and national health insurance. The committee, however, decided to take a different approach. As the preface of the report notes,

[t]his report goes beyond the traditional medical model to consider and address the needs of people with disabling conditions after those conditions exist and after they have been "treated" and "rehabilitated." Prevention of the initial condition (primary prevention) is certainly important, but the emphasis in this report is on developing interventions that can prevent pathology from becoming impairment, impairment from becoming functional limitation, functional limitation from becoming disability, and any of these conditions from causing secondary conditions. Theoretically, each stage presents an opportunity to intervene and prevent the progression toward disability. Thus, the report sets forth a model developed by its authoring body, the Committee on a National Agenda for the Prevention of Disabilities, that describes disability not as a static endpoint but as a component of a process.

One impetus for the committee's decision on its approach came from the sheer size of the charge it had to address. We decided that perhaps the best contribution we could make was to, first, describe the significance and magnitude of disability as a public health issue; second, describe a conceptual framework for consideration of disability prevention, taking into account quality of life and the strong emphasis the committee wanted to give to the social and other risk factors so essential to the causes of disability; and, third, develop recommendations that would serve as an infrastructure for a national program for prevention. By infrastructure, we mean the leadership, coordination, surveillance, research, personnel development, and public support needed for such a program, which would provide a framework for a long-term, comprehensive, and coordinated effort involving specific interventions. Thus, we did not formulate exhaustive lists of interventions for each area of disability addressed in the report (although the "focus chapters" on developmental disability, injury, chronic disease, and secondary conditions do present information on various types of intervention strategies, including some primary prevention, and their development status or proven effectiveness). Indeed, it is the report's focus on secondary and tertiary prevention that helps to set it apart from many other efforts in the field and, we believe, constitutes a major contribution to disability prevention for those individuals who already have potentially disabling conditions.

It is regrettable that Dr. Stone chose not to continue active participation in the committee and contribute more fully to its work. Many of the points she raised in her July 1989 paper appear in the report; see, for example, the recommendations on access to care in Chapter 9. Her views undoubtedly would have been better served, however, by fuller participation in the collegial deliberative endeavor that is the hallmark of this institution's consensus-building committee process.



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