Dr. John H. Knowles discusses the doctor-patient relationship.
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GUEST: John Knowles
I’m Richard Heffner, your host on The Open Mind, and usually a rather restrained type, seldom given to the vernacular. But it’s also seldom that something a distinguished foundation president writes makes you feel as though you’ve just gotten a good, swift kick in the backside. Well, that’s the way I feel right now, having not yet recovered from the reading of an essay on “Americans Health and the Responsibility of the Individual,” written by today’s guest, Dr. John H. Knowles, President of the Rockefeller Foundation.
Dr. Knowles, following what I said about that good, swift kick, I gather you’re angry, and angry at us. You’re sort of saying, “Stop bellyaching about bellyaches unless you do something to stop them.” And I wonder whether this isn’t a rather unique posture for a doctor and foundation president.
KNOWLES: Well, I think it is, primarily because the idea of individual responsibility for almost anything today in American life seems to be withering and going by the wayside. I think we’ve been through a, say, 30, 40, 50 year cycle now of looking more and more towards an institution or particularly to government and legislation to pave the way to the promised land. And the idea that the individual has some responsibility for himself or herself or the life in their block or their community seems to have gone by the board. Take just one example: trash in New York City. If the 10 million people stop littering the city you wouldn’t spend one tenth of what we now spend on the collection of garbage. But we’re talking about health. And there are certain simple things that individuals should be doing to protect their own health. And in the absence of that they look to institutions, to taxation, to the supply of services by government or the private sector, and they wonder continually why their premiums rise, why we spend now $550 per capita on each American for health, 8.3 percent of the growth national product in the aggregate, $120 billion more than any country or any individual expenditure in the entire world on health. Now, what’s the cause of all this ill health and premature death? Well, it turns out they are largely preventable diseases, the causes of premature death. The heart attacks, strokes, cancer, chronic lung disease, even such things as peptic ulcers. Accidents, the largest single cause of death in people under the age of 35, accidents. Due to what? Alcohol. We have an incidence of alcoholism in the United States that’s staggering. It’s 10 times the incidence in Great Britain. They’ve taken certain moves that we haven’t. When you reduce the speed limit on the New Jersey Turnpike or the turnpikes in California by 10 miles an hour, you reduce the number of deaths and disabling injuries by as much as 40 percent during that time span.
HEFFNER: This is a kind of novel approach for one who heads a giant foundation where presumably the responsibility for society has been assumed, where one takes for granted the notion that there’ll be foundation grants that will help extend the possibility of longevity. But you take a different point of view. You say it’s in our own hands.
KNOWLES: Absolutely. And we’ve more and more in our own policies in the Rockefeller Foundation have focused on individual development, individual support, whether in the arts or humanities, and the idea of individual activity. I agree with you. Your point is a good one, that foundations in distributing grants to institutions for the social good and so forth may have been party, much like the government, in distributing money, there was the idea that it was somebody else’s fault, somebody else’s or some other institution’s responsibility. The whole subject vis-à-vis health, health education and preventive medicine, a very sexless, uninteresting subject. People aren’t interested in their health until they lose it. Well, why should they? Why should we be gloomy all our lives thinking about the next catastrophe that might happen if we didn’t have the extra piece of ice cream or smoke the odd cigar or have the odd cocktail or something? So you don’t want to lose all the pleasures of living, so to speak. And within certain limits, you know, he who hates sin hates humanity. But at the same time we’ve gotten to such a state in the preventable diseases in this country that it resulted in staggering costs to all of us that we can only conclude that one man or woman’s or licentious behavior or irresponsible behavior is another person’s shackle in taxes and skyrocketing health premiums. Now, which way do we want to have it? We have sanctified individual freedom and individual liberty, and I’m all for that. That’s the hallmark of our civilization. At the same time the price of all that can be prohibitive at times.
HEFFNER: Are you suggesting therefore that we have to pay too large a price for the freedom to drink, the freedom to smoke, the freedom to drive wildly?
KNOWLES: Absolutely. I most certainly am. You take alcohol. Over the last 40 years in England as contrasted to the United States, that we have 10 times the incidence of cirrhosis or the scarring of the liver from too much alcohol, 10 times the incidence of alcoholism that there is in Great Britain. Great Britain decided that they would limit the hours of sale of alcohol, that they would raise the taxes markedly on alcohol, that they would help the industries that were producing all that booze to turn into more fruitful, productive areas. And as a result of all that – and I would agree that there are other factors in addition, but those are the major factors that caused a change. In the 1920’s, the immediate post World War I period we had a similar incidence of alcoholism and cirrhosis. Today we far outstrip them. We haven’t been willing to limit hours of sale, foster the change of the industries into other more productive areas, and raise the taxes even further on alcohol. Now, at the same time, there are other things we’ve been unwilling to do. Now, vis-à-vis smoking we certainly have shown what a public health program can do where there’s a massive attempt through all the media and through raising taxes and at least going part of the way we have staunched the flow of increasing numbers of people who smoke. Even there, however, it has been shown in the last five years that the number of teenage girls for some unknown reason has almost doubled the number of smokers. Teenage males hasn’t skyrocketed that way. However, the remaining figures show some stability and reduction in the number of smokers.
HEFFNER: Well, let me get this straight. Quite seriously I’m impressed with the studies that you refer to in this article of yours, in these comments of yours. You talk about, you say that there’s a life expectancy and health increase, significant increase, if you follow certain health habits. You say three meals a day at regular times and no snacking, breakfast every day, moderate exercise two or three times a week, adequate sleep seven or eight hours a night, no smoking, moderate weight, no alcohol or only in moderation. Now, I have the feeling that you’re going beyond the general prescription for individual health. You’re saying that society can’t afford – I think you’re saying – society can’t afford to let us go helter-skelter our own way.
KNOWLES: I don’t think we can. I really don’t. You look at venereal disease. We have two million, at least, new cases a year now in the United States. Eighty to 100,000 new cases of syphilis. Venereal diseases should have been eradicated from advanced civilizations, and almost were at one point. They are now massively endemic and epidemic again in this country. I can tell you where a lot of it’s pervade in New York City too. Well, at any rate, there we are.
HEFFNER: I didn’t ask you. (Laughter)
KNOWLES: Well, it’s right around where the offices of the Rockefeller Foundation are unfortunately, in the Times Square area and so on. You take the whole business of an adequate diet or maintaining the optimum weight. Do you realize that something like 40 percent of Americans, or 80 million people, are overweight for their age, sex, and height.
HEFFNER: And that leads to a shorter life expectancy?
KNOWLES: Without question. I’ll give you a shopping list of what overweight does. It can predispose you to high blood pressure, to heart attacks, to strokes, to accidents. You can’t jump out of the way as quick if you slip on the ice, you’re more apt to go down if you’re fat than if you’re skinny. It will predispose you to degenerative arthritis or joint disease, degeneration of the joints of the knee and hip in particular. It leads to flat feet and fallen arches. It predisposes you to adult types of diabetes. It predisposes you to skin disease because the rolls of fat get all moist and suppurative. It’s harder to keep yourself clean hygienically. I mean, I hate to go through such a dismal shopping list, but just the business of malnutrition of the overweight variety is terrible and leads to premature death, disease, and disability. That’s just one.
Now, the business of exercise has been shown – I’m talking about moderate exercise. I don’t say we all have to run around Central Park eight laps every morning between six and eight o’clock. I’m talking about moderate exercise. Walking, playing tennis, skating, walking to work instead of riding. Getting moderate exercise each week, you can reduce the morbidity and mortality from heart attacks. It’s been shown that the person who exercises and gets a heart attack does much better in terms of shorter stay in the hospital, more rapid convalescence, less possibility of his dying from the disease in the hospital. And that’s just simple exercise.
Now, we certainly don’t want Big Brother yelling over the loudspeaker at us all day, and we don’t want to have ourselves legislated to death by a fascistic, beneficent Big Brother. But you take it to another extreme, you can certainly put emphasis through the mass media, through our political leaders, on the idea of individual responsibility vis-à-vis health. And there are legislative moves that you can make which would save lots of money for the American people vis-à-vis health, rising Blue Cross and insurance premiums, more taxes through government for Medicaid, Medicare, and so on.
HEFFNER: Dr. Knowles, are you stopping short of becoming a prohibitionist?
KNOWLES: No, because again I think that was shown that that simply didn’t work. You legislate alcohol out of existence and at least in our society what that resulted in was a still life, so to speak, in the mountains of the United States, and it resulted in the drinking of methyl alcohol which led to blindness, it resulted in a large, expanding criminal element that would import it from other places. And pretty soon the costs versus the benefit of trying to legislate a pleasure out of business got prohibitive. So I don’t think you have to do that. I think for one thing you’ve got a tremendous captive audience in the United States in kindergarten through high school. And that is the future of our country. Ask me about health education programs in the high schools and elementary schools in the United States and I won’t be able to tell you much, quite frankly.
HEFFNER: You mean because there are not such?
KNOWLES: There aren’t any that are anything more than peremptory sick calls, very frequently doctor friends of the local politician in power. It’s a nice cushy sinecure. There are no assiduous attempts to lace health education, knowledge of health at a young, impressionable stage where you can show what the establishment of good habits will do for longevity and a healthy life and a much happier one. You talk about sex education itself, and half the country rises up in arms and somehow thinks of pornography if you educate youngsters about human sexuality, venereal disease, and so on and so forth. Most children get all the way through high school, they don’t know how to get into the health system, they don’t know what it means, they don’t know their choices that they can make. You know, democracy depends on an individual being able to make a choice with full knowledge. If the individual chooses to smoke, drink, drive fast, or submit or lie down to sloth and gluttony and stuff himself with goodies all day long, well then I think he’s got to do it with full knowledge that he’s weakening the country, that somebody else is having to pay for that. And he can stop complaining about it. Now, on the other hand I do think you have to have social controls; or if we don’t have them let’s stop complaining about it. Sit back and enjoy it and let the gross national product go to 10 percent on health. Let us all spend $600 per person next year. You know, that’s about $2,500 per family of four. And you know what happens to the inflationary element in medicine and in Blue Cross and Medicaid and Medicare, federal, general taxation for medical service programs. I’m only saying it’s about time the country came to its senses and made choices or stopped complaining. I would rather keep complaining.
KNOWLES: … because I think it’s rational and logical and I have great faith in the school system and education and in the people of this country to do the right thing. Why can’t we get a president of the United States to use some of his prime time on the subject of American health? You look at the draft rejection rate in World War I and World War II and during the Vietnam War and it is a pox on a civilization that is spending as much money as we do on health to find that as many as 20, 30, 40 percent of draft eligible youngsters in our country were in fact ineligible on the basis of ill health.
Now, we haven’t even mentioned dentistry, the good lord forbid, for some reason or other we forget about teeth. And nutrition starts with teeth. And what do you do about that? Well, you can fluoridate water. Now, it’s a democracy, and we haven’t, some segments of the community say, “You’re not going to poison me with fluoride.” Well, I hate to say it, and I don’t want to get a barrelful of mail tomorrow, there’s no good evidence that the amounts of fluoride where it’s been allowed to fluoridate the water supplies of cities has any ill effect on health over the long range.
HEFFNER: How about a good effect?
KNOWLES: Quite to the contrary. To the good effect is it markedly reduces the incidence of cavities in the teeth. And that is well worth it. If you get a big slag full of pustular, excavated teeth, your mouth falls in, your breath smells, you can’t chew food properly, your nutrition is bad, and you’re chronically infected. Now, who wants that? You can certainly do that through fluoridation. You can avoid mass public health programs. You can do it through the use of fluoridated toothpaste over a period of time, and you can certainly pay much more attention to dental hygiene in the school systems in the United States. I’m not trying to go out after all 214 million American people at this juncture. I say the focus should be on the school health system and the future of our country vis-à-vis preventive medicine, health education with some real muscle. Well, then somebody cowers and says, “Oh, no. come on. Get off it. People tried that. They’re not interested.” I say, “They haven’t tried it. They have not tried it. The country has not put a priority on school health systems.” We spend a pittance on infants, children and youth in health education prevention, and using it though school health system. We spend a pittance. The number of people involved have even tried to figure it out, to say nothing of even the study of the use of television as a cognitive medium, as a knowing medium. What are people going to learn from this program? Anything? Are they just going to remember the stripes in the tie and the fact that I get all excited and …
KNOWLES: … I either like him or I don’t like him? But will they remember anything about it? There was a program here in New York City one time about venereal disease. It was quite exciting apparently because over the next three weeks the clinics of this city were clogged with people wanting to find out whether they had venereal disease or not.
HEFFNER: For three weeks?
KNOWLES: For three weeks. Six weeks later it was business as usual. Point: You have to sustain the effort with the community at large to sustain an effort, to change behavior in the good sense of the word, not the Big Brother sense.
HEFFNER: Yes, but you mention Big Brother gain. And I again have the feeling that you’re quite so involved in this and you’re quite so excited that you’re not going to stop with, you almost said before, “Well, if the fellow wants his teeth to fall out and if he wants to take on this posture, let him have his bellyache.” But I have the feeling you’re saying he can’t because it’s too much of a danger to society at large.
KNOWLES: It’s too much of a drain on the whole community …
HEFFNER: What do we do?
KNOWLES: … and for those… I think you’ve got to develop first of all systems of school health education, so that the most reasonable people, educated people through the school system will choose voluntarily in a democracy to behave differently.
HEFFNER: Excuse me, Dr. Knowles …
KNOWLES: Secondly, I think you have to legislate certain sanctions. I don’t think …
HEFFNER: Ah ha!
KNOWLES: Oh, yes. You’re certainly not going to deny those people the care. But you may be able to legislate certain things through insurance premiums, what have you, for maintaining the right weight so that it will cost us less if we maintain the right weight, get exercise, eat three decent meals and so on and don’t smoke or booze. We may have to have social legislation which in fact enforces certain things which would penalize misbehavior. Now, that gets us into other problems. If you maintain a speed limit of 45 miles an hour versus 75, you can save an awful lot of money. But if people choose not to do it … People are wonderful, you know. They can beat almost any system, whatever is dreamed up, they can figure out a way to beat it. So they beat the speed limit. Then what do you have to do? Well, you have to hire a bigger police force and a bigger this, that and the other thing. And pretty soon you’re spending so much on, you’ve got to have one policeman per car driver in order to keep everybody at 45. I’m just drawing an extreme example. So that may not be the answer. To my mind it is a sustained effort to give logically minded, educated people a decent choice about their health over the long range.
HEFFNER: Let me ask you this: In your acquaintance, which is wide, among intelligent and well educated people, are you so certain that they are among those who follow these rules, these strictures about how to put …
HEFFNER: Well then, why the emphasis upon intelligence and education?
KNOWLES: Let’s say it this way. A lot more of them are today than were 10 years ago. A lot of them have stopped smoking, a lot of them have markedly reduced drinking, a lot of them have regained a decent weight, and a lot of them are exercising, interestingly enough. You see people jogging around today that were never doing it 10 years ago. So you do see some measurable change in these people, yes. But it’s with a relatively minimal effort, Dick, is my point. I think you’ve got to have a sustained effort.
HEFFNER: And are you serious about higher insurance premiums for those who are overweight, for those who aren’t following the obvious health rules?
KNOWLES: Yeah, and I think in some instances that’s been attempted. Yeah. I think that’s one approach to it, yes. I think we’ve got to put a lot more attention and good creative minds as to how we could change behavior without brainwashing people. I don’t want to get a lot of letters saying, “Ah ha! You had a fascist on the program yesterday. He’s trying to change everybody’s behavior.”
HEFFNER: Aren’t you?
KNOWLES: I’m trying to change behaviors because I believe that most human beings are rational and well intentioned, and if given the choices early on in their lives that they will make better choices than they’ve been making in recent times.
HEFFNER: But isn’t your profession to a very large extent, the medical profession, responsible for the assumption on our part that somehow or another you’re going to take care of it? I’m not talking about Big Brother or big government, but medical advances will handle it all.
KNOWLES: Oh yes, oh, well, that’s true of civilization, our entire civilization. We have an undeniable belief in the technological fix. Yeah, we can go ahead and smoke, drink, and drive fast, because we can always build a great big car with special springs on it and we can drive 180 a miles and nothing will happen, or we’ll invent a special kind of cigarette that makes your hair grow longer and won’t give you cancer, or we can somehow take the booze out of booze so it doesn’t hurt your liver, or, you know, on and on and on we go. We have an undeniable faith in the technology and scientific fix. And let’s face it, we have fixed a lot of things through that, no question. And this isn’t a plea to stop research in medicine. It may turn out that there, and it frequently does, in schizophrenia, for example, or in many forms of vascular disease, they see they do seem to run in families. There must be a genetic or constitutional or chemical factor that can be hereditary that we don’t know enough about. It we could learn more about it then, and might be able to prevent that and then you could eat all you want to and lie around and get no exercise. After all, look at Winston Churchill. He never got any exercise. He dipped cigars in brandy every morning and smoked big, long things all day long and lived to be 90. He was under stress and tension all the time. He drank, he smoked, raised hell, was in the political kitchen constantly. He lived to be 90! So, but that’s the fallacy in that, because most people behave that way will not live to be 90. But there’s some genetic factor that allowed him to do that.
HEFFNER: Well, I’m totally fascinated by the statistics you offer here that indicate that it’s not likely that basic breakthroughs, medical breakthroughs are going to bring about lengthened life expectancy at this point, but that individual concern for the way we run our own lives will, that it’s sort of, not past the last horizon or frontier, but now it’s up to us. This seems to be your message.
KNOWLES: I do believe that. I really do. I most certainly do. And I think we’re at a watershed now in medicine and health in the United States. And I’m not the only onesthat’s saying this. Many other people are beginning to feel this way and talk this way. Medical school curricula are beginning to change. We’re seeing more and more emphasis on the environmental causes of cancer. Never mind things that you and I do or don’t do such as smoking. But there are other things: the excessive use of drugs, the use of estrogens in pregnant women can come up, pop up 15 years later as cancer in their offspring, vaginal cancer. There are various environmental additives to food. Many people are now saying today that practically all cancer is caused by external agents. That’s quite an extreme statement. So there’s more and more research going into such things as red dye #2. There’s more and more of a shopping list. Vinyl chloride all of a sudden, people working in those plants have cancer of the liver. All of a sudden women taking birth control pills pop up – a small percentage but significant – with little benign tumors in the liver over a long period of time. We keep adding these things up. And there are things where no matter what you and I do isn’t going to make any difference. But we’ve got to support more research on environmental causes of these things. Now, the environment of course starts at home. The environment that you and I can control is food, sleep, alcohol, smoking, exercise, weight. They’re fundamental, because the morbidity and mortality in those people who don’t have those good habits is twice what it is in a comparable sample. If you don’t do that at age 45 your average life span is about 75. If you do do it at 45 it’s about 62 or 65, you see. So you’re talking about 10 years of productive living. And I don’t want everybody to, after they’ve seen this to swear they’re going to go into good habits all of a sudden.
HEFFNER: Sure you do.
KNOWLES: Well, I would prefer that because I think that in the last analysis they’d have a lot more fun in the last analysis. A little of all these things in moderation isn’t going to kill anybody. And after all life is still meant to be enjoyed. We sometimes forget that these days. It’s a short passage through this world, and one of the reasons for being alive is to enjoy it. And the occasional drink or cigar or what have you isn’t going to kill anybody. But if they get grossly overweight, if they’re smoking all the time, boozing too much, getting no exercise, and not getting decent sleep at night, not eating three reasonable meals a day without a lot of junk being pushed in all day and all night, they simply will shorten their life spans. They won’t feel as good anyway.
HEFFNER: I gather in the minute that we have left that you also feel that this is connected to a pampering of ourselves and a general attitude in which we do what we feel, we think feels good at the moment.
KNOWLES: Yeah, there’s a little of that. We get heavy in that in the 1960’s, the here and now culture, you know. Whatever felt good and was good for me, me, I, I could go ahead and be done. Now, that doesn’t apply to the vast … We get the warped idea in this country that a lot of people are like that. You know, the vast number of people in this country are hard working, decent, honorable people. You’d never know it if you read the newspaper every morning or look at the tube every night. The first five things you see on the television set are the latest killing, the latest robbery, the latest tenement house burned down, the latest crisis in City Hall. Now, I think that most people are reasonable, most people live temperate lives, and turn the wheels of this democracy. But we can do a lot better vis-à-vis health and human responsibility.
HEFFNER: One thing is certain: I’m going to stop smoking, stop drinking, sleep a lot more, and do many of the things that you’ve suggested. (Laughter)
HEFFNER: But thanks a lot for joining me today Dr. John Knowles, President of the Rockefeller Foundation.
And thanks, too, to you in the audience. I hope you will join with us again on The Open Mind.
And meanwhile, as an old friend used to say, “Good night, and good luck.”