or nonexistent training in rheumatic diseases in the cur- ricula of schools for associated profes- sional personnel or in the postgraduate education that is offered to these personnel contributes, substantially, to the present desperate shortage of physical therapists and to the scarcity of other health workers ~—all of whom should be instrumental in providing optimal care and education for arthritics. In the training of physicians, the orientation of medical undergraduate experience is toward acute, rather than chronic. illness. Needs Are Great. The prevention of dis- ability and the restoration and maintenance of function require the long-term services of an expensive team of specialists. The facilities that such a team requires are pro- portionately costly, and they range across a broad spectrum—from acute care beds in a hospital to special devices in a pa- tient’s home. There is much to be learned about this complex and costly disease, arthritis. If new knowledge is to be developed and dis- seminated, postgraduate training for physi- cians who are already in practice is imperative. Associated professional per- sonnel must be increased in number and better trained to deal with the problem of crippling arthritis. And medical students must be exposed to the challenge of this provocative disease. In addition, the victim of arthritis, his family, and the general public must be set free of the notion that nothing can be done about this disease. Fundamental research must be contin- ued, but a comparable effort must be mounted in the clinical area. Exemplary care centers should be supported as the focus of study, teaching, and consultation. And, of particular importance, the com- munity must be helped to organize and to support facilities that will provide a full range of services to the chronically ill, in- cluding the arthritic. Everyone who is concerned with health care must be im- bued with the philosophy of a team effort, of a persistent and concerted attack, which will not falter in the face of discourage- ment or disappointment. It must not be forgotten that the needs of millions of Americans will be met only if society de- cides to redirect its investment, to mold public and private resources into a force that will halt the crippling of arthritis and its impact on the Nation. Recommendations 1. That the Surgeon General designate arthritis a major health threat that must be surmounted. Arthritis is the foremost crippler in the United States. Its impact on the citizens of this country is staggering. Though rarely fatal, arthritis far exceeds the killer diseases in terms of human suffering, mis- ery, and privation. In addition, it imposes on the economy the burden of providing for citizens who have been permitted to become crippled and unproductive. In our society, this burden is accepted. However, since the immense costs of arthritis to the Nation can be prevented, further squander. ing of these human resources is neither economically nor morally justified. Ar- thritis is a major threat to the health of the citizens of the United States. As such, it warrants a concerted effort to overcome it by all available means. “orn 13 2. That facilities for the diag- nosis and treatment of ar- thritis be maintained, im- proved, and created ac- cording to geographic, population, and commu- nity needs. It has been shown that the early initia- tion of comprehensive treatment and care activities is essential to the prevention of disability from arthritis. As was pointed out earlier in this report, however, diag- nostic and treatment facilities for arthritis do not meet today’s needs. The optimal care of chronic arthritic patients requires the combined capabilities of a team of skilled health professionals. The patient’s family physician is a most important member of this team, since it is he who is charged with the key role in management. If optimal care is to be provided on an effective and widespread basis, without interfering with the tradi- tional doctor-patient relationship, facilities and personnel for early diagnosis and com- prehensive treatment should be established and supported at four basic levels: Re- gional Arthritis Centers; Diagnostic and Treatment Clinics; Roving Consultation Boards; and an Arthritis Advisory Com. mittee of the Rheumatism Section of The Arthritis Foundation (formerly, American Rheumatism Association). Regional Arthritis Centers should be uni- versity-based or affiliated with large med- ical centers. They should provide facilities for the diagnosis and exemplary, compre- hensive care of outpatients, by both full- time and part-time medical and associated professional personnel, and each Center should contain a limited number of beds for short-term inpatient care. In addition, each Center should operate an automated multi-test laboratory and make laboratory services available to other diagnostic facil- ities and to physicians in the area. Such laboratories would provide for quality- controlled uniformity and standardization of diagnostic tests—services that are not presently available. Diagnostic and Treatment Clinics should be established in existing arthritis centers and service clinics and in accredited hos- pitals or other qualified medical facilities. These clinics would provide facilities for the diagnosis and comprehensive treatment of outpatients from a defined geographic area. They would be staffed by part-time medical and associated personnel, and pol- icies of financing and admitting would be identical to those of the parent institutions, the Regional Arthritis Centers. Roving Consultation Boards would make periodic visits to hospitals in communities in which arthritis consultation services are not available. These Boards would be com- posed of professional personnel from the region’s Arthritis Center or nearby Diag- nostic and Treatment Clinic. An Arthritis Advisory Committee of the Rheumatism Section of The Arthritis Foundation would be responsible for estab- lishing standards of quality and of pro- cedure for quality control of Regional Arthritis Centers, their automated multi- test laboratories, the Diagnostic and Treat- ment Clinics, and the Roving Consultation Boards. The Committee would work closely with the U. S. Public Health Service, all other public and voluntary health agencies, and with the American Medical Associa- tion. The philosophy of providing these facil- ities for early diagnosis and comprehensive treatment should be one of building on the strengths and eliminating the weak- nesses of present resources, rather than of creating a new structure. Maximum util- ization of and sustained support for cur- rently available facilities, together with the creation of new facilities, where needed, will give local physicians easy access to new information, as it becomes available; provide a mechanism for early diagnosis and treatment at the grass-roots level; and provide for the standardization of labora- tory criteria for diagnosis. Responsibility for achieving and maintaining a high standard of medical care will rest with the patient’s family physician, leading rheu- matologists, and the Arthritis Advisory Committee. 3. That recruitment programs and undergraduate, grad- uate, and continuing edu- cation programs for the physician and for asso- ciated health personnel be improved and expanded in the area of the rheumatic diseases. Meeting the needs of the patient with arthritis begins with the recruitment and education of those who will care for and manage the patient. Proper management of arthritis patients can be provided only by persons who have professional knowl- edge, technical skills, and a commitment to the provision of optimal care and to the development and dissemination of knowl- edge. Professional people who fit this description—who can meet the ever-in- creasing demands for patient care, educa- tion, and research in chronic illness—are in extremely short supply. It is precisely because special and sup- porting skills are not available in quan- tities sufhcient to provide optimal care for the arthritic that there is an urgent need for support of education in these fields, coupled with intensive and imaginative re- cruiting programs. Because recruiting suc- cess is, in the end, largely dependent upon the excellence of educational and training programs, the great need is for programs with the kind of built-in appeal that attracts medical students, well-trained physicians, and associated professional personnel. For this reason, exemplary, comprehensive care centers should be established in conjunc- tion with medical schools. These centers would be multi-categorically oriented, but would focus on arthritis as a prototype of chronic disease. They would serve as edu- cational facilities in which physicians would work in concert with associated profes- sional personnel and would provide grad- uate education for all fields. Federal grants to medical schools should be offered to assist in planning facilities and curricula, as well as for the support of faculty. As- sistance is also required for the support of large-scale, cooperative studies among all or most of the arthritis teaching centers and study units in the country. 4, That training for and sup- port of better clinical in- vestigation be encouraged by all available means. The current approach to clinical investi- gation has produced an abundant and di- versified body of knowledge in recent years. For a variety of reasons, however, the emphasis has been on studies of bio- 1 16 chemical, immunologic, and morphologic aspects of the disease. Support for these studies has been, and should continue to be, available. In the long run, they are of the utmost significance. Nevertheless, there has been a tendency for these efforts to overshadow fundamental clinical stud- ies, to preempt the attention of investi- gators, and, thus, to inhibit work that is more directly applicable to patient needs and to the prevention of disability. The detailed recommendations that follow serve to identify means by which this imbalance in attack may be corrected. It is recommended that support for the Research Training Grant Program be ex- panded, thus accelerating the training of teachers and clinicians who are primarily concerned with patient care as a research and teaching activity.. Physicians who are capable of asking the pertinent clinical questions, of designing studies that are capable of answering such questions, and of carrying these studies through to com- pletion are in short supply. There has been too little emphasis on the kind of excellent clinical judgment and critique that is man- datory in such work. It is further recommended that clear and forthright support be made available to clinicians of proven capacity who are in a position to give and to teach excellent patient care and to conduct clinical investi- gation. Support has been inadequate for the physician whose area of major con- tribution is in such clinical spheres as defining natural history of disease and es- tablishing the role of a given therapeutic modality. It must be recognized that these problem areas are of fundamental im- portance, that they are distinctly worthy parts of the total investigational effort, and that, as such, they are areas in which com- petent. research-oriented clinicians should be supported. It is recommended that support for hos- pital beds for clinical investigation be provided within the framework of the ar. thritis center concept. Hospitalization is of major, yet poorly defined, significance in the management of crippling arthritis. Proper clinical studies cannot be performed without an adequate supply of hospital beds that are available to the subjects. The cost of providing such facilities is more than justified by the fact that each bed serves not one, but three interlocking purposes— exemplary patient care, the teaching of exemplary care to learners in all profes- sional health fields, and clinical investiga- tion. It is recommended that research grant applications that pertain, in large degree, to clinical studies be evaluated on a com- petitive basis with similar studies, rather than with programs that are based primar- ily in the experimental laboratory. Clinical studies are generally considered to be much more difficult to evaluate than experi- mentally induced results because of the extended observation programs that are required, the many subjective factors that impinge on the observer, and the slower evolution of scientific truths from observed data. Despite these problems, value judg- ments can be made if clinical studies are compared only to each other. There is a great need for a central co- ordinating agency that would be concerned exclusively with the clinical and epidemio- logical features of arthritis. Such an agency would provide continuing consultation in the areas of experimental design, biomet- rics, and data processing. It would serve as a focal point for drawing together widely separated investigators, who might then elect to join others in cooperative studies. And it would be expected to origi- nate investigative efforts of its own. Finally, it is recommended that an ar- thritis research coordinating agency be es- tablished as a function of the U.S. Public Health Service. This agency would, on a voluntary basis, contribute to the design and execution of cooperative clinical stud- ies, provide technical consultation in ex- perimental design and biometrics, and assist in efforts to standardize criteria and laboratory procedures. In general, it would coordinate clinical research activities in three major problem areas: 1) The natural history of the diseases and the effect upon them of therapy or lack of therapy, includ- ing analysis of such areas as patient mo- tivation and the useful patterns of various agencies, such as centers, clinics, and hos- pitals; 2) The study of diagnostic criteria, therapeutic efficacy, and such patterns as remission and exacerbation, including both laboratory and clinical features; and 3) Classical epidemiological work, both in terms of measuring the extent of the prob- lem in various areas and under various circumstances and in terms of identifying etiological factors. 212-957 0 - 66-2 5. That all agencies that are concerned with crippling arthritis dramatically im- prove and expand pro- grams of public education and information. Comprehensive programs of public ed- ucation and information are essential to the effective control of crippling arthritis. An uninformed patient and general public can neither intelligently seek good care nor demand that health authorities provide proper treatment and care facilities for arthritis. In lieu of professional help, the victims of arthritis spend $250 million annually on worthless and fraudulent treat- ments for arthritis. Obviously, neglect of this disease problem, on all fronts, has created, and is, in turn, caused by, a com- posite of apathy, ignorance, and misunder- standing. Breaking this frustrating chain of hopelessness will require intelligent and aggressive action by a number of agencies, at a variety of levels, A public education and information program on arthritis should work to achieve the following goals: To motivate arthritics to seek qualified care, to seek it sooner than they might otherwise, and to stick with it; to improve the attitude of the pub- lic toward arthritis and the attitude of the arthritic toward his disease; to motivate those who produce and disseminate health information to place more emphasis on arthritis; to create in the public an aware- ness of the size and seriousness of the ar- thritis problem; and to stimulate wide- spread interest in a major effort to meet the challenge that the problem of crippling arthritis poses. If these objectives are to be accom- plished, all agencies that are concerned with arthritis must concentrate their efforts in a continuing, nationwide program of in- formation dissemination that will make maximum use of all the tools of communica- tion to inform and educate the general and special publics about arthritis. In years past, the role of the Federal Government in focusing public attention on, and in pro- viding support for, the amelioration of crip- pling from arthritis has been small. It is now time for the U.S. Public Health Serv- ice to provide the resources and leadership that will enable public, private, and vol- untary agencies to work together to es- tablish a program of arthritis education 17 18 and information that will deal system- atically, thoroughly, and realistically with the needs of the millions of arthritics in this country. 6. That a substantial portion of Federal grants for the chronically ill and aged be earmarked for comprehen- sive community _ service programs for the arthritic. The chronic nature of arthritis often re- quires that programs of supervision and care be continued for a prolonged period of time after the patient returns from the hospital to his home. Basically, two types of supervision are required: Home care programs, for the patient who is still home- bound; and outpatient care programs, for the patient who can leave home. Although necessarily different, both approaches to patient care depend for their success on the availability of a variety of facilities and skills. The availability of these skills and facilities is, in turn, directly dependent upon the support that is given to communi- ties to plan and to operate comprehensive service programs. The ultimate aim of treatment of the arthritic patient is to enable him to engage in productive activity in his home and in the community. Because of the tremendous variations in the prevalence of illness and in the resources that a community might have to combat the social, emotional, and economic, as well as the medical, problems of chronic illness, each community must develop the patterns by which it may use its particular resources to the fullest. It is while communities are developing patterns of resources utilization that they should give serious consideration to the desirability of combining programs for the long-term management of arthritic patients with those that are designed to cope with other chronic diseases. Combined efforts are usually more effective and more feasible than separate attacks on different disorders; and they enhance the management of the arthritic patient without unduly increasing the economic burden on a small community. Community planning should include pro- vision of facilities for all types of care; the development of appliances and equipment and the training of the patient and his fam- ily to use them; the means of bringing to- gether, most effectively, the patient, per- sonnel, and facilities; and the development of recreational and social activities that can be operated in conjunction with those that are enjoyed by other members of the community, Programs should also include means of evaluating their strengths and weaknesses, in order that they may be modified and improved on the basis of ex- perience. The need is great for community serv- ices that go beyond the hospital and the clinic—that enable the arthritic patient to lead a satisfying and productive life. Fed- eral formula and project grants that are earmarked for arthritis would, if provided, stimulate States and communities to come to grips with the problem of planning for and providing the long-term care that is needed to prevent crippling arthritis. Background Papers Workshop 1 Public Education and Information William S. Clark, M.D., Chairman It is to be hoped that we have just about reached that stage of civilization when we can say: “Our society can no longer afford the crippling diseases, the most notorious of which is arthritis.” As distinct from the killer diseases, on behalf of which a dramatic mobilization of resources has enlisted overwhelming public response and cooperation, the gen- eral attitude toward this most familiar of the crippling diseases has become one of apathy. Perhaps because some form of arthritis has been known as far back in the history of man as we can go, and perhaps because a habit of frustration has been built up through the years (by the medical profession and by the lay public), this at- titude seems to be based on a belief not dissimilar to that held until very recently about poverty: that “rheumatism, like the poor, has always been with us.” The built-in implication, of course, is that it always will be and that there’s not much point in doing anything about it. But today, we are taking a new look at poverty in the midst of abundance, and we are attempting to apply intelligent and in- tensive effort towards its elimination. It would seem to be more than about time to take a new look at the country’s leading crippler. This necessarily includes an ex- amination of what can be done to clear away the mists of apathy, now lying like some vast primordial miasma between us and the prospect of successful subjugation of this crippler of mankind. Let us first look at the facts. Arthritis, the second most prevalent chronic disease, affects an estimated 13,000,000 persons in the United States— one out of every 15 people—and adds 250,000 new victims each year. Over 3,300,000 persons are limited in their ac- tivities by arthritis, of which number 697,- 20 000 are unable to work, keep house, or go to school. Of the 915,000 persons who are confined to their homes by chronic dis- eases, 17 percent attribute their problem to arthritis and rheumatism. Sixteen percent of over 16,000,0000 individuals who are classified as having limitation of major ac- tivity report arthritis as the responsible cause, Arthritis and rheumatism cause 1,223,- 000 persons to be confined to bed for one or more days each year. According to the National Health Survey, arthritis caused the loss of 12,000,000 days from work in a recent single year. Arthri- tis is estimated to cost the Nation approx- imately $2,000,000,000 a year, including $500,000,000 in productivity loss and $130,000,000 in disability benefits. When arthritis strikes, there is a double loss: a worker ceases to produce at top capacity, perhaps to produce at all, with all that that means in loss of productivity to the economy, as a whole, and in terms of tax dollars for city, State, and Federal governments. In fact, only too often the wage earner is moved from the plus side of the ledger to the debit side; he becomes a consumer of tax monies. Proportionately, the arthritides consti- tute the most neglected group of diseases in the modern approach to good health. The general public has demonstrated no great concern. Funds from private and tax-sup- ported resources that are allocated for re- search support that is directly related to arthritis are something less than $15,000,- 000. Facilities that are provided by the public for diagnosis, treatment, and _re- habilitation are generally inadequate or lacking. Of the Nation’s medical schools and teaching hospitals, less than one-third have noteworthy programs and projects for treatment, teaching, and research. Fewer than 1,600 physicians in the United States manifest an active interest in the arthritis problem, and it is estimated that there are fewer than 500 properly qualified medical specialists in the field of rheumatology. We have an ironic situation. On the one hand, there are not enough adequate facilities and not enough professional com- petence to meet the need; on the other hand, $250,000,000 a year is spent on worthless and fraudulent treatments. We have a sit- uation in which, even when adequate pro- fessional help exists, large numbers of pa- tients do not seek or avail themselves of good care on the assumption that nothing can be done about arthritis—that it’s a hair shirt they just have to live with. Re- inforcement of this traditional point of view, driven home by families, friends, and even physicians. is probably deepened by incessant, day-in-and-day-out TV commer- cials: “Medical authorities state there is no cure for arthritis; take aspirin to relieve the pain.” Yet, it is now true that, with early diagnosis and comprehensive care, 75 percent of the crippling that is incident to arthritis can be prevented. It becomes obvious that the neglect of the arthritis problem is due to an amalgam of apathy, ignorance, and misunderstand. ing. Any solution must include intelligent and aggressive programs, by a number of agencies, at a variety of levels. Greater public awareness of the nature and magnitude of the problems of arthritis and rheumatism should have the following purposes: 1. To motivate patients to seek qualified medical services and to seek them sooner. so that they will receive earlier treatment and more effective prevention of disability. To improve attitudes toward those that are afflicted, including those in the fam- ily, employees, teachers, neighbors, schoolmates, and friends, by encourag- ing them to replace a fatalistic attitude of gloom with a constructive and hope- ful outlook. To motivate large numbers of prac- ticing physicians to become more knowledgeable and more skillful in the field of rheumatology. To motivate more educators to provide, at all levels, more effective and more attractive programs for continuing edu- cation. To motivate more hospitals and related agencies to provide optional facilities and resources, as required by knowl- edgeable physicians. To encourage paramedical personnel to acquire increasing awareness and to improve general skills, knowledge, and services. Paramedical educators will, of necessity, improve programs for un- dergraduate and postgraduate educa- tion. To provide for medical students, in- terns, and residents greater exposure to the diseases and to motivate them to take greater interest, with the result that more young persons will seek re- search and clinical careers in rheuma- tology. 8. To make more funds available for clinical and basic research. 9. To stimulate the development of new and more effective treatment methods. Impressing the public with the nature and importance of an insidious and undra- matic chronic disease, such as arthritis, is a challenge to physicians, health educators, and specialists in communication tech- niques. The successful methods that are appli- cable to acute and limited morbidity and to the dreaded fatal diseases are not likely to be as effective in public education pro- grams that involve less dramatic, long- term chronic diseases. The problem is further complicated by the need for cor- recting false and misleading concepts, which are held by vast segments of the public. New and imaginative methods, involv- ing the development of educational con- tent and of communication, must be de- vised. Crash programs must be launched. Dedicated representatives from the fields of medicine, health education, and the communications professions must develop and apply techniques that will get the mes- sage across—that will compete favorably with public information programs in other fields. A new attitude toward health informa- tion must be cultivated in editors, news- casters, and writers in the years ahead. Moreover, the effort of government and voluntary agencies must be stepped up to achieve a greater impact. The combined public education activities of agencies should be focused on an immediate goal, the amelioration of crippling. A critical appraisal of public education by all who play a responsible role is long overdue. Such a review should take inven- tory of the past and current efforts. On the basis of current and future needs and trends in health education and mass com- munication, a program must be designed that will deal systematically, thoroughly, and realistically with the problem. 21 22 Workshop 2 Diagnosis and Treatment Facilities Ephraim P. Engleman, M.D., Chairman The objectives of our Workshop will be: (a) To consider those community-oriented facilities that are needed for the diagnosis and short-term treatment of arthritis; and (b) to explore the resources that are po- tentially available for such facilities. It is appropriate, at this time, to define the term “arthritis,” as it will be used in our Workshop. For purposes of our dis- cussion, the term “arthritis” will be used in a general sense to refer to a group of articular and para-articular diseases, often chronic that cause painful disability, which may be evanescent, episodic, static, or pro- gressive. Examples of such diseases are gout and bursitis, in which the disability may be evanescent or episodic, degenera- tive joint disease (osteoarthritis), in which disability may be static, and rheumatoid arthritis, in which disability is often pro- gressive. There are certain problems that must be recognized prior to our discussion of fa- cilities for diagnosis and treatment of arthritis. In the first place, we have little or no information about the cause or pre- vention of these diseases. Secondly, there is no unequivocal diagnostic test. And of those tests that are commonly used, there are at least two sets of diagnostic tests for which there is no uniformity or standardi- zation. I refer, specifically, to the tests for the rheumatoid and lupus factors and to the criteria for radiologic diagnosis. Thus, our methods for diagnosis are tra- ditional. They include the time-consuming history and physical examination and the performance of laboratory tests and X-ray studies, A third problem concerns the lack of a cure. Thus, in most instances, we employ several therapeutic modalities, which may be used simultaneously. Examples of such modalities are rest and exercise, in proper balance, and drugs and simple orthopedic supports or appliances. Often the treat- ment is palliative. Nevertheless, the proper management of early disease will usually reduce pain, preserve function, and pre. vent progressive deformity. Furthermore, proper treatment will minimize the likeli- hood of iatrogenic disease. Some 13 million people in the United States maintain that they have some form of arthritis. This prevalence is so high that responsibility for these patients must be assumed by their local physicians, by doc- tors with varying interests, including those in general practice. This brings us to the fourth problem, namely, the shortage of physicians with at least a modest degree of skill, or even interest, in the care of the arthritic patient. The gap that exists be. tween the knowledge that is available about arthritis and its application to the patient can only result in a critical delay in accu- rate diagnosis and proper treatment. At the community level, we are faced with a fifth major problem: the shortage of arthritis clinics. Although there are ap- proximately seven thousand accredited hos. pitals in the United States, there are only 300 arthritis clinics, many of which are poorly staffed and equipped. And most of these clinics are restricted to large popu- lation centers. Finally, it must be noted that there is an almost complete absence of certain arthritis facilities that are available in many other parts of the world. Thus, we have, in the United States, virtually no provision for rural arthritis services, hospital beds for arthritis, national registry of patients with arthritis, a directory of diagnostic and treatment facilities that are available, and/or an assessment of screening tech- niques, which might provide early diag. nosis on a large-scale basis. This, briefly, is the current status of the diagnosis and treatment of arthritis in the United States. That there are vital needs is self-evident. Nearly one-half of the pa- tients who have arthritis are receiving no medical care. Thus, they are candidates for crippling or disability, which might be prevented or minimized. Our Workshop will make practical recommendations, which, hopefully, will satisfy some of our needs. Workshop 3 The Long-Term Care of Patients with Arthritic Disabilities Currier McEwen, M.D., Chairman A. Who are the patients with whom we are concerned? It is assumed that arthritic patients in acute and severe subacute stages need gen- eral hospital facilities and that this Work- shop is concerned with those who have progressed beyond those stages. These pa- tients have need of less complex facilities, but, nevertheless, specialized skills and programs. The patients who are in need of this care include: 1. Those with inflammatory types of ar- thritis, in mild subacute and chronic stages, without deformities, but whose illnesses can be expected to remain active for many weeks or months; 2. Those with similar arthritis who have developed deformities that probably can be corrected with nonsurgical measures; 3. Similar patients with advanced deform- ities, which require surgical measures for correction; 4. Patients with advanced deformities and disabilities, which have little promise for more than very limited correction; 5. Patients with osteoarthritis of the dis- abling type, who require intensive pro- grams of physical therapy and therapeutic exercises ; 6. Similar patients who require surgical measures ; 7. Patients with arthritic disabilities, who have little potential for rehabilitation be- cause of other handicaps, such as senility, stroke, etc.; 8. Patients who should be removed from their home environments for short periods, either for intensive supervision of correc- tive measures or for psycho-social reasons; 9. Patients who are in need of learning Aids to Daily Living; 10. Patients who require prevention of de- formity, as well as correction. These groups include patients of all fi- nancial levels, but the needs are especially important for those in low and moderate income groups. 23 24 B. Where do these patients now receive care? Information that is currently available permits only general answers to this ques- tion. The great majority of these patients now receive very inadequate care, either in their own homes, in general hospitals, in chronic disease hospitals, or in nursing homes. It is probably true that, in many in- stances, even well-to-do patients, in their own homes, receive inadequate care be- cause of lack of (a) suitable programs, (b) skilled personnel, (c) knowledge of available community resources, and (d) coordination of existing community re- sources. C. What are the special needs? The special needs of the various types of patients who are listed under section A include: 1. Facilities of the simple hospital type with which they can be effectively and economically cared for; 2. Skilled consultant services, provided on a team basis, to plan and_ periodically assess each patient’s program; 3. Ready access to general hospital beds for those patients whose course of disease demands that level of care, because of intercurrent illness, exacerbation of dis- ease, or suitability for a definitive surgical or other therapeutic measure; 4. Financial arrangements that will permit patients of all economic levels to receive optimal care for whatever period is re- quired; 5. Means of continuing supervision of the program after the patient returns home; and means of providing for his total needs, including care of all illnesses other than the arthritis; 6. Arrangements to facilitate the retrain- ing of patients for jobs that are within their capabilities and assistance in job placement; 7. Development of arrangements to meet the ultimate needs of those patients who have no homes and whose potential for rehabilitation is small. D. What skills are needed? The essential skills include those of the: 1. Rheumatologist; 2. Orthopedist; 3. Physiatrist; 4. Physical Therapist; 5. Occupational Therapist; 6. Psychologist; 7. Social Worker; 8. Vocational Coun- selor; 9. Nurse and Aide; 10. Public Health Nurse (including Visiting Nurses). E. What facilities are needed? These include: 1. Facilities of a simple physical type, which provide a pleasant atmosphere, beds. medical supervision, nursing care, space and equipment for therapeutic exercises. splinting and other unelaborate measures, and facilities for recreation, where con- structive rehabilitation programs can be most effectively and economically carried out for patients of the types that were noted under section A; 2. General hospital beds, tu which patients can be transferred readily if their medical needs demand it; 3. Consideration must be given to the roles of existing types of facilities, such as nurs- ing homes, in the care of these patients: 4. The patient’s own home should be the most important facility of all in the ulti- mate care of the arthritic. Means must be developed to make the home an effective place for the continuation of constructive programs; 5. Development of more shops with faeili- ties for the employment of rehabilitated arthritic patients. Workshop 4 Professional Education Howard F. Polley, M.D., Chairman Increasing attention is being given to arthritic diseases, not only because they are conditions for which satisfactory scien- tific answers have not yet been found, but also because of the increasing awareness of the associated public health and com- munity problems. No doubt, both scien- tific and public interests have been stimu- lated by research efforts, especially those of the last 15 years or so, that have been directed toward the solution of both the clinical and the basic science aspects of the biochemical, cellular, and other abnor- malities that occur in various arthritic dis- eases. Although interest in arthritis prompted such investigations, the resulting scientific and public health benefits may extend to areas far beyond those of the diseases toward which the efforts were initially directed. The increasing attention that arthritis has received has also revealed major ob- stacles to the solution of community health problems that arthritic diseases present. The recognition that there are such ob- stacles and that they may not yet have been defined well enough to facilitate their solu- tion is the basis for this conference, which has been called by the Surgeon General, U.S. Public Health Service Our Work- shop’s attention is particularly directed to the professional education aspects of the prevention of disability from arthritis. Obstacles that are related to the pro- fessional education aspects of better public health management of arthritis may in- clude: (1) shortages of skilled professional personnel in various pertinent medical and paramedical fields; (2) inadequate use of presently available knowledge and public health techniques to determine which per- sons and which areas would be amenable to preventive measures; (3) public and professional indifference to the ever-in- creasing magnitude of the social and eco- nomic consequences of failure to prevent disability; and (4) financial requirements of the correction of recognized deficiencies. In order to obtain a better approach to the solution of these obstacles and of those that are, possibly, less well recognized, it seems necessary to define, more clearly, the current resources, such as the number of presently available medical and para- medical specialists, whose skills could con- tribute to the prevention of disability in areas in which they are now located. It seems necessary, in addition, to determine how they function in their medical and social communities. A whole series of corollary questions that are suggested are listed below. How can the talents of these specialists best be used? What are the optimal methods of teach- ing and training medical and paramedi- cal skills at the professional level? How can professional education attract the dedicated interest of knowledgeable graduate physicians and scientists and paramedical personnel, such as physical and occupational therapists, social-serv- ice workers, nurses, nutritionists, and others, for prevention of disability? What are the relationships, if any, be- tween the undergraduate educational ex- periences in either clinical or research aspects of rheumatic diseases and gradu- ate professional education? Who can undertake professional educa- tion most effectively, and where? 25