REMARKS OF U.S. REPRESENTATIVE JOHN E. FOGARTY
SECOND CONGRESSIONAL DISTRICT OF RHODE ISLAND
AT GEORGETOWN UNIVERSITY SYMPOSIUM
WASHINGTON, D.C.

THURSDAY, JUNE 9, 1966 AT 6:00 P.M.

DISABILITY

A NATIONAL HEALTH PROBLEM AS SEEN FROM CAPITOL HILL

I accepted with pleasure this invitation to appear here tonight,
because I welcome every opportunity to participate in an activity whose
aim is to improve the health of the American people. | This seminar
today is such an activity. |

Ihave been asked to talk to you this evening on disability, a
subject that is of as much concern to me asa legislator as it is to you
as physicians and health workers, although from a somewhat different .
point of view.

Health matters have traditionally been a great concern of law
as well as of medicine. The history of health legislation is almost as
‘old as the history of lawmaking itself in this country. Let me go back
for just a moment to these earliest efforts on the part of governing
bodies to halt the inroads of disease on the citizens of our first colonies. -
Our earliest health laws were related almost exclusively to the spread
of disease through travel, which was originally of special importance
in maritime traffic and more recently has become important in air

traffic.
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In Colonial America, the earliest quarantine restriction, to
halt the spread of disease from foreign ships, was enacted in 1647 by
the Massachusetts Bay Colony against ships arriving from Barbados,
and in 1700 the Province of Pennsylvania enacted legislation ''to pre-
vent sickly vessels coming into the government. "

“Although the original legislative health efforts were directed
specifically against communicable diseases entering by sea, governing
authorities began to develop broader health concerns as early as 1754
when the Colonial. Government of New York imposed a tax on all sea-
men and passengers entering the port of New York, and with these
funds provided not only quarantine hospital accommodations but estab-
lished the first city dispensaries and provided financial support to the
Society for the Reformation of Juvenile Delinquents.

In 1798 the U.S. Public Health Service, now the principal health
agency of our Country, was created as a Marine Hospital Service when
an act of Congress providing for the relief of sick and injured seamen
was signed by President John Adams. Proponents of the Act were not
concerned with the humanitarian considerations alone, but argued also
that the National defense demanded a National program of direct med-
ical and hospital care for seamen, since the merchant fleet had always
been a major element of the Nation's naval defense. |

In the more than a century and a half which followed these

pieces of legislation, Congress has often demonstrated its continuing
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interest in the health of the American people. This interest is based
upon a conviction that a healthy nation is a productive nation and that
a general state of National health is an economic asset and an essen-
tial component of defense even if there were no human issues involved.
This Congressional concern has been reflected in such laws as these:

Legislation to control a third "killer" disease was enacted '
in 1833 as the result of a widespread outbreak of cholera, and
authorized the use of revenue cutters in enforcing quarantine laws
of States and cities.

The world-wide pandemic of influenza in 1918 stimulated
Congress to appropriate one million dollars for the Public Health
Service to use in suppression of influenza in the United States. In
the 20's, the Veterans Bureau, later to become the Veterans Ad-
ministration, and the Bureau of Indian Affairs were both established
by law.

And. so it has gone, with each decade bringing new laws
relating to health and disease control.

A new dimension of health concern began with the National
Health Survey of 1935, the fir at definitive survey of health.to deter-
mine the relationship of disease and certain environmental factors
such as income, education, and housing conditions. This survey brought
together for the first time information that formed a basis for Federal,
State, and local action directed toward the prevention and control of the

chronic as well as the communicable diseases, and stimulated the
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development of programs aimed at the bettering of social and economic
conditions among the deprived of our Nation.

Beginning with the impact of the findings of the first National
Health Survey, and given additional impetus from World War ll, there
has been a gradual but substantial shift of legislative perspective in
regard to health. This has evolved as a response to the changing
health needs of a changing society. That our society has changed, few
per sone would argue.

For example, while by no means entirely eliminated from the
health picture, the communicable diseases and the sanitation problems
incident to these no longer have a dominant claim on either medical or
legislative attention. Just as our society has changed greatly in the
past 30 years, so it will no. doubt continue to change, at least into the
foreseeable future. A glance at the population’ figures reveals one
very basic factor: we are becoming a Nation of the very young and the
very old. We have increased our life expectancy to span the decades
in which chronic diseases are increasingly common and their crippling
effects more disabling. -

We have managed to control the great killers of the past --
yellow fever, smallpox, cholera ~- but we have created new killers and
cripplers to take their place. Heart disease, cancer, and stroke claim
over a million lives’every year and disable many more. Vehicles with

fatal highway speeds cause mass crippling in the youth of our land.
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We have acquired great technological skill, but with it a longer life
span in which to develop social and economic hardships in the so-called
"golden years".

We have, in short, set the stage for disability. For nearly a
century we have collected statistics on mortality. Only in recent
years have we really begun to realize the vast implications -- of chronic
and malignant diseases, of injuries and old age -- for those who do not
appear on our mortality tables because they are not yet dead.

What are some of these implications? ‘In the three great killer
diseases I have just mentioned -~ heart disease, cancer, and stroke --
death itself is not the only tragedy. If those individuals we have listed
in the statistical tables as "survivors" are merely snatched from the
jaws of death to become doomed to a bedfast existence at home or in
the back wards of public institutions then the advances merit only
limited praise. There is abundant evidence, however, that disability
no longer need be accepted as the natural and inevitable aftermath of
cancer surgery, or heart disease, or stroke, or old age; evidence
that disability can be prevented or minimized; evidence that knowledge
already available could be more fully utilized to offer useful and pro-
ductive years to be lived in dignity by millions of chronically ill and
aged persons. | |

Iam referring, of course, to that area of medical care known
as medical rehabilitation. For in this portion of comprehensive health

care lies our conception of medical science as a tool for health, rather
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than limiting it to the bare provision of basic bodily survival. We
have in the past directed our major medical and legislative efforts
toward those activities -- from immunization to organ transplant --
designed to prevent death. But we have an additional obligation to |
those whom we have rescued -- we must insure that that life is worth
living. We must do more than substitute one tragedy for another.
And this is where medical rehabilitation comes into focus.

The respect I have for those who cultivate the fields of
yehabilitation is profound. I have come to know many of these workers
well. Through the work of the appropriations subcommittee which I
have chaired for several years, I too have endeavored to serve the
disabled people of this country. In these years I have had an oppor-
tunity to gain an understanding of the national problem posed by dis-
ability and an awareness of the obstacles to delivery of medical reha-
bilitation services to those who need and could benefit from them. I
have come to understand that medical rehabilitation, or disability
control, or whatever you choose to call it, has vast potentials, not
only in restoring the disabled to a high level of independence, but in
preventing disability from developing.

Those of you here today are demonstrating by your presence
at this seminar on the management of the chronic disease patient
your concern for better care of this segment of the population. You

and your counterparts in other sessions of this type are seeking to
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expand the horizons of medical care for this neglected group. You
are denying, in effect, the validity of medical attitudes which claim
that nothing can be done for those so unfortunate as to be afflicted
with chronic diseases and oldage. You are attempting to find solu-
tions to the common problems associated with disability. We have
learned by now that shutting the disabled out of sight accomplishes
nothing. We can never build enough custodial "boxes'' even for this.
And we should not try.

In the process of gathering information relative to disability
and to the need for rehabilitative services throughout the country,
I have come to view rehabilitation in its broadest sense -- health care
concerned with preventing disability and maintaining function, as
well as restorative services to those with existing impairments --
as the window on the future. I am convinced that health measures
enacted by Congress and health services provided by physicians and
other health professionals must all take into account the chronicity
of many illnesses and conditions. In our fight for life-saving tech
niques, let us make sure that it is really the whole life we are saving.
Let our philosophy be based on reality, and let our goals be based on
a belief in the true worth of man.

Workers in public health know that when large numbers of
people need health services which in the usual course of events they
do not receive, then it becomes a public health problem. When such

a need is widespread, then it becomes also a national problem and of
concern to legislative authorities. That there has been legislative
recognition of such national health problems is evident in such laws
as the following:
| The Community Health Services and Facilities Act of 1961,
which provides for demonstrations of new methods of providing com-
munity health services, including a variety of rehabilitation services.
The Health Professions Educational Assistance Act of 1963

and the Nurse Training Act of 1964 are both designed to increase pro-

 

fessional health manpower, for without sufficient personnel to provide
health services, the most desirable and effective medical program
falls short of its goal.

The Heart Disease, Cancer, and Stroke Amendments of 1965
which assigns responsibility to the Public Health Service for encouraging
and assisting the establishment of regional cooperative arrangements
among medical schools, research institutions and hospitals, designed
to forge a closer link between the centers of scientific and academic
medicine on the one hand, and community health services on the other.
This legislation specifies that this forthright program must not inter-
fere with present patterns of patient care and professional practice,
but it is nonetheless a revolutionary piece of legislation. It is de-
signed to develop and disseminate medical knowledge of treatment
techniques through cooperative efforts of medical resources in the.

community.
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Nowhere in the legislation, or in the testimony in its support
before the Congressional committees, will you find a blueprint for
this program -- because there is no Federal blueprint and it is not
intended that there should be one. The pattern of grants-in-aid,
already so well established and so successful in the support of med-
ical research, will also be followed in this new program. These
grants will be made in response to local initiative, to facilitate local
planning, and to assist local execution of the plans. The emphasis of
this program is clearly on bringing this country's proven research
capability -- as reflected in the medical schools and research hos-
pitals -- into a closer relationship with medical practice, as a re~
source for the practitioner, the local hospital, and the community
health services in a wide geographic area.

The Social Security Amendments of 1965, which provide health
insurance benefits to the aged and is popularly known as "Medicare".
This legislative package evolved out ofa recognition that it is one
thing to have improved medical service, but quite another thing to pay
for it. The rapid and dramatic increase in the costs of hospital care
andhealth services generally is alarming. It is alarming because it
means that despite our general prosperity we are still putting some
forms of medical care beyond the reach of many of our citizens. This
is not a tolerable situation. Iam not contending that the charges made
for medical services are excessive in relation to costs, or in relation

to value but merely that they are still too often excessive in
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relation to ability to pay. Fear of the doctor's bill or the hospital
bill should not be the factor that keeps members of any economic
group from availing themselves of medical care.

There is another aspect to this problem of costs which
disturbs me. This is the attempt to extend to the field of health
services and medical research the concepts of cost-benefit
economics generated by our defense and space technology. These’
approaches start off with the assumption that every public act
must be weighed in terms of its economic rate of return. This
is a concept which we must reject out of hand. It involves a prin-
ciple which cannot be applied to health.

This is not to say that there are never economic savings as
a direct result of medical care. Certainly, the nearly 200, 000
vocationally rehabilitated persons each year are returning to the
labor market and paying taxes where formerly they contributed
only to the costs of medical care, or prevented a family member
from being employed. But there are millions of citizens with no |
employment potential. Those over 40, handicapped and uneducated
for other than manual tasks; those with deteriorating chronic dis-
eases; those past retirement, What of these ? How do we measure
the dollar costs to society of not providing them with necessary
health services? And if we could do this, would it be in any way a

yardstick of the human values involved?
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There will be new advances in medical science in the years:
to come, and there will be new laws relating to health. Hopefully,
breakthroughs in preventing death will lead to enriching human
life as well, and emerging legislation will consider the human
above the economic values of life. Medicine and law have been
partners for generations in this land of ours. I expect this to
continue into more and more areas, such as poverty -- which goes
hand in hand with disease and disability -- arid old age ~- which
has outlived the killer diseases of youth only to fall heir to the
chronic diseases in later years -- and ignorance -- which prevents
the delivery of appropriate health services to all who need them.

Only then, when all men have the opportunity to achieve
and to maintain their highest potentials, may we -- the health
professions and the lawmakers -- rest upon our laurels secure

in the knowledge that we have done our job faithfully and completely.