公共衛(wèi)生的過去與現(xiàn)在[翻譯可編輯]

1、外文翻譯原文：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夕卜文出處 Public health- United States外文作者 Michael R. Grey, MP, MPH譯文:公共衛(wèi)生的過去與現(xiàn)在介紹從1935年到1947年，在聯(lián)邦政府資助的一個(gè)廣泛的平民醫(yī)療護(hù)理計(jì)劃的支 持下，美國農(nóng)業(yè)部的農(nóng)場安全管理局(FSA)和金融服務(wù)局的任務(wù)詩-修復(fù)農(nóng)民公 共衛(wèi)生體系，小生產(chǎn)者，以及移民的它找到綜合醫(yī)療護(hù)理計(jì)劃被視為規(guī)劃高峰, 超過650萬

48、農(nóng)民和100萬移民就讀于有醫(yī)療診所合作社或農(nóng)業(yè)勞動(dòng)力有三分之 一的農(nóng)村縣。盡管新交易有是豐富歷史學(xué)家，出奇的小開采寫攻擊)但在近半個(gè) 世紀(jì)以來，因?yàn)樗钡酵ㄟ^醫(yī)療保險(xiǎn)和醫(yī)療補(bǔ)助,FSA項(xiàng)U最大的政府資助的訃 劃主要是致力于提供醫(yī)療服務(wù)為指定的民眾團(tuán)體。FSA的成功在很大程度上要 歸功于策略該機(jī)構(gòu)采用推進(jìn)醫(yī)療功課在懷疑的醫(yī)生。這些策略是相關(guān)的指導(dǎo)自 己的國家問題再度面臨國家衛(wèi)生安全。想避免沖突與本地醫(yī)師和有組織的 藥,FSA強(qiáng)調(diào)可自由選擇的醫(yī)生和自愿參加。其分布式方法提升自治和給醫(yī)生結(jié) 實(shí)有力，但是沒有絕對(duì)的操作控制的醫(yī)療計(jì)劃。當(dāng)然，慈善、工會(huì)，醫(yī)師和私營 行業(yè)各種預(yù)付保健計(jì)劃贊助在這一時(shí)期。然

49、而，公私而言，廣泛的注冊，全面涵 蓋范圉規(guī)定，和預(yù)防定位程序金融給它一個(gè)歷史意義輕易的超過或平行的衛(wèi)生 保健程序。在宇宙的這一時(shí)期，美國醫(yī)學(xué)協(xié)會(huì)激烈反對(duì)聯(lián)邦參與醫(yī)療交貨。盡 管如此反對(duì),醫(yī)生支持基層FSA訃劃是相當(dāng)大的和受人道主義和經(jīng)濟(jì)利益。當(dāng)醫(yī) 生看到程序作為聯(lián)邦的努力提供醫(yī)療體系，以一個(gè)無資力，集團(tuán)，該機(jī)構(gòu)本身追 趕更廣泛的公共衛(wèi)生的議事日程。金融服務(wù)局的公眾和預(yù)防衛(wèi)生行動(dòng)，其系統(tǒng) 使用公共健康護(hù)士、營養(yǎng)學(xué)家和美國公共衛(wèi)生服務(wù)醫(yī)療官員與公眾的姿勢而擺 出的機(jī)構(gòu)。隨著時(shí)間的推移，金融服務(wù)局多方面的農(nóng)村衛(wèi)生項(xiàng)U和它最后聯(lián)盟 支持了改革家全民健康保險(xiǎn)醫(yī)生越來越不艱難。這種困境的同時(shí)，提高醫(yī)師的

50、收益降低經(jīng)濟(jì)壓力在他們身上，在未來的兒年導(dǎo)致第二次世界大戰(zhàn)。日益增長 的國會(huì)反對(duì)新合同社會(huì)立法分裂的爭論，全民健保、與協(xié)同反對(duì)FSA的農(nóng)場集團(tuán) 的做更增加了機(jī)構(gòu)的困境。與之形成鮮明對(duì)比的是，康涅狄格大學(xué)的健康中心, 康涅狄格州法明頓市,.自愿組織這項(xiàng)山私人贊助的CT,例如計(jì)劃提前還款?！皠P 撒皇宮”藍(lán)十字，和醫(yī)生服務(wù)局不太容易受到襲擊，使穩(wěn)步收益于戰(zhàn)后的時(shí)代。 現(xiàn)在回想起來，然而,FSA的根源計(jì)劃的最終消亡是一場意識(shí)形態(tài)沖突的政府、 醫(yī)療行業(yè)。因?yàn)檫@個(gè)原因,FSA的歷史醫(yī)療保健計(jì)劃闡明了思想、經(jīng)濟(jì)、和人道 主義在美國內(nèi)科的動(dòng)機(jī)。面對(duì)衛(wèi)生事業(yè)改革，醫(yī)藥衛(wèi)生在20世紀(jì)30年代，美國醫(yī)學(xué)，如同整個(gè)社

51、會(huì), 20世紀(jì)30年代，在過渡。獨(dú)立實(shí)踐和精神仍然主導(dǎo)醫(yī)療實(shí)踐以及農(nóng)村醫(yī)院為數(shù) 不多的，經(jīng)常專有的。然而，最后的全科醫(yī)師的影響，上升的優(yōu)勢。專家、集中 心思的醫(yī)院都順利進(jìn)行。1932年，委員會(huì)醫(yī)療保健的費(fèi)用報(bào)告其劃時(shí)代岀版的 美國人民醫(yī)療，最詳盡和有影響力的研究國家的美國人健康與醫(yī)療的時(shí)候被出 版。委員會(huì)發(fā)現(xiàn)貧窮的社會(huì)經(jīng)歷更多的疾病和很少受到的待遇較富裕的社區(qū)。 醫(yī)療資源，豐富而混亂，沒有根據(jù)需要的分布，而是根據(jù)實(shí)際或應(yīng)該支付能力的 病人服務(wù)。"人口數(shù)值,收入、地理失調(diào)了全科醫(yī)師和專家委員會(huì)得出這樣的結(jié) 論：國家需要更少的專家和更一般的醫(yī)生。最后，此委員會(huì)訪問和成本與關(guān)鍵問 題上在于

52、人口，定調(diào)兒乎全部健康保健改革到現(xiàn)在，一個(gè)明顯而經(jīng)常被忽視的 事實(shí)是，最一些問題在我們的醫(yī)療保健體系未到期的變化，如爆炸的醫(yī)療技術(shù)、 加速醫(yī)學(xué)專業(yè)化、護(hù)理的優(yōu)勢后，以二次世界大戰(zhàn)。委員會(huì)的1932年報(bào)告呼吁 建立一個(gè)集成系統(tǒng)，提供大多數(shù)急性及預(yù)防描施。具有先見之明的服務(wù)。大蕭 條時(shí)期大大加劇但沒有制造出了問題的委員會(huì)。成本的醫(yī)療保健。失業(yè)率上升 到前所未有的25%,壓倒性的私人和當(dāng)?shù)氐木葹?zāi)機(jī)構(gòu)。缺錢迫使許多人到?jīng)]有醫(yī) 療服務(wù)，或者一個(gè)單獨(dú)的嚴(yán)重疾病，足以陷入大比例穩(wěn)定增長的美國家庭長期 債務(wù)?！拔乙呀?jīng)把許多家庭，” 一位醫(yī)師表示哀悼，“關(guān)的眼睛蒙住了，不是我 的指令的執(zhí)行。”''醫(yī)生的凈利潤下降了 17%,而很多農(nóng)村醫(yī)生的收入降到50%, 其他保健專家同樣的影響。大蕭條時(shí)期美國農(nóng)村衛(wèi)生體系被蹂蹣。機(jī)械化和土 地整平的農(nóng)業(yè)調(diào)整行為企圖創(chuàng)造最大