Presidential address to American Rheumatism Association. The crusade against arthritisThe role of the American Rheumatism Associationкод для вставкиСкачать
Arthritis and Rheumatism o8;ciaIjournd of the grnerican Rheumatismassociation VOL.VI, NO. 4 AUGUST, 1963 Presidential Address to American Rheumatism Association The Crusade against Arthritis: The Role of the American Rheumatism Association By EPHHAIM P. ENCLEMAN D URING THE PAST YEAR as President I have been privileged to participate in policy meetings of our national voluntary and governmental agencies in arthritis. This has been a rewarding and revealing experience. Many vital, unresolved problems still prevail in our crusade against arthritis, not the least being cause and cure. Nevertheless, progress has been impressive; especially since rheumatology has assumed the status of an important section of medical science only in recent years. As recently as 1925 rheumatology was a chaos of ignorance and apathy. Progress had not been made in classification, diagnosis or treatment; scientific contributions were rarely made. Little wonder that rheumatism had signally failed to qualify for scientific discussions and academic curricula. The American Rheumatism Association (AHA), since its incorporation in 1939, has provided scientific leadership in arthritis. We can be proud of the record. Our scientific meetings and publications are now held in high esteem. The sustaining committees on Nomenclature and Classification and Diagnostic and Therapeutic Criteria continue to provide requisite guidance for physicians around the world. By 1948 it had become apparent that financial aid had to be sought in order to support critically needed research in arthritis, patient services and public education. In that year the AHA was largely instrumental in the creation of a voluntary health agency dedicated *exclusivelyto the fight against arthritisThe Arthritis and Rheumatism Foundation (A. & R. F.). The A. & R. F. has served faithfully, led by loyal lay volunteers under the chairmanship of Mr. Floyd B. Odlum. While the ARA as such has no decisive voice in A. & R. F.’s major policies, relationships between these two organizations have always been cordial. Indeed, many of ARA’s activities could not be accomplished were it not for the financial assistance of this organization. Although restricted by limited funds, its medical program and Medical Director, Doctor Ronald Lamont-Havers, deserve our warmest praise. To confirm this fact one has only 311 ARTHRITISAND RHEWMATISM, VOL. 6, No. 4 (AUGUST),1963 312 EPHRAIM P. ENGLEMAN to refer to the impressive list of 120 A. & R. F.-supported Research Fellows and their distinguished contributions. ARA members, along with representatives of the A. & R. F., were largely influential in the decision in 1950 to expand the activities of the National Institutes of Health to include arthritis. The accomplishments of the National Institute of Arthritis & Metabolic Disease (NIAMD) are well-known. In the past year NIAMD has supported 43 Arthritis Training Grants while awards for arthritis research have approximated 5 million dollars. In 1958 a long and well-establishedvoluntary agency, The National Foundation, entered the field of arthritis. While ARA does not claim credit for this event, many of its members are major participants in this new program. The National Foundation and the Director of its Medical Department, Doctor William Clark, are commended for their endorsement and support of the many arthritis research projects and Arthritis Clinical Study and Treatment Centers in several of our teaching institutions. Progress, then, has been impressive, especially in research and scientific communication; and ARA has played a key role. However, I submit that ARA has not played as forceful a role as the tremendous task demands. There are many challenges of arthritis which ARA has not really faced. To do so will require an effort far greater than any made up to now, an awakening of many more people throughout the nation, a mobilization for a far more vigorous crusade of human energies now dormant. How will the membership of ARA fulfill its significant role? Before presenting a plan for the future I wish first to take note of certain trends and innovations as well as likely objectives. Ours has been an expanding economy with a constantly improving standard of living for our people. Thus we have been able to support through taxes multiplying governmental services while at the same time contributing more to private philanthropic health causes. Although more voluntary health agencies are now active than in previous years, and although some of these agencies are growing at a phenomenal rate, I would emphasize that the philanthropic share of the total health effort is diminishing when compared with the government’s program. A major objective in our future crusade against arthritis will be a sustained program in research. The current, extra-mural dollar support of research in arthritis by the National Institute of Arthritis and Metabolic Diseases is at least five times that of the combined support of the Arthritis and Rheumatism and National Foundations. Does this mean that we must think only in terms of federal support in the health research field with a diminishing role of private philanthropy? While it is agreed that most financial aid will come from tax-supported sources, physicians should give balance to governmental programs with the private initiative and support of the voluntary health agencies which have become such an essential part of our way of life. The voluntary agencies have greater opportunities for experimentation than those which are tax-supported and are not constrained by the prerogatives and mandates of legislatures; they can react quickly to new opportunities, to new emergencies; they can demonstrate new methods which, if successful, may be desirable for adoption by the tax-supported health agencies. In fact, the activities of the private and public agencies must be PRESlDENTIAL ADDRESS 313 coordinated so that they supplement and complement each other in a manner that will best serve the health of the nation. Perhaps the most urgent objective in our crusade against arthritis will concern the improvement of professional education and patient care. Some twelve million people in the United States have rheumatic diseases. This prevalence is so high that responsibility for these patients must be assumed by doctors with varying interests, including general practice. There is today a critical shortage of physicians with at least a modest degree of skill, or even interest, in the care of these individuals. As in other branches of medicine, a serious gap exists between the knowledge available about rheumatic diseases and its application for the benefit of the patient. The degree of interest in rheumatism generated in most medical students and house officers has been woefully small. The usual explanation for this deficiency has been that most of these diseases are chronic, showing slow progression, and presenting complexities in management which can be most frustrating. But more fundamental causes of this deficiency must have been partly our state of ignorance or, in recent years, inadequate instruction. For it is now increasingly apparent that young physicians, when exposed in the properly enlightened and academic environment, do respond to the challenge of rheumatic diseases. To be successful, a teaching program must rely in part on full-time academic personnel. Nearly one-half of the medical schools in the United States are still without full-time rheumatologists. The present and future Trainees and Fellows in arthritis will of course be candidates for such positions. But the mere presence of a full-time academician in rheumatology does not in itself guarantee first-rate or even adequate instruction for students. Many full-time members of medical school faculties do not regard teaching as their primary responsibility. Research is generally considered to be the primary obligation, which, when fulfilled, leads most rapidly to academic promotion and reward. Furthermore, some of our best teaching is done by the part-time clinician. Public health funds or even medical school funds are rarely available for the support of full-time or part-time men whose major interests are in clinical instruction. The support of such teachers with a background and interest in rheumatology must come, at least for the foreseeable future, from other sources, and notably the appropriate voluntary health agency. Similar source of support must also be found for the creation of clinically oriented traineeships in rheumatic diseases in order to disseminate skill and knowledge far beyond our teaching hospitals. Most currently available postdoctorate traineeships require commitments to academic careers with emphasis on basic, laboratory research, Funds are almost non-existent for the doctor who wants postresidency training in rheumatology to enter clinical practice. Provision for improved clinical training in rheumatic diseases is imperative if we are to meet the objective of optimal patient care. What about the continuing education of the practicing physicians? How can we sustain their interest and skill in treating rheumatic disease? The problem of continuing education of physicians is not peculiar to rheumatism. 314 EPHRAIM P. ENGLEMAN We actually have few data with which to appraise critically the effects of traditional postgraduate educational programs. The concensus is that they are relatively ineffective and fail to stimulate interest among physicians generally. Continuing reappraisal of all methods employed in postgraduate education in rheumatology is urgently needed. This is a task for which the private foundation is ideally suited. The physician’s unresponsiveness to continuing education is a problem in which tax-supported agencies are not likely to be involved. Another educational weapon in our fight against arthritis wiIl be an intensified campaign in public education. We need an urgent all-out attack on the public’s ignorance of arthritis and its effects. We need to inform the public better on some simple facts; for example, that most arthritis is not a disease of old age; that gout is a common form of arthritis; that a systemic lupus is not necessarily a fatal disease. The public must be told of the significant results and potential benefits of current research, and of the merits and limitations of medical treatment. People need to be awakened to the social implications of arthritis and the staggering effects of arthritis upon our economy. The transmission of this message to the public will be a critical objective of our crusade. Our exploding population and changing life expectancy are increasing the demand on existing facilities and personnel established for patient care. The mobility of Americans emphasizes the need for dynamic planning for future services in suburbs and rural areas as well as large cities and teaching centers. A11 of this points to the need for adaptability and imagination in the design of new community service programs, so vital to our crusade. Information and referral services, rehabilitation centers, work evaluation units, vocational and home counseling are only a few types of local services which may help physicians in their patient care and help patients help themselves. This is the kind of service at the grass-root level best planned and implemented in the communities themselves. The local units of voluntary health organizations have already demonstrated skillful leadership in the development of community health services. Our campaign against arthritis must be an ambitious one. It will be expensive. But I need not remind this audience that arthritis and allied diseases are among the major health problems of our time. And while most financial support inevitably will come from federal agencies, we cannot overemphasize the indispensable contribution and function of private philanthropy. What will be the role of the ARA in our crusade? How can the ARA contribute most effectively to the all-out fight? The answer to these questions can be stated in one word: leadership. ARA has an obligation to exercise this leadership; leadership toward the fulfillment of the objectives of our crusade; leadership in arthritis not only in science, but also in education, patient service and public service. By what device will this leadership be exerted? If we of the ARA are in full agreement with the objectives of this crusade, and if we really believe in the indispensable function of the philanthropic agency in arthritis, then ARA must assume its share of responsibility in the leadership of such a movement. In this capacity ARA can best demonstrate its determination to lead a successful crusade. The membership of ARA must be prepared PRESIDENTIAL ADDRESS 315 to participate as active partners with interested lay people in all phases of activity. We would depend for administrative counsel on our non-medical colleagues, and they wauld look to us for medical decisions; together we would assume responsibility for policy. Just as medical and non-medical people would share equal responsibility at the national level, so would they work together in local communities.This will mean the expenditure of large amounts of time and energy by all physicians and lay persons to whom the challenge of arthritis is meaningful, The private arthritis agency of this day and age does not and cannot confine itself to the business of raising and spending money. It must also serve as a source of authority in arthritis. Its deputies must be available for consultation with spokesmen for all groups concerned with the nation’s health: medical and paramedical societies, civic organizations, health and social agencies, industry, the military and, most significantly, with spokesmen for legislative bodies and public health services. Little wonder that the arthritis agency must speak for medical and lay leaders alike. And let us not overlook the fact that the most successful of today’s philanthropic health agencies, notably those established for heart, cancer and tuberculosis, are the results of an integrated partnership of scientific organizations and lay bodies. Thus committed to an all-out crusade against arthritis, ARA will have one more major responsibility. In my opinion, ARA must exert leadership toward consolidation under one roof of all philanthropic activity in the field of rheumatic diseases. We must join forces. The increasing competition for the taxpayer’s dollar indicates a critical need for concentration of available efforts and available strength. Multiple appeals for funds in the field of arthritis will ultimately result in diminished public support for even the worthiest agency. Givers desire and expect the solidarity of effort represented by a single agency concerned with a single disease or group of diseases. Practicing physicians, basic scientists and educators devoted to rheumatic diseases will best concentrate their available efforts and energies when all of these can be focused within one philanthropic force. Many of us are already finding ourselves unavoidably involved with more than one voluntary organization. This can result only in harmful dilution of our efforts and division our loyalties, Consolidation of philanthropic activities in arthritis will increase total effectiveness and do away with unnecessary duplication. It will focus the public’s attention on the urgency of our great problem and will serve as a motivating and accelerating force toward its solution. Consolidation will best serve the interest of the patient, the public and the doctor. The only means by which voluntary efforts in arthritis can be consolidated is through the leadership and active partnership of the American Rheumatism Association. I am happy to announce that an ARA committee will meet soon with representatives of leading voluntary health agencies to consider means of developing a strong voluntary effort in arthritis, involving both lay and professional leadership. Through such a cooperative effort, the fulfillment of our objectives and a victorious crusade against arthritis will be assured. 31.6 EPHRAIM P. ENGLEMAN REFERENCES 1. Betts, R. A.: An address. 8th National Conference on Solicitations. St. Louis, 1963. 2. Carter, R.: Gentle Legions. New York, Iloubleday & Co., 1958. 3. Dryer, B. V.: Lifetime learning for physicians. J. M. Educ., 36: 1962. 4. Miller, G. E.: Teaching and Learning in Medical School. Cambridge, Mass., Harvard University Press, 1961. 5. Research and Education in Rheumatic Diseases. Transactions of First National Conference. Washington, 1954. 6. Ibid. Transactions of Second National Conference. Washington, 1957. 7. Smyth, C. J.: American Rheumatism Association-A quarter of a century of progress. Arth. & Rheumat. 2:475, 1959. 8. Voluntaryism and Health. National Health Council. New York, 1962. Ephraim P . Engleman, M.D., Associate Clinical Profes*soY of Medicine, and Director, Arthritis Clinical Study Center untl Rheumatic Disease Group, Department of Medicine, University of California School of Medicine, San Francisco, Calif.