Setting Goals and Priorities by wos93944


									                                                    Setting Goals and Priorities
                                                     1984 Presidential Address
                                                           SUSAN S. ADDISS, MPH, MURS

     When I began, some months ago, to give thought to this                       into a dense thicket of excess hospital beds, from which we
Presidential Address, I had some difficulty dealing with the                      are still trying to extricate ourselves.
realization that the address would be delivered not quite one                           In the 1960s, our consciences brought us to press for
week after a national presidential election. I felt a nagging                     programs that would provide access to health care for groups
anxiety-that perhaps I should prepare two speeches in order                       that did not then have it-the poor and the elderly. Instituted
to have one that would be appropriate, no matter who won                          in 1965, Medicaid and Medicare began by reimbursing for
the election. As the weeks and months passed, however, I                          hospital services-the big ticket items-giving little or no
came to see that the outcome of the 1984 election was in no                       thought to the possible positive impact that paying for
way a determining factor for my remarks. The radical                              preventive services might have on hospital utilization. Now,
changes buffeting our health care system cannot be attributed                     not quite 20 years later, Beethoven's cello would object
solely to either political party, nor to any particular admin-                    vociferously. Both programs are virtually out of control
istration in Washington, although the policies of various                        fiscally, and decision makers at the federal and state levels
administrations may certainly increase or diminish the am-                        are frantically applying bandaids and tourniquets, apparently
plitude of those changes. Policies may modify the impact of                      without any thought other than to stop the fiscal bleeding.
a change somewhere on the continuum between ripple and                                  At the same time that we instituted these reimbursement
tidal wave, but the fact of the change exists independently.                     programs for the poor and the elderly, we launched the
     I am not sure whether it is harder to set goals and                         Regional Medical Programs across the country. In their early
priorities during periods of relative stability or during periods                 stages, these programs dealt almost exclusively with medical
of rapid change. I will argue, however, that in either case we                   care resources. Their purpose was to build networks linking
need to change the way we set priorities. I will explain why                     university medical centers with community hospitals. In the
I think our usual method of setting priorities is wrong, will                    early 1970s, these programs began to concentrate to some
suggest a framework to help identify some salient priorities                     extent on ambulatory services and on affiliations between
for the rest of the 1980s, and, finally, will borrow a concept                   community hospitals and community agencies. Neverthe-
from the private sector that I feel is useful when considering                   less, they continued to deal almost exclusively with health
how to implement the goals and priorities that we set.                           care resources rather than with the people who use them,
     As an undergraduate I studied music, which has re-                          although there is no doubt that over the nine years or so that
mained an important part of my life. So perhaps it is not                        these programs existed they did improve the quality of
inappropriate if I draw an analogy between the way we have                       medical care by assisting community agencies and commu-
been setting priorities and the last movement of Beethoven's                     nity hospitals in obtaining better structured and more con-
ninth symphony. In the beginning of that movement, the                           tinuous access to the high level professional skills residing in
orchestra plays, in turn, little pieces from the first three                     the nation's medical schools.
movements, seeking to please a solo cello which repeatedly                             A companion to the Regional Medical Program was the
seems to be saying "No, that's not what I want." Finally, the                    Comprehensive Health Planning Network established in
orchestra tentatively puts forth a few bars from the grand                        1966. Passage of this legislation indicated that perhaps we had
chorale (The Ode To Joy), the cello excitedly voices its assent                  learned something from our experiments in simply building
and encouragement, and the movement proceeds to its                              hospital beds or simply providing access to curative care.
glorious conclusion.                                                             Now, for the first time, we expressed support for population-
     Our history of setting health priorities, at least during the               based planning and insisted that users of health services-
past three or four decades, is really quite similar. In the 1940s,               patients, or clients-must be involved in planning the system
after World War II, it was noted that we appeared to have a                      that would serve them. This distinct improvement in setting
shortage of hospital beds, particularly in rural areas. Our                      health goals and priorities lacked one crucial ingredient,
response was to pass the Hill-Burton legislation providing                       however-a mechanism for implementation. Some people
federal funding for the construction of new beds. There was                      call it clout.
a mechanism for determining priorities included in the im-                             The missing ingredient was supposedly supplied with the
plementation of this legislation. It required the states to use                  passage of the Health Planning and Resources Development
a formula which calculated beds needed per 1,000 people for                      Act of 1974, which, in addition to regional, population-based
a given optimal occupancy rate. Both the program and the                         planning involving both consumers and providers, included
planning methods it prescribed set the states on a path that                     regulatory mechanisms to implement the objectives and
focused on only one part of the health care system: the acute                    priorities set through the planning process. Some thought this
care sector. We all know by now that this path led us past                       new planning act was indeed the grand chorale, and that it
signs saying "Roemer's Law"-a built bed is a filled bed-                         would lead, over time, to a glorious conclusion. Unfortu-
                                                                                 nately, it too foundered. It was launched on the stormy seas
    This Presidential Address was delivered during the Opening General           of rapidly rising health costs, and was dismasted soon after
Session, on November 12, 1984, of the 112th Annual Meeting of the American       it left the harbor by the premature conclusion that it had not
Public Health Association, in Anaheim, California. Address reprint requests to   worked, meaning, of course, that it had not contained costs.
Susan S. Addiss, MPH, MUrS, Director, Quinnipiack Valley Health District,        The original mandate of Congress that it strive to assure
1141 Dixwell Avenue, Hamden, CT 06514.
                                                                                 access by all to primary care of high quality at reasonable cost
0 1985 American Journal of Public Health 0090-0036/85$1.50                       was ignored by evaluators who never understood how long it

1276                                                                                                       AJPH November 1985, Vol. 75, No.11
                                                                                                           PRESIDENTIAL ADDRESS

 would take to establish this new planning process and to bring      continues, "Many people conclude that declining fertility
 it to the point where it could function effectively. At present,    means we can now put less emphasis on the MCH field. I have
 individual states are deciding whether to keep the program,         a different view, namely that the situation calls for even more
 what its functions should be, and how it should be structured       concern and effort than before per child .... Because every
 and funded.                                                         child will be needed as a producer, we must put more, not
       In all of these programs except the last two, priorities      less, into their health and education on a per capita basis
 have in general been set by health care providers (usually           ...." He argues that we must "make every [intended]
 physicians), by politicians, by third party payors, in short, by    pregnancy count by carrying each to term and having healthy
 everyone except the people most affected-namely, those              babies . . . because economically we cannot afford . . . to
 who need health and medical services. Further, these prior-         waste the productivity of any child."4 Demography is des-
 ities have responded to the perceived needs of the system-          tiny.
 more hospitals and nursing home beds or the latest and most                This, it appears to me, is about as forceful a population-
 expensive piece of equipment produced by our high technol-           based argument as anyone can make for a continued and in
 ogy industry-rather than to the actual needs of the clients.         fact increased priority on the health of our children. Unfor-
 The reimbursement programs, Medicaid and Medicare, also              tunately, when we examine the present status of our children
 catered to the needs of the system rather than the needs of the      and the policies now in force that relate to children, we find
 patients. The system lobbied; the system got what it wanted.         a number of unacceptable realities.
       In its insistence on the highest quality medical care and            Overriding everything else is the stark fact that one out
 its obeisance to the imperative of new technology, the system        of every five children in the United States now lives in a
 has brought us to the point where, in 1983, we spent $355            poverty-stricken family. For black children, the figure is one
 billion for health care, or nearly $1,500 for every man,             out of two, or a staggering 50 per cent. The study, conducted
 woman, and child in the United States. Of this astounding            by the House Select Committee on Children, Youth and
 figure, 42 per cent was paid by the public sector-federal,           Families,s further revealed that the number of poor children
 state, and local. ' Although Medicare and Medicaid spending          increased by 2 million between 1980 and 1982. Corroborating
 comprise 29 per cent of the total, it is nevertheless a              studies by such agencies as the Congressional Budget Office,6
 distressing fact that the elderly are paying one-quarter of their    the U.S. Conference of Mayors,7 and others combine to paint
 health care costs out of their own pockets.2 While we may            a truly bleak picture for the 50 per cent of black children and
take some comfort in the fact that third party payors covered         20 per cent of all children now living in poverty. Over the last
73 per cent of the total expenditures, we must be concerned           five years, the disposable income of the poorest one-fifth of
about the 17 per cent, or $60 billion, of these costs which were      American families has dropped more than 9 per cent. Fam-
not covered. Whether they were paid for out of pocket by              ilies headed by non-elderly black women suffered the largest
individuals or whether they were written off by institutions as       decline-10 per cent. Taxes for these poor families actually
bad debts, $60 billion is a lot of money.                             increased between 1979 and 1984, from just under 10 per cent
       So far, it does not appear that our tinkering with one part    to nearly 12 per cent. The income gap between the richest
of the system after another has brought health care costs             fifth and the poorest fifth of our population has actually
under control. Further, while the health status of our citizens       widened since 1947. The poorest fifth now earns only 4.7 per
has indeed improved dramatically over the past few decades,           cent of total income earned in the country, while the richest
most of us would be hard put to give much credit for this to         fifth earns almost 43 per cent. This is unacceptable.
our medical care system which, after all, does not in general               While the income of the families earning more than
see the patient until the patient is already sick.                   $20,000 per year is expected to increase by $20 billion
       Is there a better way, then, to set health goals and          between 1983 and 1985, we already know that the cuts in
priorities? I think there is. If we would only focus on the          AFDC (Aid to Families with Dependent Children) embodied
health of the public, rather than on the health of the system,       in the Omnibus Budget Reconciliation Act of 1981 resulted in
our priorities would practically set themselves. Measuring           half a million people, most of them living in single parent
the health of the public is really what health planning, as          families, being dropped from the rolls. A General Accounting
envisioned by its shapers in Congress, was supposed to be all        Office study conducted in a sample of five cities showed that
about. One of the reasons I have continued to sound the alarm        one half of the families cut from the AFDC rolls since 1981
about the deterioration of our federal data systems is that the      ran out of food after losing their benefits.8 Between 11 and 28
further they erode, the harder it is for us to measure the health    per cent of the families with working members who lost their
of the public in enough depth so that we can tailor programs         benefits also lost access to medical and dental care either
to respond to what we find. This, though, is the framework           because of the expense or because they no longer had any
that we must use. A noted English social philosopher said            health insurance. This is unacceptable.
more than two decades ago, "The history of public health                   My home state of Connecticut has had a law in force for
might well be written as a "persistent redefinition of the           several years which prohibits utility companies from shutting
unacceptable. " If we turn our attention from the medical            off services to customers between November 1 and April 15.
care system to the health status of our people, Sir Geoffrey         Recently a local newscast reported that service had been
Vickers' statement becomes crystal clear.                            restored to a number of families who had been without it since
      My old friend and teacher, Jim Jekel, has analyzed the         last April. It was noted, in passing, that the average unpaid
problems and issues for public health practice in the 1980's on      bill for these families was approximately $700. Many of these
the basis of demographic changes occurring across the                customers will not be able to pay off this bill by next spring
country. After noting the rapid increase in our elderly              even if they are able to keep up with their monthly energy
population and discussing some of its implications for public        costs this winter, which is also unlikely. This means that on
health, Dr. Jekel focuses on the related demographic fact of         April 15 when services are once more shut off, the average bill
reduced fertility, which, he says, "is really the other side of      is likely to be $1500 or so, and it will rise accordingly every
the coin of aging, because it is one of its causes." He              year. For these families, many of whom are either single

AJPH November 1985, Vol. 75, No.11                                                                                              1 277

 parents with children or single elderly women, the six and                 I have recounted this litany of facts because I think there
 one-half month shut-off means no light, no refrigeration, no         is a great difference between looking at programs individually
 hot water, and no cooking capacity. For adults, this is              as they come up for renewal or for funding and looking at a
 unacceptable; for children, it is reprehensible.                     more complete array of programs that affect one population
      The reports of the return of hunger to our land and of          group, such as our children. When we do the latter, it should
 ever growing numbers of homeless people, particularly in our         be impossible to escape the obvious conclusion that if we care
 cities, have been contested as inaccurate, anecdotal, or             about our children, our present program and funding prior-
 exaggerated. Suffice it to say that reports from the workers         ities are not just counter-productive, but potentially disas-
 who run the soup kitchens and the shelters have documented           trous. As the president of Time, Inc., noted in a recent
 that three, four, even five times as many meals are being            speech, cheating other people's children of a decent start in
 served now as were being served two years ago. They also             life ultimately cheats us all."I
 document that the number of people without housing is                      This failure to assure each child in our country a decent
 steadily increasing. Again, for adults, this is unacceptable.        start in life is even more unacceptable in light of the fact that
 For a child, to have only one meal a day, often simply soup          we know what our children need. The benefits of child
 and bread, is not only unacceptable-it is unconscionable.            nutrition programs, of WIC, of Headstart, of early problem
      These unacceptable realities for too many of our children       identification and remediation in public education, and of day
 are being documented at a time when other studies project a          care have been demonstrated through numerous research
 shortage of skilled workers in the United States to wield our        projects. We must not let others whittle away or, worse yet,
 increasingly sophisticated technology. It may be true that tax       terminate these programs that serve our less fortunate chil-
 cuts are creating new jobs, but it would appear that our             dren.
 poorest youngsters will not be able to fill them. At least 20 per          Another population group plagued with unacceptables is
 cent ofthe 17 year olds in the nation-our future work force-         our elderly. Volumes have been written about the problems
 are functionally illiterate. At younger ages, where develop-         we face now and will increasingly face as our population ages.
 mental and social stimulation is so important, there are day         We hear about the need for more nursing home beds, the need
care slots for only 10 per cent of the 27.5 million children          for physician education in geriatric medicine, and the need
whose mothers work. This is unacceptable.                            for greater care in prescribing multiple medications for frail
      The epidemic of unintended teen pregnancies also mil-           and vulnerable patients. Meanwhile, 20 million of our elderly
 itates against the well-being and future productivity of our         are uninsured beyond their basic Medicare benefits, which
 nation's children. Being born of a teenaged mother greatly          leaves them paying about half of their health care costs out
increases a child's chances of getting a poor start in life due      of pocket.'2 Needed services such as day care, home care,
to low birth weight, prematurity, deficits in cognitive devel-       chore and handyman assistance, and supportive congregate
opment, and, increasingly, child abuse. Further, we know             housing, are not available or not reimbursed, fostering
that such children often become teenage parents themselves.          dependency and early institutionalization. When nearly one
This is unacceptable.                                                of every two American women over the age of 65 is living on
      It is true that there is general concern about the epidemic    less than $5,000 a year, we can hardly expect them to pay for
of one million teenage pregnancies every year in this country,       these needed services themselves. And so we see them draw
three-fourths of which are unintended. There is also concern         down their assets, apply for Title 19, and enter a nursing
about the increase in the numbers of out-of-wedlock births,          home. This is unacceptable.
even as the overall number of births to teenagers begins to                And what about the 350,000 preventable deaths caused
decline somewhat. Some suggestions to stem this unfortunate          by cigarette smoking each year? This is more than seven
epidemic, such as requiring a teenager to get parental consent       times as many people as are killed in motor vehicle accidents.
before obtaining contraceptives, decreasing the availability         Yet we are working hard to reduce the latter toll, with speed
of family life and sex education programs in our public              limits, strengthened laws against driving while intoxicated,
schools, and cutting public expenditures on family planning          redesign of roads and bridges, increased passage of child
services, are truly puzzling because they run counter to             restraint laws and, most recently, laws requiring everyone to
voluminous research conducted in this area. In West Virgin-          wear seat belts.
ia, after a parental consent rule was dropped, the family                  Against smoking, it is true, we wield all the educational
planning clinic case load rose 63 per cent, with a subsequent        tools we can muster, and we have learned a great deal about
drop in the teen birth rate of 12 per cent. Similarly, when an       how to make smoking cessation programs more effective. But
existing parental consent rule and means test was dropped by         our efforts are like those of a sailor in a small boat struggling
Pennsylvania in 1978, the family planning case load rose 75          against the winds of tobacco subsidies, attempts to lower
per cent.                                                            excise taxes on tobacco, and, perhaps worst of all, tobacco
      We know that every public dollar invested in family            advertising. In a recent issue of News and Views, put out by
planning for teenagers saves nearly $3 in public expenditures        the American Council on Science and Health, Elizabeth
in the following year alone. We also know that for every 10          Whalen, ACSH executive director, notes that "The cigarette
teenagers enrolled in family planning clinics, one unintended        is the only legal product available today which is harmful
pregnancy is averted. In the year 1982, this meant 425,000           when used as intended."'3 Yet, as noted by Larry White
prevented pregnancies, which would otherwise have resulted           elsewhere in that same issue, "Cigarettes are the most
in 119,000 more births, and 255,000 more abortions.9 Re-             heavily advertised product in American newspapers. Almost
search conducted at Johns Hopkins University further re-             half the billboards in the United States carry cigarette ads. "14
veals that teenagers who participated in family life and sex         "You've come a long way baby" is perhaps the ultimate
education programs in school are less likely to become               ironic message. Data coming in from one state after another
pregnant and no more likely to be sexually active than their         reveal that more women are now dying of lung cancer than of
peers who do not participate in such programs, doomsayers            breast cancer. This is unacceptable.
to the contrary.10                                                         We know that lung cancer can be prevented. While there

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                                                                                                          PRESIDENTIAL ADDRESS

 are identified risk factors for breast cancer, it is not clearly    solutions, justifying the one we choose for implementation.
 preventable at present. How tragic, then, that we continue to       This lever is not easy to use, however. We may think we have
 permit advertising which encourages young women to begin            the right definition, but the problem is complex, the solution
 smoking cigarettes, which reassures those who already               is controversial, and it seems as if nobody wants to listen to
 smoke by depicting smokers as healthy individuals engaged           us. We have to develop the ability to bring a new perspective
 in vigorous outdoor activities. We must try harder to get out       to bear on problems that other people think are insoluble
 the story of the epidemic of cancer, heart disease, and lung        because of the way they are looking at them.
 disease caused by the cigarette. Perhaps banning cigarette                We have had considerable success with this approach in
 ads from TV and radio was a mistake. At least while they            the corporate sector, where our repeated insistence on the
 were running, we also saw some very imaginative and                 payoff of prevention was finally accepted by business exec-
 effective anti-smoking public service announcements.                utives as a promising solution to the problem of runaway
       These few examples of the unacceptable could be               health benefits costs. The burgeoning of jogging tracks,
 multiplied many times over, but the sample is representative        exercise rooms, smoking cessation classes, hypertension
 of the whole. What all the unacceptables have in common is          screening programs, and low calorie cafeteria choices in the
 that they violate some fundamental beliefs of public health         work place is eloquent testimony to the late but ardent
 workers. We believe in health care as a right, not a privilege.     embracing of health promotion by the business world. To
 We believe in equity of access, which means providing               reinforce the message, we now have preliminary evidence of
 payment for those who cannot afford the health care they            reductions in absenteeism. And we can be certain that this
 need. We believe in government's responsibility to provide          evidence will become more widespread as time passes.
 passive protection, that is, to protect us from hazards in our           This is a good example of using leverage to influence the
 environment and our workplaces when we cannot protect               private sector. However, we must not forget, in the flush of
 ourselves individually.                                             our success, that we have influenced only one part of the
      As the industrialization of health care proceeds, we must      spectrum, and the easiest part at that. Bringing health
 hold the new health care entrepreneurs accountable to               promotion to the elderly, or to children, or to the inner-city
 society, and measure their actions against our beliefs. To do       poor will not be so easy.
 this, we must indeed accept a new mission, moving from                   Our third lever is our belief in participatory planning and
 "public health" to "the health of the public." We must              problem-solving. The process of involving clients in deci-
enlarge our sphere of influence to cover the entire health care      sions that will affect their lives is time-consuming, often
 system, and impact the entire health care budget, not just the     fractious, and frequently has its periods of near chaos.
42 per cent that comes from the public sector. This may seem         Nevertheless, the outcomes of this process are much more
like a herculean task, in view of our shrinking resources and       likely to be accepted by all of the involved parties, and thus
the growing problems we face in the traditional public health       can be put into operation more quickly.
sector. We might easily be further discouraged by our                     Our last lever is the aura of our profession. We are public
perception that the pendulum of social policy has, for the time     health professionals 24 hours a day, seven days a week. Our
being, swung away from the beliefs we espouse and advocate          behavior, which must reflect our public health philosophy,
most intensely. When the pendulum is at the opposite end of         sets an example in all of the various social contexts in which
the arc, there is a tendency to give up, sit back, and wait for     we find ourselves-agency boards of directors, advisory
it to return to where we are.                                       committees, PTAs and PTOs, even recreational gatherings.
      Discouragement and defeatism, however, are no more            We stand for social justice in health. We advocate for others
acceptable than policies damaging to the health of the public.      rather than for ourselves, and our passion and idealism are
There is a concept, well understood in the private sector,          employed for the common good, rather than for individual
which we could most profitably adopt and employ as we               gain. Not all health professionals can make that statement.
broaden our participation in the health care arena. That                  These levers are powerful tools. Nevertheless, there are
concept is known as "leverage." The American Heritage               methods we can use to make them even more powerful. One
Dictionary defines it as "positional advantage; power to act        of these is the effective presentation of data. Health planners
effectively." It implies the use of a tool to move or influence     working with lay boards learned years ago that it is indeed
a large mass that could not be moved by human muscle power          true that one picture is worth a thousand words. The new
alone. Public health professionals should be quite familiar         technology of personal computers, with their increasingly
with the concept of leverage. After all, when John Snow             sophisticated graphics packages, makes it relatively simple to
removed the handle from the Broad Street pump, he gave us           produce bar charts, pie charts, trend comparisons, and other
a symbolic lever with which we in public health have moved          summations that make boring numbers both understandable
mountains.                                                          and interesting. Public health workers have always known
      There are many tools that can be wielded as levers by         the value of good data presentation, but developing a pol-
public health workers. First and foremost, of course, is the        ished package was not always possible given deadlines and
scientific base of public health as a profession. The combi-        scarce resources. Technology has now removed these bar-
nation of epidemiology, our mother science, with the indi-          riers. In an information society, we are competing against an
vidual disciplines that we brought to our training in public        overabundance of messages, many of them counter to our
health is unique. As Milton Terris put it recently, the             own. Therefore, we must exploit the power of the picture to
epidemiology of disease, of health care financing, or of health     the fullest extent.
care regulation involves specialized multidisciplinary prac-              Another method-one that is most compatible with our
tices not common to the medical profession.'5                       multidisciplinary background-is networking and the build-
      Another lever we possess is the prerogative of definition.    ing of coalitions. Our advocacy for the health of the public
We are indeed the experts in public health and we have not          will be enhanced in direct proportion to the number of groups
only the right but the obligation to define the issues, establish   we can marshal in our cause, or with whom we can comfort-
the parameters of analysis, and present the alternative             ably join in theirs.

AJPH November 1985, Vol. 75, No.11                                                                                                1 279

      APHA has become quite good at networking and coali-                                           Footnotes
tion building over the past few years, and so have our               1. U.S.  Department of Health and Human Services, Health Care Financing
affiliates. This past winter, three of us were invited to meet          Administration, Baltimore, Maryland. Health Care Financing Review,
with staff of the National Highway Traffic Safety Adminis-              Winter 1984; 6:(2), 3.
tration. When we asked if they had any projects we could help        2. Health Care Spending Bulletin, U.S. Department of Health and Human
them with, they told us, somewhat hesitantly, that there was            Services, Health Care Financing Administration, July 1984.
a mandatory seat belt bill before the Minnesota legislature          3. Sir Geoffrey Vickers: What Sets the Goals of Public Health? NEngl J Med
that had failed by a few votes for several years in a row. The          1958; 258:(12).
                                                                      4. Jekel, JF: Public Health Practice in the 1980s: Problems and Issues.
vote in the house was to be taken in just a few days. We said            Presented at the Connecticut Public Health Association Continuing
we thought we could help. Our government relations staff                 Education Program, January 1981.
immediately put out an alert to the Minnesota affiliate and           5. US Congress, House Select Committee on Children, Youth and Families:
individual Minnesota members, who contacted their legisla-               Children, Youth, and Families: 1983. Washington, DC: Govt Printing
tors over the next few days. The bill passed the house by one            Office, March 1984; 102, 105.
                                                                     6. US Congressional Budget Office: Poverty Among Children. Washington,
vote, and the next day NHTSA staff called to thank us,                   DC: Govt Printing Office, December 3, 1984; 6.
acknowledging that our efforts were decisive. Although the           7. US Conference of Mayors: The Urban Poor and Economic Development.
bill did not pass this year in the senate, its supporters are now        Washington, DC: 1983.
much more optimistic about getting it through next year.             8. US General Accounting Office: An Evaluation of the 1981 AFDC Changes:
      These are in fact exciting times for public health work-           Initial Analyses. Washington, DC: Govt Printing Office, April 2, 1984; 4,
ers. With a new mission-really an expansion of our tradi-                5.
                                                                     9. Alan Guttmacher Institute: What Government Can Do about Teenage
tional one-with the many tools we have to use as levers, and             Pregnancy. Issues in Brief March 1984; Vol. 4, No. 2.
with enhanced use of methods we know will make us more              10. Zelnick, M, Kim, YJ: Sex Education and its Association with Teenage
effective, we can indeed exert our influence over the entire             Sexual Activity, Pregnancy and Contraceptive Use. Fam Plann Perspect
arena of health care, no matter where the pendulum happens               May/June 1982; Vol. 14, No. 3.
to be in its swing. We know how to define the unacceptable          11. Bond, J: Neglecting children today causes high costs tomorrow. Hartford
and we know what we must do to make others see it as                     Courant, March 22, 1984. (Commentary on remarks by J. Richard Munro,
                                                                         President and Chief Executive Officer of Time, Inc., to the Children's
unacceptable also. Above all other things that we profess, we            Defense Fund Strategy Conference, Washington, DC, March 2, 1984.)
believe in access to good health care as a right, as a matter       12. US Congress, House Select Committee on Aging: State of the Elderly: The
of social justice, and as a social good that serves the best             Financial Burden of Health Care. Washington, DC: Govt Printing Office,
interests of society. By the selection of our careers we have            January 26, 1984; 78, 82.
committed ourselves to contribute to the collective con-            13. Editorial: In News and Views of the American Council on Science and
science. We are all ambadassors for health, and we must                  Health, September-October 1984; Vol. 5, No. 4, p 5.
                                                                    14. Ibid., p. 1.
exercise our best statesmanship to improve the health of the        15. Terris, M: Speech delivered at the Annual Meeting of the Maine Public
public.                                                                  Health Association, October 23, 1984.

             I                                                                                                                -I

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                  * After Breast Cancer: A Guide to Followup Care
                  * Breast Reconstruction: A Matter of Choice
                  * When Cancer Recurs: Meeting the Challenge Again
                  * Advanced Cancer: Living Each Day
                  To help physicians and health professionals continue to provide the best care possible, NCI has
             updated the Breast Cancer Digest-a current, comprehensive, 212-page review of research and
                  The Breast Cancer Digest and the 11-booklet Breast Cancer Patient Education Series are available
             at no charge to health professionals. To receive free copies, write: Breast Cancer Education Program,
             Office of Cancer Communications, National Cancer Institute, Building 31, Room IOA 18, Bethesda, MD

1280                                                                                                AJPH November 1985, Vol. 75, No.11

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