G.E. ALAN DEVER
T H E P U R S U I T OF H E A L T H
ABSTRACT. This paper delineates health legislation through a review of the literature as it relates to the cost of medical care; it also demonstrates a death-coding system that would be compatible with the cause of death and not the disease. Three tables and ten figures depict the leading causes of death by number and rate for Georgia and the U.S., 1900-1973; infectious and chronic disease death rates, U.S., 1900-70; cycles of infectious and chronic disease patterns; health expenditures, U.S., 1930-75, per capita and percent of GNP; an epidemiologicalmodelfor health policy analysis;and samplecertificates of death. INTRODUCTION The pursuit of health may be appropriately described as the pursuit of illness, disability, and death. Where else in this world are we able to smoke ourselves to death, drink ourselves to death, and even eat ourselves to death? What must evolve from recognition of these facts related to poor health is a more knowledgeable, responsible individual who will seek and promote positive health behavior. Our beliefs are entrenched so deeply in the philosophy that the physician and the medical care system will be of major support to overcome our lifedeath crises. We must reduce our expectation of the medical field practitioners, for they have reached their potential in that medical arena. We cannot continue to abuse our bodies and then expect a medical team to make repairs time after time after time - because restoration and, in some instances, curing is all they are able to provide. The major point is prevention, and this aspect becomes the individual's responsibility. Another facet of the pursuit of health, therefore, is the end of medicine [2, 3, 5, 6]. With this brief introduction, I would like to propose two questions. First, if the relationship of medical care to health is tenuous, then why do we have such a costly system [2]? I will explore answers to this question through major pieces of health legislation that have been enacted in this country since the turn of the century. The second question is, 'Do we think about health in the correct way?' [2]. The answer to this question may be found by reviewing our system of coding causes of death. The purposes of this paper, therefore, -
Social Indicators Research 4 (1977), 475-497. All Rights Reserved Copyright 9 1977 by D. Reidel Publishing Company, Dordrecht-Holland
476
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ALAN DEVER
are (1) to delineate health legislation as it relates to the cost of medical care, and (2) to demonstrate a death-coding system that would be compatible with the cause of death and not the disease. HEALTH LEGISLATION
Ironically, we have been buried by health legislation that has resulted in spiraling health costs but has not reduced the spiraling death rates. We have consistently turned to new health legislation as the panacea or solution to the problems of the medical care delivery system. The answers are not found in pieces of legislation - for we cannot legislate health - although if present trends continue, it just might be a strong possibility. Probably the earliest development of health legislation appeared in the grant-in-aid program. Beginning in 1918, grant-in-aid funds were extended to public health for the control of venereal diseases, tuberculosis, maternal and child health, plus other categorical programs [ 1]. Because of the categorical nature of the grants, most health activities became greatly fragmented, and related program plans were carried out independently. The grant-in-aid program still exists today, but it should be pointed out that venereal diseases have reached epidemic proportions in this country. On the positive side, however, we have seen drastic reductions in tuberculosis and in the maternal death rate, with moderate changes in infant mortality) Thus, the primary thrust of grant-in-aid legislation was directed toward disease control. The Social Security Act of 1935, in many respects, resembled the grantin-aid program of the earlier 1900s [1]. This act provided for major programs to combat maternal and infant deaths, tuberculosis deaths, venereal diseases; and provided services to crippled children. Again, the emphasis was on disease control - and rightly so. This piece of legislation approached the problem of disease control via funding to implement curative rather than preventive programs. It is little wonder, then (as will be illustrated later), that the major chronic diseases in this country are still increasing. In 1946, another approach emerged to control the alarming and steadily increasing rates of chronic diseases. Rather than expand program involvement, a potential solution to the problem of disease control was to expand facilities. The premise for this new program was to make health services more accessible and available by constructing hospitals and public health centers in scarcity
THE PURSUIT OF HEALTH
477
areas. An additional implication was that new hospitals would attract new physicians. This new program, the Hill-Burton Act of 1946, designed to overcome the maldistribution of facilities and provide better medical care, has had limited impact on the soaring rates of chronic diseases. In 1946, it was felt, if we could get people nearer to and into hospitals, we could effect changes in our diseases. Obviously, the emphasis was still on curative and restorative approaches. The act did achieve its purpose, however, to reduce the wide range of bed-to-population ratios. Today, these ratios are of questionable utility, for many areas still have an inappropriate supply of beds. Still, the major chronic diseases have marched on. By 1965, 19 years post-Hill-Burton, the government evolved a piece of legislation to target the three major cripplers and killers in this century: heart disease, cancer, and stroke [8]. This was to be accomplished through a Regional Medical Program (RMP), whose purpose was to organize services along regional rather than geopolitical lines. Emphasis in the RMP was on outpatient and ambulatory services, rather than inpatient services as in the Hill-Burton program. Furthermore, there was a noticeable shift to prevention of disease, rather than the curative and restorative approaches. Yet, through a simple realignment of services in a regional network, it was concluded, the pursuit of health may be accomplished by rearranging the way we seek, provide, and deliver health care. This was quite unrealistic, since the pursuit of health can be accomplished, practicably, only by changing behavior to reflect positive health action. Not one year after the RMP was initiated, the Comprehensive Health Planning Act (CHP) was established. There was now a sense of urgency, crisis, shock, and even irrational moves toward overcoming the problems of still increasing rates of chronic diseases. For between 1965 and 1974, we had six pieces of major legislation directed toward combating the major health problems in this nation. The major purpose of CIIP was essentially to integrate various health activities that the health care delivery system was developing as it pleased. Costs were rising, quality control licensing was lacking, and legal authority of health programs had no direction. Then Congress decided that to "promote and assure the highest level of health for every person, in an environment which contributes positively to healthful individual and family living" [1] there was a need to combine, link, integrate, cooperate, coordinate, or whatever, to overcome fragmentation. The planning for health services, health
478
G.E.
ALAN DEVER
manpower, and health facilities must be combined to carry out the stated purpose. Unfortunately, the purpose as stated for addressing our major chronic diseases was to have no effect whatsoever on the major issues: to reduce illness and disability and to promote longevity. The same year, 1966, probably the two most significant acts of health legislation in this country were Medicaid and Medicare. The basic premise of these two acts was to reduce financial barriers to seeking health care for selected populations. Thus, the poor, the disabled, and the aged were provided conditional access to health care, since financial barriers were removed. The pursuit of health, however, is not advanced by removing financial barriers, because our illnesses are primarily a result of our own behavior and the environment in which we live. Certainly, Medicaid and Medicare provided for curative and restorative medicine - and probably set back our preventive programs by 15 to 20 years. Because we have, in essence, given a 'laying on of hands' to hostile life styles that create disease by saying, we will pay for the problem even though you and I are the cause. There is no motivation for prevention. By 1973, eight years after RMP, CLIP, Medicaid and Medicare, a new thrust occurred - Professional Standards Review Organization (PSRO) - a peer-review type of legislation directed at physicians in the area of quality control. We now had concluded that if we wanted to control our major health problems we should monitor or audit the physician. Obviously, in some cases this might have been appropriate when unnecessary types of operations were being performed or in situations where the correct procedures were not being followed. Realistically, this approach will have had little or no effect on the overall reduction of chronic diseases. By 1974, a major piece of legislation called the National Health Planning and Resource Development Act created Health System Agencies (HSA), making RMP and CHP defunct. But if the RMP and the CHP programs were unable to effect desired changes, how could we have expected the HSAs to provide this aspect of health? This could have been, quite easily, labeled the 'Replacement Act of 1974'. A simple change in boundaries for the delivery of health services will have minimal impact on disease entities. For the pursuit of health is a personal thing - and not a political boundary that is shaped to reflect legislative and political actions.
479
THE PURSUIT OF HEALTH
SHIFTING DISEASE PATTERNS Costs o f medical care and rates o f chronic diseases must be considered so that we may have a better perspective on the nature o f our problems as expressed in the preceding section. TABLE I Leading causes of death, number, rate per 100,000 population and percent, Georgia and United States, 1900 rank cause of death
1 2 3 4 5a 6 7 8 9 10
number of deaths
rate
percent
Georgia
Georgia U.S.
Georgia U.S.
TOTAL, AllCauses 26,941 Influenza & Pneumonia 2,598 Tuberculosis 2,651 Gastritis, etc. NA Heart Diseases 1,350 All Other Accidents (Other Than Motor Vehicle) NA Cancer 373 Diphtheria HA Typhoid Fever 1,766 Measles NA Syphilis NA All Other Causes
U.S.
1,308,132 1,215.6 153,862 147,927 108,586 104,553 55,016 48,700 30,666 23,817 10,121 9,131 543,753
117.2 119.6 60.9
16.8 79.7
1,719.1
100.0
100.0
202.2 194.4 142.7 137.4
9.6 9.8
11.8 11.3 8.3 8.0
72.3 64.0 40,3 31.3 13.3 12.0 714.6
5.0
1.4 6.6
4.2 3.7 2.3 1.8 0.8 0.7 41.6
a For Georgia Malaria would rank 5th with 3.8% of the total deaths. Source: U.S. Figures - Publications from National Center for Health Statistics, Department of HEW; State Figures - Health Services Research and Statistics, Division of Physical Health, Department of Human Resources. In 1900, our diseases were primarily infectious in nature. Table I demonstrates that influenza and pneumonia, tuberculosis, gastritis, diphtheria, typhoid fever, and measles occupied high positions in reference to the top ten diseases in the country and in Georgia. A graphic depiction o f these diseases is demonstrated in Figure 1. By the 1970s, and even as early as 1940, diseases were chronic or non-infectious in nature. The major diseases in 1973, as demonstrated by Table II, were heart d i s e a s e ; c a n c e r ; s t r o k e ; m o t o r vehicle accidents; all other accidents; homicides; diabetes mellitus; and diseases o f the
480
G. E. ALAN
DEVER
PERCENT o
b
o
o
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Influenza lind pneumonia
J_l I Heart dilmm
"1 I All otlw accidenu
(It 0
~mcer
(1) 0
C~
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Typhoid Fever
Measles
I
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Syphilis
0
0
0
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THE P U R S U I T OF H E A L T H
PERCENT b
b
b
b
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482
6. E. ALAN DEVER
T/~BLE n Leading causes of death, number, rate per 100,000 population, and percent, Georgia and United States, 1973 rank cause of death
1
2 3 4 5 6 7
8 9 10
TOTAL, All Causes Diseasesof the Heart Cancer Cerebrovascuiar Disease Motor Vehicle Accidents All Other Accidents
number of deaths
rate
percent
Georgia UIS.
Georgia U.S.
Georgia U.S.
43,910 14,922 6,532 5,897
1,973,003 915.1
940.2
100.0
100.0
757,075 311.0 3 6 0 . 8 351,055 136.1 1 6 7 . 3
34.0 14.9
38.4 17.8
214,313 122.8
102.1
13.4
10.9
1,847
55,511
38.4
26.5
4.2
2.8
1,657
60,310
34.5
28.7
3.8
3.1
1,648
62,559
34.3
29.8
3.8
3.2
1,179
30,613
24.6
14.6
2.7
1.6
58,676 23.3 20,465 20.5 38,208 16.0 324,218 153.2
27.9 9.8 18.2 154.5
2.6 2.2 1.8 16.7
3.0 1.0 1.9 16.4
Influenza &
Pneumonia Diseasesof Respiratory System Diseasesof Arteries, Veins, & Capillaries Homicides Diabetes MeUitus All Other Causes
1,120 985 772 7,351
Source: U.S. Figures - Publications from National Center for Health Statistics, Department of Hew; State Figures - Health Services Research and Statistics, Division of Physical Health, Department of Human Resources. arteries, veins, and capillaries. Figure 2 depicts these facts for Georgia, while Table II illustrates the number, rate, and percent for the United States and Georgia. By comparing Tables I and II and Figures 1 and 2, a dramatic shift in disease patterns is evident. Table III, a comparison of rates for Georgia and the Unites States, 1 9 3 0 70, demonstrates the trend of increasing chronic disease rates even after all of these years of legislation to promote better health. In the United States since 1930, as noted in Table III, the most significant increases have been: COPD (chronic obstructive pulmonary disease), 245%; cirrhosis of the liver, 115%; heart disease, 67%; cancer, 67%, diseases of the arteries, veins, and capillaries, 31%; and stroke, 14%. Significant decreases have been: tuberculosis, 96%; influenza and pneumonia, 70%; diseases o f early infancy, 57%; suicides, 26%;
28.1 26.9 18.9 15.5 15.2 11.6 8.3 8.3 2.6
31.0 21.3 16.7 11.3 5.4 10.6 4.7 12.2 6.1
25.3 23.1 26.6 9.2 3.7 11.4 5.3 12.2 22.5
19.8 26.2 26.6 8.6 4.8 14.4 6.2 10.0 45.9
21.4 26.7 19.1 7.2 4.4 15.6 8.8 11.2 71.1
362.0 369.0 356.8 292.5 216.7 162.8 149.2 139.8 120.3 97.4 101.9 108.0 104.0 90.9 89.0 21.3 37.4 40.5 30.2 49.6 30.9 37.3 31.3 70.3 102.5 29.5 31,0 37.5 47.0 53.1
1970 1960 1950 1940 1930
United States
31 1 -1 115 245 -26 -6 -26 -96
67 67 14 -57 -70 -44
% Change 1930-70
22.6 38.9 16.4 10.0 13.4 12.0 18.4 8.6 2.6
25.0 26.1 12.4 6.5 4.5 9.4 10.9 11.8 5.4
16,1 26.3 12.0 5.3 2.4 8.3 14.8 10,9 23.5
11.5 25.8 12.2 4.8 3.9 9.1 20.5 6.8 49,0
10,5 21.1 12.3 5.1 4.3 10.1 19.9 7.4 75.7
308.1 290.1 263.5 193.0 153.6 129.3 110.4 97.2 64.1 54.0 121.9 138.8 121.3 101.9 103.6 24.9 46.8 49.7 59.0 61.1 37.8 45.6 42.7 91.8 121.1 33.6 34.9 36.0 42.0 47.0
1970 1960 1950 1940 1930
Geor~a
115 84 33 96 211 18 -8 16 -97
100 139 18 -59 -69 -29
%Change 1930-70
Note: Diseases are grouped by ICDA codes: 8th Revision, 1970, 7th Revision, 1 9 6 0 ; 6 t h Revision, 1950; 5th Revision, 1940 4th (?) Revision, 1930. Sources: Vital Statistics of the United States, 1970, 1960, 1950 (NCHS/HEW). Mortality Statistics, 1930, 1940, 1950, 1960 (Census Bureau, Department of Commerce). Georgia Vital and Morbidity Statistics, 1970, 1950 (Biostatistics Services, Department of Public Health). Prepared by: Health Services Research and Statistics Section, Division of Physical Health, Georgia Department of Human Resources.
Diseases of the Heart Cancer Cerebrovascular Disease Diseases of Early Infancy Influenza and Pneumonia AllOther Accidents Diseases of Arteries, Veins, and Capillaries Motor Vehicle Accidents Diabetes Mellitus Cirrhosis of Liver COPD Suicides Homicides Congenital Anomalies Tuberculosis
Cause
Death rates per 100,000 population for selected leading causes of death, Georgia and the United States, 1930, 1940, 1950, 1960, and 1970
TABLE [II
g
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~o
re re
484
G.E.
ALAN
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and congenital anomalies, 26%. The shift in disease patterns shows decreasing death rates due to infectious diseases and increasing death rates due to chronic diseases. In Georgia, the changes are approximately the same as the United States', except for the magnitude of the changes (Table lII). Thus, increases have been documented for COPD, 211%; cancer, 139%; diseases of the arteries, veins, and capillaries, 115%; heart disease, 100%; cirrhosis of the liver, 96%; motor vehicle accidents, 84%; diabetes mellitus, 33%; strokes and suicides, 18%; and congenital anomalies, 16%. Significant decreases occurred for tuberculosis, 97%; influenza and pneumonia, 69%; diseases of early infancy, 59%; all accidents other than motor vehicle, 29%; and homicides, 8%.2 RATE PER I00,000 POPULATION 900-
A
800. 700.
CHRONIC DISEASES
li
600-
500-
/ ../~...-,
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II
400300"
200i00" 0
I
I
I
I
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1900 1910 1920 1930 1940 1950 1960 1970 Source: Marshall,C. L. and Pearson, D.: Dynamics of Health and Disease, AppletonCentury Ciofts, New York, N.Y., 1972, p. 131. Prepared by: Health Services Research and Statistics, Division of Phyisical Health, Department of Human Resources.
Fig. 3. Infectiousand chronic diseasedeath rates, United States, 1900-1970. The crossroads for infectious and chronic diseases occurred about 1925 (Figure 3). Collectively, deaths due to infectious diseases have declined from about 650 deaths per 100,000 population in 1900 to about 20 deaths per 100,000 population in 1970 (a decline of 96%). A major epidemic of influenza occurred in 1918, with the death rate mounting to 850 deaths per 100,000 people. Chronic diseases, on the other hand, collectively accounted for about
485
THE PURSUIT OF HEALTH
350 deaths per 100,000 people in 1900 and increased to about 690 deaths per 100,000 in 1970 (an increase of 97%). This disease transition - not unlike a demographic transition - represents a shift, in this instance, a shift in our disease patterns. The reason for this shift in disease patterns is apparent in a societal shift from an agrarian type of society to an industrialized type of society. The point is that the diseases which afflict a given segment of our culture at a specific point in time vary with the social and physical conditions characterizing that society. Thus, at the turn of the century, we emerged with our roots in a life style that was agricultural in nature; with the advent of industrialization, societal roots changed. Consequently, our disease patterns shifted.
CYCLE OF DISEASE PATTERNS INFECTIOUS DISEASE MODEL
/
AGRARIAN
CULTURAL
INFLUENCE
\ HIGH
FERTlUTY
e8 YEAR8 ANO OLDER -
HIGHMORTALITYOF
PRESCHOOL CHILDREN ALL DEATHS - 341k L E 8 8 THAN 5 YEARS OLD
21 yEARS AND UNDER -
MALNUTRITIONOFPRESCHOOL/ CHILD CONTRIBUTES TO: 1 - INFECTIOUQ DISEASE8 2 - PARASITIC PROOLEM8 (NO | P | C I P I r
TR|ATIlUlI'(|
9
Fig. 4
Our agrarian society has resulted in a cycle of events that is portrayed in the infectious disease model (Figure 4). The agricultural era in the United States reflected high fertility. The needs were basic: food, shelter, and clothing. Thus, in 1900, 52% of our population was under 20 years of age, and 3% was over 65. (This type of population pyramid is typical of developing countries today.) The results were devastating. Parasitic diseases, infectious diseases, and
486
ALAN
G.E.
DEVER
malnutrition, with no specific treatment, contributed to high infant and preschool mortality. In fact, 34% of all deaths occurred in the ages from birth to five. Because of high mortality in an agrarian culture, we noted high fertility as compensation to high mortality; additionally, large families were essential to harvesting food from the land.
CYCLE OF DISEASE PATTERNS CHRONIC DISEASE MODEL INDUSTRIALANDPOST-INDUSTRIALSOCIETY
\
LOWFERTILITY LIFESTYLES ! - SOCIETY 2 - L E I S U R E TIME 3 - AFFLUENCE 4 - CHANGING VALUES
05 YEARS AND OLDER
21 Y E A R S A N D U N D E R
MORTALIT- Y ALL DEATHS
51~ 05 YEARS ANt) OLDER
CHRONIC 1 2 3 4 5 e )" 8
-
DISEASES
/
CORONARY HEART DISEASE CANCER DRUG ABUSE ACCIDENTS HYPERTENSION-STROKE ALCOHOLISM DENTAL PATHOLOGY P R O B L E M S OF N E W B O R N I N F A N T
Fig. 5 Industrialization effected changes or shifts in our disease patterns. The cycle of diseases during this period in our society is demonstrated by the chronic disease model (Figure 5). Contemporary life, because of its changing values, can induce certain kinds of disease. Thus, deleterious social, physical, emotional, and environmental ways of life have resulted from affluence, changing values, and increased leisure time. This overall societal change provided low fertility: the population under 20 years decreased to 40%, and the population over 65 years increased to 8% (1970). Consequently, the diseases of an older age group began to plague the country. Increases in chronic diseases and an overall mortality level showed that 51% of all deaths
THE P U R S U I T OF H E A L T H
487
occurred in the age group older than 65. The big three - heart disease, cancer, and stroke - accounted for more than 60% of all deaths. The pursuit of health changes complexion, reflecting the dictates of an agrarian/industrial society and the infectious/chronic disease patterns, but impacts via health legislation have not withstood the rigors of time. Patterns of disease are now evident; our methods for changing disease patterns, however, seem to be elusive, since individual pleasures appear to outrank individual responsibilities in the never-ending search for decreased illness and disability and increased years of life expectancy.
H E A L T H CARE COSTS 3
The soaring health expenditures in the United States certainly relate to the increased pieces of health legislation and to the epidemic nature of our chronic diseases. One would think that if we spent more dollars on health care, this should impact on our disease rates. The reverse is true. As the costs for medical care have skyrocketed, so the rates of chronic diseases have been PER CAPITA DOLLAR EXPENDITURE SSO' SO0' 450' 400' 3S0" 300' 2S0, 200,
150' 100' SO' V 0 FISCAL YEAR
1 9 3 0 1 9 3 5 1 9 4 0 194S 1 9 5 0 1 9 5 5 1 9 6 0 196S 1 9 7 0 1 9 7 5
Fig. 6. Health expenditures in the United States, 1 9 3 0 - 1 9 7 5 , per capita.
488
G. E. ALAN
DEVER
soaring.4 This is illogical. It appears we are trying to be Humpty-Dumpty's men, who tried to put all the pieces together again; but, as we are well aware, the pieces could not be put back together. Per capita health expenditures rose from $29 in 1930 to $547 in 1975, a 1,786% increase (Figure 6), while at the same time chronic disease rates increased from 500 deaths per 100,000 population in 1930 to 690 deaths per 100,000 population in 1970 (a 38% increase). Additionally, the GNP expenditure for health increased 130%, from 3.6% in 1930 to 8.3% in 1975 (Figure 7). HEALTHEXPENDITURESIN THE UNITEDSTATES,1930-1975 PERCENT OF GROSS NATIONAL PRODUCT
PERCENT 10'
6' 4" 2"
FISCAL YEAR 1930 1935 1940 1945 1950 19S5 1960 1965 1970 197S
Source: 'Research and Statistics Note', DHEW Pub. No. (SSA) 76-11701, Note No. 2 0 - 1975. Prepared by: Health Services Research and Statistics Unit, Division of Physical Health, Department of Human Resources. Fig. 7. Healthexpenditures in the United States, 1930-1975, percent of
gross national product. A simple exponential projection of per capita health expenditures and GNP notes alarming trends for this country, s By 1980, projected expenditures could reach $658; 1985, $939; 1990, $1,340; 1995, $1,912; and by the year 2000 - $2,729. This projection neither accounts for an aging population nor the possibility of a National Health Insurance scheme. Imagine! In less than 25 years our per capita expenditures for health may be $2,729! Of course, this number does not apply to all people; therefore, many segments of our population will spend considerably more per year - perhaps upwards of$15,000 to $20,000.
489
THE PURSUIT OF HEALTH
The percentage of GNP for 1980 is projected to remain the same as in 1975, 8.3%; but in 1985, 1990, 1995, and 2000 the projections are, respectively, 9%, 9.9%, 10.8%, and 11.8%. Incredible to think that almost 12% of our GNP may be spent for health care for restorative and curative purposes. From the preceding discussion, 1 believe it is evident we will not find the answers in health legislation, for this apparently increases costs and does little to reduce disease rates. Therefore, with respect to the first question proposed, 'If the relationship of medical care to health is tenuous, then why do we have such a costly system', I believe it has been demonstrated that the dollar amount spent for health care in this country has nothing to do with health except to perpetuate ahealth care system that is responsive only to restorative and curative measures.
MARKETING PREVENTION
To promote the concept of prevention and demote the restorative and curative approaches, we must begin to market health. For instance, we could have a
BIOLOGY
ENVIRONMENT~-~-"-~ MODEL FOR HEALTH ~
I
I POLiCy ^.A, vs,s I
LIFE STYLE
Fig. 8
HEALTHCABE~
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CURATIVE I
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490
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slogan, 'Themes in Prevention', with the acronym, TIP. This could be used for promoting better health behavior. Thus, we could market a TIP on health behavior; for example, 'Exercise regularly to prevent heart disease.' In another publication, I have outlined an epidemiological model for health policy analysis, which may be used for marketing prevention (Figure 8) [3]. Four elements and several set components comprise this model. Environment, Human Biology, Life Style, and Health Care Organization are the major elements, and it appears this framework may be quite manageable in terms of marketing TIPs.
THE WAY WE THINK ABOUT HEALTH In the introduction of this paper, I proposed a second question: 'Do we think about health in the correct way?' Unequivocally, No! To demonstrate, I will describe scenarios of four individuals who were - or were not - in the pursuit of health.
Scenario I It was 6:30 p.m. and time for Jack, age 23, to leave to pick up his date. Meeting her at 7:00 p.m., they proceeded to a dance, where they enjoyed dancing, food, and drink. After the dance, Jack took his date home. One hour later, a piercing ring suddenly awakened the household of Jack's family. The message was clear. Jack had been killed in an automobile accident while en route from his girl-friend's house to his home. The death certificate recorded immediate cause of death, "substantial head and chest injuries due to a motor vehicle accident" (Figure 9). In addition, the ear speed was estimated at 70 m.p.h., resulting in Jack's loss of control of the car, thereby hitting a bridge abutment.
Reviewing Jack's behavior, we are able to determine the exact cause of his death. In actuality, Jack had been under extreme pressure from his parents to find a job. The party that night was to be a release from their subtle haranguing. At the party, he had fallen prey to the admonishments of his friends to 'chug-a-lug just one more'. After leaving his girl-friend, he became a victim to the lack of responsibility and inhibition which the excessive consumption of alcohol produces. He was also subject to the Marie Andretti syndrome - a sense of great power over an inanimate machine. Hence the high speed and lack of caution.
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THE PURSUIT OF HEALTH
493
In essence, the death certificate recording should have been (Figure 10): 1. 2.
Excessive alcohol intake Failure to use seat belt
3. 4.
Excessive speed Societal pressure
In other cases, physical environmental factors may be the cause; for example: I.
Road under construction
2.
Inclement weather
3.
Poor lighting
Scenario H Frances, a middie-aged female of 53, labored many years as a laboratory technician in a chemica~ industry. Her efforts were directed toward earning money for her daughter's education. The pressures were many. Her husband had died two years ago and she had never been able to adjust to that loss. She began to be very tired and ill and died within six months of the diagnosis: the death certificate reported pulmonary insufficiency due to carcinoma of the lung. Frances died from a disease called lung cancer, but let us review the probable causes of death. Because of pressures in the last year, she began to drink excessively, but this was also combined with almost 30 years of heavy cigarette smoking. Of course, the fact that her employment was in a chemical industry caused her to suffer from an occupational risk. Consequently, the causes of death should have been recorded as: 1. 2.
30 years of smoking Excessive intake of alcohol
3.
Employment - chemical industry hazard
Scenario III Mary Jo, 19 years of age, was picked up by an ambulance at her high-rise apartment. She had left home two weeks earlier because of the constant harassment of her family to complete her college education. During those two weeks, she had become introverted. When the ambulance arrived at the hospital, the young teenager was recorded as a "D.O.A."
494
G . E . ALAN D E V E R
- Dead on Arrival. The death certificate showed that the cause of death was "drug overdose, self-administered, took approximately 30 capsules."
Suicide is the disease, but the causes are many. In the case of Mary Jo, she became extremely depressed with her situation. Anxiety states occurred because of the social isolation she experienced. Because of home pressures and her inability to cope with a marked change in life style, she resorted to drugs. In actuality, the death certificate should have recorded the causes as: 1. 2. 3. 4. 5.
Depression Anxiety Social isolation Inability to cope with change Use of drugs Scenario I V
A top salesman in his company for the last five years, Walter, age 42, was beginning to feel he was sitting on top of the world. Two days before his annual vacation, Walter had to close a major business transaction that he had worked at for many long hours for several weeks. Unfortunately, the deal was never closed. Walter died from a heart attack while leaving his office at 7:30 p.m. that evening. The certificate of death recorded acute respiratory and circulatory collapse due to an acute myocardial infarction and hypertension.
Waiter's life style in the last five years, and even prior to his new business venture, was one he chose for himself. He weighed about 240 pounds, because his diet contained an imbalance between refined sugar and cholesterol intake. He smoked incessantly and, on many occasions, had too much alcohol. Certainly, his attitude of 'my job comes first, personal considerations are secondary' improved his chances for premature death. Thus, the exact causes that should have been recorded on his death certificate were: 1. 2. 3. 4. 5. 6.
Obesity Lack of exercise Diet - refined sugar]cholesterol intake Alcohol Excessive smoking Elevated blood pressure
THE PURSUIT OF HEALTH
495
Is this the pursuit of health? We are not thinking about health in the proper perspective. Death certificates code diseases - they do not code causes. Traditionally, we ask, what is the cause of death? Traditionally, we answer, heart attack, lung cancer, automobile accident, and so on. We should answer, lack of exercise, inadequate diet, smoking, excessive drinking, air poHution: depression, etc. Disease classifications should incorporate these changes, and the list of the top ten diseases should be the top ten causes. We are attacking the process after it has been completed, and in this vein we never expand our knowledge. More accurately, we do not think about health in the correct way.
SUMMARY
The pursuit of health has been attempted through many forms of health legislation, various financing methods which have increased expenditures for health, and several death-coding revisions of diseases rather than causes. From 1900 to the present, we have attempted various methods of overcoming our major health problems in this country. We have had disease control programs (grant-in-aid, Social Security Act); constr~ction and facility development programs (Hill-Burton); regional planning mixed with disease control programs (RMP); coordinated programs to overcome fragmentation (CHP); financial programs to overcome cost barriers to health care (Medicaid, Medicare); physician-medical audit and monitoring programs (PSRO); and f'mally, termination of previous programs to replace with a sub-state area delivery program (HSA). After all, the chronic diseases are now at epidemic proportions, the costs of medical care are soaring, the proportion of the Gross National Product (GNP) spent for medical care is increasing, and disease prevention is a concept with low visibility. This could quite easily be conceived as the end of medicine as we know it today - for the pursuit of health is a personal endeavor for which we are all responsible. I am convinced we have not learned our lessons yet, because history has demonstrated that things to not happen until there is a real concern among persons of influence, or that the time is ripe for social change. This is ironic. We live in a world of 'future shock', where rapid social change has become commonplace, but apparently this is not true in terms of health legislation that promotes positive health behavior. What is the future for health in this nation? Probably the most significant
496
G.E. ALAN DEVER
exercise that we must, and will, go through before we recognize that our illness p r o b l e m s c a n n o t find solutions in health legislation is National Health Insurance. By reducing the cost barriers to care, this in essence gives carte blanche to our destructive styles, modes, and ways o f life.
Office of Health Services Research and Statistics Division of Physical Health Georgia Department of Human Resources ACKNOWLEDGMENTS As with any endeavor, the contributions o f m a n y individuals are required to assure success. A p p r e c i a t i o n and recognition are warranted to the following: A n n e Caldwell and S c o t t Barton, w h o c o m p i l e d the statistical data, graphs, and charts; Charles P l u n k e t t , - w h o provided the statistical analyses on the projections; and J u d y Morris, w h o provided editorial assistance and also t y p e d the text. Certainly, the paper could n o t have been c o m p l e t e d w i t h o u t the skills and expertise o f these individuals.
NOTES I For example, the tuberculosis death rate in the U.S. for 1930 was 71.1 per 100,000 population, while in 1970 it had decreased to 2.6 per 100,000 population. 2 Some of these patterns, or rates, are noted differently in two U.S. publications: 'Mortality Trends for Leading Causes of Death, U.S., 1950-69', DHEW, NCHS, Series 20, No. 16, and 'Mortality Trends: Age, Color and Sex, U.S., 1950-69', DHEW, NCHS, Series 20, No. 15. There are two reasons for these differences. One, the U.S. publications covered a time period of 1950-69, while this document represents the time period of 1930-70. Two, the U.S. publications use age-adjusted data, while crude rates are presented in this publication. Despite these differences, however, there is very close agreement in the trends. 3 To apprise the reader of the confusion concerning health care expenditures versus health care prices and the effect of rising prices and expenditures in terms of constantgrowth dollars, I offer the following quote (Rashi Fein: 'Some Health Policy Issues: One Economist's View', Public Health Reports 90, No. 5 (1975, Sept. - Oct.), p. 388): "We often find references to the 'soaring costs of medical care.' Sometimes 'costs' mean prices and sometimes expenditures. Surely we know that we mean price when we say that the cost of sugar is going up. Yet, we mean expenditures when we say the costs of police protection are rising. When we turn to medical care, however, we are unclear about our meanings or - at best - leave the reader or listener unclear. This lack of precision contributes to confusion. We have enough disagreements about matters when we do understand each other, not to need the additional disagreements caused by the use of the same words to mean different things. "Together with this inaccuracy and confusion, growing out of it and supporting it, we fred the myth that the bulk of the increase that we have witnessed in total expenditures
THE P U R S U I T OF H E A L T H
497
is due to increases in health care prices and that few additional explanatory variables are required. Thus, one finds sentences such as: 'Largely as a result of inflation, from 1965 to 1972 alone the nation's health care expenditures rose from $39 billion to $83 billion.' This rise is termed a 'massive inflationary tide'. The fact of the matter is that the Social Security Administration estimates that 'about 52 percent of the $38.4 billion increase from fiscal year 1965 to fiscal year 1972 reflected the rise in prices, 10 percent ($3.8 billion) was the result of population growth, and the remaining 38 percent (14.7 billion) was attributable to grea,er utilization of services and the introduction of new medical techniques' (Cooper and Worthington: 'National Health Expenditures, 1929-72. Soc. Security Bull. 36: 3-20, Jan. 1973). In analyzing the increase in expenditures, it is surely necessary to take account of the fact that inflation alone leaves 48 percent of the increase unexplained." 4 There are those who will take issue with this statement, since we have almost eradicated most infectious diseases and certainly reduced some chronic diseases. I would say, however, the statement is accurate. 5 The exponential model, Y = ae bx, yielded a coefficient of determination of 0.97 (17 observations) for per capita health expenditures and a coefficient of determination of 0.91 (17 observations) for GNP. Four models were tested, with the exponential model yielding the best results. The other models were the linear equation, power curve, and logistic curve.
BIBLIOGRAPHY [ 1 ] Bergwall, D. F., et al.: Introduction to Health Planning. Information Resources Press, Washington, D.C., 1974. A comprehensive review of health legislation. [2] Carlson, R. J.: The End o f Medicine. John Wiley & Sons, N.Y., 1974. [3] Dever, G. E.A.: 'An Epidemiological Model for Health Policy Analysis', Soc/al Indicators Research 2 (1976), pp. 453-466. [4] Fuchs, V. R.: IYho Shall Live? Basic Books, Inc., New York, 1974. [5] Illich, Ivan D.: MedicalNemesis. Calder and Boyan, London, 1974. [6] Kass, L. R.: 'Regarding the End of Medicine and the Pursuit of Health', The Public Interest 40 (Summer 1975), pp. 11-42. [7] Reinke, W. A.: Health Planning: Qualitative Aspects and Quantitative Techniques. Waverly Press, Inc., Baltimore, Md., 1972. A comprehensive review of health legislation. [8] 'A National Program to Conquer Heart Disease, Cancer, and Stroke', U.S. Government Printing Office, President's Commission on Heart Disease, Cancer, and Stroke, Washington, D.C., 1964.
