in III flimilli - NUARY 1969 AO Published by the American Medical Association VOLUME 47 FOR THE AMERICAN FAMILY NUMBER 1 Helping Your Youngster Beat Bankruptcy .................................... 20 James J. Cox Viet Nam's Yin Yang Medicine .................................................... 24 Gwenn R. Boardman Figure Skaters' Mecca ................................................................ 28 Earle Lass Regional Medical Programs Mobilize Against Disease .................... 32 Theodore Berland How to Survive Women ................................................................ 40 Joseph N. Bell A Woman Who Changed Our History ............................................ 44 Webb Garrison Patients With a Purpose .............................................................. 46 Theodore Irwin "No One Else Can Be as Helpful .. ................................................ 52 Virginia Apgar, M.D. Your Body's Silent Partners ........................................................ 54 Ralph Bugg Niagara's Winter Ice Show .......................................................... 57 Mike Michaelson Consider the Mushroom .............................................................. 60 Gaynor Maddox Tracking the Mystery Rash .......................................................... 66 Alexander A. Fisher, M.D. The Meaning of Hospital Accreditation ........................................ 88 Roger Olin ALSO IN THIS ISSUE That's a Good Question ........................... ... ..... .. .... ... ................. 3 The Look You Like ............................ ..... ... ...... ... . . . ..................... 4 Linda Allen Growing Pains ......................................................................................6 Today's Health News ............................................................................ 9 Alton L. Blakeslee Let's Talk About Food .......................................................................... 12 Philip L. White, Sc.D. How to Belt In Your Children .............................................................. 14 F. Glen Loyd Medical Briefs ...................................................................................... 17 Research Links Air Pollution, Disease .................. ............................... 18 New Dimensions for Blind Youngsters .................................................. 34 ECG Machine Gives "Instant" Heart Profile ........................................ 74 Tips for Your Home and Family ........................ .................. ............... 77 First Aid: Heart Attack ......................................... .............................. 80 Carl J. Potthoff, M.D. A Woman's Way ................................ .................... ........................... 85 Cissie Elliott H. McCleary Editor TODAY'S HEALTH articles are indexed in Readers' Guide to Periodical Literature. William R. Vath Managing Editor Ralph Linnenburger Art Director CHANGE OF ADDRESS: Be sure to notify us of your change of address at least six weeks before the change F. Glen Loyd Mike Michaelson Alan Rosenthal Associate Editors is made, including an address label clipped from your latest copy. Give both your old and Lucille E. Morrisey Administrative Associate Kent C. Starr Art Associate new address and include your Zip Code. Copyright, 196B Frederic T. Jung, M.D. Medical Adviser Charles S. Lauer Advertising Director American Medical Association TO HEALTH is published monthly by Robert A. Enlow Circulation Manager John F. Casurella Assistant Circulation Manager theDAAY'mserican Medical Association. Yearly subscriptions: U.S., U.S. Possessions, Canada Cover Photo: Ozzie sweet and Mexico, $4; other foreign countries, $8. Single copy, 50 cents. Volume 47, Number ADVERTISING OFFICES: 122 East 42nd Street, New York, N.Y. 10017, Area Code 212, TN 7-6640. 1. Printed in U.S.A. 535 North Dearborn, Chicago, Ill. 60610. Area Code 312, 527-1500. 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The health projects focus on three major causes of death and disability: heart disease, cancer, and stroke. Text and photos by THEODORE BERLAND IF YOU DRIVE south to Florida on U.S. Highway 41, you pass through the quiet community of Hopkinsville, Kentucky, population 19,465. It is surrounded by hard- wood forests checkerboarded by golden fields of ripening tobacco. Here and there, the rolling horizon is punctu- ated by rising wisps of smoke from blackened curing shacks. Until recently, if you were stricken with a heart attack in Hopkinsville, the nearest coronary-care unit would have been in Nashville, Tennessee, some 70 miles away. (Heart-attack patients in small towns receive excellent treatment; however, intensive-care facilities contain vital specialized equipment.) Today, a family doctor with a heart patient in Hop- kinsville's Jennie Stuart Memorial Hospital merely picks up his phone, dials 79, and is on a direct line to Vanderbilt Universitv Medical School in Nashville. He need only ask the operator to be connected with a cardiologist, with whom he can quickly consult. Now being installed, and perhaps in operation by the time you read this, will be an even more direct corn- munication link. Electrical signals (ECG, for electro- cardiograph) from sick hearts will be sent directly over trunk lines to Vanderbilt's coronary-care unit (CCU) . There the readings will be interpreted by a cardiologist, who can analyze them over the phone for the patient's doctor and offer advice on treatment. Before long, hospitals in seven smaller communities within a 60-mile radius of Hopkinsville will be on the ECG communications line. Muhlenberg Community Hospital in Greenville, Kentucky, 48 miles north of Hopkinsville, already has an always-open phone hookup. An ECG line also is in operation between Vanderbilt and the Williamson County Hospital in Franklin, Tennessee. Franklin is only 18 miles from Vanderbilt, but in terms of a heart-attack victim, that represents For Dr. Jules J. McNerney, director of the Hopkinsville, Ky., about 30 minutes by ambulance-half an hour which office of the Tennessee Mid-South Regional Medical Program, could easily mean the difference between life and death. the day begins with another sheaf of lifesaving projects. The Williamson hospital has a newly built coronary- TODAY'S HEALTH/JAN. 1969 -2- care unit with piped-iii oxygen, heart monitors, and heart starters (defibrillatoi-s) Today, every blip from a sick heart shown on a monitor in the nursing station' in Franklin's CCU also olows on a monitoring screen at Vanderbilt's CCU. The telephone line between the two hospitals is tlNva)-s open, so that a coroiiary-care nurse in Nashville Nvlio spots @t change in a heartbeat signal can immediately alert the Franklin nurse to call a doctor,and advise her ivliat measures to take in the meantime. These new communication links between Nashville and its rural environs serve an urgent purpose: saving lives. In coming @@eirs, similar iietivoi@ks will be intilti- plied throughout the nation. And this is just the be- ginning of perhaps the most ambitious medical care undertaking evei- started. U.S. Surgeon General William H. Stewart li@is called it "one of the most exciting de- velopments in the IiistorN, of medicine." Formally known as the Regional Ale(lical Programs (RMP) , it is a unique and effective coalition of federal government fin;in(-itilol- and coordination, local medical planning and implementation. Across the country, 24 Regional Medicil Pro,@l-ams are now in operation, in areas as diverse as New York, New Mexico, South Caro- lina, and Oregon. Others are gettina started in parts of Illinois, Hawaii. PeiiiisN,IN@ania, ind Nebraski. But the whole Regionaf Medical Program is still in its cliild]IOOLI and a lono iv;t), from being rea(tv to serve the tremendous needs seen for it five years ago. That was back in Nlarcli 1964, when Pres. Lytidon B. .Johnson appointed a Commission on Heart Disease, Cancer, and Stroke, ivitli famed Houston cardiovascular surgeon Michael E. DeBakey as chairman. The next month, ivhen this distinguished committee of doctors, health administrators, and laymen met for the first time in the White House, the President said, "Unless we do better, two-thirds of all Americans now living will suffer or die from cancer, heart disease, or stroke. I expect you to do sometliin- about it." The year before, this deadly disease trio took 1.2 million lives. Today, they account for more than 70 percent of all deaths in the nation. As the commission stated in its final report in December 1,964, "Compared ivitli them, all the other enemies of man-the great range of infectious diseases, accidents, congenital and nutritional disoi-dei-s-fade into relative insignificance." Ironically, the ascendancy of these three killers was w- the result of the most rapid and meaningful medical AW progress in history. The commission noted: "A few short tlecades ago, tuberculosis was the greatest single menace to American health. Pneumonia and influenza took a heavy toll each year. Infectious diseases of infancy cut off many lives that had barely begun. For the over- ivorked physician of lioi-se-and-buggy days, heart disease and cancer were far down on his list of preoccupations." Advances in medical science have lessened the dangers W of TB, pneumonia, and the infectious diseases, making cancer, heart disease, and stroke the leading medical problems. Research and its results in the Big Three diseases Heartbeats of patient in coronary-care Unit (top photo) of have been considerable. The chief problem is imple- Fi-a?iklin, Tenn., hospital are 7izonitoi-ed by ntirse. Signal.5 mentation. These illnesses are, (Co?itinued on page 84) simultaneously show on Vanderbilt CCU's screen in Nashville. TODAY'S HEALTH/JAN. 1969 - 3- in medical parlance, chronic diseases. -was an aII-white school, and Meharry The instructors will he learning, too Unlike polio and measles, they appar- was all-Negro; now both institutions are They will see how physicians in the ently cannot be whisked away with an integrated. hinterlands and city slums practice. They effective vaccine. They require buildings The birth of Tennessee's RMP was will get a better idea of how to better full of equipment, manned by doctors, arduous. Early in 1966, a committee of educate tomorrow's doctors. nurses, and other personnel trained in' medical professors contacted 47 sur- Education also is a prime goal of the special skills in addition to their exten- rounding county medical societies to tell coronary-care links between Vanderbilt sive formal education. them about RMP and ask their needs. and outlying hospitals. The federal Thus much knowledge exists to more "First we wrote them," recalls Dr. government paid the biggest part of the efficiently care for heart disease, cancer, Lloyd Ramsey, associate professor of installation costs for the hospitals at and stroke. But it needs to be lifted off medicine at Vanderbilt. "Their responses Franklin, Tennessee, and Hopkinsville, library shelves and applied. In the words were quite varied. You know, doctors Kentucky. But in two years these instal- of the President's commission: "For ev- are generally very skeptical about inno- Iations will be supported solely by local ery breakthrough, there must be follow- vations, Many of them waited for some funds. In the meantime, the physicians of through." sort of edict. After a while, they realized Franklin and Hopkinsville will have The next step was up to Congress. that there would be no edict, that there learned more about up-to-date care of After a year of hearings and parlia- would be no one to tell them what to coronary patients, including the skillful mentary maneuvering, Public Law 89- do, and that they would have to define new interpretations of ECG's and the 239 was passed. President Johnson signed their own needs." complex but crucial care of patients in it on October 6, 1965. This is perhaps the greatest strength their first minutes, hours, and days after To date, the 54 regions now organized of RMP: While it was conceived at the heart attacks. have been awarded grants totalling some national level, it is designed for strictly Then, once the coronary-care teams at $80 million. Last September, Congress local implementation. The initial funds Hopkinsville and Franklin are operating, extended the law for another two years come from the federal government, but their doctors,'in turn, can go out into and added amendments to make the pro. the programs spring from within the the surrounding countryside to pass on grams more effective. community. their knowledge and teach newly ac- For the first time in American his- The Vanderbilt committee visited ev- quired skills to others. tory, "health-market areas" were defined. ery county medical society in their re-, "Much of this information," explains These regions do not necessarily follow gion. In most cases, because the idea Dr. Faxon Payne of the HopkinsvilIe state borders. (Some states have two was novel, they had to suggest the sort hospital, "is passed on at national and or even three regions within their bor- of help that a community might request state medical meetings. But the bedside ders.) Instead, the regions are natural to improve its care of heart disease, training is missing. Besides, rural doctors communities of patients including one cancer, and stroke patients. seldom take time off to travel across the or more major medical centers, much The experts found that the key to state or the country to medical meetings. as a residential community is served by better care in the Tennessee Nlid-South We're going to have to bring their les- shopping centers. [A medical center is Regional @edic-al---Program is better sons to them, even if it means setting any school or other institution which communications. This was obvious in up mobile medical classrooms, which is supplies postgraduate medical training, the planning stages and has been proven something we are planning." _ and its affiliated hospital (s) .] true since the program became opera- Doctors aren't the only ones who re- The concept of regionalization of tional in February 1968. ceive further education under RMP. health care services didn't begin with According to Dr. Stanley W. Olson, Nurses from throughout the region have RMP. It first appeared more than three first coordinator of the program, and taken special RMP-sponsored coronary- decades before. In 1932, remotely located now in Washington as national director care classes at Baptist Hospital in Nash- hospitals and doctors in Maine were of RMP (a division of the Department ville. They are schooled in the intricacies liniWd with university centers in Boston of Health, Education, and Welfare), "If of heart attacks and the care of heart pa- for the same purpose: learning to apply it has done nothing else, it has en- tients. They also learn how to use ad- the latest medical techniques to current hanced relations between the races." vanced electronic equipment to monitor health problems. Doctor Olson was speaking of the close diseased hearts and to "restart" them Today, the 54 regions have received cooperation between Vanderbilt and when necessary. The open trunk lines federal RMP grants to plan heart dis- Meharry. between Vanderbilt, HopkinsvilIe, and ease, cancer, and stroke programs. Each Dr. Frank A. Perry, Negro surgeon and Franklin provide further education for local project is unique; there is no director of Meharry's RMP projects, these nurses. .1 typical" region. Missouri's includes the agrees. The program has made feasible So far, care and treatment of cancer western part of the state and is head- follow-up education of the 86 Negro patients in this RMP has concentrated quartered at the University of Missouri's physicians in the state, Doctor Perry on the further training of x-ray techni- medical school in Columbia. The Bi- points out. cians in the use of radiation treatments. State RMP, headquartered in St. Louis, Meharry has begun an intensive post- "In less than a year, we have doubled covers east6rn Missouri and southern Il- graduate education program for busy the number of radiation technologists in linois. Georgia's program includes the Negro doctors. It's designed to teach the this county alone," Doctor Ramsey points whole state and operates from offices of physicians to apply results of new medi- out. In addition, Meharry plans a new the Nledical Association of Georgia. cal breakthroughs to save lives and de- course to train x-ray technicians and will The Tennessee Mid-South RMP in- crease disabilities from heart disease, open- a supervoltage radiation facility cludes eastern and central Tennessee and cancer, and stroke. At the same time, for treating cancers. a contiguous part of Kentucky. The pro- teams of visiting instructors are being One advance in radiation therapy is gram is jointly administered by two organized to go out and teach the new the computation of doses by computer. medical schools: Vanderbilt University techniques of care to doctors who can't i-This system is far faster and more ac- School of Medicine and Meharry Medi- leave their practices@ven briefly. curate than computing by hand. Thanks cal College. Until recently, Vanderbilt to the new trunk lines, and the new (Continued on page 87) -4- TODAY'S HEALTH/JAN. 1969 cooperation, all institutions within the In 1967, Doctor Metcalfe left the group o A bank of special computerized data Mid-South RMP may soon have direct practice he had organized and went to is available to radiologists in Nladison lines with the big Vanderbilt computer, Nashville to work in RMP. Since he and Milwaukee for use in radiation treat- and, potentially, with any other com. knows the needs of doctors in his region, ment of uterine cancer. Eventually all puter installed in the program. he is very responsive . to their requests. hospitals in the Wisconsin RNIP will For example, Meharry and its neigh- "At the moment, we are considering 35 have access to such computer informa- bor, Fisk University, plan to install proposals, of which only five or six are tion, which permits accurate radiation data-processing equipment which will do likely to be recommended," he says. treatment of this leading cancer killer Computations while linked to the Van- His predecessor, Doctor Olson, now in of women. derbilt computer's much larger memory. Washington, states: "The problems of As the original DeBakey report stated, Among the exciting projects scheduled medical care are getting more complex. ". . . heart disease, cancer, and stroke for this computer complex by Mehar. The Regional Medical Program idea is need not kill so many people today ... ry's Dr. Leonard Victor is MuItiTesting a good solution to many of the problems. Tomorrow still more premature deaths -which includes automated, computer- It encourages people at local levels to will be within our power to prevent." ized processing of blood and other sam- adopt the latest techniques to their needs. The 54 Regional Medical Programs ples from patients. This system is de- It allows the practicing doctor to use the are moving toward this goal. Their vic- signed to help doctors screen some 100 latest results of scientific progress in his tories will be measured in lives saved patients a day. Its primary aim is detec- practice." and disabilities diminished. END tion of minor clues which can give ad- Here's a sampling of what other RMP's vo!nced warning of serious disease-warn- across the country are doing to help roll ing which comes early enough to permit back the death rates and improve treat- heading off heart attack,- cancer, or stroke ment of heart disease, cancer, and stroke: before they become major disasters. o The Albany, New York, RMP has The tests will not replace the doctor, set up a special program to detect and but will help him to practice preventive treat cervical cancer. The program in- medical care better and more accurately. volves educating women to take " pap" They will supply accurate data to sup- smears, training nurses and doctors in plement what he finds in physical exami- the proper methods of taking smears, nations of patients. and their proper interpretation. The Hopkinsville doctors also plan to link project stresses the need for follow-up. up to the Vanderbilt computer to help As soon as a cancer is suspected, both compute doses of radiation to treat the patient and her doctor are noti- cancer. And they have devised another ked; later the doctors are queried to imaginative, lifesaving use of the trunk see what retesting showed and whethe-r line. A rural doctor, simply by dialing the treatment was begun. the phone, can talk to the librarian of a o Project Radiate is the Missouri- medical school, thus gaining access to RMP's unique facility which lets a ra- vital, hard-to-attain information. The diologist "talk over" what he sees on an librarian can find the information perti- x-ray with a computer. This "discussion" iient to a patient and his treatment, lets the doctor make his own heart-dis- read the highlights to the doctor, then ease, cancer, or stroke diagnosis-on the duplicate the material and mail it to basis not only of his own findings, but the physician's office. In the near future, of information which the computer has all the information may be sent instantly drawn from case histories and other via facsimile transmission. sources. In the meantime, the horizons of the 0 The North Carolina RMP has a Tennessee Mid-South RMP are expand- Cancer Information Center enabling ing. Next to join the network probably family doctors in outlying areas to get will be an extended-care facility at immediate consultation via telephone Oneida, Tennessee. The greatest prob- on problem cance@ cases. This is fol- lem of this remote Cumberland Moun- lowed up by printed material sent to tain facility is staff. Once enough health them on the specific cases in question. people are recruited, RMP will retrain Three medical schools are involved in them in the intensive posthospitalization this information project. care of elderly patients. * Stroke teams in 16 communities of Dr. Robert Metcalfe, who now heads the Iowa RMP are beginning education- Tennessee Mid-South RMP, knows the al programs for health personnel dealing problems well. He practiced as an in- with'stroke patients. They will consult ternist in Crossville (population: 4668) with physicians, strengthen arrange- for 22 years. ments for continuity of care, and super- "I was amazed," he recalls, "when vise nursing rehabilitation services. the Vanderbilt faculty team first came 0 Doctors in remote areas of south- through and talked to me about my prac- east Alaska are linked by phone and tice. The burdens of rural practice are radio to Seattle, under auspices of the heavy. I asked, 'What do you have?' Washington-Alaska RMP. The lines and they answered, 'What do you want?' permit lectures, consultations, seminars, When I said I wanted a coronary-care and ECG hookups. unit and radiotherapy unit they didn't even blink." TODA-Y'S HEALTH/JAN. 1969