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THE GROWING CHALLENGE OF DISABILITY CONTROL IN AN ERA OF COMPREHENSIVE MEDICAL CARE * * * * * * * * ** A symposium in the public interest sponsored by Liberty Mutual Insurance Company in Boston, October 15-16, 1959 * * * 4c * * * * INTERPRETIVE SUMMARY OF THE SYMPOSIUM'S DISCUSSIONS AND FINDINGS by Rene J,, Dubos Member and Professor Rockefeller Institute for Medical Research As you all know, there are more than one hundred million adults in this country, and as you also know that makes at least one hundred million worthy "experts" in the matters of medicine, sociology and economics, I am one of those "experts". Now, this is not a facetious remark. It is a very serious remark, be cause it does symbolize, I believe, the fact that the subject which is before us is a subject that has very many different facets on which all of us have some experience and practically all of us opinions. My role here is to reflect before you as many of those facets as I have been able to catch light from, and the very fact that there are so many facets is one which of itself is important to the symposium, because the differences are not only, as has been emphasized several times yesterday and today, the differences resulting from conflicts of interests, of selfish interests between labor, management, insurance, society, and society in general, etc. More im portantly, these differences result from the fact that we are dealing with a human problem which is affected by almost every component of life. In attempting to bring to you the composite impressions that I have ob tained, allow me to start with the least pleasant aspect of it, almost the gloomy aspect of our symposium, and I do believe that in all our discussions there has been a background of pessimism as to the difficulties of the problem to be solved. This pessimism is well justified by the fact, as all of us know, that our society is becoming more and more complex, and each and every member of it in terdependent upon the other, so that whatever one does to one member of society is likely to affect the other and often in unfavorable manner. Most important, perhaps, from this point of view is the position of the working man in our society. The very complexity of our civilization has com pelled us to specialize the working man, specializing his occupation, and when (1) I speak of the working man I am not only speaking of the man working in a plant in Detroit. This applies to each and any one of us who makes his living out of his specialized occupation. Now, our very specialization does bring about a tremendous decrease in the degree of freedom with which we can operate. Few of us are free to move around from one occupation to the other, because, in fact, we are fitted for only a very limited range of occupation, so that if we lose what we have it is not very likely that we will find something equivalent. In this light, I believe, it is clear that society has a responsibility toward the working man who for one accident or another loses his job, and this justifies, in my opinion, the demand for all sorts of protection on the part of the working man, but it is clearly so that too much protection brings about a sort of paralysis of our economy and that clearly management cannot yield readily to the demands for excessive protection, because it destroys its pressent freedom of operation, and upon this freedom progress in technology depends. All of us fear a paralysis of our society through too much protection and regulation. The biologist has in mind all the animals and plant species that disappeared because they lost through overprotection the ability to maneuver and to adapt themselves to changing environment. All of us also have in mind the disappearance of societies in the past that have become too completely organized and protected. I believe that Toynbee has described in his monumental history many examples of those arrested civili zations that have become too specialized. Another source of worry which I have preceived throughout our discussion and which, for that matter, has been clearly reflected in many of the questions that were brought from the floor to the members of the panels has to do with an attempt not so much to define what occupational injury is, but, rather to try to differentiate it from incapacity due to general disease. This is obviously a problem which is absolutely essential to our symposium. To state again examples that were brought out yesterday and which Dr. White and, I believe. Dr. Binger again mentioned this afternoon, how can we convince indus try to reemploy a man who has had a cardiac accident or some psychiatric dis order, if industry thereby becomes liable for any subsequent accident in the life of this individual once he is again employed. I did not hear, I'm afraid, or perhaps I missed any very serious attempt at defining this difficulty, but I'm convinced that in the minds of the literallyminded people this must be a very disturbing problem. I believe that we should discuss it, that one will have to discuss it, and I'm not competent to discuss it, but I'd like at least to bring out the two as pects of the problem that came to ray mind while listening to the discussion. One aspect of the problem is that in my opinion medicine, the physician, the teaching of medicine, has a responsibility in the present attitude of fear of the public and, therefore, of the employers toward employing again a man who has suffered some accident in his past life. It is true that yesterdqy and (2) again today we have heard it well stated, forcefully stated that a man who has had a cardiac accident is almost just as good as another, but in truth all of us know that this kind of teaching is on the whole rather new. Almost any phy sician that was trained 20 or 30 years ago came out of medical school with the feeling that this man should protect his life and by "protect his life" that means as far as possible do nothing. And this applies also, of course, to many other kinds of disorders, psychiatric disorders, e.g., so that I have an impres sion that there is here more than a responsibility, a duty on the part of the medical profession to convey more effectively than is being done at the present time to the public and therefore to the employers the concept that an accident in one's life in the past is not necessarily such a dangerous situation to be considered with regard to the future. Then I was interested, by the way, in listening this afternoon to Dr. White's report that obviously the committee of which he spoke has the intention of communicating this point of view to the public. Then there is another difficulty with regard to disassociating disability due to working conditions or accidents while working and medical disability in general, and here again I believe the medical profession is in part at fault, and it comes in my judgment from a kind of teaching which is still too prevalent even though here again I realize that times are changing in the definition of cause of diseases. There is still in the scientific in general and, of course, in the lay pub lic the concept that one thing has a cause and that if an accident happens you can always trace it to a well-defined cause. Some of the examples that were given yesterday point very clearly to the fact, well recognized, of course, by many of you, that this is a very fallacious way of looking at things. An individual, a worker with a dependent personality makes a wonderful ad justment to a certain environment and performs well. Then there happens to him a minor accident, minor in terns of what is done to him physically, but that minor accident, because of a complexity of other social causes, acts as a trig- gjCi 4o-iUid*j+o oxxCxi uCvCi luxntiCoeo ^xrn nxw na C OcoCvx ^xv/uoc qc+q+6 vx aQxiTx^Qax^*r*Oc When you listen to that story you realize that it is practically impossible to trace what is the one cause, which part is to be traced to the working'condi tions and which part to the whole other components of the social structure in which this individual functions, so that here again it seems to me that the medi cal profession will have to reeducate legal people away from the view that one can readily and clearly determine the cause of an event. Allow me here to quote for you an account that I read some two years ago in the English "Lancet" which has to do with this situation. A working man con tracted pneumonia, some kind of respiratory infection.' Apparently he felt that he had contracted it because the plant in which he went to work in the early morning was cold and drafty and wet. The case was taken to court, and eventually he won the case. I read the proceedings of this case and they are very pertinent to what we are discussing today. On one side some of the medical experts claimed that, as we all know, the individual who developed that respiratory disease became sick because of the multiplication of some bacteria or some viruses which he had all (3) the time carried in his own body, so that in reality the cause of the pneumonia was him. On the other hand, the working man or his lawyer convinced his Lord ship that it wouldn't have happened if the room had not been cold and drafty, and here we see clearly exemplified the difficulty of the concept of causation in pathology. I have no doubt that one of the greatest difficulties that we will see in the elaboration of legislation dealing with the problems that are before us is that of defining the cause of an accident. I have focused so far on the gloomy, pessimistic aspects of our discussion, but fortunately our meeting began yesterday morning in the most optimistic mood, because I wonder whether there has ever been held a medical meeting in which three eminent clinicians could state such pleasant terms the happy fate of the very sick man who can make such pleasant adjustments to life, and, in reality, what was stated by the clinical cardiologists yesterday is clearly an illustra tion of fact that whereas man, as a component of the social structure, is very difficult to manage, man, as a human, living thing, has tremendous powers of adaptability, or if you don't want to use the word "adaptability" at least of adjustment to all sorts of difficult conditions in life. Perhaps the center of all of what was said yesterday and today is precisely the fact that man can perform wonders of adaptation, even in the face of the greatest possible odds, and obviously it is around this power of adaptation of man that one needs construct all the position constructive legislation and prac tices to deal with the problem which is before us. I did not recite before you all the clinical evidence that was offered yesterday as to the ability of the individual suffering even from extensive cardiac damage to function effectively in his environment. As you will recall, this was told in the mostpicturesque manner by Dr. Levine, who convinced all of us that if you can not drive the bus yourself you can at least take a taxi andthat the only objection to flying an airplane is because airplanes are still So unsafe, not so much because man is unsafe. Clearly, we see herethat both physically and mentally even the very defi cient man can adjust himself to all sorts of new situations in life, to a large extent, of course, because man is a thinking animal and most of the adaptations of which we have been speaking are not biological adaptations but social adapta tions. Then, of course, we heard, as we all know, of the enormous advances that technical medicine has made in permitting a man to correct his trouble and to adjust himself. There is hardly any point in reciting here the therapeutic mira cles achieved by drugs and surgery. I would only need warn surgeons when they show magnificant pictures, as they showed yesterday, that they be sure not to cause too much damage in the audience, as happened yesterday. That we are only at the beginning of all this has been made clear this morning by what was shown during the panel on connective tissue. It is plain'that only during the past decade have we begun to know something of the structure of the tissues that are being repaired. (4) Dr. Schmitt spoke a while ago as if we were only at the stage where blood coagulation was a hundred years ago. Well, I think that was even too optimistic. We are just beginning to work on this. IJwish'hS had pointed out, or rather I will point out the hope that I am not putting any false interpretation on this report, that not only are we beginning to discover the structure of the molecules of which the body is made, not only are we beginning to sense that these molecules and these structures are under the control of regulatory mechanisms, but more important to me for the future is speculation on the results which show this morning that even a component of the body that looks as solid, as permanent, as something to last forever as connective tissue, collagen and the complex poly saccharides of it -- that these constituents obviously can undergo reversible changes. It happens that as we were told this morning of a substance derived from the sweetpea which does bring about a change of collagen, now the important as pect of this discovery is not the particular fact that a certain simple substance can change collagen. The important fact is that obviously so early in the game one has encountered substances that can change the appearance, structure, the properties of a component of the body that used to be thought & permanent compo nent, so there is no doubt in my mind that in the very near future -- and when I say "very near future" I am not speaking, of course, of next year -- in a few decades we will manage to control through all sorts of regulatory processes the deposition and the organization of all sorts of structures of the body, and it is then, I believe, that even the most elaborate kind of surgery like that which we saw yesterday will look incredibly primitive, will look like the first indus trial revolution, as compared with what is going on at the present time. In view of all these facts, it is even more interesting to talk about reha bilitation than in the light of what has already been accomplished. I think what we are doing of rehabilitation at the present time is really of the crudest, most mechanical form, because it happens to be the only thing that we know how to do. However, without looking too far into the future, we must take note of that fact which has been so constahtly and brilliantly emphasized during the past two days, namely that rehabilitation is not something that must come after the individual is cured, more or less. Rehabilitation must begin immediately with the very first doctor's visit. I think this is a point of view which is so simple that there will be little difficulty, in my opinion, in bringing it to the public, and when I speak of the public I speak of the general public, of the employer and of the worl<4ng man as such an obvious simple truth that before long the pressure of public opinion will be so great to demand that all steps for rehabilitation be taken from the very beginning of the accident that without question some form of legislation will come about which will make it compulsory. After everything we heard yesterday and today, I don't see how wd can --how there is any need of debating whether ways, financial or legal, must be found to introduce that into the practice of our life, into medical practice. It is plainly obvious that if you were to state to anybody the views that were expressed yesterday and today, it would be considered a crime not to arrange that anybody who has an accident, and that being an accident caused in work or (5) or any kind of an accident, must be handled in such a manner that immediately what is done to him is something that has in view his complete rehabilitation, that is, as complete as circumstances permit. I think when things are as simple, as obvious, as painfully evident, that we needn't worry about the legal aspects of it. Public opinion will force it, so that we might just as well accept it. I, for one, am convinced that if an effective campaign is not begun in the present day that within two or three years some form of political action, if necessary, will come about which will compel action of that sort. I remember some 15 years ago, at the time when penicillin production and production of streptomycin were so expensive that there was much question whether the general public could afford to use it, that it was immediately accepted that whatever the cost that drugs of that sort had to be made available to the public, even though the financing had to be done through other than normal comraerical financing. I think it became very clear throughout all our discussion and especially this morning that litigation for financial compensation should have no place in the decision of what is done to a patient, to the victim of an accident, and here again I'm convinced that whether the accident is occupational or not, and that is always so hard to define, as I said before, ways would be found whereby a whole new kind of medical approach to the treatment of accidents would be based on the fact that there is a fundamental human duty and a very practical selfish social duty to treat a patient, whether or not money is available at that time, to treat him in such a manner that he will be put back in as good a shape as possible. I think this cameout very clearly from our discussion during the past two days. I was, like everybody else, highly entertained by the statement that part of rehabilitation came from the possibility of influencing the patient as he recovers from surgery, while he is still under anaesthesia. I was only surprised +wViiiaow+ r\n Ow*T*iyo njoTt+lrinorl wuv j. a wj. rv>+ of4*-S el O /n'P vx +vVn>a2+v vpYi.r*^a/-v + /-o 9 uvva. if you can influence the patient in such a manner that you convince him that he is well or better or cured, I think the same kind of medicine can be used for far less desirable ends, and if it comes to be practiced l*m sure there will be some large problems of regulation that I was surprised not to hear mentioned this morning. Now I come to that_other aspect of rehabilitation which has to,,do with pre paring the patient either for a job or some other occupation. Here I was quite surprised -- I must say I have no familiarity with this field, as all of you know -- very surprised to hear two very different, opposite points of view being expressed. Mary panelists, on the basis, of course, of very extensive practical evi dence, feel that on the whole it is very difficult to train a patient for a job other than the one that he occupied before. It does not work well, and it makes the man unhappy. I don't doubt the validity of the statement, but I find it a very sad state ment, because it reflects on the fact that our way of life limits enormously the (6) A range of adaptability of the individual, I couldn't help thinking that even the Russian prince or princess that never had to work before, when she suffered the accident of the Russian Revolution at least could find a job as an entertainer in New York or Paris, so that at least even in the past even the most favored people who never had to work could find some other occupation. It's really a sad reflection on our type of civilization if we manage people in such a manner that they are so incapable of changing their life. However, I must say that we heard another view o this. We heard that many patients with psychiatric disorders or at least with psychiatric difficul ties, like dependent persons, are precisely the ones that may be most effective in certain situations in our work As this was being discussed, I was surprised not to hear someone mention that the anthropologist, Ruth Benedict, discussed this problem at great length in her book, "Pattern of Culture." She pointed out that many of the individuals who were the psychopaths of the Zuni society would have the personality type, the type of behavior that would have made them the most successful men in the American competitive civilization. On the other hand, she showed how certain types of persons that are so well fitted to our present society cannot function in other societies. All this, and,of course. Hr. Deutsch presents us with a most entertaining example of that inmate in an asylum that could be the most useful man provided you employed his services to deal with Indian affairs -- all this, I believe, points to the fact that in highly complex societies like ours there are needs for all sorts of types and that before a person is declared to be non-employable we should explore a little more thoroughly than we do if there is not some place in society where his kind of personality justifies itself. Everybody agreed that it is well and good to treat people well, to reha bilitate them, but the cheaper form of control is the prevention of accidents. Needless to say, everybody agreed on that. Moreover, what is more important, I believe, is that what everybody has come to realize, that the prevention of accidents is not only best on theoretical abstract grounds but is best from the selfish point of view for all parties con cerned, whether they be management, labor or the insurance industry, so that the real problem is how to prevent accidents. I need not repeat all the wonderful words that have been said about this topic, and I need not state how much progress has been made in industrial manage ment toward the prevention of accidents. - There is one item, however, that has been touched on but not well discussed, for lack of knowledge, of course, namely, is it possible to select beforehand the individual least likely to have accidents? Is it possible to recognize those most likely to suffer accidents? Well, all of us have known for some 25 years about the existence of those individuals who are accident prone, but we are told, I'm sure wisely, that even though there is a hard core of individuals who are accident prone, all of us on the whole can at a given time under the proper circumstances become involved (7) in accidents, because of disturbances in our own life more than because of a special situation that calls for an accident. Moreover, we have been told that there is no way of telling what individu als will become victim of some psychiatric disorder. Most people seem to make under normal circumstances some kind of adjustment to the environment in which they have to live, and that adjustment is usually so perfect, outwardly speak ing, that it permits them to function. One is not aware of their difficulties, and those difficulties come out only when the environment changes. . Here I'd like to interject the point which certainly is conclusion to all our discussion, namely the fact that our entire society changes so rapidly, be cause of changes in technology and social structure, that the chances of reveal ing latent psychiatric potentialities will become greater and greater, I believe, as our society continues to evolve faster and faster. As against these negativistic views towards the possibility of selecting people, we should know that statements to the contrary have been made. Two of the speakers stated that the past performance of the individual, even though* it does not give you any warranty of what he is going to do, at least increases the statistical chance of your being right in guessing what might happen to him. Another statement was made that all in all the best judgment we can form of that is to look into what the parents of this individual have had in the past, bow they have behaved in the past, and as soon as we say that you recog nize, of course, that there is perhaps a genetic component to that kind of be havior difficulty. I think, however, that the problem cannot be stated simply in terms of either genetic past experience of the individual or in terms of environment. Everybody who thinks about problems of genetics now knows that whatever your genetic background, what will happen "to you is determined by the enviornmen- tal circumstances under which you are placed, so I believe that this calls for more extensive study than is available at the present time, more extensive ana- lysis of* "tlis relation of6 itis gsnoil +v. en^^0c.0t^ lexCaurivA/CD oo. 'V'lrl +V\ environment, to determine, to explain accidental events and phenomena in the lives of individuals. Here, again, I want to reemphasize that our greatest difficulty in the fu ture is the fact that our society is changing so terribly fast that many of us do not have time to become adjusted, that many of us do not have the occasion to receive from our teachers or from our family the kind of wisdom that usually helps in social behavior, and here I'd like to quote from memory a statement made by Ambassador Cannon some couple of years ago, in which he was dealing with political problems and in which he said, "Whenever society changes so fast thath the experience of the father is of no use to the son, then you can expect trouble" and these are precisely the conditions of our rapidly changing civilization. I have no doubt that we have here a new situation, due to the fact that neither in our personal life nor in the lives of those that have preceded us can we derive the acquired wisdom that has so much facilitated adjustments in the past. (8) Now, as the time is coming to an end I'd like to end on some very much larger issues on what I make bold to call a sort of philosophy of control of disability, which in some way will be a sort of dogmatic statement of what has been said befofe me. I think everybody agrees that control of disability is to the benefit of everybody in our society, of the working man, of management, as well as of the insurance industry, because all of it is tied to efficiency in production, to costs and, therefore, to the welfare of all. It is true enough that all of us have different points of view. We see the problems in different lights, we have slight differences of interest, but these are very minor compared with the size of the problem, and I would like to quote here from something that was mentioned yesterday which to me states the problem well: "The control of disability is less a question of fixing the responsibility for it than it is one of exercising every possible means of prevention and, of the care and rehabilitation of the disabled person. The rising costs of disa bility, of course, are of major concern but exceeding them in importance is the matter of remaking the worker, not merly of slapping an expensive fiscal plaster onto the wreck that he has become, with or without well intentioned encourage ment." But I think the problem is even larger than this statement quoted from the New England Journal of Medicine. The problem is larger than that, because, in my opinion, the problem that we have discussed is not a problem peculiar to the working man and his disability. I think what we have been discussing are problems very peculiar to our so ciety as a hole, to each and every one of us. Our social structure is such that this problem must be dealt with by techniques other than the conventional tech niques, and I was very impressed by the fact that both Mr. .Black and Mr. Pollack, who represent such different aspects of our society, both emphasized the absolute need of developing new formulae, formulae that would fit the tech nical growth and the financing of medicine so that they can be fitted within the needs of our new society. Clearly, the problem before us isthat all of us are becoming involved in a highly technological, specialized society and that we are creating a new en vironment for which we are not prepared, for which we cannot prepare ourselves completely. We speak of the obvious disabilities that come today from a man cutting his hand or being burned but these will be very small problems compared. with those that we will have to meet next year or next decade, that will come from poison ing substances released from the exhausts of our factories or from radioactive elements. We have to think not in terms of workmen's compensation, but in terms of protection of society. We have to learn to adapt ourselves to the new techno logical society that we are creating, and as Dr. Schmitt said, I believe, this morning, the ability to adapt is on the whole one of those obvious forms of intelligence. (9) I There is no doubt that the problem that we have discussed will serve as a pattern for all sorts of social changes in the management of disease, and I cannot see terminating without telling' you how all this has influenced my own way of looking at these problems. Until a couple of years ago, I used to think that the problems of health were symbolized by the great goddess Hygeia in,the Museum of Athens, showing the beautiful Greek maiden, wonderfully balanced, mar velously adjusted in a peaceful manner to her environment, and obviously this attitude of a healthy living in a health environment, has colored all the formulae of public health in our teaching. I have come to think that this is- a sort of defeatist attitude to take, because in reality this view of Hygeia, of the Greek maiden so well suited to her lovely environment, has meaning only in a static society, a society that is not going to live much longer, because no static society can survive in the face of competition. In contrast, now-, I think as representing medicine of that bust of Hippoc rates which is in the British Museum in London, in which you see this thinking man, not as attractive, of course as Hygeia, but obviously concerned with every thing that is going on around him. He does not believe in a static Utopia be cause a statis Utopia is dead. He believe, as Hippocrates taught, that as society changes, as the world, physical or social, around us changes, we must change, and it is, I believe, the most hopeful aspect of this symposium that every speaker, whatever his subject, has emphasized not a static definition or a final.solution to our problem but rather the development of formulae that permit us to adjust ourselves to the changes that will continue to come to us. Clearly, enough, nothing will be solved forever. We must always be ready to meet the unforseen contingencies, but this is life, and not only is it life, but it is growth, and that is what all of us here are dedicated to. (10)