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. Preventive Medicine: Mo-Ning from Labs to Laws In a series of messages to Congress, President Nixon has made it clear that preventive medicine is about to get a booster shot. The first inkling came on January 22 when, during his annual State of the Union address, he said: "I will propose new programs to encourage better preventive medicine, by attacking the causes of disease and injury, and by providing incentives to doctors to keep people well rather than just to treat them when they are sick:' A week later came The Budget Message, which included this statement: "During the current session, I will send a message to the Congress that will set out a national health strategy for the seventies and propose significant changes in the Federal role in the Nation's system of health care. This strategy will seek to expand preventive care, to train more doctors and other health personnel, and to achieve greater equity and efficiency in the deliv- ery of health services:" Congress to Advise and Consent: As he continued, and in the days and weeks that followed, President Nixon endorsed and recommended a vast range of health care reforms and innovations. Many are concepts that have long been advocated by practitioners of preventive medicine. Others are an extension of curative health services which are desperately needed. Now the full thrust of the President's call for "a new national health strategy" is on the record. It came on February 18, again in a message to Congress. Preventive medicine, so often the stepchild of our medical schools and programs, has been given top priority in planning the nation's health care system. Before this priority becomes law, however, Congress must act and, in acting, changes in the President's proposals are inevitable. Some of the proposals that warrant special consideration, both in Congress and by medical authorities generally, are restated here for future reference purposes.... Excerpts from President's Health Care _llessage "In most cases, our present medical system operates episodically-people come to it in moments of distress, when they require its most expensive services. Yet both the system and those it serves would be better off if less expensive services could be delivered on a more regular basis. "If more of our resources were invested in preventing sickness and accidents, fewer would have to be spent on costly cures. If we gave more attention to treating illness in its early stages, then we would be less troubled by acute disease. In short. we should build a true'health' system-and not a`sickness' system alone:' Delivery of Services: "In recent years, a new method for delivering health services has achieved growing respect. This new approach has two essential attributes. It brings together a comprehensive range of medical serv- ices in a single organization so that a patient is assurod of convenient access to all of them. And it provides ` 4

needed services for a fixed contract fee which is paid in advance by all subscribers. "Such an organization can have a variety of forms and names and sponsors. One of the strengths of this new concept, in fact, is its great flexibility. The general term which has been applied to all of these units is H. M.0.-Health Maintenance Organization:' Advantages of H.M.O.'s: "Under traditional systems, doctors and hospitals are paid, in effect, on a piece work basis. The more illnesses they treat, and the more service they render, the more their income rises. Th.is does not mean, of course, that they do any less than their very best to make people well. But it does mean that there is no economic incentive for them to concen- trate on keeping people healthy. "A fixed-price contract for comprehensive care reverses this illogical incentive. Under this arrangement, income grows not with the number of days a person is sick, but with the number of days he is well. Patients and practi- tioners alike are enthusiastic about this organizational concept. So is this Administration. That is why I am now making the following additional recommendations: 1) "We should require public and private health insur- ance plans to allow beneficiaries to use their plan to purchase membership in a Health Maintenance Organi- zation when one is available. 2) "To help new H.M.O's get started-an expensive and complicated task-we should establish a new $23- million program of planning grants to aid potential sponsors in both the private and public sector. 3) "We should provide additional support to help spon- sors raise the necessary capital, construct needed facili- ties, and sustain initial operating deficits until they achieve an enrollment which allows them to pay their own way. For this purpose, I propose a program of Federal loan guarantees which will enable private spon- sors to raise some $300-million in private loans during the first year of the program:" Blue Cross' , , , of rising big share ... hospital costs Blue Crosa ® Total ,50 . is 0 1 I w ,. t! ta tsw 1955 rhio tvBS liio tt7B0 D.ta- Health insurance Counc,l, Blue Crosa •65 '66 •67 •66 '6D•7o Dete: Deot. of Labor Business Week National Health Insurance: "In the last 20 years, the segment of our population owning health insurance has grown from 50% to 87%, and the portion of medical bills paid for by insurance has gone from 35% to 60%. But despite this impressive growth, there are still serious gaps in present health insurance coverage. "I am proposing that a National Health Insurance Stan- dards Act be adopted which will require employers to provide basic health insurance coverage for their em- ployees. In the past, we have taken similar actions to assure workers a minimum wage, to provide them with disability and retirement benefits and to set occupa- tional health and safety standards. Now we should go one step further and guarantee that all workers will receive adequate health insurance protection. "I am also proposing that a new family health insurance plan be established to meet the special needs of poor families, who would not be covered by the proposed National Health Insurance Standards Act.... Our pro- gram would also require the establishment in each state of special insurance pools which would offer insurance at reasonable group rates to people who did not qualify for other programs: the self-employed, for example, and poor risk individuals who often cannot get insurance:" Better Than Before: If there are loopholes yet to be filled, and there are, it is nonetheless true that benefits of the President's plan would be far greater than those now available. Apparently, the group to benefit most will be middle-class Americans, some 150-million em- ployees and their families, whose medical costs have out-distanced their ability to pay in recent years. Under the health-care package presented by the Presi- dent, all employers will be required to purchase private medical insurance. Employees would pay 35% of the cost of premiums until 1976; and 25% thereafter. Medi- caid was substantially altered by the new insurance plan, but Medicaire continues with few profound dif- ferences. For catastrophic illness, total payments can go as high as $50,000-far above most existing policies. Other provisions include all maternity care, with no "deductibles;' and well-child services, with coverage of childhood vaccinations and periodic checkups by pediatricians. Building froni Strength: In reviewing the President's proposals, our purpose has been to focus attention on those aspects most closely identified with preventive medicine. There are other elements, however, which deserve general approval, because they will help improve the existing health care system. These include: new grants to aid our financially-distressed medical schools; the providing of health personnel in rural and slum areas having few or no doctors; assistance for students from disadvantaged backgrounds to become health professionals; expansion of research on cancer and sickle cell anemia; and a 50% increase over 1971 levels in the training of allied health personnel. It is being said the President did not go far enough, and that he is promoting the insurance industry. It has also been said that he is offering "something for every- 5

one;' and wooing votes for 1972. Upon reflection, it seems to us, his intent has been to build from the strengths that now exist, while setting the stage for a continuing series of reforms. It is a comprehensive and financially responsible plan. Perhaps the President's own words are the best measure of its resolve.... The New Strategy: "The toughest question we face is not how much we should spend, but how we should spend it. It must be our goal not merely to finance a more expensive medical system, but to organize a more efficient one.... It does little good to increase the demand for care unless we also increase the supply. Helping more people pay for more care does little good unless more care is available. This axiom was ignored when Medicaid and Medicare were created-and the nation paid a high price for that error. The expectations of many beneficiaries were not met, and a severe inflation in medical costs was compounded. "It will not be easy for our nation to achieve this goal. It will be impossible to achieve it without a new sense of purpose and a new spirit of discipline .... Nineteen months ago I said that America's medical system faced a`massive crisis: Since that statement was made, that crisis has deepened. All of us must now join together in a common effort to meet this crisis-each doing his own part to mobilize more effectively the enormous potential of our health care system:' President Sends Noise Level Plan to Congress With Warning it's Time for Leaders to Listen After years of complacency by Federal officials, the case for effective noise abatement laws is about to get a full Congressional hearing, and a hopeful constituency of anti-noise groups is waiting impatiently to hear what happens. Fully aware of their anxieties and numbers, President Nixon submitted (2/8/71) his plan for new noise level standards, while telling Congress that U.S. citizens have "rightly become increasingly annoyed" by growing levels of noise which can "interrupt sleep, dis- turb communication, create stress, produce deafness and other adverse health effects'." Indeed, noise can do all this and more. But just how much more even the experts don't know with certainty, for extensive research is still needed. One prominent acoustical physicist has 'said: "Noise, like smog, is a slow agent of death. If it continues to increase for the next 30 years as it has for the past 30, it could become lethal'." Another scientist contends common household noise is likely to be the unsuspected cause of ailments that have a psychosomatic component. Most investigators now agree that prolonged exposure to any extreme noise- industrial, household, urban, music, etc.-will result in a definite hearing loss. Many also believe or suspect that a wide range of physiologic, emotional, and mental dam- age is directly related to noise levels-especially sudden, sharp noises. I $ Losses Crescendo, Too: Union officials in the U. S. have estimated that 60% of their workers are subjected to noise that exceeds an acceptable level. They also claim about $2-million annually is spent in workmen's compensation cases as a result of noise levels. Even more discomforting, however, is a newly available report from the World Health Organization. It estimates that more than $4-billion is being spent annually on acci- dents, worker inefficiency, lost work time and compen- sation -all because of industrial noise. The WHO report was cited by Congressman William F. Ryan at a recent noise abatement forum in New York City. Mr. Ryan had set the theme for the forum's conclu- sions in saying: "I insist that concern for the cost of preventing and reducing noise be replaced by the reali- zation that it costs less to control noise than to endure noise:" Setting New Standards: If and when enacted, the plan now before Congress will authorize the fledgling En- vironmental Protection Agency to (1) set standards for noise levels on transportation and construction equip- ment, and (2) require the labeling of consumer products to indicate their noise characteristics. The new stan- dards would apply to equipment used in interstate commerce, which means that Federal limitations will be in effect even if local and state laws are not. The labeling requirement, on the other hand, permits con- sumers to make their selections on a basis that will encourage the development and marketing of quieter products. No Noise Level for Lawmakers: Despite mounting pub- lic pressures for strong anti-noise laws, the President's plan is expected to clash with other programs and other priorities. No time was wasted, for example, in noting the Administration is also seeking more money for the SST, which produces sideline noise greater than Federal levels set for subsonic commercial jets. To date, moreover, the only Congressional attempt to define "acceptable" noise levels was the Walsh-Healy Act of 1968. It finally established a maximum decibel level of 90 for industrial settings. At this level, you have to shout to be heard. White House calls for a still lower range may not fall on deaf ears. But they will bring a predictable discord into the coming decibels debate- probably beginning at the 90-plus level. A Definition of Decibels: Physicians, engineers, and acoustical physicists measure sound in decibels. Ac- cording to Medical World News, a decibel represents the smallest difference of loudness that can ordinarily be detected by the human ear between the loudness of two sounds. The same medical journal also points out: * "Conversation in a relatively quiet setting ranges around 60 decibels, and the roar of traffic or sounds of factory machinery are typically at about 80 decibels. Anything above 80 is likely to be uncomfortable. At 90 or above, the experts start worrying about effects on health:" o"One common household appliance, the food blender, emits 93 decibels, and a subway train screeching around 6

a curved track goes up to 95. The motorcyclist revving up his bike generates 110 decibels, and a jet plane taking off will assault unprotected ears with 150. Some other decibel levels of everyday noisemakers include: garbage disposal units, 80; rivet.ing guns, 110; textile looms, 106; power lawnmower, 96; farm tractor, 98; and a news- paper printing press, 97:' •"The lowest audible sound is defined as one decibel. Louder sounds are measured on a logarithmic scale ac- cording to the power with which the sound assaults-or tickles-the ear. Thus, a 20-decibel sound is 10 times as loud as one of 10 decibels, and 80 decibels is a million times louder than 20. Surprisingly, a dropped pin, the proverbial softest sound, actually can reach several decibels, especially when it lands on a library flooi?' Health Scares (cont.) most forms, metal or vapor, and in organic and inorganic compounds. Its major industrial use is in making chlo- rine and lye, and it is also used in dental fillings, most paints, batteries, and in sprays to kill fungus-to name but a few outlets. No one knows the threshold level for mercury poisoning. The FDA has set a limit of 0.5 parts per million as the maximum permissible amount in food- stuffs. As a guideline for safety, even this limitation is not absolutely reliable. Until new legislation arrives, and more is learned about the sources of mercury contami- nation, court injunctions and stiff penalties for all con- tributors to air and water pollution will continue to be the best kind of prevention. Fending for Food: Legislative solutions to the food- additive controversy are likely to be long in coming, but new FDA actions are expected soon. Caution is required, because the issues are highly complicated, essential research is lacking, and experts frequently disagree over available data and the standards to apply. It is against this background that Jean Mayer, professor of nutrition at Harvard, recently wrote: "After the recent spate of headlines on the inherent dangers of additives such as cyclamates and antibiotics, one can almost understand the suspicion voiced by some that there is a massive plot afoot to poison the popula- tion of the United States. Obviously, such is not the case; We must remember that our food supply today is actually much safer than it was in the past when spoil- age and microbe infestation exposed the public to the constant threat of gastroenteritis, not to mention typhoid, cholera, tuberculosis, and a variety of other food-borne diseases:' Malnutrition, moreover, is recognized as a far more urgent problem. Almost half of the world's 3.6-billion people are said to be undernourished, and it is estimated that 10,000 die every day of starvation. Population control'is seen as one answer. Among many other often 'cited measures are aid (financial and technological) to under-developed nations, and the "Green Revolution"- an effort by agricultural scientists to increase world food production with new high-yield seeds, chemicals, and new farming methods. WE MAY BE ON THE WAY TO ZPG 5.0 4.5 4.0 3.0 2.5 2.0 Births 1920 1930 1940 1950 C-3 proj®ctions 1970 1980 Fortune Population Growth Projections: Census Bureau records charted above show possible future annual birth rates. "C" assumes U. S. families will average 2.8 children each; "D"projects 2.5; and ZPG only 2.1. Defusing the Population Bomb: What must be the best indication to date that Congress is really serious about the population growth issue came last December. It was titled The Family Planning Services and Population Research Bill, approved by both houses, and signed into law by President Nixon. Passage of this act authorized $382-million in 1971-73 for services, research, training, and educational material, while requiring that a five-year program be submitted to Congress within six months. Other factors which seem to mitigate the awesome over-population claims of recent years are also at hand. In its February issue, Fortune magazine reported: "A number of reasons have been advanced for the trend to smaller families. One is the pill. Another is the rising cost of properly raising and educating children. Beyond these, concerns about pollution, the environment, and the possible overcrowding of parts of the U.S. have to- gether somewhat tarnished the ideal of the immediate y1I