AMERICAN JOURNAL OF VolumeI67,
Etabise 1911
Noveber197 67 Number Volume~~~~
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To the Victim Belong the Flaws EDITOR Alfred Yankauer, MD, MPH EDITORIAL BOARD Michel A. Ibrahim, MD, PhD (1977) Chairperson Rashi Fein, PhD (1978) Ruth B. Galanter, MCP (1977) H. Jack Geiger, MD, MSciHyg (1978) George E. Hardy, Jr., MD, MPH (1978) C. C. Johnson, Jr., MSCE (1977) George M. Owen, MD (1979) Doris Roberts, PhD, MPH (1977) Pauline 0. Roberts, MD, MPH (1979) Ruth Roemer, JD (1978) Sam Shapiro (1979) Robert Sigmond (1979) Jeannette J. Simmons, MPH, DSc (1978) David H. Wegman, MD, MSOH (1979) Robert J. Weiss, MD (1977) STAFF
William H. McBeath, MD, MPH Executive DirectorlManaging Editor Allen J. Seeber Director of Publications Doyne Bailey Assistant Managing Editor Deborah Watkins Production Editor CONTRIBUTING EDITORS George Rosen, MD, PhD Public Health: Then and Now William J. Curran, JD, SMHyg Public Health and the Lawt Jean Conelley Book Section
There is a distressing tendency these days to focus attention on the victims of problems rather than on the problems themselves. Focusing on the victim is easy and convenient. In the first place, something is obviously wrong and it seems necessary to assign responsibility; the victim is particularly vulnerable, helpless, and unlikely to fight back. In the second place, focusing on the victim conveniently diverts attention from other possible causes of the problem, such as conditions of life, work, or housing or the inefficient operations of an institution. The outcome of such misdirected attention thus leads to all-out efforts to change the behavior of the victims rather than the circumstances responsible for the problem. There are many examples of this tendency. In California, recently an appellate judge reversed a rape conviction because of a procedural error at the trial and observed quite gratuitously in his judicial opinion that any woman who hitch-hikes is inviting sexual advances (i.e., if she is raped it's her own fault, not the fault of the rapist). * Other examples abound: * workers exposed to carcinogens in the workplace "must'" be taught not to smoke so as to reduce their risk; * hypertensives who live under perpetually stressful conditions "must" be taught to relax; * children constantly exposed to the lures of junk food "must" be taught to eat the right food; * mothers of children with lead poisoning from the peeling paint they have ingested "must" be taught to stop their children from eating paint; * people who take tranquilizers because their physicians prescribe them are seen as "drug abusers"; * people who arrive at an outpatient department on time and leave in disgust four hours later because they have not been seen are "appointment breakers" and "must" be taught to keep their appointments. Neighborhood health centers, Medicaid financing, and medical school outreach affiliations were created to make up for the failures of private and public health services to reach many of those in need of health care. But the new programs have not solved the problems. However, instead of replacing inadequate programs with programs better designed to get the job done, the health care industry and its regulators in government have chosen to emphasize the task of changing the individual's lifestyle. Of course individual behavior influences health-and of course individuals can control some of their behavior. But many other behaviors and the problems with which they interlace are simply beyond the realm of individual action or can be far more effectively tackled by societal or institutional action. The current issue of the Journal contains an example. Hertz and Stamps, after reviewing critically the catalogue of blaming the appointment-breakers, examined the experience of their own institution critically.2 They concluded, perhaps too politely, that "most of the traditional approaches to the problem of appointment-keeping behavior have ignored . *The state Court of Appeal subsequently substituted less derogatory language for that of the appellate judge while leaving the reversal and basic implication unchanged. I
AJPH November 1977, Vol. 67, No. 11
1 025
EDITORIALS
organizational factors that might be implicated." Their report demonstrates what an institution serving the underprivileged can do to adapt its own behavior to the needs of those it serves. The versatility of science astounds: using the same methods and the same language, it can help solve problems or it can shield problems from solution. For years, researchers have happily studied and described the ethnic, age, or sex groups that are the most or least reliable in keeping appointments instead of asking what makes an appointment likely to be kept. By asking better questions, Hertz and Stamps found out that the institution's behavior had a lot to do with the problem. The same may be said of many other current health problems. Thus, in the general effort to reduce the escalation of health care costs, providers and government are quick to blame patients for overuse of medical services or prescription drugs. There seems to be less enthusiasm for looking seriously at price-gouging, monopoly control, drug pushing by drug companies, fainthearted regulation, agency capture by regulatees, and other "organizational factors which may be implicated" in the problem of health care costs. Whether or not the victim is actually blamed or merely identified as having the "relevant" age, sex, or ethnicity
makes very little difference. In either case, the practical effect of focusing attention on the victim instead of the problem is to permit health care institutions, government, and the people in charge to evade responsibility for their own actions. There is certainly nothing wrong with efforts of health care providers and institutions to help individuals to make the best use of their own lives. Yet clearly those of us who work in institutions that deliver or regulate health care must also continue to pressure those institutions to look critically at themselves and shoulder those responsibilities which are rightly theirs rather than those of their clients.
RUTH B. GALANTER, MCP Address reprint requests to Ruth B. Galanter, MCP, Editor, Health Law Newsletter, National Health Law Program, 2401 Main Street, Santa Monica, CA 90405. Ms. Galanter is a member of the Journal Editorial Board.
REFERENCES 1. "Court Alters Controversial Rape Decision". Los Angeles Times, Aug. 9, 1977, Pt. II, P. 1. 2. Hertz, Philip, and Stamps, Paula L. Appointment-keeping behavior re-evaluated. Am. J. Public Health 67:1033-1036, 1977.
Strategy for Prevention Half a century ago, the Massachusetts Department of Public Health pioneered in tuberculosis and cancer control. Cautiously but unmistakably, as indicated in Dr. Fielding's commentary in this issue, the Department is now moving into the new areas of prevention discovered in the second epi-
demiologic revolution.I A variety of approaches have been taken by the Department. Among the most important is the proposal to collect and disseminate cost-benefit data for preventive measures, an approach that health officers used effectively in the past to gain public support and public funds for the control of infectious diseases. The suggestion that insurance premiums take self-imposed health risks into account is favored, but the difficulty in identifying risks is recognized, as well as the possibility that national health insurance will reverse any progress made in this direction. This need not be the case, however; the financing of a national health care program by a variety of tax funds should properly include the revenues from substantial taxation of cigarettes and alcohol. Recommendations are made in the article for economic incentives to hospitals to develop preventive programs; for an educational program for primary care practitioners so they may explain health risks to their patients; and for giving prevention a high priority in the plans of the Health Systems Agencies. Although these are attractive proposals, they will 1026
be difficult to achieve without the availability of substantial funds earmarked for specific preventive programs. Such funds will not be forthcoming in the absence of extensive public education. The Massachusetts Department of Public Health not only favors a strengthened health education curriculum in the schools, but cosponsors demonstration projects for prevention with various civic groups and is involved in cooperative agreements with radio and television stations for programs on smoking, alcohol and other health risks. These are elements of what should become a manypronged, sustained and vigorous educational campaign by all health departments-local, state and federal-to inform the public of the findings of our epidemiologic colleagues. Without the support of an informed public, progress in the new areas of public health will be difficult indeed. Dr. Fielding favors adoption of a taxation policy that provides disincentives for use of harmful products and provides funds to promote their non-use, citing bills taxing alcohol and cigarettes that have been introduced into the Massachusetts State Legislature. His overall view is a realistic one, stating that "in order for these strategies to work, we need to build a consensus for change that includes the use of legislative and financial levers." This is a far different emphasis than that of the currently fashionable "life-style" approach which reduces behavior to the individual level and, by ignoring the social environment which creates life-styles, avoids AJPH November 1977, Vol. 67, No. 11
Etabise 1911
Noveber197 67 Number Volume~~~~
_
To the Victim Belong the Flaws EDITOR Alfred Yankauer, MD, MPH EDITORIAL BOARD Michel A. Ibrahim, MD, PhD (1977) Chairperson Rashi Fein, PhD (1978) Ruth B. Galanter, MCP (1977) H. Jack Geiger, MD, MSciHyg (1978) George E. Hardy, Jr., MD, MPH (1978) C. C. Johnson, Jr., MSCE (1977) George M. Owen, MD (1979) Doris Roberts, PhD, MPH (1977) Pauline 0. Roberts, MD, MPH (1979) Ruth Roemer, JD (1978) Sam Shapiro (1979) Robert Sigmond (1979) Jeannette J. Simmons, MPH, DSc (1978) David H. Wegman, MD, MSOH (1979) Robert J. Weiss, MD (1977) STAFF
William H. McBeath, MD, MPH Executive DirectorlManaging Editor Allen J. Seeber Director of Publications Doyne Bailey Assistant Managing Editor Deborah Watkins Production Editor CONTRIBUTING EDITORS George Rosen, MD, PhD Public Health: Then and Now William J. Curran, JD, SMHyg Public Health and the Lawt Jean Conelley Book Section
There is a distressing tendency these days to focus attention on the victims of problems rather than on the problems themselves. Focusing on the victim is easy and convenient. In the first place, something is obviously wrong and it seems necessary to assign responsibility; the victim is particularly vulnerable, helpless, and unlikely to fight back. In the second place, focusing on the victim conveniently diverts attention from other possible causes of the problem, such as conditions of life, work, or housing or the inefficient operations of an institution. The outcome of such misdirected attention thus leads to all-out efforts to change the behavior of the victims rather than the circumstances responsible for the problem. There are many examples of this tendency. In California, recently an appellate judge reversed a rape conviction because of a procedural error at the trial and observed quite gratuitously in his judicial opinion that any woman who hitch-hikes is inviting sexual advances (i.e., if she is raped it's her own fault, not the fault of the rapist). * Other examples abound: * workers exposed to carcinogens in the workplace "must'" be taught not to smoke so as to reduce their risk; * hypertensives who live under perpetually stressful conditions "must" be taught to relax; * children constantly exposed to the lures of junk food "must" be taught to eat the right food; * mothers of children with lead poisoning from the peeling paint they have ingested "must" be taught to stop their children from eating paint; * people who take tranquilizers because their physicians prescribe them are seen as "drug abusers"; * people who arrive at an outpatient department on time and leave in disgust four hours later because they have not been seen are "appointment breakers" and "must" be taught to keep their appointments. Neighborhood health centers, Medicaid financing, and medical school outreach affiliations were created to make up for the failures of private and public health services to reach many of those in need of health care. But the new programs have not solved the problems. However, instead of replacing inadequate programs with programs better designed to get the job done, the health care industry and its regulators in government have chosen to emphasize the task of changing the individual's lifestyle. Of course individual behavior influences health-and of course individuals can control some of their behavior. But many other behaviors and the problems with which they interlace are simply beyond the realm of individual action or can be far more effectively tackled by societal or institutional action. The current issue of the Journal contains an example. Hertz and Stamps, after reviewing critically the catalogue of blaming the appointment-breakers, examined the experience of their own institution critically.2 They concluded, perhaps too politely, that "most of the traditional approaches to the problem of appointment-keeping behavior have ignored . *The state Court of Appeal subsequently substituted less derogatory language for that of the appellate judge while leaving the reversal and basic implication unchanged. I
AJPH November 1977, Vol. 67, No. 11
1 025
EDITORIALS
organizational factors that might be implicated." Their report demonstrates what an institution serving the underprivileged can do to adapt its own behavior to the needs of those it serves. The versatility of science astounds: using the same methods and the same language, it can help solve problems or it can shield problems from solution. For years, researchers have happily studied and described the ethnic, age, or sex groups that are the most or least reliable in keeping appointments instead of asking what makes an appointment likely to be kept. By asking better questions, Hertz and Stamps found out that the institution's behavior had a lot to do with the problem. The same may be said of many other current health problems. Thus, in the general effort to reduce the escalation of health care costs, providers and government are quick to blame patients for overuse of medical services or prescription drugs. There seems to be less enthusiasm for looking seriously at price-gouging, monopoly control, drug pushing by drug companies, fainthearted regulation, agency capture by regulatees, and other "organizational factors which may be implicated" in the problem of health care costs. Whether or not the victim is actually blamed or merely identified as having the "relevant" age, sex, or ethnicity
makes very little difference. In either case, the practical effect of focusing attention on the victim instead of the problem is to permit health care institutions, government, and the people in charge to evade responsibility for their own actions. There is certainly nothing wrong with efforts of health care providers and institutions to help individuals to make the best use of their own lives. Yet clearly those of us who work in institutions that deliver or regulate health care must also continue to pressure those institutions to look critically at themselves and shoulder those responsibilities which are rightly theirs rather than those of their clients.
RUTH B. GALANTER, MCP Address reprint requests to Ruth B. Galanter, MCP, Editor, Health Law Newsletter, National Health Law Program, 2401 Main Street, Santa Monica, CA 90405. Ms. Galanter is a member of the Journal Editorial Board.
REFERENCES 1. "Court Alters Controversial Rape Decision". Los Angeles Times, Aug. 9, 1977, Pt. II, P. 1. 2. Hertz, Philip, and Stamps, Paula L. Appointment-keeping behavior re-evaluated. Am. J. Public Health 67:1033-1036, 1977.
Strategy for Prevention Half a century ago, the Massachusetts Department of Public Health pioneered in tuberculosis and cancer control. Cautiously but unmistakably, as indicated in Dr. Fielding's commentary in this issue, the Department is now moving into the new areas of prevention discovered in the second epi-
demiologic revolution.I A variety of approaches have been taken by the Department. Among the most important is the proposal to collect and disseminate cost-benefit data for preventive measures, an approach that health officers used effectively in the past to gain public support and public funds for the control of infectious diseases. The suggestion that insurance premiums take self-imposed health risks into account is favored, but the difficulty in identifying risks is recognized, as well as the possibility that national health insurance will reverse any progress made in this direction. This need not be the case, however; the financing of a national health care program by a variety of tax funds should properly include the revenues from substantial taxation of cigarettes and alcohol. Recommendations are made in the article for economic incentives to hospitals to develop preventive programs; for an educational program for primary care practitioners so they may explain health risks to their patients; and for giving prevention a high priority in the plans of the Health Systems Agencies. Although these are attractive proposals, they will 1026
be difficult to achieve without the availability of substantial funds earmarked for specific preventive programs. Such funds will not be forthcoming in the absence of extensive public education. The Massachusetts Department of Public Health not only favors a strengthened health education curriculum in the schools, but cosponsors demonstration projects for prevention with various civic groups and is involved in cooperative agreements with radio and television stations for programs on smoking, alcohol and other health risks. These are elements of what should become a manypronged, sustained and vigorous educational campaign by all health departments-local, state and federal-to inform the public of the findings of our epidemiologic colleagues. Without the support of an informed public, progress in the new areas of public health will be difficult indeed. Dr. Fielding favors adoption of a taxation policy that provides disincentives for use of harmful products and provides funds to promote their non-use, citing bills taxing alcohol and cigarettes that have been introduced into the Massachusetts State Legislature. His overall view is a realistic one, stating that "in order for these strategies to work, we need to build a consensus for change that includes the use of legislative and financial levers." This is a far different emphasis than that of the currently fashionable "life-style" approach which reduces behavior to the individual level and, by ignoring the social environment which creates life-styles, avoids AJPH November 1977, Vol. 67, No. 11
