HEART DISEASE AND PUBLIC
HEALTH

LOUIS I. DUBLIN, PH.D.
New York, N. Y.

Reprinted from
AMERICAN HEART JOURNAL
St. Louis

Vol. 28, No. 1, Pages 16-21, January, 1942
(Printed in the U. S. A.)

 

 

 
HEART DISEASE AND PUBLIC HEALTH
CURRENT TRENDS AND PROSPECTS

Louis I. Dusuin,* PH.D.
New York, N. Y.

S I am to discuss heart disease and public health, it will avoid mis-

“understanding if at the outset I attempt to define what we mean
by public health. It is that branch of medicine which concerns itself
with the prevention and control of disease from the point of view of
the community as a whole. In contrast with the practicing physician,
the health officer has the people of the city, county, state, or nation as
his patients, and he utilizes the resources of the community in his ef-
fort. We all know that, under modern conditions, the individual patient
and the individual doctor are often helpless in combatting the spread
of infection, as, for example, in controlling yellow fever, typhoid fever,
or malaria. It takes the resources of the state to do that. Even in
relation to such diseases as tuberculosis and syphilis, it has become a
well-established principle, learned through sad experience, that not only
prevention, but treatment, is properly a public health function. The
individual patient, in many instances, is unable to provide himself with
the care which he needs, and the community is to that extent endangered.
The public interest, therefore, demands that the necessary treatment be
given, even if at public expense. In all this, there is no real conflict
between the public health officer and the individual practicing physician.
There are broad areas of mutual interest. The wise health officer will
attempt to make all practicing physicians his associates, and all good
doctors will look to their health officer for guidance and support in help-
ing them with their patients. These general principles are gradually
being evolved, although they have not yet been completely crystallized.
The functions of the health officer, on the one hand, and of the prac-
ticing physician, on the other, are being worked out in the light of ex-
perience and of changing conditions, and the public interest, in the last
analysis, determines their mutual responsibilities.

What are the most important problems in heart disease, and what is
or should be the relationship of the public health officer to them? Heart
disease is the outstanding feature of the medical picture, and will be
increasingly so in the future. Clearly, the health officer cannot ignore
a field so wide in extent and affecting the public health so vitally. Essen-

 

Presented before the Annual Meeting of the American Heart Association, Cleveland,
Ohio, May 30, 1941.

Received for publication June 9, 1941.

*Third Vice-President and Statistician, Metropolitan Life Insurance Company, New
York. :

 
 

tially, his problems in this field are the same as those of the practicing
physician, although his approach and functions are necessarily different.
As I have already indicated, the health officer must concern himself with
those phases of heart disease in which large-scale prevention or measures
of control are attainable. The well-recognized public health procedures
are clearly applicable to the control of rheumatic fever and syphilis.
The control of premature hypertensive and arteriosclerotie heart disease
has to date received scarcely any attention from health officers. Im-
perceptibly shading off from the last category is the numerically most
important group, which comprises cardiac disease in old people. Toa
greater or lesser degree, the health officer, as we shall see, can function
to advantage in all of these four phases.

Rheumatic fever is today one of the foremost health problems of child-
hood. Between the ages of 5 and 9, deaths from it are outnumbered
only by those from the four principal communicable diseases of ehild-
hood, as a group, and by pneumonia.* At the ages of 10 to 14, it is the
leading cause of death. Between the ages of 15 and 25, it is second only
to tuberculosis. Although it is true that the mortality from rheumatic
fever has declined, the rate of fall is less than that from other diseases,
so that the proportion of deaths from rheumatic fever to the total num-
ber of deaths among persons under the age of 25 has increased.

By its very nature, rheumatic fever is a disease in every phase of
which the health officer can be of great help, but he has done compara-
tively little. He may actively participate in a case-finding program.
He can take over or amplify facilities for the treatment and eare of
children with the disease. Practically nowhere are these facilities com-
mensurate with the needs. His laboratory can function in research in
rheumatic fever, the cause of which has thus far eluded scientific in-
vestigation, and his records may help to unravel the complex epidemi-
ology of the disease. He can provide convalescent and sanatorium care
in suitable types of institutions. In certain parts of the country he can
make use of facilities built for other purposes, but which are not fully
used, particularly the tuberculosis sanatoriums. Furthermore, since non-
specific factors seem to be responsible for most of the decline in rheu-
matic fever, public health officials can actively promote improvement in
certain matters which come under their aegis or in which they have some
influence, as, for example, in housing and in popular education in health
and nutrition.

In the control of syphilis, the health officer has already contributed
a great deal. In fact, the progress that has been made reflects the de-
gree to which health officers have been willing and able to take respon-
sibility, not only in finding cases but also in treatment. In the Sean-
dinavian countries, where syphilis has been largely controlled, it has

 

*Since this paper was written, mortality from pneumonia has fallen below that for
rheumatic fever.

4
been the public health service which has carried the brunt of the work.
If in our country some progress in this direction has been made, there
is no denying the fact that in the present national emergency, with huge
numbers of young men concentrated in camps and in defense industries,
and with no correspondingly increased facilities for handling the case
load, we may lose the gains of the last ten years. The task of the health
officer is manyfold—finding the victims of the disease, and providing
adequate facilities for treatment and seeing that they are used. He
needs a broad concept of his job and resourcefulness in dealing with it.

The most difficult aspect of the problem in heart disease, both for
medicine and for public health, is constituted by the relatively large
numbers of persons in the prime of life who fall prey to early and some-
times preventable heart and coronary artery diseases of other etiologic
types. They affect men chiefly. The root of much of this problem is
probably related to the process of aging of the human organism, the
study of which has been scarcely begun. Fortunately, there is increas-
ing awareness of the necessity for research on the fundamental prob-
lems involved, and a number of medical men and other scientists and
public agencies are already engaging in this work. Notable is the work
being done in one public institution, the Research Unit of New York
City’s Hospital for Chronic Diseases, and in several other places. But
a greater part of our public medical resources can and should be de-
voted to this field.

Apart from this, however—and the wide difference between the death
rate of the two sexes is, in my judgment, a good indication—a large
number of early deaths from heart disease can be avoided or postponed.
Many are probably due to faulty living habits with respect to the
routine of daily life, or to lack of attention to infections. Intensive
research and popular health education, both of which are important
functions of modern public health organizations, can do a great deal in
this regard.

For one thing, the health officer can help in the early detection of
incipient heart disease by popularizing the periodic medical examina-
tion. In this matter a more receptive attitude on the part of the medi-
cal profession generally is much to be desired. It is admittedly true
that symptoms of early heart disease are often hard, sometimes impos-
sible, to detect, but too many patients receive little or no medical super-
vision until long after the disease has progressed. It may not be too
early for the two professions to consider the desirability of providing
public clinies for the periodic medical examination of certain groups of
the population that cannot themselves afford such service.

The public health officer should consider in what ways, efficient and
economical, he can utilize available medical resources in cases of early
heart disease, or in acute attacks of chronic disease. For example, do
we not all know of working men and women with cardiac disease who

5

 
would benefit from relatively short periods of sanatorium care, where
prescribed rest and other measures would be carried out under suitable
conditions, and where re-education of the patient in his way of life
could be carried out better than in the atmosphere of worry and strain
of the home and work place? In a few places, the overbuilt sanatorium
facilities for tuberculosis, or other hospitals now unutilized, could be
devoted to this purpose.

The health officer can make increasing use of the visiting nurse serv-
ices under his supervision for chronic cardiac disease and, when such
services are lacking, can develop or amplify them. Visiting nurses now
operating very widely all over the country are of value not merely in
actual bedside care, but in the broader fields of psychologic adjustment
of the patient or his family, and in interpreting the doctor’s instruc-
tions to them. These phases are often neglected because they take more
time than the busy physician can give them. But they can be handled
well by visiting nurses, particularly if nurses are given special training.

Old people with cardiovascular disease present a somewhat different
set of problems which are much more difficult in character and limited
in scope. The chief needs are for additional clinic facilities, for more
home care, and for institutional care of the semihospital type. The
numbers of aged cardiac patients are already so great and so rapidly
increasing that there is urgent need for a long range program for their
care. The very nature of the situation is such that a major part of the
financial burden must be borne by public funds. Public health officers
must recognize their responsibility here and seek the help and guidance
of the whole medical profession in developing programs that are con-
sonant with the welfare of the patients, the public, and the doctors.
We cannot safely add to the burdens of voluntary hospital clinies if
they are to continue to do good work. A larger number of public clinics,
run by full-time men, is the only desirable solution for impoverished
ambulant patients. When such patients are confined at home, public
medical service may be necessary, but the work of physicians may be
lightened and rendered more efficient by the proper use of visiting
nurses and, in selected cases, of medical social workers. Increasing
numbers may best be handled in institutions, but these cannot and need
not be elaborate and costly hospitals.

Heart disease, then, presents many different tasks, responsibilities,
and opportunities for public health officers. But before any large-scale
advance can be made, both they and the medical profession as a whole
must accept the view that heart disease is a proper field of work for
the health officer. They need also to agree on the respective roles of the
private and public physician.

In this respect, the problem of heart disease reminds one of the sit-
uation which prevailed in tuberculosis about thirty years ago. At that
time health officers were just beginning to recognize that the problem

6
of the tuberculous patients was largely one for them to solve. There
was considerable hesitation in entering the field, and uncertainty in
developing the necessary technique and procedures. They lacked diag-
nostic classifications and standards, staffs trained in the special treat-
ment of the disease, and sufficient diagnostic and sanatorium facilities
for the care of patients.

What a change thirty years has brought about, thanks to the increas-
ingly better understanding of the basic factors of the situation by both
practicing physicians and the growing profession of health officers. Once
it was realized that a disease so widespread, yet everywhere so concen-
trated among poor people, was the province of the public authorities,
constructive steps, one after another, were taken by health officers and
physicians in developing new procedures, with the result that, within
a single generation, prodigious advances were made, not only in cut-
ting down the ravages of the disease, and in protecting persons against
it, but also in developing an understanding of the nature of the disease
itself.

I am bold enough today to stress this analogy with reference to heart
disease. I appreciate, of course, inherent and fundamental differences
between the one disease which stems from an invasion of the body by a
bacillus, and the other disease or group of diseases, the bulk of which
represents sequelae of many factors, both exogenous and endogenous in
nature, in the aging patient. Prevention of tuberculosis did not prove
a hard nut to crack once the nature of the problem was understood and
properly organized efforts were brought to bear. Prevention of heart
disease will be a very different proposition because so large a part of
it is the end result of accumulated insults incidental to the functioning
of the body. On the other hand, there are enough phases of heart
disease in which prevention is possible to excite the health officer with
the real job he can do in this field.

But my major interest is the idea that the field of heart disease is
fundamentally one in which the health officer can function and bear
a major responsibility. There is every reason why the organized official
and voluntary public health agencies should participate in the work to
be done. Health officers have a tremendous contribution to make in
supplementing and strengthening the efforts of the medical profession
and in developing appropriate administrative procedures for the prac-
tical care of patients. For this disease, the most common in adult
life, involves such long periods of disability that the medical costs are
far beyond the resources of most of its victims. The very economics of
the situation make it impossible for the ordinary relationships of physi-
cian and private patient to be fully effective. Thus far this situation
has been met by the establishment of free or low-cost outpatient clinics
in public and private hospitals, in which much of the service of the
physician is rendered without compensation. Patients either cannot be

7

 
 

seen sufficiently often or are treated too superficially because of the
crowded conditions of most of the clinics. This situation will get worse,
rather than better. Obviously, we must think in terms of modifying
our present types of organization and medical care for these people.

Leaders in medicine and public health must face frankly a situation as
patent as this, and take the necessary steps for integrating the care of
those suffering from heart disease into a general scheme, in which the
proper share is borne by public funds, under the administration of the
health officer, just as has been done in the case of tuberculosis. I have
no illusions that this scheme can be developed overnight. The tubereu-
losis problem, which was simpler, took decades to get under way toward
solution. But the important and first step is the acceptance by physi-
cians and health officers of the concept that heart disease is a suitable
field for similar exploitation. Then, in good will, all interested parties
can get together in planning their respective parts of the job, on ways
of effective cooperation, and on the sequence of steps which would be
most likely to assure progress and win the support of the community.