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Presidential address to American Rheumatism Association. The crusade against arthritisThe role of the American Rheumatism Association

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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
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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.
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