KEYNOTE ADDRESS-CHALLENGES FOR ENVIRONMENTAL HEALTH
Ronald G. Blankenbaker, State Health Commissioner
Indiana State Board of Health
Indianapolis, Indiana 46206
I would like to discuss with you some of the concerns and challenges we face during
this decade regarding environmental health. Then I will present some comments on current
special environmental health. Then I will present some comments on current environmental issues. Last, I will try to answer any questions you may have.
In the 1940s and 1950s technical development and increased production were the
primary goals of the health care professions as they were of industry in general. Cost was
generally only a minor consideration, with quality, innovation and excellence being the
primary motivators. However, the 1960s brought civil rights, Medicare, Medicaid and antitrust actions, with consequent social intervention in the delivery of health care as well
as industrial development. This was influenced by a desire for lower cost and greater
availability. Consumerism, in the eyes of many, pushed quality medical care to a secondary
role.
Health care became oriented toward groups, categories and diseases, with an inherent
depersonalization of the individual. Society did not find this acceptable and supported
a movement toward the humanistic approach. In the latter 1960s and early 1970s primary
care became a household word and family practice the 20th medical specialty. It was
suddenly fashionable to have a "family doctor"—a concept popular in the 1800s and early
1900s. The 1970s consequently developed a promise of "quality, personalized care for
everyone."
However, the economy could not support this concept, and "cost containment" under
the guise of health planning became the guiding light. It seemed prudent to bridle the
spiraling costs of health care, which were increasing faster than inflation. Early on we
heard that there were not enough physicians; then, that there were enough but that they
were just poorly distributed; and now, that there are too many-in each case these reasons
have been listed as a cause of excess cost. Quality of care again seems to have taken an
unnecessary secondary role.
To complicate matters, good health today means freedom from any cause which would
prevent one from carrying out his/her chosen lifestyle. This is so broad that essentially
everything we do and everyone with whom we come in contact has a potential positive
or negative effect upon our health.
If all of this seems confusing, it is—primarily due to the generally poor understanding
of the workings of the health care delivery system. At one time the medical profession
ran this system with authority and warranted credibility; however, its failure to provide
acceptable solutions to assertions concerning the "underprivileged and underserved classes" resulted in the federally controlled Medicare and Medicaid programs. However, government did not take total control of health care and, consequently, left the rest in limbo.
This set the stage for the public to question the medical profession's credibility (resultant
increase in malpractice suits, etc.). This further eroded the profession's control. The
public took charge of the system directly through its use or nonuse of the system (determinations based on whims, etc.) and indirectly through its government (health planning,
utilization review, etc.), even though it did not wish the latter to have total control.
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