Cong. John E. Fogarty
American Association of

Public Health Physicians
October 18, 1965

Fragmentation in the Health Services:
The Problem and its Solution

As many of a here today know, public health has long
been a prime concern of mine. Even before I had the honor to
serve on and then chair the House Health, Education, and Wel-
fare Appropriations Subcommittee, the methods and problems of
public health long interested and sometimes disturbed me.

I am, therefore, most grateful for this opportunity to
speak with you men and women who have foregone the material
rewards of private medical practice, to undertake careers in
what I believe to be a more broadly challenging and eratify-
ing branch of medicine--public health.

Yet, the service of public health--as all of you well
know--does present its own peculiar frustrations. Chief among
these are those caused by fragmentation--the dispersal of
health services among many different government agencies.

Fragmentation has led to the confusion of those seeking
health services, a decrease in the quality of those services,
and the delegation of health functions to agencies neither
created for these purposes, nor staffed by persons qualified

to administer them.
But fragmentation, unlike many other problems encountered
in the health professions, is manmade--and so can be "man-undone."
I know that your association has been in the forefront in the
drive to reverse fragmentation that has already occurred and to
prevent the further dispersal of health services. Unlike many
who also deplore fragmentation, but do little but talk about
it, the American Association of Public Health Physicians has been
particularly active in working with government and private health
agencies to remedy fragmentation situations which often border
upon the scandalous.

In a recent issue of The Bulletin of your association
there was a fine editorial by Dr. Ben Freedman who has. been
unusually astute in pin-pointing some of the real reasons why
fragmentation has occurred.

I was particularly interested to see that Dr. Freedman laid
the chief blame for fragmentation at the door of the physician
himself. As he recalls, when state and local governments began
to develop medical service programs, shortly after World War I,
the medical profession, carrying out the feeling of the American
Medical Association hierarchy, turned its head when called upon
for guidance and support. As Dr. Freedman pointed out, even
public health physicians shared the apathy of their colleagues

in private practice out of professional sympathy or fear of

ostracism.
Local governments and voluntary health groups were then
forced to turn to other, non-medical sources for support--and
they got it.

It is a eredit to your organization--which for over two
decades has promoted the cause of public health--that it has
elected a leadership perceptive enough to acknowledge these
truths and courageous enough to admit them publicly.

And, I am glad to say, in recent months there has been a
heartening indication that even in the AMA doldrums, a fresh
wind is stirring. After spending millions of dollars opposing
Medicare, the AMA has accepted the facts of life and has
indicated that it will cooperate with the plan. The AMA has
been even more conciliatory with the new heart disease, cancer,
and stroke program and helped work out a compromise version
which is now Law.

All of this is encouraging to me, for, as your own presi-
dent has said, it is not too late for the medical profession
to regain its former influence and to reassume leadership in
the public health field. If the admission of a mistake is to
be considered a first step in this direction--as I truly
believe it is--then your profession is at last on its way to

constructive corrective action.
~4-

But--many of you may ask--how will this leadership be
regained? What is the way to regain lost prestige?

That is what I would like to briefly discuss tonight. For
right now the time is ripe for the medical profession to re-
assert itself. As a result of new far-reaching federal public
health Legislation--physicians now have a golden opportunity
to again take up the reins of leadership.

The Medicare program is one example. The provisions of the
Medicare act specifically charge the state departments of health
with the responsibility for accrediting hospitals and nursing
homes for the program. Here is a ready-made opportunity for
leadership in one of the boldest public health programs ever
enacted. Physicians must not fail to assume this leadership
now, or-~as history has shown us--someone else surely will.

Medicare itself is a great force against fragmentation for
it takes the care of our elderly out of the hands of local wel~
fare departments. Under Medicare, elder citizens do not have to
prove need or indigence to qualify for medical services. Under
Medicare it is the physician who makes the decisions. To begin
with, the physician determines if hospitalization is needed.

It is the physician's duty to see that essential services are
provided, ence the patient is admitted. It is the physician

who determines the proper length of his patient's stay.
I emphasize that these are the duties of the physician
and no one else. |

Another national program which affords great opportuni-
ties for the medical profession to reassume leadership and
prominence, has only just recently been signed into law.

I speak of the national program to establish regional
arrangements for research, diagnosis, and treatment of the
three major killer diseases: heart disease, cancer, and
stroke.

As you will remember, the impetus for this program came
from the report of a commission appointed by the President of
the United States. This commission, chaired by and made up
in part by some of this nation's most distinguished physicians
was charged with assessing the current state of medical
knowledge and its potential application for our continuing war
on disease. Based on this assessment and on bold, imaginative
thinking, the commission then formulated a broad plan of attack.

As never before, the medical profession is being called
upon for its wholehearted support and cooperation. I am not
speaking merely of cooperation between community physicians
and administrators in Washington--though this often-sought

working relationship is always essential.
But, I also refer to cooperation among the various elements
of the medical profession itself, on regional and local levels--
cooperation between physicians in private practice and those
in public health; and cooperation among medical schools,
hospitals, state health departments, and state medical societies.
In fostering this spirit the killer disease program offers great
promise of bringing together the so-called opposing poles of
"town and gown."

The machinery has been set up. All that remains is for
old animosities to be buried--petty jealousies to be set aside--~-
and for a return to the old-fashioned idea of service to
humanity.

I am proud that in my own home region of New England, pro-
gress toward this end has already been made. The Bingham
Associates Program has been active for a number of years in New
England in establishing relationships between the Boston Medical
Center and community hospitals in other parts of New England.
The Vermont state health department has already begun making
arrangements with local medical schools to work out the details

of a killer disease program.
But, as much as [I take pride in these achievements, such
progressive thinking is far from common. T.e State health
departments are still not in close peviners ip with academic
medicine and the major hospitals within the states. To my
knowledge, North Carolina and Virginia are about the only
states outside New England where similar progress is underway.

In calling upon physicians to rally under the banner of .
these new and exciting national heaith programs, I do not
mean to imply that we should abandon efforts to correct the
fragmentation in areas not embraced by Medicare and the killer
disease programs.

Far from it. Like all of you, I am appalled by the situ-
ations which exist in the organization and administration of
health services in many of our communities. I know well of
instances where families in desperate need of quick medical
attention are shunted around from agency to agency--many of
which are staffed with personnel who do not have the slightest
concept of medical care requirements. I am also aware of the
negligence of many hospitals in reporting cases of persons
treated by them for communicable diseases, such as tuberculosis

and syphilis, to local public health authorities.
~8-

The efforts of your association, the American Public Health
Association, and the Association of State and Territorial Health
Officers to remedy situations like these are highly commendable.
I know that many victories that have been won over the iocces of
fragmentation are the direct results of your diligent efforts.

I particularly applaud your attempts to overcome these
pressures that would split mental health programs from the rest
of community health services to which they are so closely
allied.

No, I certainly do not call for the abandonment of these
worthwhile efforts. But I do say, that swift, effective action
on the part of physicians in leading these new national health
programs is of great importance to assure the attainment of the
highest possible professional medical standards in these pro-
grams and to prevent further inroads by the forces of fragmen-
tation.

Once physicians have clearly demonstrated their intention
to throw off their reluctance to lead, once it is seen how much
better it is to have medical men and women at the helm of med-
ical service programs, then, I am confident, the way will be
paved for consolidation of all health services under health-

oriented leadership.
~ 9.

Full cooperation between all the branches o° the medical
profession--between "town and gown", between pub’ic and
private--this is the wave of the future. Physicians must not
duck this wave but, rather, meet it and ride it cut. There
will never be a greater opportunity than now for physicians to
regain the leadership of the health services they formerly
chose to shun. [I urge all of you now to seize and make the
most of it.

We have learned much in recent decades of medical research.
The time has come for us to bring this knowledge out of the
laboratory and into the hospitals, to the bedside of every
person who has been disabled with cancer, heart disease, stroke
and other diseases. The time has come to bring the benefits
of modern medicine to our elderly who have heretofore been
denied them because of inability to pay.

Congress has shown its clear recognition of these needs.
It has acted swiftly and well to meet them. All of us now
turn to you and your colleagues--the men and women of medicine
to set the machinery going and to work the marvels of which

modern medicine is capable.
~ 10+

With physicians in the forefront of the national health
programs, fragme::etion will be surely doomed. Jnder the
knowledge and guidance of medical men and women, health services
will become easily accessible to all who need them. They will
improve in quality, and decrease in cost.

We simply have to accept the idea that fragmentation is
but a symptom of a lack of effective medical leadership. It
will cease only when that leadership is provided--for the

ultimate benefit of us all.

THF