公共卫生的过去与现在[翻译可编辑]

1、外文翻译原文：Public Health Then and NowThe Medical Care Programsof theFarm Security Administration,1932 through 1947: A RehearsalforNational Health Insurance?IntroductionFrom 1935 to 1947, the federal government sponsored an extensive civilianmedical care program under the aegis of the US Department of Ag

2、ricultureFarm Security Administration (FSA). The FSAs missionto rehabilitate lowincome farmers, sharecroppers, and migrant workersled it to develop a comprehensive medical care program described by the Saturday Evening Post as a "gigantic rehearsal for health insurance.,n At the program's p

3、eak, more than 650 (XH) p<K)r fanners and a million migrants were enrolled in medical care cooperatives or farm labor clinics in a third of all iural counties (Figure I). Although the New Deal has been richly mined by historians, remarkably little has been written atK)ut this "gigantic rehea

4、rsal'1 in the nearly half-century since it ended. Until the passage of Medicare and Medicaid, the FSA program was the largest government-sponsored program dedicated to providing medical care for a specified civilian group The FSA*s success owes much to strategies the agency adopted to promote it

5、s medical program among skeptical physicians These strategies are relevant guidelines as our nation again confronts the issue of national health security. Eager to avoid confrontation with both local physicians and organized medicine, the FSA emphasized free choice of physician and voluntary partici

6、pation. Its decentralized approach promoted kical autonomy and gave physicians substantial but not absolute control over the operation of the medical care plans. Certainly, philanthropies, unions, physicians, and private industry sponsored various prepaid health care plans throughout this period and

7、 even eariier However, the public/private character, extensive enrollment, comprehensive coverage coverage provisions, and preventive orientation of the FSA program gives it a historical import that exceeds that of eariier or parallel health care delivery programs.Throughout most of this period, the

8、 American Medical Association vehemently opposed federal involvement in medical care delivery. In spite of this opposition, physician support of the FSA plans at the grassroots level was substantial and was driven by humanitarian and economic concerns While physicians saw the program as a temptirary

9、 federal effort to provide medical care to an indigent group, the agency itself pursued a broader public health agenda The FSA's extensive public and preventive health efforts and its systematic use of public health nurses, nutritionists, and US Public Health Service medical officers belie the p

10、ublic posture assumed by the agency. Over time, the FSAs multifaceted rural health programs and its eventual alliance with reformers favoring national health insurance made physicians increasingly uncomfortable This discomfort coincided with physicians* improving incomes and the easing of the econom

11、ic pressures on them in the years leading up to World War II. Growing congressional opposition to New Deal social legislation, the divisive debate over national health insurance, and concerted opposition to the FSA by conseIA ative farm groups only added to the agency's woes. In sharp contrast,

12、other The author is with the Department of Medicineand the Department of Community Medicine and Heahh Care, University of Connecticut SchtH)l of Medicine, Farmington.Conn. Requests for reprints should be sent to Michael R. Grey, MD. MPH. Section of Occupational and Environmental Medicine Bldg 12. Un

13、iversity of Connecticut Health Center, Farmington, CT 06030. privately funded voluntary group prepayment plans (e.g. Kaiser Permanente, Blue Cross, and physician service bureaus) were less vulnerable to attack and made steady gains in the postwar era. In retrospect, however, the root cause of the FS

14、A plans* eventual demise was an ideological conflict between the government and the medical profession. For this reason, the history of the FSA medical care program illuminates the ideological economic, and humanitarian motivations of American physicians in the face of health care reform Medicine an

15、d Health in the 1930s American medicine, like much of society in the 1930s, was in transition. Solo practice and fee-for-service still dominated medical practice, and rural hospitals were few and often proprietary. However, the waning influence of general practitioners, the rising dominance of speci

16、alists, and centralization of care in hospitals were well under way by that time.*A In 1932, the Committee on the Costs of Medical Care published its landmark report Medical Care for the American People, the most exhaustive and influential study of the state of American health and medicine that had

17、ever been published The committee found that poor communities experienced more sickness and received less care than more affluent communities. Medical resources, while plentiful, were not Hdistributed according to needs, but rather according to the real or supposed ability of patients to pay for ser

18、vices.The numericaL income, and geographical imbalance between general practitioners and specialists led the committee to conclude that the nation needed far fewer specialists and far more general practitioners Finally, the committee linked access and cost barriers as critical issues for undersened

19、populations, setting the tone for virtually all heaith care reforms to the present day,” An obvious but often neglected fact is that the most nettlesome problems in our health care system antedated changes such as the explosion of medical technology, the acceleration of medical specialization, and t

20、he dominance of hospital-based care in the wake of World War II. The committee's 1932 report calling for an integrated system in which generalists provide the majority of acute and preventive services was prescient. The Great Depression greatly exacerbated but did not create the problems highlig

21、hted by the Committee on the Costs of Medical Care Unemployment soared to an unprecedented 25%, overwhelming private and local relief agencies Lack of money forced many people to go without medical services, and a single serious illness was enough to plunge a large and steadily increasing percentage

22、 of American families into prolonged debt. HI have to treat many families/1 lamented one physician, nshutting my eyes to the fact that not one of my instnjctions can be carried out.HM Physicians1 net income plunged by 17%, and many rural physicians1 incomes dropped below 50% of billings." Other

23、 health care professionals were similarly affected The Great Depression devastated njral America. Mechanization and land consolidation, the nations worst-ever drought, and blunt legislative efforts such as the Agricultural Adjustment Act conspired to create the largest internal migration in our hist

24、ory. Vast numbers of families left their farms buried in dust, loaded up their jalopies, and headed west (see photo on next page). The Department of Agriculture estimated that between 1 and 2 million of the estimated 10.5 million people employed in agriculture were migrants.1 The health conditions o

25、f rural citizens, which had been declining relative to those of urban Americans since the turn of the century, were also adversely affected Rural areas had 80 physicians per 100 0(K) population, vs 171 per 100(X)0in urban areas. In 1900, nearly 50% of medical school graduates practiced in rural area

26、s; by 1931. fewer than 21% did so.!,M, In nietrojXJlitan areas, 72% of births occurred in hospitals, infant mortality was 34.2 per 1000 live births, and immunizations averaged 89% In contrast, only 14% of njral babies were born in hospitals, rural infant mortality was 43.3 per 1000 live births, and

27、only 37% of rural children were immunized/In New England there were 81 hospital beds per 100 (XX) population, while in ihe more rural Sou什 1 there were only 30 beds per 100 (KX). Ninetyfour percent of all water supplies in the South, according to the 1940 census, were open; 66% of Southerners still

28、used privies, and fewer than 12% had potable water within 50 feet. A third of the nation's 3070 counties had no public health unit; virtually all were rural.0 Health conditions among migrants were particularly abysmal. Outbreaks of infectious diseases such as typhoid, dysentery, and tuberculosis

29、 created vigilante movements that were sometimes led by local health departments. Wrote one county health officer, HOne has to deal with a people whose cultural and environmental background is so bad that for a period of more than 3(M) years no advances have been made in living conditions among them

30、." Racism, xenophobia, and fear of contagionpowerful historical themes in society's response todisease epidemicsled to the violent and systematic destruction of squatter eamps or HHoovervilies.H To many people, disease and degraded mortality seemed equally contagious." Riwseveit quickl

31、y moved to promote massive federal intervention during the famous HHK) days” of his presidenc7 Congress passed an omnibus relief measure creating the Federal Emergency Relief Administration (FERA) in Mareh 1933. The FERA channeled direct federal relief through state emergency relief administrations

32、and created a division devoted solely to rural relief and rehabilitation. The hallmarks of the FERA rural rehabilitation programfriendly supervision and easy creditremained at the core of all subsequent efforts. The ereation of the Works Progress Administration (WPA) and the Resettlement Administrat

33、ion in 1935 signaled a shift in federal policy away from direct monetary relief. The more well-known WPA concentrated on massive infrastructure projects and urban work relief. The Resettlement Administration assumed the rural rehabilitation prerogatives of the FERA and operated for 2 years as an ind

34、ependent cabinet-level agency under brain truster and political lightning rod Rexfbrd TugweIL In 1937, the president renamed the Resettlement Administration the Farm Security Administration and placed it inthe more conservative Department of Agriculture. In 1943, as part of wartime restiucturing, th

35、e War Food Administration assumed responsibility for the FSA migrant programs.'1 (For clarity, the acronym FSA is used throughout this essay.) The FSA promoted marketing, farming, and equipment-buying farm cooperatives to help smaller and poorer producers compete in the agricultural marketplace.

36、 The agency also believed that these cooperatives would promote economic stability, enhance self-reliance, and foster loeal leadership Pressure on the agency to maintain good loan repayment among its rehabilitation clients soon conflicted with the FSAs humanitarian thrust, and when it became clear t

37、hat ill health was responsible for 50% of all loan defaults,the FSA moved into the field of health care delivery. As US Public Health Service senior surgeon and FSA chief medical ofTieer Ralph C Williams stated, "a family in good health was a better credit risk than a family in bad health.Medic

38、al Care CooperativesWilliams told those attending the 1939 American Public Health Association convention that the FSA medical program was an "incidental by-product of a depression-born loan program for farm families unable to obtain credit elsewhere, anddesigned to accommodate a special economi

39、c group only.” This economic justification pacified vocal groups unsympathetic to the agenc7 s scKial agenda, such as organized medicine, conservative politicians, and organized farm groups. However Williams" public posture understated the powerful ideological eonimitment of the agency s medica

40、l hierarchy to make more public the practice of medicine In line with the agency's cooperative philosophy, local FSA supervisors encouraged fanners to establish medical cooperatives. These supervisors asked local physicians to provide care to FSA clients in a group prepayment scheme to lower cos

41、t barriers and ensure access to needed medical care Bundled into their annual loans, rehabilitation clients (also called borrowers) received a federal subsidy (typically around $35), which they then paid into a tiustee-supervised fund. Participating physicians billed this fund, and if billings excee

42、ded the amount set aside that month, doctors received prorated reimbursement. Flexibility at the local level was critical to the program's success with farmers and physicians alike The policy of promoting cooperatives and local determination of local needs also fit into the FSA's commitment

43、to participatory democracy. HAny plan in which the families unite lo help themselves should reduce the eost of medical aid and thereby make more effective the funds thus expended sti that a worthwhile beginning can be made by the families themselves toward better health.Healthier clients made the ta

44、sk of supervision easier, and credit risks diminished as clients* health improved. This fact not only was a source of pride for the agency but was also critical to continued congressional support. Nearly 90% of all loans were eventually repaid in full. The FSA plans were also a new source of income

45、for hard-pressed rural diKtors, Participating doctors collected 65% of their fees from a group that had previously been able to pay little, if anything, for medieal care It was not the intent of the FSA in the medical cooperative program to fundamentally restructure the delivery of rural health serv

46、ices. Group prepayment was grafted onto traditional fee-for-service practice. Concessions of this sort, along with the fact that physicians* participation was voluntary and the extension of care was limited to a specified low-income group, made the FSA programs palatable to financially strapF>ed

47、njralpractitioners Still, the agency's promotion of consumer.Public health United Stayes, p 1678-1678夕卜文出处 Public health- United States外文作者 Michael R. Grey, MP, MPH译文:公共卫生的过去与现在介绍从1935年到1947年，在联邦政府资助的一个广泛的平民医疗护理计划的支 持下，美国农业部的农场安全管理局(FSA)和金融服务局的任务诗-修复农民公 共卫生体系，小生产者，以及移民的它找到综合医疗护理计划被视为规划高峰, 超过650万

48、农民和100万移民就读于有医疗诊所合作社或农业劳动力有三分之 一的农村县。尽管新交易有是丰富历史学家，出奇的小开采写攻击)但在近半个 世纪以来，因为它直到通过医疗保险和医疗补助,FSA项U最大的政府资助的讣 划主要是致力于提供医疗服务为指定的民众团体。FSA的成功在很大程度上要 归功于策略该机构采用推进医疗功课在怀疑的医生。这些策略是相关的指导自 己的国家问题再度面临国家卫生安全。想避免冲突与本地医师和有组织的 药,FSA强调可自由选择的医生和自愿参加。其分布式方法提升自治和给医生结 实有力，但是没有绝对的操作控制的医疗计划。当然，慈善、工会，医师和私营 行业各种预付保健计划赞助在这一时期。然

49、而，公私而言，广泛的注册，全面涵 盖范圉规定，和预防定位程序金融给它一个历史意义轻易的超过或平行的卫生 保健程序。在宇宙的这一时期，美国医学协会激烈反对联邦参与医疗交货。尽 管如此反对,医生支持基层FSA讣划是相当大的和受人道主义和经济利益。当医 生看到程序作为联邦的努力提供医疗体系，以一个无资力，集团，该机构本身追 赶更广泛的公共卫生的议事日程。金融服务局的公众和预防卫生行动，其系统 使用公共健康护士、营养学家和美国公共卫生服务医疗官员与公众的姿势而摆 出的机构。随着时间的推移，金融服务局多方面的农村卫生项U和它最后联盟 支持了改革家全民健康保险医生越来越不艰难。这种困境的同时，提高医师的

50、收益降低经济压力在他们身上，在未来的儿年导致第二次世界大战。日益增长 的国会反对新合同社会立法分裂的争论，全民健保、与协同反对FSA的农场集团 的做更增加了机构的困境。与之形成鲜明对比的是，康涅狄格大学的健康中心, 康涅狄格州法明顿市,.自愿组织这项山私人赞助的CT,例如计划提前还款。“凯 撒皇宫”蓝十字，和医生服务局不太容易受到袭击，使稳步收益于战后的时代。 现在回想起来，然而,FSA的根源计划的最终消亡是一场意识形态冲突的政府、 医疗行业。因为这个原因,FSA的历史医疗保健计划阐明了思想、经济、和人道 主义在美国内科的动机。面对卫生事业改革，医药卫生在20世纪30年代，美国医学，如同整个社

51、会, 20世纪30年代，在过渡。独立实践和精神仍然主导医疗实践以及农村医院为数 不多的，经常专有的。然而，最后的全科医师的影响，上升的优势。专家、集中 心思的医院都顺利进行。1932年，委员会医疗保健的费用报告其划时代岀版的 美国人民医疗，最详尽和有影响力的研究国家的美国人健康与医疗的时候被出 版。委员会发现贫穷的社会经历更多的疾病和很少受到的待遇较富裕的社区。 医疗资源，丰富而混乱，没有根据需要的分布，而是根据实际或应该支付能力的 病人服务。"人口数值,收入、地理失调了全科医师和专家委员会得出这样的结 论：国家需要更少的专家和更一般的医生。最后，此委员会访问和成本与关键问 题上在于

52、人口，定调儿乎全部健康保健改革到现在，一个明显而经常被忽视的 事实是，最一些问题在我们的医疗保健体系未到期的变化，如爆炸的医疗技术、 加速医学专业化、护理的优势后，以二次世界大战。委员会的1932年报告呼吁 建立一个集成系统，提供大多数急性及预防描施。具有先见之明的服务。大萧 条时期大大加剧但没有制造出了问题的委员会。成本的医疗保健。失业率上升 到前所未有的25%,压倒性的私人和当地的救灾机构。缺钱迫使许多人到没有医 疗服务，或者一个单独的严重疾病，足以陷入大比例稳定增长的美国家庭长期 债务。“我已经把许多家庭，” 一位医师表示哀悼，“关的眼睛蒙住了，不是我 的指令的执行。”''医生的净利润下降了 17%,而很多农村医生的收入降到50%, 其他保健专家同样的影响。大萧条时期美国农村卫生体系被蹂蹒。机械化和土 地整平的农业调整行为企图创造最大