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nade it evident to us that physicians are reported y is more aware of the pertension. 3art disease was obtained : surveys. We observed vn free will actually had a persons who had never +ed similar findings but Our explanation is that related to medical asual capacity for rability to atherogenic ie cardiac patient, many of etiology need to be reexam- ersuasivefindings are being onged emotional stress, il mobility, and stressful involved in the pathogenesis far from clear and further e 653 Statement of Bernice C. Sachs, M.D.; Seattle, Washington After graduating from the University of Michigan Medical School "with distinction" in 1942, I took my intern- ship and post-graduate training at Michael Reese Hospital and Medical Center, and the Institute for Pyschosomatic and Psychiatric Research and Training, in Chicago, 1942-1949. Since that time, I have practiced psychiatry and psychosomatic medicine in a pre-paid Cooperative Plan which delivers comprehensive medical care to Seattle, Washington, and its environs. The Cooperative has 325 board-certified or board- eligible physicians who serve a population of 285,000, and it owns and operates two hospitals comprisina 450 beds. It is one of the first, and one of the largest, Health Maintenance Organizations (H:0) in the United States. I am President of the Academy of Psychosomatic Medicine, Trustee of the King County Medical Society assigned to the Drug Abuse and Alcoholism Committee, member of The Cooperative's Cancer Committee, Board Member of the Education and Research Foundation of the American Societv of Clinical Hypnosis, and Chairman of its Research and Grants Committee. I am past Chief of The Cooperative's Mental Health Service (1970-72, 1976-78), past President of the American Medical Women's Association, American Society of Clinical Hypnosis, American Psychiatric Association's Seattle Branch, and past

654 Chairman of the Cooperative's Alcohol and Drug Abuse Committee. In my medical practice, I have seen thousands of patients and given talks to and met with thousands of persons who shared my interests in community health and welfare. My curriculum vitae and bibliography are attached. The large body of psychiatric experience demonstrates that disease is a problem of the individual as a whole, and not an autonomous disturbance localized in a particular organ. The extraordinary complexity of the activities and reactions of man leads physicians trying to understand and classify them to talk about the mind and body as if they were distinct and separate entitites. The emphasis on specialization in medical practice of past decades increases this dichotomy of thinking. . ~ But, in every area, including smoking and health, we are dealing with a whole entity; an interrelated complex of underlying, constitutionally determined, physical and psychic patterns of behavior. Since causes of reaction are complex, so the causes of disease are multiple. The 1964 Surgeon General's Advisory Committee on smoking and health recognized this basic proposition: "All members," the Report notes, "shared . a common conception of the multiple etiology of biological processes" and "all were thoroughly aware of the fact that there are series of events in occurrences and developments 2 0 in these fields, and of many actions and c What we carr association--even if real--is whether bott statistically associe hidden factors such z differences which thE Accumulated data sugc is so. In a presider Society 20 years ago, cancer: "There is a mind is a power capal enhance or inhibit ti In a state: Congress was conside: packages and adverti of cigarettes could ness, rather than de time, it was long si officials had brande health. As I predi of warning statement particularly girls,

and Drug Abuse Committee. housands of patients ;ands of persons who _th and welfare. My : attached. -ic experience demonstrates ividual as a whole, and zed in a particular organ. activities and reactions 3erstand and classify as if they were distinct s on specialization in reases this dichotomy of :ing smoking and health, an interrelated complex 2rmined, physical and ire complex, so the a 1964 Surgeon General's ealth recognized this the Report notes, "shared etiology of biological aware of the fact that rences and developments .. 655 in these fields, and that the end results are the net effect of many actions and counteractions." What we cannot tell from simple statistical association--even if it is assumed that the association is real--is whether both smoking and the various diseases statistically associated with it are correlated with other hidden factors such as psychological and physiological differences which themselves exert the true causal force. Accumulated data suggest a number of reasons to believe this is so. In a presidential address to the American Cancer Society 20 years ago, Dr. Eugene Pendergass stated about cancer: "There is a distinct possibility that within one's mind is a power capable of exerting forces which can either enhance or inhibit the process of this disease." . In a statement to the Congress in 1965, when the Congress was considering proposed warnings for cigarette packages and advertising, I warned that admonitory labeling of cigarettes could well fan the fire of youthful rebellious- ness, rather than deter smoking by teenagers. At that time, it was long since well-known that public health officials had branded cigarettes smoking as deleterious to health. As I predicted, surveys following the adoption of warning statements showed a rise in smoking by children, particularly girls, fast catching up with boys. Yet, a high 3

656 percentage of youngsters believe that cigarette smoking can cause lung cancer, emphysema, heart disease. Relatively more smoking students in 1971 than 1964 believe that smoking impairs health. Still, it was reported that despite the anti-smoking campaigns and programs, approximately 1-1/4- 1-1/2 million adolescents were starting smoking each year. Education to the health hazards of smoking didn't deter them. Scare techniques and preaching didn't deter them. They smoke anyway. Teenagers rebel against restriction. Teenagers feel that they should be able to do the things they want to do when adults tell them they can't do them. Teenagers want to control what happens to them. Consider teenage-sex activity, which adolescents fully know can produce venereal disease, and pri~gnancy, with high rates of premature deliveries and congenital anomalies. Availability of contraceptive measures to teenagers, costly and extensive educational efforts about birth control, have not decreased the number of teenage pregnancies. These pregnancies have increased. HR 4957 purports to find the present Federal, State and private initiatives insufficient to warn the American public about the dangers of smoking. This is not the fact. The fact is that awareness does not alter behavior after a point. The people reached by warnings about smoking have been reached. The others are not going to change their behavior, whatever Differer among them: • 1) To c 2) For 3) -To r 4) As a in t also of a 5) To c, If we lo, that I have had a: years--campaigns ai teenage pregnancie_ abort drinking (30' have alcohol-relatc and birth control c teenage pregnancie: is more drug-takinc populations than ec Committee on Drug I Chairman, has addre of physicians, as w

:igarette smoking can ease. Relatively more eve that smoking : that despite the )proximately 1-1/4- I smoking each year. :ds of smoking didn't :hing didn't deter .bel.against '- should be able to do tell them they can't st happens to them. 7,-which adolescents a, and pregnancy, s and congenital ive.measures to ional efforts about number of teenage ncreased_ ~_}.' - present Federal, ient to warn the smoking. This is not does not alter behavior warnings about smoking : going to change their 657 behavior, whatever the warning. Different people smoke for different reasons, among them: ' 1) To cope with feelings of anxiety and stress; 2) For pleasurable relaxation; 3) To raise energy levels; 4) As a "suicidal act," not only consciously - in the hope that health will be impaired, but also unconsciously as an inner-directing of aggressive behavior; 5) To control hostility and anger. If we look at initiatives conveying health warnings that I have had a lot of experience with in the past fifty years--campaigns about alcohol, pill-popping, drugs, smoking, teenage pregnancies--we find that law (prohibition) did not abort drinking (30% or more of hospitalized patients today have alcohol-related problems); availability of contraceptives and birth control education to children did not decrease teenage pregnancies; numbers of people continue to smoke; there is more drug-taking throughout the adult and adolescent populations than ever before. The King County Medical Society Committee on Drug Abuse & Alcoholism, of which I am past Chairman, has addressed itself to campaigns for the education of physicians, as well as the general population. There has 5

been no discernible change in behavior, unless it is in the direction of increasing tension-relieving behavior. The way to learn about people's attitudes and reactions is to work closely, as I have, with thousands of patients. I have not seen a patient since the mid-fifties who was not aware of the assertion that they should not smoke. This information had even filtered down to children, who learned to tell their parents not to smoke in the belief that parental smoking is harmful to their parents and themselves. But of course I see every day patients with cancer, and lung and heart disease, who have never smoked. Medical "preventive" health is a personal problem. People are apprised of the dangers of smoking, but they have their own personal reasons for not giving up smoking. Dire medical advice coming from legislative bodies is not effective advice. Smoking is a personal medical matter, not a legal issue. Stringent warnings have a negative effect. As The Smoking Digest, U.S. Dept. HEW, NCI, 1977 stated: "Fear-arousing messages actually increase smoking among the particularly vulnerable people and those with low self- esteem. Such messages tend to make the smoker defensive and harden his attitude and resistence. People who smoke to reduce anxiety z strong health tY fear." If inec it must address ways to deal wit report stated: "Stres smoki that situa begin conti of ci The Report furth "Exist stres and s proba degre From the researc, conclude that th ~ay be the stres. process or produ, It is i stress in the po: that engender gu.

or, unless it is in the _eving behavior. )ple's attitudes and iave, with thousands of = since the mid-fifties :hat they should not :ltered down to children, Dt-to smoke in the nful to their parents day patients with cancer, a never smoked. th is a personal problem. of smoking, but they have giving up smoking. Dire ive bodies is not effective cal matter, not a legal . negative effect. As NCI, 1977 stated: :crease smoking among and those with low self- the smoker defensive and People who smoke to 659 reduce anxiety also often smoke more after receiving a strong health threat in order to reduce their anxiety and fear." If medicine is to teach "preventive" medicine, it must address itself to finding and promoting adaptive ways to deal with stress. The 1964 Surgeon General's report stated: "Stress seems to be related to smoking and there is evidence that the experience of stressful situations contributes to the beginning of the habit, to its continuation and to the numbers of cigarettes cansumed." The Report further stated: "Existence of an association between stress and tensions on the one.hand and smoking behavior on the other can probably be accepted with a reasonable degree of confidence." From the research material in the smoking field we could conclude that the same stress that stimulates heavy smoking may be the stress that precipitates the complex cancer process or produces the coronary-prone individual. It is up to the medical profession to reduce stress in the population -- and not by fiats or mandates that engender guilt, anger and resistance, which in turn 7

660 create more stress and can promote the very diseases they are trying to prevent. It is costly and inappropriate for Congress to busy itself in this area. 'Good health" and "good behavior" cannot be legislated. It is physicians who should and do address themselves to the e~ rson -- to the person's constitutional diathesis and self-motivation, and to techniques for reducing the person's stress with its deleterious physiological reactions and maladaptive responses. _ /'d,_,_'-, C /,~, .Z) 7-, - C~/~ /.2 , i ,~A s Z CURRICULUM VITAE and BIBLIOGRAP: 1918 - Born September 16, Passa4 1939 - B.A. Cum Laude, Universit 1942 - :f.D. "with distinction," 194?-1949 - Internship and post- Michael Reese Hospi; for Psychosomatic ar Michael Reese Haspit 1949 - Practice of Psychiatry ar Cooperative of Puget Sour Health Medical Center 19; HOSPITAL STAFF: Group Health Medical Cent St. Francis Xavier Cabrir PROFESSIONAL SOCIETIES: American Medical Associatic Washington State Medical Sc King Task Force on Nationa'. King County Medical Sc County Medical Society Mental Health Committe Chairman, Alcohol and Trustee 1982-84 and De Fellow of Academy of Psychc Executive Council 197: President-Elect 1981 - Washington Academy of Clini Honorary President 19; Society for Clinical and Ea

=e for Congress to busy 3 "good behavior" cannot :zould and do address son's constitutional techniques for reducing us physiological 661 BERNICE COHEN SACHS, M.D. MENTAL HEALTH SERVICE GROUP HEALTH COOPERATIVE OF PUGET SOUND 200 - 15th Avenue East (206)-326-7050 Seattle, Washington 98102 CURRICULUM VITAE and BIBLIOGRAPHY 1982 1918 - Born September 16, Passaic, New Jersey 1939 - B.A. Cum Laude, University of Michigan 1942 - M.D. "with distinction," University of Michigan Medical School 1942-1949 - Internship and post-graduate medical training in Chicago at Michael Reese Hospital and Medical Center and the Institute for Psychosomatic and Psychiatric Research and Training at Michael Reese Hospital and Medical Center. 1949 - Practice of Psychiatry and Psychosomatic Medicine at Group Health Cooperative of Puget Sound; Chief of Mental Health Service, Group Health Medical Center 1970-72, 1976-78 i HOSPITAL STAFF: Group Health Medical Center St. Francis Xavier Cabrini Psychiatry Service PROFESSIONAL SOCIETIES: American Medical Association Washington State Medical Society Task Force on National Health Insurance King County Medical Society Alternate Delegate King County Medical Society, Media Relations Committee 1973-76 Mental Health Committee 1970-73 Chairman, Alcohol and Drug Abuse 1974-81 Trustee 1982-84 and Delegate to the Washington State Medical Association Fellow of Academy of Psychosomatic Medicine, Credentials Cocm., 1950 Executive Council 1973-76, Secretary 1976-77, Executive Council 1978-81, President-Elect 1981 - President 1982 Washington Academy of Clinical Hypnosis, President 1970-74; 1973-77 Honorary President 1978- Society for Clinical and Experimental Hypnosis (Fellow) Jv -

Pan-American Medical Women's Alliance Corresponding Secretary 1960-62 Vice-President of USA 1962-64 Medical Women's International Association Puget Sound Association of Phi Beta Kappa A.M.W.A. Sponsor of the BERNICE C. SACHS JUNIOR BRANCH OF UNIVERSITY OF WASHINGTON SCHOOL OF MEDICINE Women's Medical College of Pennsylvania (Board Member, ex-officio) American Association for the Advancement of Science Aerospace Medical Association American Psychiatric Association - President-Elect, Seattle Chapter 1975-76 President, Seattle Chapter 1976-77 Council of Medical Administrators International Platform Association American Geriatrics Society, Founding Fellow, West Division, 1973 American Psychosomatic Society American Psychiatric Association - Observer - Consultant to Council of International Affairs 1978-79 Observer - Consultant 1978-79 Committee on Professional Liability 1980-86 " Loss Control Review 1980-86 CO}@IL'NI1Y ORCANIZP Board of Dire Governor's Ad Group Health NATIONAL ORGANIZAT Soroptomist Women's Unive American Asso National Reso-. Associat Women's Confe: Mortar Board HONORS: 1955 - Gold K. 1964 - "Berni, tion" c 1965 - Theta Specia: 1966 - "Medic: "In rec commun= 1967 - ",[yrtle contir 1969 - Honorar "beca of 1ez Univer 1975 - "SALUTE "For ar Industr 1979 - Elizabe to medi 1980 - Preside "In sir. America