TO Sah Ne

COMBATING HEART DISEASE, CANCER,
STROKE, AND OTHER MAJOR DISEASES

 

 

HEARINGS

BEFORE THE

SUBCOMMITTEE ON HEALTH

OF THE

— COMMITTEE ON
LABOR AND PUBLIC WELFARE
UNITED STATES SENATE

EIGHTY-NINTH CONGRESS
FIRST SESSION
ON

S. 596

A BILL TO PROVIDE ASSISTANCE IN COMBATING HEART
DISEASE, CANCER, STROKE, AND OTHER MAJOR DISEASES

 

FEBRUARY 9 AND 10, 1965

 

Printed for the use of the
Committee on Labor and Public Welfare

ae

. . U.S. GOVERNMENT PRINTING OFFICE
C 48-6600 WASHINGTON : 1965

5 ol

 
COMMITTEE ON LABOR AND PUBLIC WELFARE
LISTER HILL, Alabama, Chairman

PAT McNAMARA, Michigan JACOB K. JAVITS, New York
WAYNE MORSE, Oregon WINSTON L. PROUTY, Vermont
RALPH W. YARBOROUGH, Texas PETER H. DOMINICK, Colorado
JOSEPH S. CLARK, Pennsylvania GEORGE MURPHY, California
JENNINGS RANDOLPH, West Virginia PAUL J. FANNIN, Arizona

HARRISON A. WILLIAMS, Jz., New Jersey

CLAIBORNE PELL, Rhode Island

EDWARD M. KENNEDY, Massachusetts

GAYLORD NELSON, Wisconsin

ROBERT F. KENNEDY, New York
Srewart E. McCuure, Chief Clerk
JOHN S. ForsYTHE, General Counsel
SrppHEN KUBZMAN, Minority Counsel

 

SUBCOMMITTEE ON HEALTH

LISTER HILL, Alabama, Chairmen
RALPH W. YARBOROUGH, Texas JACOB K. JAVITS, New York
HARRISON A. WILLIAMS, In., New Jersey GEORGE MURPHY, California
CLAIBORNE PELL, Rhode Island
EDWARD M. KENNEDY, Massachusetts
ROBERT W, BARCLAY, Professional Staff’ Member
Roy H. MILLENson, Minority Clerk
 

CONTENTS

CHRONOLOGICAL LIST OF WITNESSES
FeBrouary 9, 1965

The Honorable Anthony J. Celebrezze, Secretary of Health, Education,
and Welfare, accompanied by Dr. Edward W. Dempsey, special assistant
to the Secretary (Health and Medical Affairs) and Dr. David E. Price, .
Deputy Surgeon General. _._...__.-_- eee 36

Dr. Robert Berson, executive director, Association of American Medical
Colleges, accompanied by Dr. George Wolf, president, Association of
American Medical Colleges, and Dr. Thomas Turner, president-elect,
Association of American Medical Colleges. __......_.-----__-------_- 73

Dr. Carleton B. Chapman, president, American Heart Association, accom-
panied by Dr. James V. Warren, past president, Jesse R. Fillman,
member, board of directors, and Rome Betts, executive secretary,
American Heart Association............._..___..--.._.-_--_-_-___- 82

Dr. Murray Copeland, president, American Cancer Society, accompanied
by Dr. Harold S. Diehl, senior vice president for research and medical
affairs, American Cancer Society_...._.....__......--------------_- 92

Fesruary 10, 1965

Dr. Michael E. DeBakey, Chairman, President’s Commission on Heart

Disease, Cancer, and Stroke____________-_.__._____-_-----..______ 102, 107
Dr. Sidney Farber, Chairman, Subcommittee on Cancer__..__________-- 109
Dr. John Stirling Meyer, Chairman, Subcommittee on Stroke__________- 136
Dr. Howard A. Rusk, Chairman, Subcommittee on Rehabilitation_______ 132
Dr. Irving Wright, Chairman, Subcommittee on Heart...___......--___ 126
Kennedy, Hon. Robert F., a U.S. Senator from the State of New York_. 105
Dr. Michael E. DeBakey—resumed_.__._._____..-__-__-___-_-__-_---- 107
Marion B. Folsom, director, Eastman Kodak Co____._______..-_----_- 113
Dr. John Stirling Meyer, Chairman, Subcommittee on Stroke, President’s

Commission on Heart Disease, Cancer, and Stroke____________.____-- 136

STATEMENTS
American Cancer Society, prepared statement______._.____..-_-__.._-_- 93
Association of American Medical Colleges, prepared statement_-__.-.-_-_ 78
American Dental Association, prepared statement____________________- 161

Berson, Dr. Robert, executive director, Association of American Medical
Colleges; accompanied by Dr. George Wolf, president, Association of
American Medical Colleges, and Dr. Thomas Turner, president-elect,
Association of American Medical Colleges........_..------_---_----- 73

Chapman, Carleton B., president, American Heart Association; accom-
panied by Dr. James V. Warren, past president, Jesse R. Fillman,
member, board of directors; and Rome Betts, executive secretary,
American Heart Association. ._____.......___._--.--------------_- 82

Celebrezze, Hon. Anthony J., Secretary of Health, Education, and Wel-
fare; accompanied by Dr. Edward W. Dempsey, special assistant to the
Secretary, and Dr. David E. Price, Deputy Surgeon General_________- 36

Copeland, Dr. Murray, President, American Cancer Society; accompanied
by Dr. Harold S. Diehl, senior vice president for research and medical
affairs, American Cancer Society________-..-_-_.______-__---__-_-_-_- 92

Additional statement_....._-...0 2.2222 eee sooo sees ee 93
IV CONTENTS

DeBakey, Dr. Michael E., Chairman, President’s Commission on Heart Page
Disease, Cancer, and Stroke_-_-------------------------------+--->- 102
Supplemental statement----__.------------------------------7-- 143
DeBakey, Dr. Michael E.—resumed__-_---------.------------+---7777- 107
2 Farber, Dr. Sidney, chairman, Subcommittee on Cancer ---------------- 109
Folsom, Marion ~, director, Eastman Kodak Co-_--------------------- 113
Prepared statement__.-_-----.-----------------------------777-- 113
Lane, Warren Zeph, M.D., prepared statement_---.----------.--77--7- 167

Meyer, Dr. John Stirling, Chairman, Subcommittee on Stroke, President’s
Commission on Heart Disease, Cancer, and Stroke------------------ 136
Rusk, Dr. Howard A., chairman, Subcommittee on Rehabilitation_- ----- 132
Prepared statement___----------------------------------------- 135
Wright, Dr. Irving, chairman, Subcommittee on Heart _..-------------- 126

ADDITIONAL INFORMATION

Appendix B.—Summary of appropriations recommendations including
those for new programs and increases for existing programs and com-

parison with estimates of current levels of support.__---_------------ 295
Advancing the Nation’s Health (H. Doc. 44), President’s message on

health, January 7, 1965.___---------------=-------5,------g7747777 16
Article entitled “Albany Regional Hospital Program,” a preliminary

report._.._----------------------------- 27-22 rea 28
Cities with estimated population of 400,000 and over on January 1, 1964_ 69

Letters to Senator Hill from:
Blasingame, F. J. L., M.D.,- American Medical Association, Chicago,

Ill., dated February 18, 1965----~------------=:-----+----7777-- 162
Chapman, Carleton B., M.D., president, American Heart Association,
New York, N.Y., dated February 24, 1965-_---.----------.---- 165
Gelvin, E. R., M.D., Gelvin-Haughey Clinic, Concordia, Kans.,
dated January 14, 1965_.-----_-------------=--<------------->- 163
Hilberry, Clarence, president, Wayne State University, Detroit,
Mich., dated February 16, 1965_..--.------------------------ 170
Kolb, Mary Elizabeth, president, American Physical Therapy Asso-
ciation, New York, N.Y., dated February 9, 1965_.__----------- 165
Kottke, Frederic J., M.D., professor, University of Minnesota Medi-
cal School, dated February 9, 1965_-_-------------------:------ 163
McNamara, Hon. Pat, a U.S. Senator from the State of Michigan,
dated February 24, 1965___--------.--------------<=-----7-<7-7 169
Moss, Hon. Frank E., a U.S. Senator from the State of Utah, dated
February 12, 1965_.--.-------------------------------- pap 156
Mattison, Berwyn F., M.D., executive director, American Public
Health Association, Inc., dated February 10, 1965_---_-.-------- 162
Williamson, Kenneth, associate director, American Hospital Associa-
tion, dated February 16, 1965..-----------------n-7-575--57757 157
Letter to Senator Kennedy of New York, from Henry J. Heimlich, M.D.,
president, National Cancer Foundation, dated February 15, 1965--- - -- 166
Letter to Senator McNamara from William L. Simpson, M.D., Detroit
Institute of Cancer Research, dated February 20, 1965_-------------- 169
List of scientific papers published by Dr. Henry G. Hadley ..----------- 165
Members of the President’s Commission on Heart Disease, Cancer, and
Stroke_..___._-_------------------- 22 eee 155
Subcommittee reports of the President’s Commission on Heart Disease,
Cancer, and Stroke. --_-----------------------------------00rr0 171
Cancer Panel_._.____------------------------- eer e 182
Communication_____-___--_.--------------------------+ 7-7 --7- 250
Facilities. ___..____-_------------------------------9 cert 256
Heart Disease.___._.--_---------------------------+-err cre 171
Manpower... __-------------------------- 9-20 rrr errr 229
Rehabilitation. _____..---------------------------<----cctc rc 199
Research._...___-------------------------- oe nore ert 273
Stroke__._______----------- eee ener 193
Telegram to Senator Philip A. Hart from Harlen Hatcher, president, the
University of Michigan_------.------------------------+---7--77-7> 170
Page
102
143
107
109
113
113
167

136
132
135
126

 

295
16
28
69

162

165

163

 

COMBATING HEART DISEASE, CANCER, STROKE, AND
OTHER MAJOR DISEASES

TUESDAY, FEBRUARY 98, 1965

USS. Senate,
SUBCOMMITTEE ON HEALTH OF THE
ComMITTEE on Lanor AND Pusiic WELFARE,
Washington, D.C.

The subcommittee met, pursuant to notice, at 10:05 a.m., in room
4232, New Senate Office Building, Senator Lister Hill, chairman of
the subcommittee, presiding.

Present : Senators Hill (chairman), Yarborough, Pell, Kennedy of
Massachusetts, and Javits, members of the subcommittee, and Senator
Kennedy of New York, member of the full committee.

Committee staff members present : Stewart E. McClure, chief clerk ;
John S. Forsythe, general counsel; Robert W. Barclay, professional
staff member; and Roy H. Millenson, minority clerk.

The Cratrman. The subcommittee will kindly come to order.

The subcommittee is meeting this morning to receive testimony on
S. 596 that would provide assistance in.establishing regional medical
complexes to combat heart disease, cancer, stroke, and other major
diseases.

(S. 596 and the President’s message on health follow :)
2 COMBATING HEART AND OTHER MAJOR DISEASES

80TH CONGRESS
ist Session S 5 9 6
e

 

IN THE SENATE OF THE UNITED STATES

JANUARY 19, 1965

Mr. Hitz introduced the following bill; which was read twice and referred
to the Committee on Labor and Public Welfare

 

A BILL

To amend the Public Health Service Act to assist in combating

heart disease, cancer, and stroke, and other major diseases.

—_

Be it enacted by the Senate and House of Representa-
2 tives of the United States of America in Congress assembled,
3 That this Act may be cited as the “Heart Disease, Cancer,
4 and Stroke Amendments of 1965”.

5 Sec. 2. The Public Health Service Act (42 U.S.C., ch.
6 GA) is amended by adding at the end thereof the following

7 new title:

 
en

COMBATING HEART AND OTHER MAJOR DISEASES 3

1 “TITLE IX—REGIONAL MEDICAL COMPLEXES
FOR RESEARCH AND TREATMENT IN HEART
3 DISEASE, CANCER, STROKE, AND OTHER
4 MAJOR DISEASES

We)

5 “PURPOSES
6 “Sec. 900. The purposes of this title are—
7 “(a) Through grants, to encourage and assist in the

8 establishment of regionally coordinated arrangements among
9 medical schools, research institutions, and hospitals for re-
10 search and training and for demonstrations of patient eare in
11 the fields of heart disease, cancer, stroke, and other major
12 diseases;

13 “(b) To afford to the medical profession and the med-

14 ical institutions of the Nation, through such coordinated

15 arrangements, the opportunity of making available to their

16 patients the latest advances in the diagnosis and treatment

17 of these diseases; and

18 “(c) To accomplish these ends without interfering with

19 the patterns, or the methods of financing, of patient care or

20 professional practice, or with the administration of hospitals.
21 “AUTHORIZATION OF APPROPRIATIONS
22

“SEC. 901. (a) There are authorized to be appropriated
23° $50,000,000 for the fiscal year ending June 30, 1966, and
such sums as may he necessary for each of the next four fis-

25 cal years, for grants to assist public or nonprofit private uni-

Ceeeeeeeeee ee a
10
11
12
13
14
15
16
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20
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22
23
24

25

COMBATING HEART AND OTHER MAJOR DISEASES
versities, medical schools, research institutions, and other
public or nonprofit private institutions and agencies in plan-
ning, establishing, and operating regional medical complexes
for research, training, and demonstration activities for carry-
ing out the purposes of this title. Sums appropriated under
this section for any fiscal year shall remain available for
making such grants until the end of the fiscal year following
the fiscal year for which the appropriation is made.

“(b) A grant under this title shall be for part or all of
the cost of the planning or other activities with respect to
which the application is made, except that any such grant
with respect to construction of, or provision of built-in (as
determined in accordance with regulations) equipment for,
any facility may not exceed 90 per centum of the cost of such
construction or equipment.

“(c) Funds appropriated pursuant to this title shall not
be available to pay the cost of hospital, medical, or other
care of patients except to the extent it is, as determined in
accordance with regulations, incident to research, training, or
demonstration activities.

“DEFINITIONS

“Sec. 902. For the purposes of this title—

“(a) The term ‘regional medical complex’ means a
group of public or nonprofit private institutions or agencies

each of which is engaged in research, training, diagnosis,
 

 

COMBATING HEART AND OTHER MAJOR DISEASES 5

1 and treatment relating to heart disease, cancer, or stroke and,

2 at the option of the applicant, any other disease found by the

eo

Surgeon General to be of major significance to the health of

+ the Nation; but only if such group—

ao

“(1) is situated within a geographic area, composed

6 of any part or parts of any one or more States, which

~I

the Surgeon General determines, in accordance with

8 regulations, to be appropriate for carrying out the pur-

co

poses of this title;

10 (2) consists of one or more medical centers, one
11 or more categorical research centers, and one or more
12 diagnostic and treatment stations; and

13 (3) has in effect arrangements for the coordina-
14 tion of the activities of its component units which the
15 Surgeon General finds will be adequate for effectively
16 carrying out the purposes of this title.

W “(b) The term ‘medical center’ means a medical school

18 and one or more hospitals affiliated therewith for teaching,
19 research, and demonstration purposes.

20 “(c) The term ‘categorical research center’ means an in-
21 stitution (or part of an institution) the primary function of
#2 which is research (including clinical research), training of
specialists, and demonstrations and which, in connection
24 therewith, provides specialized, high-quality diagnostic and

25 treatinent services for inpatients and outpatients.

) ”
bo

mB Ww

Oo om -l

10

11

12

13

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23
24.

COMBATING HEART AND OTHER MAJOR DISEASES

“(d) The term ‘diagnostic and treatment station’ means
a unit of a hospital or other health facility, the primary func-
tion of which is to support and augment local capability for
diagnosis and treatment by providing specialized, high-
quality diagnostic and treatment services to outpatients and
inpatients.

“(e) The term ‘nonprofit’ as applied to any institutior
or agency means an institution or agency which is owned anc
operated by one or more nonprofit corporations or associa
tions no part of the net earnings of which inures, or may
lawfully inure, to the benefit of any private shareholder o
individual.

“(f) The term ‘construction’ includes construction an
initial equipment of new buildings, expansion, remodeling
and alteration of existing buildings; including architects’ serv
ices, but excluding off-site improvements and the acquisitio
of land.

“GRANTS FOR PLANNING AND DEVELOPMENT

“Sno, 903. (a) The Surgeon General, after consultatio
with the National Advisory Council on Medical Complex
established by section 905 (hereinafter in this title referre
to as the ‘Council’), is authorized to make grants to publ
or nonprofit private universities, medical schools, resear

institutions, and other public or nonprofit private agenci
 

COMBATING HEART AND OTHER MAJOR DISEASES 7
1 and institutions to assist them in planning the development of
2 regional medical complexes.
3 “(b) Grants under this section may be made only upon
4 application therefor approved by the Surgeon General. Any
5 such application may be approved only if it contains or is

6 supported by reasonable assurances that—

7 “(1) Federal funds paid pursuant to any such grant
8 will be used only for the purposes for which paid and in
9 accordance with the applicable provisions of this title
10 and the regulations thereunder;

11 (2) the applicant will provide for such fiscal con-
12 trol and fund accounting procedures as are required by
13 the Surgeon General to assure proper disbursement of
14 and accounting for such Federal funds;

15 “(3) the applicant will make such reports, in such
16 form and containing such information as the Surgeon
17 General may from time to time reasonably require, and
18 will keep such records and afford such access thereto
19 as the Surgeon General may find necessary to assure the
20 correctness and verification of such reports; and
21 (4) the applicant will provide for the designation
22, of an advisory group, to advise the applicant (and the
23 resulting regional medical complex and its component
24 units) in formulating and carrying out the plan for the
25 establishment and operation of such regional medical

)
 

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14
15
16
17
18
19
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21
22
23
24
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COMBATING HEART AND OTHER MAJOR DISEASES

| complex, which includes representatives of organizations,
institutions, and agencies concerned with activities of the
kind to be carried on by the complex and members of
the public familiar with the need for the services pro-
vided by the complex.

“GRANTS FOR ESTABLISHMENT AND OPERATION OF

REGIONAL MEDICAL COMPLEXES

“Src, 904 (a) The Surgeon General, after consultation
with the Council, is authorized to make grants to public or
nonprofit private universities, medical schools, research insti-
tutions, and other public or nonprofit private agencies and
institutions to assist in establishment and operation of re-
gional medical complexes, including construction and equip-
ment of facilities in connection therewith.

“(b) Grants under this section may be made only upon
application therefor approved by the Surgeon General. Any
such application may be approved only if it contains or is
supported by reasonable.assurances that—

“(1) Federal funds paid pursuant to any such grant

(A) will be used only for the purposes for which paid

and in accordance with the applicable provisions of this

title and the regulations thereunder, and (B) will not
supplant funds that are otherwise available for establish-

‘ment or operation of the regional medical complex with

respect to which the grant is made;

- sammmanaat
 

 

COMBATING HEART AND OTHER MAJOR DISEASES 9
1 “(2) the applicant will provide for such fiscal con-
2 trol and fund accounting procedures as are required by
3 the Surgeon General to assure proper disbursement of
4 and accounting for such Federal funds;
5 (3) the applicant will make such reports, in such
6 form and containing such information as the Surgeon
7 General may from time to time reasonably require, and
8 will keep such records and afford such access thereto as
9 the Surgeon General may find necessary to assure the
10 correctness and verification of such reports;
11 “(4) the applicant has designated or will designate
12 an advisory group, described in paragraph (4) of sec-
18 tion 903 (b), to advise in carrying out the plan for the
14 regional medical complex; and
15 (5) any laborer or mechanic employed by any
16 contractor or subcontractor in the performance of work
17 on any construction aided by payments pursuant to any
18 grant under this section will be paid wages at rates not
19 less than those prevailing on similar construction in the
20 locality as determined by the Secretary of Labor in ac-
21 cordance with the Davis-Bacon Act, as amended (40

22 U.S.C. 276a—276a-5) ; and the Secretary of Labor

23 shall have, with respect to the labor standards specified
24 in this paragraph, the authority and functions set forth
25 in Reorganization Plan Numbered 14 of 1950 (15 F.R

ee
10

pe ke

a a >» WwW

oOo mo xa

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12
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14
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22
23

24

COMBATING HEART AND OTHER MAJOR DISEASES

3176; 5 U.S.C. 1332-15) and section 2 of the Act of
June 13, 1934, as amended (40 ULS.C. 276ce).
“NATIONAL ADVISORY COUNCIL ON MEDICAL COMPLEXES
“Sno, 905. (a) The Surgeon General, with the ap-
proval of the Secretary, may appoint, without regard to the
civil service laws, a National Advisory Council on Medical
Complexes. The Council shall consist of the Surgeon Gen-
eral, who shall be the Chairman, and twelve members, not
otherwise in the employ of the United States, who are lead-
ers in the fields of the fundamental sciences, the medical sci-
ences, or public affairs. At least one of the appointed
members shall be outstanding in the study, diagnosis, or
treatment of heart disease, one shall be outstanding in the
study, diagnosis, or treatment of cancer, and one shall be
outstanding in the study, diagnosis, or treatment of stroke.
“(h) Each appointed member of the Council shall hold
office for a term of four years, except that any member ap-
pointed to fill a vacancy prior to the expiration of the term
for which his predecessor was appointed shall be appointed
for the remainder of such term, and except that the terms of
office of the members first taking office shall expire, as
designated by the Surgeon General at the time of appoint-
ment, four at the end of the first year, four at the end of

the second year, and four at the end of the third year after
 

COMBATING HEART AND OTHER MAJOR DISEASES 11

1 the date of appointment. An appointed member shall not
2 be eligible to serve continuously for more than two terms.

3 “(c) Appointed members of the Council, while attend-
+ ing meetings or conferences thereof or otherwise serving on
> business of the Council, shall be entitled to receive compen-
6 sation at rates fixed by the Secretary, but not exceeding
7 $100 per day, including travel time, and while so serving
8 away from their homes or regular places of business they
9 may be allowed travel expenses, including per diem in lieu
10 of subsistence, as authorized by section 5 of the Administra-
11 tive Expenses Act of 1946 (5 U.S.C. 73b-2) for persons
12 in the Government service employed intermittently.

13 “(d) The Council shall advise and assist the Surgeon
14 General in the preparation of regulations for, and as to policy
15 matters arising with respect to, the administration of this
16 title. The Council shall consider all applications for grants
17 under this title and shall make recommendations to the
18 Surgeon General with respect to approval of applications
19 for and the amounts of grants under this title.

20 “REGULATIONS

21 “Src. 906. The Surgeon General, after consultation
22 with the Council, shall prescribe general regulations cover-
23 ing the terms and conditions for approving applications for
24 grants under this title and the coordination of programs

25 assisted under this title with programs for training, research,

) eee
©o oO nA

10
11
12

13

25

COMBATING HEART AND OTHER MAJOR DISEASES

and demonstrations relating to the same diseases assisted
or authorized under other titles of this Act or other Acts of
Congress.

“REPORT

“Sno, 907. On or before June 30, 1969, the Surgeon
General, after consultation with the Council, shall submit to
the Secretary for transmission to the President and then to
the Congress, a report of the activities under this title to-
gether with (1) a statement of the relationship between Fed-
eral financing and financing from other sources of the activi-
ties undertaken pursuant to this title, (2) an appraisal of the
activities assisted under this title in the light of their effective-
ness in carrying out the purposes of this title, and (8) recom-
mendations with respect to extension or modification of this
title in the light thereof.”

Suc. 3. (a) Section 1 of the Public Health Service Ac
is amended to read as follows:

“SpoTion 1. Titles I to TX, inclusive, of this Act may
he cited as the ‘Public Health Service Act’.”

(b) The Act of July 1, 1944 (58 Stat. 682), a
amended, is further amended by renumbering title TX (asi
effect prior to the enactment of this Act) as title X, and b
renumbering sections 901 through 914 (as in effect prior t
the enactment of this Act) , and references thereto, as sectior

1001 through 1014, respectively.
COMBATING HEART AND OTHER MAJOR DISEASES 13

89rmu CONGRESS
ist Session S 5 9 6
e

 

IN THE SENATE OF THE UNITED STATES

Feprvary 1 (legislative day, January 29), 1965

Referred to the Committee on Labor and Public Welfare and ordered to be
printed

 

AMENDMENTS

Intended to be proposed by Mr Lone of Louisiana to 8. 596,
a bill to amend the Public Health Service Act to assist in
combating heart disease, cancer, and stroke, and other major

diseases, viz:

1 On page 10, line 21, immediately after “Sxo. 906.”,
2 insert the subsection designation “(a)”.

3 On page 11, between lines 3 and 4, insert the following:
4 “(b) No part of any appropriated funds may be ex-
5 pended pursuant to authorization given by this title for any
6 grant for any research or development activity unless such
7 expenditure is conditioned upon provisions effective to insure
8 that all information, copyrights, uses, processes, patents,
9 and other developments resulting from that activity will be

Amdt. No. 15

43-669 O- 65 - 2

i
14 COMBATING HEART AND OTHER MAJOR DISEASES

1 made freely available to the general public. Nothing con-
2 tained in this subsection shall deprive the owner of any back-
3 ground patent relating to any such activity, without his con-
4 sent, of any right which that owner may have under that
5 patent. Whenever any information, copyright, use, process,

a

patent, or development resulting from any such research or
development. activity conducted in whole or in part with

appropriated funds expended under authorization of this title

om wo a

is withheld or disposed of by any person, organization, or
10 agency in contravention of the provisions of this subsection or
11 of any condition imposed pursuant to this subsection, the
12 Attorney General shall institute, upon his own motion or
13 upon request made by any person having knowledge of per-
14 tinent facts, an action for the enforcement of the provisions
15 of this subsection in the district court of the United States
16 for any judicial district in which any defendant resides, is
17 found, or has a place of business. Such court shall have
18 jurisdiction to hear and determine such action, and to enter
19 therein such orders and decrees as it shall determine to be
20 required to carry into effect fully the provisions of this sub-
21 section. Process of the district court for any judicial dis-
22 trict in any action instituted under this subsection may be
23 served in any other judicial district of the United States by
24 the United States marshal thereof. Whenever it appears to

25 the court in which any such action is pending that other

wos ema TT
 

COMBATING HEART AND OTHER MAJOR DISEASES 15

1 parties should be brought before the court in such action,
2 the court may cause such other parties to be summoned from

3 any judicial district of the United States.”
 

16 COMBATING HEART AND OTHER MAJOR DISEASES

89TH CONGRESS HOUSE OF REPRESENTATIVES DocUMENT
{st Session No. 44

ISRO

ADVANCING THE NATION’S HEALTH

 

MESSAGE

FROM

THE PRESIDENT OF THE UNITED STATES

TRANSMITTING

ADVANCING THE NATION’S HEALTH

ene

January 7, 1965,—Referred to the Committee on Ways and Means and ordered
to be printed

ee

To the Congress of the United States:

Jn 1787, Thomas Jefferson wrote that, ‘Without health there is no
happiness. An attention to health, then, should take the place of
every other object.”

That priority has remained fixed in both the private and public
values of our society through generations of Americans since.

Our rewards have been immeasurably bountiful. ‘An attention to
health’—of the individual, the family, the community and the
Nation-——has contributed to the vitality and efficiency of our system

as well as to the happiness and prosperity of our people.

Today, at this pomt in our history, we are privileged to contemplate
new horizons of national advance and achievement in many sectors.
But it is imperative that we give first attention to our opportunities—
and our obligations—for advancing the Nation’s health. For the
health of our people is, inescapably, the foundation for fulfillment of
all our aspirations.

In these years of the 1960’s, we live as beneficiaries of this century’s
great—and continuing—revolution of medical knowledge and capa-
bilities. Smallpox, malaria, yellow fever, and typhus are conquered
in this country. Infant deaths have been reduced by half every two
decades. Poliomyelitis, which took 3,154 lives so recently as 1952,
cost only 5 lives in 1964. Over the brief span of the past two
decades, death rates have been reduced for influenza by 88 percent,

tuberculosis by 87 percent, rheumatic fever by 90 percent.
a

 

COMBATING HEART AND OTHER MAJOR DISEASES 17

A baby born in America today has a life expectancy half again as
long as those born in the year the 20th century began.

The successes of the century are many.

The pace of medical progress is rapid.

The potential for the future is unlimited.

But we must not allow the modern miracles of medicine to mes-
merize us. The work most needed to advance the Nation’s health
will not be done for us by miracles. We must undertake that work
ourselves through practical, prudent, and patient programs—to put
more firmly in place the foundation for the healthiest, happiest, and
most hopeful society in the history of man.

Our first concern must be to assure that the advance of medical
knowledge leaves none behind. We can—and we must—strive now
to assure the availability of and accessibility to the best health care
for all Americans, regardless of age or geography or economic status.

With this as our goal, we must strengthen our Nation’s health
facilities and services, assure the adequacy and quality of our health
manpower, continue to assist our States and communities in meeting
their health responsibilities, and respond alertly to the new hazards
of our new and complex environment.

We must, certainly, continue and intensify our health research and
research facilities. “Despite all that has been done, we cannot be
complacent before the facts that—

Forty-eight million people now living will become victims of
cancer.

Nearly 15 million people suffer from heart disease and this,
together with strokes, accounts for more than half the deaths in
the United States each year.

Twelve million people suffer arthritis and rheumatic disease
and 10 million are burdened with neurological disorders.

Five and one-half million Americans are afflicted by mental
retardation and the number increases by 126,000 new cases each
year.

In our struggle against disease, great’ advances have been made,
but the battle is far from won. While that battle will not end in our
lifetime—or any time to come—we have the high privilege and high
promise of making longer strides forward now than any other genera-
tion of Americans.
~~ “The measures I am outlining today will carry us forward in the
oldest tradition of our society—to give “an attention to health” for
all our people. Our advances, thus far, have been most dramatic
in the field of health knowledge. We are challenged now to give
attention to advances in the field of health care—and this is the
emphasis of the recommendations I am placing before you at this time.

 

J. Removine Barriers TO HEALTH CARE

In this century, medical scientists have done much to improve
human health and prolong human life. Yet as these advances come,
vital segments of our populace are being left behind—behind barriers
of age, economics, geography, or community resources. Today the
political community is challenged to help all our people surmount
these needless barriers to the enjoyment of the promise and reality
of better health.

"me
18 COMBATING HEART AND OTHER MAJOR DISEASES
A. HOSPITAL INSURANCE FOR THE AGED

Thirty years ago, the American people made a basic decision that
the later years of life should not be years of despondency and drift.
The result was enactment of our social security program, ® program
now fixed as a valued part of our national life. Since World War IT,
there has been increasing awarenes: of the fact that the full value of
social security would not be realized unless provision were made to
deal with the problem of costs of illnesses among our older citizens.

I believe this year is the year when, with the sure knowledge of
public support, the Congress should enact a hospital insurance program
for the aged.

The facts of the need are well and widely known:

Four out of five persons 65 or older have a disability or chronic
disease.

People over 65 go to the hospital more frequently and stay
twice as long as younger people.

Health costs for them are twice as high as for the young.

Where health insurance is available it is usually associated with an
employer-employee plan. However, since most of our older people
are not employed they are usually not eligible under these plans.

‘Almost half of the elderly have no health insurance at all.

The average retired couple cannot afford the cost of adequate
health protection under private health insurance.

L ask that our social security system—proved and tested by three
decades of successful operation—be extended to finance the cost of
basic health services. In this way, the specter of catastrophic hos-
pital bills can be lifted from the lives of our older citizens. I again
strongly urge the Congress to enact a hospital insurance program for the
aged.

Such a program should—

Be financed under social security by regular, modest contribu-
tions during working years;

Provide protection against the costs of hospital and post-
hospital extended care, home nursing services, and outpatient
diagnostic services;

Provide similar protection to those who are not now covered
by social security, with the costs being paid from the administra-
tive budget;

Clearly indicate that the plan in no way interferes with the
patient’s complete freedom to select his doctor or hospital.

Like our existing social security cash retirement benefits, this
hospital insurance plan will be a basic protection plan. Tt should
cover the heaviest cost elements in serious illnesses. In addition,
we should encourage private insurance to provide supplementary
protection.

1 consider this measure to be of utmost urgency. Compassion and
reason dictate that this logical extension of our proven social security
system will supply the prudent, feasible, and dignified way to free
the aged from the fear of financial hardship in the event of illness.

Also, I urge all States to provide adequate medical assistance under
the existing Kerr-Mills program for the aged who cannot afford to
meet the noninsured costs.
 

COMBATING HEART AND OTHER MAJOR DISEASES 19
B. BETTER HEALTH SERVICES FOR CHILDREN AND YOUTH

America’s tradition of compassion for the aged is matched by our
traditional devotion to our most priceless resource of all—our young.
Today, far more than many realize, there are great and growing needs
among our children for better health services.

Acute illness strikes children under 15 nearly twice as fre-
quently as it does adults.

One in five children under age 17 is afflicted with a chronic
ailment.

’ Three out of every 100 children suffer some form of paralysis
or orthopedic impairment.

At least 2 million children are mentally retarded, with a higher
concentration of them from poor families.

Four million children are emotionally disturbed.

At age 15, the average child has more than 10 decayed teeth.

If the health of our Nation is to be substantially improved in the
years to come, we must improve the care of the health of our 75
million preschool and school-age children and youth.

There is much to do if we are to make available the medical and
dental services our rising generation needs. Nowhere are the needs
sreater than for the 15 million children of families who live in poverty.

Children in families with incomes of less than $2,000 are able
to visit a doctor only half as frequently as those in families with
incomes of more than $7,000.

Public assistance payments for medical services to the 3 million
needy children receiving dependent children’s benefits through-
out the Nation average only $2.80 a month, and in some States
such medical benefits are not provided at all.

Poor families increasingly are forced to turn to overcrowded
hospital emergency rooms and to overburdened city clinics as
their only resource to meet their routine health needs.

Military entrance examinations reveal the consequences. Half of
those rejected cannot pass the medical tests. Three-fourths of them
would benefit from treatment, and earlier treatment would greatly
increase recovery and decrease lifelong disability.

The States and localities bear the major responsibility for providing
modern medical care to our children and youth. But the Federal
Government can help. J recommend legislation to—

Increase the authorizations for maternal and child health and
crippled children’s services, earmarking funds for project grants to
provide health screening and diagnosis for children of preschool
and school age, as well as treatment and followup care services for
disabled children and youth. This should include funds to help
defray the operational costs of university-affiliated mental
retardation clinical centers. Provisions should also be made for
the training of personnel who will operate medical facilities for
children.

Broaden the public assistance program to permit specific Federal
participation in paying costs of medical and dental care for
children in medically needy families, similar to the Kerr-Mills
program for the aged.

Extend the grant programs for (a) family health services and
clinics for domestic agricultural migratory workers and their
children and (5) community vaccination assistance.
20 COMBATING HEART AND OTHER MAJOR DISEASES
c. IMPROVED COMMUNITY MENTAL HEALTH SERVICES

Mental illness afflicts 1 out of 10 Americans, fills nearly one-half
of all the hospital beds in the Nation, and costs $3 billion annually.
Fortunately, we are entering a new era in the prevention, treatment,
and care of mental illness. Mere custodial care of patients in large,
isolated asylums is clearly no longer appropriate. Most patients
can be cared for and cured in their own communities.

An important beginning toward community preparation has been
made through the legislation enacted by the 88th Congress author-
izing aid for constructing community ‘mental health centers. But
facilities alone cannot assure services.

It has been estimated that at least 10,000 more psychiatrists
are needed.

Few communities have the funds to support adequate pro-
grams, particularly during the first years.

Communities with the greatest needs hesitate to build centers
without being able to identify the source of operating funds.

Most of the people in need are children, the aged, or patients
with low incomes.

I therefore recommend legislation to authorize a 5-year program of
grants for the initial costs of personnel to man community mental health
centers which offer comprehensive services.

p. A NEW LIFE FOR THE DISABLED

Today, we are rehabilitating about 120,000 disabled persons each
year. | recommend a stepped-up program to overcome this costly
waste of human resources. My 1966 budget will propose increase
funds to rehabilitate an additional 25,000.

Our goal should be at least 200,000 a year. T recommend legislation
to authorize—

Project grants to help States expand their services.

Special Federal matching so that rehabilitative services can
be provided to a greater number of the mentally retarded and
other seriously disabled individuals.

Construction and modernization of workshops and rehabilitation
centers.

II. STRENGTHENING THE Natvion’s HEALTH FAcILITIES AND SERVICES

In our urbanized society today, the availability of health care
depends uniquely upon the availability and accessibility of modern
facilities, located in convenient and efficient places, and on well-
organized and adequately supported services. The lack of such
facilities and services is, of itself, a barrier to good health care.

A. MULTIPURPOSE REGIONAL MEDICAL COMPLEXES

In this century, we have made more advance than in all other
centuries toward overcoming diseases which have taken the heaviest
toll of human life. ‘Today we are challenged to meet and master the
3 killers which alone account for 7 out of 10 deaths in the United
States each year—heart disease, cancer, and stroke. The Commission
on Heart Disease, Cancer, and Stroke has pointed the way for us
toward that goal.

-
 

COMBATING HEART AND OTHER MAJOR DISEASES 21

The newest and most effective diagnostic methods and the most
recent and most promising methods of treatment often require equip-
ment or skills of great scarcity and expense such as— :

open heart surgery;
advanced and very high voltage radiation therapy;
advanced disease detection methods.

It is not necessary for each hospital or clinic to have such facilities,
*quipment, or services, but it is essential that every patient requiring
such specialized and expensive procedures and services have access
to them. Multipurpose medical complexes can meet these needs.
They would—

speed the application of research knowledge to patient care,
so as to turn otherwise hollow laboratory triumphs into health
victories ;

save thousands of lives now needlessly taken annually by the
three great killers—heart disease, cancer, and stroke—and by
other major diseases.

A plan to improve our attack upon these major causes of death
and disability should become a part of the fabric of our regional and
community health services. The services provided under this plan
will help the practicing physician keep in touch with the latest medical
knowledge and by making available to him the latest techniques,
specialized knowledge, and the most efficient methods.

To meet these objectives, such complexes should—

Be regional in scope.

Provide services for a variety of diseases—heart disease,
cancer, stroke, and other major illnesses.

Be affilated with medical schools, teaching hospitals, and
medical centers.

Be supported by diagnostic services in community hospitals.

Provide diagnosis and treatment of patients, together with
research and teaching in a coordinated system.

Permit clinical trial of advanced techniques and drugs.

Medical complexes—consisting of regional organizations of medical
schools, teaching hospitals, and treatment centers tied into community
diagnostic and treatment facilities—-represent a new kind of organi-
zation for providing coordinated teaching, research, and patient care.
When we consider that the economic cost of heart disease alone
amounts to 540,000 lost man-years annually—worth some $2.5
billion—the urgency and value of effective action is unmistakable.

Action on this new approach, stemming from recommendations of
the Commission on Heart Disease, Cancer, and Stroke, will provide
significant improvements in many fields of medicine.

I recommend legislation to authorize a 5-year program of project
grants to develop multipurpose regional medical complexes for an all-out
attack on heart disease, cancer, stroke, and other major diseases.

B. IMPROVED SERVICES FOR THE MENTALLY RETARDED

Mental retardation in any individual is a lifelong problem of the
most serious nature for the family and for the community. But we
know today that the problem need not and must not lead to tragic
hopelessness. Much is being done to provide a decent, dignified,
place in society for these unfortunate individuals.

till
22 COMBATING HEART AND OTHER MAJOR DISEASES

The 88th Congress provided a substantial foundation for building
ap effective national program for the prevention of mental retardation
and care of the mentally retarded. Under this authority, grants are
authorized-—

For construction of mental retardation research centers, com-
munity mental retardation centers, and university-affiliated
mental retardation centers,

For planning by all the States of comprehensive action to com-
bat mental retardation at the State and community levels.

The 1966 budget includes $282 million—a $40 million increase—for
these programs and other mental retardation services, including pre-
ventive activities and the training of teachers of the retarded. I urge
that this full amount be appropriated.

Extensive resources and programs need to be developed in the
States and communities to prevent mental retardation and to care for
the mentally retarded. The existing authority for planning grants
will end on June 30, 1965. The developmental needs and effective
utilization of the construction grants require followup action.

T recommend the enactment of mental retardation program development
grants for 2 additional years to help the States continue this essential
work.

C. MODERNIZATION OF HEALTH FACILITIES

Great progress has been made throughout the Nation in the provi-
sion of new general hespitals under the Hill-Burton program. But
relatively little assistance has been available for modernization of the
older hospitals, found particularly in our large cities. Without aid,
deterioration threatens and rapid scientific and technical change is

assing by these essential links to health care for millions of our people.

The 1966 budget will include funds for a greatly increased hospital
modernization effort as well as for expansion in the number and quality
of nursing homes. J urge the Congress to approve the full amount

requested tor each of these purposes. .
D. AID FOR GROUP PRACTICE FACILITIES

New approaches are needed to stretch the supply of medical
specialists and to provide a wider range of medical services in the
communities. The growth of voluntary, comprehensive group
practice programs has demonstrated the feasibility of grouping
health services for the mutual benefit of physicians and patients by—

Integrating the burgeoning medical specialties into an efficient
and economical system of patient care.

Reducing the incidence of hospitalization which may now
oecur because there are few alternative centers for specializec
care,

The initial capital requirements for group practice are substantial
and the funds are not now sufficiently available to stimulate th
expansion and establishment of group practice. To facilitate an¢
encourage this desirable trend, T recommend legislation to authoriz
a program of direct loans and loan guarantees to assist voluntary associ
ations in the construction and equipping of facilities for comprehenswv
group practice.
 

 

 

COMBATING HEART AND OTHER MAJOR DISEASES 23

TI. Manrower ror toe Hearty Services

The advance of our Nation’s health in this century has, in the final
measure, been possible because of the unique quality and fortunate
quantity of men and women serving in our health professions.
Americans respect and are grateful for our doctors, dentists, nurses,
and others who serve our Nation’s health. But it is clear that the
future requires our support now to increase the quantity and assure
the continuing high quality of such vital personnel.

In all sectors of health care, the need for trained personnel continues
to outstrip the supply:

At present, the United States has 290,000 physicians. In a
decade, we shall need 346,000.

Today we are keeping pace with our needs largely because of
the influx of numbers of foreign-trained doctors. Last year 1,600
came into the United States, the equivalent of the output from
16 medical schools and 21 percent of our medical school graduates.

Population growth has badly outpaced the increase in dentists
and the shortage of dentists is now acute.

To begin to meet the Nation’s health needs, the number of new
physicians graduated each year must increase at least 50 percent by
1975, and the output of new dentists by 100 percent.

The Health Professions Educational Assistance Act of 1963,
authorizing grants to schools for construction of medical and other
health education schools and loans to students, will help meet this
problem. The magnitude of the need is demonstrated by the response °

Ninety applications have been received from medical and
dental schools, requesting $247 million in Federal aid for con-
struction.

Only $100 million is available in 1965; and the full authorization
for 1966, which I will shortly request in the budget I am sub-
mitting, will provide $75 million more.

In the light of these needs, J urge the Congress to appropriate the full
amount authorized and requested for the Health Professions Educational
Assistance Act program.

While we must build new medical and dental schools, we must also
retain and sustain the ones we have. To be neglectful of such schools
would be wasteful folly.

We «must face the fact that high operating costs and shortages of
operating funds are jeopardizing our health professions educational
system. Tuition and fees paid by medical and dental students meet
less than half the institutional costs of their education. Several
underfinanced medical and dental schools are threatened with failure
to meet educational standards. New schools are slow to start, even
when construction funds are available due to lack of operating funds.

I therefore recommend legislation to authorize—

Jormula grants to help cover basie operating costs of our health
profession schools in order that they may significantly expand both
thewr capacity and the quality of their educational programs;

project grants to enable health profession schools to experiment
and demonstrate new and improved educational methods.

Traditionally, our medical profession has attracted outstanding
young talent, and we must be certain that this tradition is not com-
promised. We must draw the best available talent into the medical
profession. Half of last June’s medical school graduates came from

EEE
NEE

24 COMBATING HEART AND OTHER MAJQR DISEASES

families with incomes of over $10,000 a year. The lizh costs of
medical school must not deny aceess to the medical profession for
able youths from low- and middle-income familes.

I therefore recommend legislation to aithorize scholarships far medical
and dental students who would otherwise not be able to enter or
complete such training.

Looking to the future

We must also look to the future in planuing to meet the health
manpower requirements of the Nation,

Unmet health needs are already large. American fumilies ure
demanding and expecting more and better bealth services. In the
past decades the proportion of our gross national product devoted ta
health has increased by more than 50 percent. The trend is still
upward. Hf we are to meet our future needs and raise the health of
the Nation, we lust —

improve utilization of available professional health persornel ;

expand the use and training of technicians and ancillary health
workers through special schools and under the Vocational Educa-
tion Aet and Manpower Development and Trainmeg Act programs;

expand and improve traiming programs for professional and for
supporting health personnel;

plan ahead to meet requirements for which the leadtime is
often 10 years or more,

With these objectives inimind, J have asked the Seeretary of Health.
Qdueation, and Welfare to develop a long-range health manpower pro-
gram for the Nation and to recommend to me the steps which should
be taken to put ut into effect.

IV. Hearts Researcu aAnp RESEARCH FAcILITIES

Two decades ago this Nation decided that its Government should
be astrong supporter of the health research to advance the well-being
of its people. This vear that support wnounts to more than two-
thirds of the total national expenditure of $1.5 billion for health

research,
Continued growth of this research is necessary and the 1966 budget
includes:

Ten-percent growth in expenditures for health research and
for the related training.

Funds to begin an automated system for processing the ex-
ploding volume of information on drugs and other chemicals
related to health.

Health research, no less than patient care, requires adequate
facilities. Over the past 8 years the Health Research Facilities Act
has been highly successful in helping provide research facilities to
universities and other nonprofit institutions. Federal grants of
$390 million to 990 construction projects have generated over $500
million in matching institutional dollars.

This authority expires on June 30, 1966, and J recommend that
it be extended for 5 years with an inereased authorization and with a
larger Federal share for specialized research facilities of a national or
regional character.

ce  mmntare pore pmne  E cate 9908 10:6 EL EAT
 

COMBATING HEART AND OTHER MAJOR DISEASES 25

V. Hearty Grants anp Prorection MEASURES

Our complex modern society is creating health hazards never before
encountered. The pollution of our environment is assuming such
important proportion I shall shortly send to the Congress a special
message dealing with this challenge.

, But the protection of the public health also requires action on other
ronts.

A. HEALTH GRANTS TO COMMUNITIES AND STATES

In safeguarding and advancing the Nation’s health, States and
communities have long had special responsibilities. General and
special-purpose health grants have proved an eftective means of
strengthening the Federal Government’s partnership with them in
improving the public health.

I have directed the Secretary of Health, Education, and Welfare
to study these programs thoroughly and to recommend to me necessary
legislation to increase their usefulness.

Authorizations for many of these programs expire at the close of
fiscal year 1966. So that a thorough review may be made, J recom-
mend that the Congress extend the authorizations through June 30, 1967.

B. CONSUMERS HEALTH PROTECTION

Modernization of the Federal Food, Drug, and Cosmetic Aci is
imperative if our health protection program is to keep pace with tho
technological and industrial advances of recent years.

The health of all Americans depends on the reliability and safety of
the products of the—

food industry which alone generates nearly $100 billion in retail
sales each year;
drug industry with sales reaching $6 billion;
cosmetic industry which markets $2.5 billion of products.
All must be operated under the highest standards of purity and safety.

Yet, despite recent improvements in food and drug le islation, seri-
ous gaps in our ability to protect the consumer still exist. The law
should be strengthened to provide adequate authority in the regula-
tion of nonprescription drugs, medical devices, cosmetics, and food.

Narcotics are not alone among the hazardous, habit-formin drugs
subject to improper use. Barbiturates, amphetamines, and other
drugs have harmful effects when improperly used. Widespread traffic
resulting from inadequate controls over the manufacture, distribution,
and sale of these drugs is creating a growing problem which must be
met. We must also counter the threat from counterfeit drugs.

I recommend legislation to bring the: production and distribution of
barbiturates, amphetamines, and other psychotozic drugs under more
effective control.

For the fuller protection of our families, I recommend legislation to
require—

Adequate labeling of hazardous substances.

Safety regulation of cosmetics and therapeutic devices by pre-
marketing examination by the Food and Drug Administration.

Authority to seize counterfeit drugs at their source.
96 COMBATING HEART AND OTHER MAJOR DISEASES

CoNncLUSION

I believe we have come to a rare moment of opportunity and
challenge in the evolution of our society. In the message 1 have
presented to you—and in other messages T shall be sending “Vv
purpose is to outline the attainable horizons of a greater society whic
a confident and prudent people can begin to build for the future.
Whatever we aspire to do together, our success in those enterprises—
and our enjoyment of the fruits that result—will rest finally upon the
health of our people. We cannot and we will not overcome the
barriers— oT surmount all the obstacles—in one effort, no matter how
intensive. But in all the sectors I have mentioned we are already
behind our capability and our potential. Further delay will only
compound our problems and deny our people the health and happiness
that could be theirs.
The Eighty-eighth Congress wrote a proud and significant record of
accomplishment in the field of health legislation. T have every con-
fidence that this Congress will write an even finer record that will be
remembered with honor by generations of Americans to come.

Lynpon B. JOHNSON.
Tue Waite House, January 7, 1965.
 

el nee

COMBATING HEART AND OTHER MAJOR DISEASES 27

The Cuamman. The basic objective of this legislation is to improve
the medical care of patients. This would be achieved by extending to
a wider geographic area and to a broader population base the benefits
of the strong programs of clinical care, research, and medical educa-
tion at our medical centers,

Over the last two decades we have developed new medical knowledge
at an unprecedented rate. Leading scientists have testified that the
last 20 years has been the most productive era in the history of medi-
cine.

As a result of this progress, the young physicians of this country are
no longer required to travel to the capitals of Europe for the best. in
medical education. In fact, the situation is reversed. Each year
thousands of physicians from other countries come to the medical cen-
ters of this country to advance their education. j

And, an increasing number of patients from other lands are seeking
treatment in the United States, because it is recognized that the best
medical care available today is being provided at our medical centers
which have active research and strong education programs,

The experience of the Veterans’ Administration is a good illustra-
tion of the close connection between patient care and medical educa- I
tion and research. You will remember that prior to 1945 it was the q
policy of the Veterans’ Administration to operate its hospitals in iso-
lation and apart from the medical resources of the communities in
which they were located.

This isolation produced a poor quality of care that was recognized
by the American Legion as early as 1941 when its members approved
their famous Resolution 528 that was highly critical of the Veterans’
Administration. They later recommended than an outstanding mem-
ber of the medical profession head the Department of Medicine and
Surgery and called for a reorganization of the department.

The pressures for reorganization did not abate until 1945 when
Gen. Omar Bradley was appointed Administrator of Veterans’ Affairs.

General Bradley, Maj. Gen. Paul R. Hawley, chief surgeon of the
European Theater, an Brig. Gen. Elliott C. Cutler, professor of
surgery at Harvard Medical School, at a conference determined that
if the medical care of veterans was to be improved it would be neces-
sary to affiliate veterans’ hospitals with the medical educational forces
of the United States.

I may say a similar proposal had earlier been advanced by Dr. Paul
B. Magnuson, professor of orthopedic surgery at Northwestern Uni-
versity Medical School, but had been rejected by the former Adminis-
trator of the Veterans’ Administration. As we recall, Dr. Magnuson
subsequently served as medical director of the Veterans’ Administra-
tion.

The program of affiliation and the establishment of the deans com-
mittee led to a rapid improvement in the medical care for veterans.
Five years later an advisory committee under the chairmanship of Dr.
Charles W. Mayo appraised the new medical care program in these
terms:

One of the major reasons for the high caliber of medical care given to the
veteran is the constant emphasis placed on education and research. * * * It
has been amply demonstrated that the educational program in a veterans

hospital, by being available to all physicians in the area, has uplifted the general
level of medical practice in the entire community. * * *

 

 
28 COMBATING HEART AND OTHER MAJOR DISEASES

The experience of the Veterans’ Administration is pertinent in the
consideration of this pending legislation, since it vividly portrays the
importance of research and education to a high quality program of
patient care.

Under the provisions of S. 596, assistance would be provided to
communities in strengthening services to patients through the estab-
lishment of regional medical complexes that are comprised of a close
alliance of clinical care, medical research, and health education
programs.

The new program, in effect, is a logical outgrowth and extension of
the clinical research center programs administered by the National
Institutes of Health since 1959. In the case of the National Cancer
Institute, for example, there are 10 clinical research centers throughout
the country with approximately 200 beds. All patients are referred
to the centers by their personal physicians and are admitted to the
centers only when their participation will contribute to a specific
medical research study.

The regional medical complex, however, differs from the clinical
research center in that it provides for extending the influence of the
medical teaching center beyond the confines of the college or university
and thereby extends the advances in medical research to more patients.

I may say I am submitting for the record an article that appeared
in the New England Journal of Medicine of September 20, 1962. This
article describes the Albany regional hospital program that links the
Albany Medical College with six hospitals in Schenectady, N.Y.,
Pittsfield, Mass., Springfield, Mass., and Poughkeepsie, N.Y.

(The article referred to follows:)

THe ALBANY REGIONAL HospITAL PROGRAM *
A Preliminary Report

(Henry 8. M. Uhl, M.D.,? William P. Nelson ITI, M.D.,? and Frank M. Woolsey,
Jr.. M.D.,’ Albany, N.Y.)

The Albany regional hospital program began formal activities in September
1960. Adequate financing over a 5-year period is assured by support of the
National Heart Institute and by an annual contribution by each of the partici-
pating hospitals amounting to an average of $12,500 per year.

The project was established within the newly organized Department of Post-
graduate Medicine at Albany Medical College, and three full-time members of
the medical college faculty and this department are responsible for its admin-
istration and direction.

Although a number of medical colleges have developed a variety of plans to
improve educational activities in community hospitals, we believe that the
Albany regional hospital program is unique in the depth with which it is attack-
ing the many difficult problems and in the frequency and intensity of its efforts
to work closely with the educational directors, the chiefs of services. the admin-
istration and the trustees of each hospital.

 

1From the Department of Postgraduate Medicine. Albany Medical College of Union
University. Presented in part at the annual education meeting, ‘Association of Hospital
Directors of Medical Education, Chicago, Iil., Feb. 3, 1962.

* Assistant professor of postgraduate medicine, Albany Medical College of Union Uni-
versity.

* Agsoctate professor of postgraduate medicine, Albany Medical College of Union Uni-
versity. .

4 Professor of postgraduate medicine and chairman, Department of Postgraduate Medi-
cine, Albany Medical College of Union University.

ne
 

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COMBATING HEART AND, OTHER MAJOR. DISEASES 29

The five educational programs are located in the Hllis Hospital, Schenectady,
N.Y.; the Pittsfield Affiliated Hospitals (the Pittsfield General and St. TLuke’s
hospitals) in. Pittsfield, Mass.; St. Clare’s Hospital, Schenectady, N.Y.: the
Springfield Hospital, ‘Springfield, Mass.; and the. Vassar Brothers Hospital in
Poughkeepsie, N.Y. (fig. 1). Thus, six general hospitals are directly involved. :

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ALBANY “&:

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“~~, Massachusetts

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NEW YORK

The purpose of this program is to determine the extent and degree to which a
medical college, through formal collaboration, can contribute to the development
of graduate and postgraduate medical education in a selected group of. non-
university community teaching hospitals. In. this paper we shall present a
preliminary report describing our experience in the first phase of the project.

EXPOSITION

If this purpose, with its many ramifications, is to be achieved it is necessary
to understand and define the special problems of community hospitals. What
are their shortcomings? What are the needs that the medical college will have
to meet?
Medical educators agree that the complexity and importance of graduate
medical education equal those of undergraduate medical education in determin-
ing the quality of practice of the physician. Ideally, therefore, graduate medical
education ought to be planned, administered, and conducted at the same profes-
sional level as undergraduate medical education. However, there are many
problems that interfere with the realization of this ideal.* These may be
summarized as follows:
The position of the director of medical education remains one of professional
isolation, with a lack of real authority in the conduct of educational activities.
Furthermore, because it is a new field of work there is a nationwide shortage of
experienced physicians to fill this difficult role. i .
There is a serious lack of knowledge about medical education among hospital
administrators. and hospital trustees. j
Very few community hospitals possess a teaching faculty. i
There is the continuous conflict between the requirements of the standards of i
medical education and the service demands of the hospital and the visiting staff 1
in the care of patients. i
There is a serious lack of knowledgeable department heads for the major i
clinical, divisions, such as medicine, surgery, pediatrics and obstetrics and i
gynecology. :
There is a lack of personnel and special facilities for competent teaching of |
basic sciences.
bf
|

 

'Uhl, H. 8S. M., director of medical education in nonuniversity community teaching
hospital, New Eng. J. Med. 266: 647-652, 1962, .
° Barnes, F. W., Jr., graduate clinical education. J. M. Edue. 37: 192-200, 1962.

43-669—65——-8

 
ee.

30 COMBATING HEART AND OTHER MAJOR DISEASES

There is a serious lack of continuing education activities in which the visiting

staff participates. ‘
There is a lack of appropriate procedures for the recognition and promotion of
visiting-staff members on the basis of educational activities:

There is generally a lack of research programs that can contribute effectively
to strengthening the graduate edueation program.

There is a lack of systematic and objective. methods for evaluating the prog-
ress of the house staff in individual training programs.

Most community hospitals are chronically faced with an insufficient number
of interns and residents in their individual training programs. Furthermore,
there may be wide shifts in the number of candidates in the program from one
year to the next.

This is an extensive list of problems and needs. No doubt other items could
be added—for example, the cost of these educational programs and how these
costs are to be met by the community hospital.” .

In the selection of individual hospitals for the Albany regional hospital pro-
gram searching conferences were held with officials of the visiting staff and the
administration, and in some cases with hospital trustees. These special prob-
lems of the community hospital were clearly identified. A formal contract was
entered into between the medical college and the individual hospital only after
agreement was reached that the goals of the project were to establish sound
educational activities by working out appropriate solutions to these problems.

Two vital points were stressed: officials of the medical college and of this
department would in no way interfere in the internal affairs of the hospital ; and
the medical college would guarantee nothing in the way of recruitment of interns
and residents for any of the hospitals.

OPERATION OF THE PROGRAM

The program is administered by 3 full-time members of the department of post-
graduate medicine. It is worth noting that each one has devoted many years to
administrative and teaching responsibilities. Dr. Woolsey *® and Dr. Nelson *
have for the past 10 years been active in undergraduate, graduate, and post-
graduate medical education at the Albany Medical Center, and Dr. Uhl’s previ-
ous activities include almost 8 years as a full-time educational director in com-
munity hospitals. The combined experience has been of practical value in an
understanding of the psychology of the practicing physician in his community
hospital, and in an evaluation of his commitments to medical education.

Our three basic activities in the Albany regional hospital program include
administration, teaching, and consultation. We are continuously involved in
scheduling weekly visits for members of the medical-school faculty to each of
these hospitals. In addition, one of us visits each of the five participating hos-
pitais each week, with occasional exceptions. During these visits we conduct
teaching rounds and conferences, and we carry on informal meetings providing
information, advice, and guidance to the director of medical education, to mem-
bers of the administration and to responsible members of the visiting staff.
Consultation activities refer to more formal requests for special meetings in
which one or more of us meets with the hospital administrator, trustees, director
of education, and key staff officials to discuss long-term problems and policy devel-
opments in the program. These meetings are held either at the hospital or at
the medical college.

In addition to these three basic and continuous activities we have taken cer-
tain steps to assist the regional hospitals in recruitment of interns and residents.
We have visited medical schools in Italy and Switzerland to interview American
citizens studying abroad who have intended to take their hospital training in the
United States. We placed advertisements in several major medical journals,
such as the Journal of the American Medical Association and the British Medi-
cal Journal, describing briefiy the Albany regional hospital program and the
yarious training programs offered. However, we have refused thus far to encour-
age undergraduate students.at Albany Medical College to apply to the regional
hospitals, despite some pressure put upon us by one or two of the educational
directors.

—

7 Pratt, O. G., and Hill, L. A.. “Price of Medical Education ; Dissection of One Hospital's
Expenditures.” “Hospitals.” 34: 44-47, 1960.

# Associate dean and associate professor of medicine.

8 Assistant dean and associate professor of medicine.
 

ne Lee

‘COMBATING ‘HEART. AND ..OPHER : MAJOR. DISEASES 31

Finally, we frequently assist the various hospitals in obtaining guest speakers
from other medical schools in the northeastern part of the country. In such
cases a portion of these costs is paid from special funds provided by a grant-
in-aid through the postgraduate program of Merck Sharp & Dohme. This addi-
tional support of the formal teaching activities of the regional hospitals has been |
especially beneficial: during the early phase of the project. Occasionally, the
Visitors take part in special teaching exercises at the medical college.

THE HOSPITALS IN THE PROGRAM
The capacities of these hospitals vary from 250 to 585 beds. There are two

One hospital has only an approved internship, one hospital has an approved
internship, a 2-year general-practice residency and a 2-year residency in pathol-
- o8y, and .the other. hospitals -have approyed, internships: and various: residency 4
programs in clinical and laboratory specialties. Two of the programs have.full-
time, and three ‘have half-time educational ‘directors. The. most experienced
of these men has been on the job about 3 years. Three are surgeons, of whom
one has recently retired from active practice, one is an internist, and one a gen-
eral physician. Two have prior Albany. Medical College faculty appointments,
one as an assistant professor of anatomy and one as an instructor in medicine.
In none of these hospitals is there any full-time physician in a clinical field,
but all have full-time department heads in pathology and radiology. In one of

medicine, with the probability that this appointment will be followed by full-time
chiefs in other clinical departments,

Research activities in these hospitals are limited although there are three in
which rather sophisticated original work is being carried out. One of, the educa-
tiorial directors is’ conducting a research program at the medical college, using
the facilities of the experimental surgical laboratory.

SPECIFIC ACTIVITIES OF THE PROGRAM

Although each hospital hay problems peculiar to its own program, to greater i
or lesser degree all hospitals exhibit difficulties related to the 11 problems listed
in an earlier section of this paper. We wish to describe how the Albany regional
hospital program is attempting to deal with. these shortcomings and deficiencies.

Variations in our approach to each hospital are related. essentially to the fre
quency and intensity with which specific methods and procedures are applied.

Tsalation of the director of education

'.. The: professional isolation of the educational director is largely relieved by
his contacts with staff members from the department of postgraduate medicine.
These contacts are achieved through our regular visits and through frequent
telephone communication. Our knowledge and experience is used week by week :
to answer routine questions, and our prestige and authority have been invaluable i
in supporting the educational director in his dealings with physicians and ad-
ministrators. The significance of these methods of support becomes even more
striking when one recalls that none of the five educational directors had any 4
previous administrative education experience. We believe this feature of the
program is one of fundamental value.

Information on medical education

Administrators and trustees of community hospitals generally have little or
no knowledge o: experience in graduate and postgraduate medical education. i
To overcome this urgent problem each of us meets as often as possible with the |
administrator and hig staff assistants on. our weekly visits. We have held a ;
joint meeting with all administrators at the medical college, and intend to do so
periodically in the future. We have provided both administrators and trustees

education, and the need and justification for these costs. As a byproduct of
this activity we are again supporting the educational director.

Lack of teaching faculty a ;
; Although few community hospitals possess'a teaching faculty; all the hospitals
in this program -pogsess. skilled and competent: attending staffs in the major
Specialties and in the laboratory fields. We believe that we can stimulate the

 
eee

32 COMBATING HEART AND OTHER MAJOR DISEASES

development of teaching faculties through two methods: by providing preeept
and example through our own teaching activities and through frequent visits
by effective teachers from the faculty of Albany Medical College; and by offering
appointments in the department of postgraduate medicine to physicians who
prove their ability to teach and their interest in the program, and who demon-
strate their own continuing educational activities. These appointments will be
reviewed annually, and there will be renewal or promotion only when such action
is clearly justified by the record. Furthermore, we believe that as each hospital
makes progress in its educational effort, it will attract outstanding physicians
interested in settling in a progressive medical community. Indeed, this has
already occurred in one case.

Conflict between medical-education standards and care of patients

We are continuously exerting our influence to establish the concept in each
hospital that service to private patients by the house staff should be directly
related to an excellent educational program. We are, however, combining real-
ism with idealism, and attempting to meet practical problems with practical solu-
tions. For example, in one of the hospitals where there is a critical shortage of in-
terns, we have recommended the appointment of a full-time salaried experienced
general physician to run the emergency ward. This step has relieved the house
staff of a service burden that it was being asked to combine with activities on
inpatient floors.

Lack of knowledgeable department heads

A most serious difficulty, and one with far-reaching implications, is the fact
that the chiefs of the clinical departments in these community hospitals are
elected to this position, and often have little qualification and inclination for
the challenging job of administering a residency program and directing a staff
of practicing physicians. We have been able to help in some cases simply by
pointing out the fact that this deficiency existed. In one of our hospitals the
problem has been. grasped so clearly that the staff and the administration have
now accepted the necessity of establishing positions for full-time chiefs, and of
searching for the right candidate from outside the hospital and the community.
The professor of medicine and the professor of surgery at the medical college
have given consultation and advice, and in one case conducted a site visit and
survey, to analyze these problems and help the hospital develop its solutions.
Undoubtedly, our activities in this area will increase with the passage of time.

Personnel for teaching of basic sciences

The teaching of basic sciences and their correlation with diagnosis and
management of the sick human being have become one of the essential elements
of graduate and postgraduate medical education. We are approaching this
problem, first by establishing a basic curriculum for the academic year in each
hospital from September to May. It has been adapted to the individual need
of each hospital by the educational director in cooperation with his department
heads and with us. Secondly, we have presented formal basic science courses
through the use of the two-way FM-radio conference network.”* Thirdly, we
have made available to the interns, the residents and the attending staffs of our
regional hospitals the opportunity to attend the special teaching days at the
medical college. Finally, we have made available information and materials
for the presentation of special courses in the regional hospitals through the
cooperation of faculty members. For example, in one of the hospitals a series
of sessions in surgical anatomy and surgical physiology will be presented by
members of the staff. Faculty members in charge of these programs at the
medical college are working with these physicians in the planning of the course
and in making available teaching aids, such as lantern slides, mimeographed
material, and other useful teaching tools.

Continuing education
Continuing education is now available in quality and depth at each hospital.

In addition, the practicing physicians are encouraged to attend special teaching
days at the.medical center. By increasing their participation in teaching con-

 

10 Woolsey, F. M., Jr., “Two-Way Radio Conferences—New Method for Postgraduate
Education.” GP 19: 185-189, 1959.

Idem. “Two-Way Radio Conferences for Postgraduate Medical Education: 4 Years of
Experience With New Method of Presentation.” - Canadian M. A. J. 82: 717-719, 1960.

a
 

TF eee

COMBATING HEART AND OTHER MAJOR DISEASES 3a.
ept
as ferences and rounds in their own hospitals, they are improving their knowl-
ing edge of medicine. We hope to stimulate these self-educational efforts by judi-
ho cious use of faculty appointments, as described above.
sl Recognition and promotion of staff on the basis of educational activities
on The attending staff of each hospital will in the final analysis determine the
tal quality of the education Program. It is the rare community hospital that has
ins developed systematic, objective procedures for evaluating the effectiveness of
129 the individual physician in his teaching role and that uses such information in
appointments and promotions. The seniority system is still the rule. Our
initial efforts have been geared to the simple task of working with the individual :
director of education to identify the able men, the potentially useful men, and i
ich the deficient men. We continually stress the opinion that the attending physi- j
tly cian who does no participate in and contribute to the program should not enjoy
al- the benefits of house-staff service and coverage on a daily basis. We have
yhu- asked the educational director to keep attendance records at teaching con-
in- ferences, to keep a continuous evaluation of each physician’s faithfulness in con-
ced ducting bedside teaching rounds and to collect, by means of a questionnaire,
use an evaluation by the intern and the resident of each member of the attending
on staff under whom he works. Eventually, we believe that the systematic col-
lection of such information will be acceptable as evidence bearing directly upon
future appointments and promotions within the attending staff.
act Lack of research programs
are One of the Inajor differences between graduate and postgraduate medical
for education in the university hospital and the community hospital is found in the j
ait different levels of research. To stimulate the development of sound investiga- ;
by tive programs in these regional hospitals, we shall make available our own qi
the knowledge, and the extensive experience of the medical school faculty, in the f
ave planning and organization of research, in the formulation of proposals for
of grants, in instruction in techniques, in providing information about the use of
ity. newer instruments and wherever the research knowledge of the faculty can
ege be of assistance. There is considerable potential for productive, independent
amd work in more than one of. these hospitals in the laboratory departments and in
ns. some of the subspecialties in medicine. We shall encourage its development
me. wherever we find the right men to do the job. House-staff members will be
encouraged to visit the medical college for advice and information about specific
projects being conducted in regional hospitals. The chief surgical resident in
and one hospital is already involved in one project and, on the basis of his past
nts record, his interest and his work, has received an appointment for next year
this in the department of anatomy at the medical college.
ach Progress of the house staff
ent Everyone recognizes that in graduate medical education Systematic, objective
SES methods for evaluating the progress of the intern and resident have never been
we applied, as they are in the education of the undergraduate medical student. We
our have been most fortunate in enlisting the cooperation of the National Board of
the Medical Examiners in developing special examinations for all the interns in our
ials regional hospitals. We are working out plans to test simultaneously the mem-
the bers of the attending staff of each hospital. All intern candidates will be
ries reexamined before the internship has been completed, and these young physi-
“by cians will take the newly developed part III examination. As our experience
the indicates, we shall work toward the development of effective testing procedures
irse for residents. This type of evaluation will be correlated with the present com-
hed monly accepted method of questionnaires er forms that are filled in by members
of the attending staff as they supervise the house officers from month to month
and year to year. At the present time standards for. reappointment and pro-
motion are minimal, since in most cases the practical necessities and difficulties.
ital. of recruitment dictate these decisions. :
ing Insufficient interns and residents in training programs
con We have taken two Specific actions in an effort to assist our hospitals with
recruitment of interns and of residents. The visits to foreign medical schools
uate attended by large numbers of ‘Americans in Italy and in Switzerland. were an
“3 of exploratory venture to determine whether or not such personal contact might
. i

influence the choice of hospital for internship by these students. More than a
few have selected their internships in our ‘hospitals, but we. shall not know

 
34 COMBATING HEART AND OTHER MAJOR DISEASES

the full value of this effort until the final results for the current recruitment
year lave been assessed. On the other hand, the advertisements plaeed in
several journals distributed throughout the world have resulted in an astonishing
interest in the possibility of residency appointments. Tt seems certain that the
regional hospitals will have more than enough eandidates. to fill all residency.
positions for the year ahead. Itis still too early to know whether this approach

will be as useful in recruitment for the internships.

CoN CLUSION

We have described the ways in which we are attempting to meet the problems

and needs of the community teaching hospitals in the Albany. regional hospital

program. The single most important feature of this project is that three full-

time members of the faculty of the Albany Medical College, whose combined
backgrounds include many years of experience in undergraduate, graduate, and
postgraduate medical education both in university medical centers and in com-
munity hospitals, are in day-by-day and week-by-week contact with the educa-
tional directors. If the program had accomplished nothing else jn this first
phase, it would have been worth the effort and the cost.

An objective or quantitative evaluation of an experimental project in medical
education in the community hospital is difficult to achieve, because what one
is trying to do is to change the degree of participation in continuing educational
activities by individual physicians and to influence the quality of hospital medical
care and ultimately all medical care in the community. However, there are
certain things that can be measured and compared over a period of several years:
the performance of house staff and attending staff in special tests; the quality
of medical records; the use of the medical library; the development of research
projects; the quality of new appointments to the attending staff; the record of
attendance and participation in conferences, seminars, and special teaching
activities; changes jn the physical plant and special laboratory and clinical
facilities in the individual hospital ; and the development and establishment of
the concept of half-time and full-time subspecialists and clinical department
heads in the individual hospital.

Systematic collection and tabulation of this type of information has already
provided us with some jndication of the impact of the project on each hospital.
Our experience to date suggests that in each hospital progress, retrogression, and
status quo can exist simultaneously put that an overall pattern of improvement
or lack of improvement can be jdentified.

The initial concern on the part of each hospital that the medical college would
interfere in its internal affairs has virtually disappeared ; indeed, in some cases
our participation in their internal decisions has been and is being actively
sought. Furthermore, each hospital has developed a more realistic attitude
toward the recruitment of a house staff of quality. No longer are magical solu-

“ tions expected. Instead, we are more and more devoting our attention to the
basic weaknesses and strengths of each hospital to develop long-range policies.
In this way we hope that our goal of providing the best in medical care for

the public whom the hospitals serve will be achieved.

The Crammsn. In concluding, may 1 say that this legislation, S.
596, will assist our hospitals across the country in fulfilling their
functions and achieving their objectives. These functions and ob-
jectives were spelled out most clearly by that great man of medicine,
Sir William Osler, in 1911, in an_address before the Northumberland
‘and Durham Medical Society in England, when he stated :

First a word on what a hospital’stands'for’in the community. primarily, for
the care of the sick and the relief of suffering ; secondly, for the study of the
problems of disease; and thirdly, for the training of men and of women to
serve the public as doctors and nurses.

Senator Javits?

Senator Javirs. 1 thank my chairman.

Mr. Chairman, first, T would like to, as I know I would reflect ever’
member of the committee on both sides of the aisle, again pay tribute
to our chairman as @ leading figure in my judgment in the Congress 0

 
 

a Lee

COMBATING HEART AND OTHER MAJOR DISEASES 35
it the United States. and in an absolutely unchallenged position in im-
in proving the participation of the United States in a tyemendous war
g on disease. o . .
e This is but another. milestone in a long progress for which the whole
7 Nation should be grateful to Senator Lister Hill, of Alabama.

The Cuairman. Let me express my heartfelt thanks to you for the
generous remarks.

Senator Javirs. It has been for so many years, Mr. Chairman, that

ns no one will challenge them in the Congress, that I know.
al The Cuairman. Thank you.
ye Senator Javits. May I say, too, Mr. Chairman, I personally regard
nd this morning’s hearing with a particular sentiment, as the very first i
m- major measure with which I had anything to do was the sponsorship :
a in the House with then Senator Pepper of the National Heart Act, i
sa Public Law 655 of the 80th Congress, signed into law on June 16, 1948, q
‘al To this day I look back on it as probably the most important single
ne piece of legislation, with the Taft-Ellender housing bill, that I had the
al honor to sponsor as a Member of the Congress in the House and Senate.
“al May I say, too, Mr. Chairman, that I am very proud of my party,
~ as ranking member both on this subcommittee and our full committee,
ity in the bipartisan. effort to wage this war on disease which incidentally f
ch is a crown of glory of our Federal establishment, the most humane, |
| be prsighted act in relation to the real welfare of the people over the
decades. :
“ar I am very proud of the role of my party in the National Heart Act 4
anit and the National Dental Facility Act of the Republican 80th Congress,
a and the Medical Survey and Construction: Act, National Health Survey
ay Act, the Health Research Facilities Act, the National Library of Medi-
nd cine Act, the Health Amendments of 1956, and the International
ent Health Research. Act of 1960, all of which occurred in the Eisenhower
years.
ses Whatever may have been said by people or myself about our 1964
ely campaign, we Republicans did pledge our support for medical research
ude in the Federal establishment unequivocally even in that platform.
vin Mr. Chairman, one further word and then I shall be through. I
the thank the Chair for calling attention to the Albany, N.Y., regional
for hospital program, very much a prototype for the kind of thing we are
doing here. I am very pleased that my State under its succession of
S, Governors, without regard to parties, and now capped by Governor
eir Rockefeller, is a leader in this field and is such an important prototype
ob- forthe Nation. — a .
ine, I have only one thing to point out, Mr. Secretary. We do find, in a
ind careful examination of the report of the President’s Commission on
Heart Disease, Cancer, and Stroke and this bill, some major points
for which we would like to explore with you as to the extent, the number,
the and the costs: of individual centers. We find the report to have had
1 to much greater specificity than does the bill. I find also in the bill a

rather open-ended commitment for 4 years with a cost price tag for
1 year. These are things I know you will want to go into with us as
well as I want to go into with you.

ery Mr, Chairman, may I again pledge what I know would be the view i
ute of this side of the aisle, that we would join with the chairman and

s of members of the. committee on the majority side in the most patriatic

 
 

ee, il a

36 ~ COMBATING HEART AND OTHER MAJOR DISEASES

and honorable effort to add yet another milestone thing to the great
history which has been written in recent year's in this tremendous war
of the Federal Government on disease.

The Cuarman. May I confirm all that the distinguished Senator
from New York has said about the very important effective part that
he was played in so many vital health programs.

He began his fight for health in the House of Representatives, before
he came to the Senate. Certainly since he has been in the Senate and
a member of this committee, he has played a great part in waging the
battle to advance these great programs for the health of our people, for
medical research, medical education, and for better clinical treatment.

Senator Javirs. Thank you.

Senator Yarsoroveu. Mr. Chairman, for 7 years I have been a mem-
ber of this subcommittee under the chairmanship of the distinguished
chairman. I have seen public health measures advanced greatly in
this country under the chairman’s leadership. Beginning with the
Hill-Burton Act, that is just a small measure of what has been ac-
complished for public health and hospitalization. If we named all of
the long list of notable acts that have been passed under your leader-
ship, it would be practically the history of the advance of the Federal
Government in alleviating disease in this country. For 27 years our
distinguished chairman has been a member of this committee. He
comes from a family with a great history in its battle against disease.
He has been chairman of this full committee for 10 years and is most
widely known for the Hill-Burton Act.

He has pushed so many acts to fruition that I predict success in
another, with this S. 596 which Senator Hill has authored. I pledge
you my cooperation and assistance, Senator Hill, and I congratulate
you in pushing this legislation for an early hearing. _

The CuHarrman. Senator, no one on this subcommittee has given
more help and finer support than you have. I appreciate your help.

Mr. Secretary, we would be very happy indeed, to have you proceed,
sir, in your own way on this pending legislation.

We are happy you have with you Dr. Ed Dempsey, your adviser on
medical affairs, former dean of Washington University Medical School,
and Dr. Dave Price, Deputy Surgeon General of the Public Health
Service, and we would be happy to have you proceed.

STATEMENT OF HON. ANTHONY J. CELEBREZZE, SECRETARY OF
HEALTH, EDUCATION, AND WELFARE; ACCOMPANIED BY DR.
EDWARD W. DEMPSEY, SPECIAL ASSISTANT TO THE SECRETARY;
AND DR. DAVID E; PRICE, DEPUTY SURGEON GENERAL.

Secretary CeLesrezze. Thank you, Mr. Chairman.

May I say Dr. Dempsey was also a member of the President’s Com-
mission on Heart Disease, Cancer, and Stroke which submitted its re-
port. I regret that Dr. Luther Terry, the Surgeon General, cannot be
here but we have budget hearings on in the House and it was his turn
on the budget; otherwise, he would be here. _

I am most pleased, Mr. Chairman, and members of the committee to
present testimony. in behalf of the proposed Heart Disease, Cancer,
and Stroke Amendments of 1965, 8. 596, introduced by the distin-
guished chairman of this committee. This legislation, if enacted,
 

a
COMBATING HEART AND OTHER MAJOR DISEASES 37
will permit the Nation to take a giant stride toward the conquest of the
; three greatest killers of people.
P In 1963, 707,830 people died of, and 25 to 30 million suffered from,
heart disease. The direct medical costs were $2.6 billion in 1962; the
r loss of income that year amounted to $19.8 billion; the total cost was
t $22.4 billion for this one disease.
Also in 1968, 278,562 people died of cancer, about 830,000 were under
7 treatment, gnd, it is estimated, 48 million people now living will have
1 cancer. The total annual cost is more than $8 billion.
° And in that same year, 201,166 people died of strokes. At least 2
r million people now alive have had strokes, Many are paralyzed. The
o economic cost is more than $1.1 billion per-year.
These are the great killers and cripplers. They sap our economy
i by $31.5 billion each year. They cause untold hardship, anguish, and
suffering. . They can be made to give ground by an organized attack.
a Early in 1964, the President established a Commission on Heart
© Disease, Cancer, and Stroke. The Commission was instructed to study
f the scientific and medical problems posed by these three deadly diseases
: and to recommend national action that would reduce their toll through
‘| new knowledge and more complete utilization of the medical knowl-
. edge we already have.
e The proposed legislation we are considering today is designed to
© embody the major thrust contained in the first three recommendations
K ofthe Commission. I believe that this program will, in fact, save many
” thousands of lives through the fuller application of existing medical
7 knowledge and by accelerating acquisition of new lifesaving know]l-
edge.
: The bill before you today, S. 596, would amend the Public Health
e Service Act by establishing a new program of grants for the creation of
n regional medical complexes to serve as a framework through which the
best in modern medical knowledge would be made swiftly and surely
E available to physicians in practice and to their patients who are suf-
, fering from heart disease, cancer, stroke, or other major diseases.
in Grants would be made to public or nonprofit. private universities,
1 medical schools, research institutions, and other public or nonprofit
7 private institutions and agencies. They would serve a twofold pur-
pose: :

First, they would permit. establishment of regional, coordinated

F arrangements, ameng the key medical resources, including medical

schools, research institutions, and hospitals, for the conduct of re-
R. search, training, and demonstrations related to heart disease, caricer,
r; stroke, and other major diseases.
Second, the coordinated arrangements thus established would af-
ford to. physicians, and to the health institutions in which they prac-
tice, the arrangements for them to. supply the latest advances. in
n- diagnosis and treatment of these diseases. Se
"e- The. proposed program. would accomplish these vital ends. with-
be out interfering with traditional. patterns of patient care, professional
rm practice, or the administration of hospitals, or with the methods ‘of

financing health care... Dos
to Let, me. develop. this last. point. a little further, Mr. .Chairman,
er’,

because there has been. ‘some misunderstanding of the Commission’s
recommendations. What, basically, we are seeking to do for victims

 

pe

 
 

38 COMBATING HEART AND OTHER MAJOR DISEASES

of these diseases is to equip existing hospitals and their ‘existing
medical staffs to provide care of a quality that is available today only
in a handful of places in the country. We are not.proposing that
the Federal Government pay for this care—either hospital costs or
physicians’ fees—except as the Government already pays for care.
that is a part of federally supported research. When we speak. of
making high quality services more widely available, we are speaking
not of the economics of health care but of the availability of the
needed professional skills. and the néeded physical equipment. in
places where they do not exist today. That, plus its stimulus to
research, is the purpose of this bill, | .

What is envisioned is a regional ‘complex of medical. facilities and
resources functioning as a coordingted unit for the. benefit, of the
physicians and residents of a given geographic area. ‘Each regional
medical complex would contain a number of component parts:

(ay One or more medical centers—a medical school and its affili-
ated hospital or hospitals ;

(b) One or more categorical research centers—an institution or
part of an institution whose primary functions are the conduct of
research, the training of specialists, and the provision of specialized
diagnostic and treatment services related to its research and training
programs; , :

(c) One or more diagnostic and treatment stations—a unit of a
hospital or other facility whose primary function is to augment local
capability by providing specialized high quality diagnostic and treat-
ment services to inpatients and outpatients. ;

In some regions, facilities and services which serve as parts of the
proposed medical complex are already in existence. In others, these
would need to be created. In every region, there is essential need for
effective coordination of its medical resources. .

Thus, it is the goal of the proposed legislation to encourage, -de-
velop, and support an administrative framework within which
individual components can function efficiently to provide the full
range of needed services without unnecessary duplication. Another
specific goal is to encourage and support the:development of essential
new facilities and services within this framework. an

Two types of grants are proposed under the legislation.

The first would aid eligible agencies and institutions in the plan-
ning and ‘development of regional medical complexes—in the develop-
ment, that is, of the administrative framework just described.

The second would aid eligible agencies and institutions in establish-
ing and operating the complexes. ee a

Applications for both the planning and the operational grants
would be reviewed by a new Council advisory to the Surgeon General,
the National Advisory Council on Medical Complexes, which would
be established by the proposed legislation. This Council would be
made up of 12 members and would include at least one outstanding
expert in each of the three disease fields. oo _.

Moreover, to assure full cooperation ‘and coordination of all in-
terested agencies and institutions at the local or regional level, each
applicant for either a planning or an operational grant would be re-
quired to designate or create a local advisory body comprising
representatives of relevant health organizations and representatives

my _ a
- Eee

COMBATING HEART AND OTHER MAJOR DISEASES 39

of the general public. This advisory group would participate both
in planning and in carrying out-the operations of the regional. med-
ical complex.

The proposed legislation would authorize the appropriation of $50
million for the fiscal year ending June 30, 1966, and such sums as i
may be necessary for each of the next 4 fiscal years, to carry out the 4
purposes of the bill.

These appropriations would spearhead a national attack on-a prob-
lem now costing many billions of dollars each year. And it is,
moreover, a problem in which the economic cost, staggering though
it is, is the least of our concerns.

Seven of every ten of our fellow citizens who die each year fall 4
victim to heart disease, cancer, or stroke.

No one can say with certainty which of these lives, or precisely
what proportion of them, might have been saved if the full measure
of health protection potentially available to us through advances in
medical science had been immediately accessible at the right moment.
But the distinguished scientists on the President’s Commission ‘and
‘their colleagues across the Nation are unanimous in declaring that-the |
numbers are many—the proportion is high. f

The Commission summed up the present status and prospect with i
respect to heart disease, cancer, and stroke in these terms: 4

America need no longer tolerate several hundred thousand unnecessary deaths i
each year from heart disease, cancer, and stroke. if

By bringing to all the people the full benefit of what is now known of i
prevention, detection, treatment, and cure, we could save, each year, a number
of lives equal to the population of a major city. a

It is the intent of the legislation before this committee to translate
this hope into reality for hundreds of thousands of our people. -

I know, Mr. Chairman, that you and your colleagues on this sub-
committee are thoroughly conversant with the extensive progress that
has been made in advancing the frontiers of medical knowledge
through scientific research. Indeed, much of this: progress can be
traced directly to the enlightened support of the Congress, and espe-
cially of this committee and especially the chairman of this committee,
Senator Hill, throughout the past two decades. I know, too, that
you are deeply concerned with the harsh fact that breakthroughs
in the laboratory are too often followed by breakdowns in delivery of
services. ae

Let us examine briefly the problems that underlie these circum-
stances, and then consider the ways in which the heart disease, cancer,
and stroke amendments are designed to bridge the gap between the
world of medical science and the world of medical practice. — |

Delivery of the best in medical care depends first of all upon
manpower—adequate supplies of highly skilled physicians and their
many professional and technical allies. Despite some progress in
the recent past and the promise of more rapid progress in the years
ahead, thanks to such legislation as the: Health Professions. Educa-
tional Assistance Act, the fact remains that a health manpower
shortage exists today and will continue to exist through the foresee-
able future. De , :

» Ehave, Mr. Chairman, a difficult time explaining to people that the
mére passage’ of -a Health -Profession. -Act.-does “not.-create nore

 
eee eee

40 ‘COMBATING HEART AND OTHER MAJOR DISEASES

physicians. That it still takes 10 years or more to turn out a good
physician, and while we are on the right road, we nevertheless will
continue to have this gap, because I have found no way yet in turn-
ng out instant physicians. It still takes a long time. ,

: Senator Yarsoroven. Mr. Secretary, I hope we can close that gap
a little in the case of San Antonio by awarding a grant for establishing
a medical school there.

Secretary Crzprezze. I would be most happy. The great State of
Texas I have a soft spot in my heart for. |

Senator Yarsoroven. I commend you for bringing that up.

Secretary CeLesrezze. My boss is from there, too.

Moreover, the pace, Mr. Chairman, the pace of scientific progress
has been so rapid in recent years that a great proportion of the
physicians now in practice have been unable—because of their total
dedication to the care of their patients—to keep abreast of the latest
developments. -

In terms of health manpower, the needs are threefold:

We need to strengthen and enlarge the institutions charged with
the production of health manpower. The medical complexes pro-
posed here will enhance the capacity for training highly skilled
specialists so necessary for advanced diagnosis and treatment. °

We need to devise patterns of organization which permit maximal
utilization of the manpower we:now have. This is the purpose of
organizing our medical resources into medical complexes. oy
' And we need to develop systems which’ enhance continuing educa-
tion and means whereby those in practice can have ready and con-
venient access to consultants who have new lifesaving knowledge
and to new equipment as it is generated in ever-increasing quantity.
The Medlars system at the National Library of Medicine is one
example of a method to make information more readily available.
It is a beginning of an improved communication system.

_And I might say, Mr. Chairman, that the index medicus at the
Library of Medicine, the index alone, contains 1,800,000 words, that
is just the index. That gives you. some knowledge of the tremendous
impact that has been accomplished in research, and the tremendous
burdens then put upon local physicians in order to consume this vast
knowledge. But nevertheless, it is something that we think is essen-
tial and certainly the establishment of this medical complex, these
medical complexes where a physician can refer his patients through
he expert who keeps up with this knowledge will save many lives.
_Senator Yarsoroven. Mr. Secretary, have steps been taken in
research centers to put these indexes on cards and use computers
and automated equipment to get this information and make it more
‘available? | ,

_. Secretary Cerzprezze. Yes, it is all automated. It is just a matter
‘of minutes or seconds before we can get the answer for you. TI would
there project, we haven't, goné into this thoroughly but in many
areas we would like to set up whereby we could have, for example,
teletype machines in which you could call in and we could teletype
“within a minute back the information that is needed and certainly
that would be one area of furnishing information from these

complexes.

ie | oo ;
 

COMBATING HEART AND OTHER MAJOR DISEASES 41

Senator Yarporouen. These complexes would have modern ‘ma-
chinery ?

Secretary Cutesrezze. Yes, sir, we are making progress toward
disseminating this knowledge to the people who need it but at the
rate that we are going, our knowledge is coming in so fast that one
of our basic problems, and really the basic reason for this type of
legislation is we have the same problem in the field of education, in
other words, which do our research, we find out the answer but’ this
gap of carrying the knowledge of a laboratory when the discovery
is made and applying it to the people, there is too great a gap there.

Now, how important is it that we get it to the people in a hurry?

fell, I think the best example that 1 could give on that is our re-
search in polio vaccine. When you think back that there were 380,000
or 40,000 cases of polio we now reduce it to a little over a hundred
a year, because of the mass immunization programs, because of the
cooperation of the medical societies in getting to the people, so that,
you see, the longer we wait on this gap the more surge there is.
When we find the knowledge, when we find a cure, we have got to
get it to the people, we have got to get it to them somehow, whether
they can afford or can’t afford it we still have to get it to them and
that is the primary purpose of these medical complexes, until such
time as we can build up the reservoir of skilled manpower which wé
lack today. _

In the field of education we have the same problem. I was check-
ing in my research on the educational bill—I found sometimes there
is a gap of 15 to 20 years in the field of education before the re-
search reaches a pupil. That is too long.

Now, the second foundation stone of our system for delivering health
services consists of the Nation’s hospitals and other medical facilities.
In this field, and again thanks to the chairman of this committee, Sen-
ator Hill, thanks in a large measure to the Hill-Burton program which
has completely redrawn the hospital map of the United States in less
than 20 years, progress has been swift and impressive. But problems
still remain, problems related to condition, distribution, and use.

In terms of the highly specialized and costly facilities required for an
all-out attack on heart disease, cancer, and stroke, there are a few
islands of abundance in a sea of unmet need. In some of our major
cities there is actually an overabundance of certain types of service—
several hospitals, for example, equipped to provide cobalt treatment
for cancer patients, each standing unused a large proportion of the
time, while not far away patients are dying for lack of such equip-
ment and for lack of the knowledge of how to acquire or to use it.

Thus, the needs for health facilities parallel those for manpower.

First, there is need to encourage and develop specialized kinds of
highly advanced facilities and equipment through construction and
renovation, designed to serve specific purposes and placed where they
will do the most good for the most eople;

Second, there is need to develop patterns of coordination which

will provide for maximum utilization of the facilities now available
and to be developed.
We have been talking almost exclusively about the problem of

bringing up-to-date health services within reach of the people whose
lives depend upon them. This is the great challenge before the health

 

 

 

 
TT

42 COMBATING HEART: AND OTHER MAJOR DISEASES

rofessions in our time—the challenge of bringing medical science
into the mainstream of medical practice.

“But the last word has not yet been spoken in the field of medical
science itself. Great as our progress has been, there still remain
great things to do. “It +3 said that “what we don’t know won’t hurt
us.” This is not true, of course, in the field of health. What we don’t
know does hurt us; what we don’t know kills us. To advance the
study of heart disease, cancer, and stroke with all possible speed,
thera is special need for a greater number of research centers de-
signed for and dedicated to a direct assault on the scientific prob-
lems presented by each of these diseases. The need is especially
acute in the area where research borders upon practice—the field of
clinical research.

- The proposed heart disease, cancer, and stroke amendments would
create a system of complexes for demonstrations, research, and teach-
ing which would be responsive to all the problems. I have mentioned
and to a degree that. could not be attained through piecemeal ap-
proaches. By approximating the worlds of medical practice, medical
research, and medical training, region by region across the Nation,
these complexes would yield three principal benefits:

(1) They would permit the full and efficient application of existing
health manpower and facilities to critical problems associated with
heart disease, cancer, and stroke.

(2) They would assure that new manpower and facilities for the
most advanced patient care and research in these fields are developed
where the needs are greatest.

(3) They would contribute to the upgrading of all medical services,
since each component of the network would serve as a point of transmis-
sion of the latest developments in scientific medicine, to both the
health professions and to the public.

The proposed regional complexes are not envisioned as a totally
new and separate pattern superimposed from above. Rather, and
this is important because many people think we are trying to create
or superimpose another structure, they are not envisioned as totally
new and separate patterns superimposed from above. Rather they are
designed to pull together the existing components of our medical
system.

Tn other words, existing universities, existing community hospitals,
and other existing agencies and institutions would be the focal points,
with new facilities and services beimg added only as the need to meet
regional requirements is demonstrated.

Thus, the plan for medical complexes is designed not to duplicate
existing resources but to strengthen them; not to trespass upon tra-
ditional prerogatives but to assist in a transition toward more effective
apnlication of such resources as now constituted.

The physician in private practice remains at the heart of the medical
care system. The regional network will help him to care for his
patients by linking him and his community hospital to a national sys-
tem transmitting the newest and best in health serviee. At the same
time, it would make each doctor a participant in the growing reservoir
of knowledge about heart disease, cancer, and stroke.

The system of regional medical complexes will not. interfere: with
existing patterns. of payment for health services. General patient
 

a —— Eee

COMBATING HEART AND OTHER MAJOR DISEASES 43

care activities are not included in the proposed legislation which states
specifically that funds appropriated shall not be used to pay for hos-
pital, medical, or other care of patients except to the extent that such
costs are. incident to research, trainin » or demonstration activities.
This, of course, incorporates the traditional pattern upon which pay-
ment of costs has been based in clinical research activities.

In summary, the Heart Disease, Cancer, and Stroke Amendments of
1965 propose a plan for the development of regional medical complexes,
each serving a large community, metropolitan area, or other geographic
region. Each complex is not a building or group of buildings but an
administrative framework linking together in coordinated effort the
existing and augmented resources of the region. Such development
of new facilities as may take place will be derivative of the overall
needs of the region.

The first purpose of the plan is to make the best in diagnosis and
treatment of heart disease, cancer, and stroke readily available to
patients in every community, through their physicians and community
hospitals which would be incorporated into the regional complex. The
second purpose is to accelerate the development of new scientific know]-
edge about these diseases.

lt is our conviction that both of these purposes would be well served
by the proposed legislation, and that important byproducts would
accrue, such as better trained: health manpower and better organized
community health services for the attack on the entire range of health 4
problems facing our people. ‘

President Johnson, in addressing his newly appointed Commission 4
on Heart Disease, Cancer, and Stroke last spring 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 something about it.

In responding, the Commission stated: “Something can be done
about it.”

The American scientific and medical community shares the cer-
tainty that something can be done about it. Today, the toll of pre-
mature death and unnecessary suffering can be reduced strikingly by
using the scientific knowledge we now possess. It can be reduced still
more dramatically tomorrow as we cross new thresholds of knowledge.

I urge your favorable consideration of this legislation which repre-
sents a vital step toward the achievement of this high purpose.

Mr. Chairman, I have Dr. Dempsey who has prepared some charts
which will sum up what the legislation would do and at this time I
would like to have him present it.

The Cuarrman, All right, Dr. Dempsey. ‘

Dr. Dempszy. Thank you. i

Senator Kunnepy of Massachusetts. Mr. Chairman, could I be per-
mitted to ask just two brief questions of the Secretary ? ‘

I have to go down to vote on the appointment of the Attorney Gen- |

 

 

eral, in the Judiciary Committee.
The Cuamrman. Just 1 minute, Dr. Dempsey. You go ahead, Sen- 4
ator Kennedy. '
Senator Kennepy of Massachusetts. I wanted to ask the Secretary
whether he saw a relationship between S. 596 which we are hearing r
this morning and also S. 595 which is the aid to the medical schools
themselves? I am thinking, Mr. Secretary, that the requirements

 
44 COMBATING HEART AND OTHER MAJOR DISEASES

which have been outlined by your very splendid testimony, and by the
legislation itself, are going to put a significant strain on many of the
medical schools throughout the country to produce the kind of people
that are going to be effective in providing service in these various
complexes.

Secretary CeLesprezze. No. I think one——

Senator Kennepy of Massachusetts. If I may just continue.

Secretary CeLmprezze. Excuse me.

Senator Kennepy of Massachusetts. I am just wondering whether
with respect to the need for doctors and technicians who have the ade-
quate training, our medical schools today are going to be able to pro-
vide the kind of first-rate service and first-rate skulls which would be
necessary to accomplish the purpose of this act.

So, I am wondering whether you see a relationship between this or
whether you are concerned about this problem, at all.

Secretary CeLesrezze. Well, we are concerned, as I stated in my
opening statement, Senator Kennedy, we are concerned about the
shortage of skilled manpower.

Senator Kennepy of Massachusetts. Yes.

Secretary CeLesrezze. We took a step in the right direction by pass-
ing the Health Professions Act of 1964 in which we make it possible
to expand our medical schools and we have pending legislation now to
further assist the students on a scholarship and forgiveness feature.

But I think this legislation will help because these complexes in-
clude some degree of training. Also our nine existing NIH institutes
are making grants available for research and clinical work. I think
certainly, as I stated earlier when you were out of the room, that there
is no such thing as turning out an instant doctor. It still takes 9 to 10
years to turn out a doctor. But I do think we are taking the neces-
sary steps at this time. The very thing about which you are so con-
cerned, Senator Kennedy, is one of the major reasons for establishing
this complex, thereby getting greater utilization of the manpower that
we now have while we are building up, during this period, the reservoir
of skilled manpower. In other words, we establish complexes in which
we can assign the skilled, trained manpower in covering a geographic
region, so that the doctor, the practicing physician, can refer his patient
there.

And thereby we are making greater utilization of what we already
have until such time as we can catch up. I think that is one of the
major points about establishing a regional complex.

I think we will continue to have a shortage for some time to come.
But we are starting along the road to eliminate it. The Health Pro-
fessions Act that was passed by Congress last year goes in that direc-
tion, but until such time as we can turn these students out in sufficient
quantity we have to make greater utilization of what we now have, and
establishing these medical complexes is one way of utilizing our trained
manpower.

Senator Kennepy of Massachusetts. Just another question.

The sentiment which I expressed, Mr. Secretary, with all due respect,
is a sentiment which has been reflected to me by many of the medical
schools up in Massachusetts who are deeply soncarned. with this ques-
tion, and are concerned about providing the kind of skilled people
which I think we envision in these medical centers, and so this 1s why
I personally feel that it is important that we consider it.

ee
. ©

COMBATING HEART AND OTHER MAJOR’ DISEASES 45
he The other question right there —— ,
he Secretary BREZZE. May I comment there for just one moment?
le Senator Knnnupy of Massachusetts, Yes, i
as Secretary Crnzprezze, Actually while you will need additional

skilled people, the medical complexes will make utilization of the

er in which they can utilize the existing skilled manpower at a particular
le- time. So, I think that while the medical schools are burdened, and we
.O- are aware of that, and while they are making every effort possible to
be turn out more physicians and dentists, and while we are trying to help

them with Federal legislation, the fact remains we have a basic prob-
or lem in that it is still going to take us a decade or longer, much longer

to train professional health personnel in sufficient quantity to meet
Ly the demand. We had better utilize what we have to the greatest degree
he possible.

Senator Kmnnpry of Massachusetts. Just one final question: On
the bill itself, you talk about disease, cancer, and stroke, and other

 

s- major diseases. I am wondering if we could just develop your think-
le ing on the other major diseases. What kind of diseases would come
to under the bill ?
Secretary Cetesrezzn, Well, I think that under the bill the Surgeon
1- General determines other Major diseases. You might get into the
as kidney diseases, for example.
ik Senator Kennepy of Massachusetts. I am thinking of mental re-
mn tardation myself.
te Secretary Crnzprezzn, Well, that is true, we can. But we do now
5. have community centers for mental retardation.
1 Senator Kennepy of Massachusetts. I understand that,
ig Secretary Ceresrezzn, We gave that our attention 2 years ago, Sena-
ut tor Kennedy.
ir Senator Kennepy of Massachusetts. T understand it.
h Secretary Cetzprezzx. It doesn’t foreclose it but it would seem to me
ic we do have existing machinery
it Senator Kennepy of Massachusetts. I would think, Mr. Secretary,
however, though, that you wouldn’t want to prohibit the possibility
Ly of seeing if there could be sufficient progress made by using these |
0 centers in treating mental illness and retardation. I would certainly
think that it would not serve a useful purpose to prohibit the idea
8. that these centers might be used in those areas,
y Secretary Cerzprezzn, Under the terms of the bill, the Surgeon Gen-
a eral would submit the question to his Advisory Council which is es-
it tablished under the bill. Right now I would say that our emphasis
d would be on these three matters.
d Senator Kennepy of Massachusetts. I understand that.

Secretary Cureprezze. In order to get these complexes started.
Senator Kenwzpy of Massachusetts. I agree,

t, Secretary Cenzerezze. Once you get the unit started, once you get
il over this inertia and get the complexes started, the bill does provide
5. care of other diseases, and it may broaden out to the area that you are
le speaking of, but I thought that we were attacking that pretty strongly
y ;

43-669—65——4

 
46. COMBATING HEART AND OTHER MAJOR DISEASES

pent now with community centers in mental retardation and mental
ealth. ;

Senator Kennepy of Massachusetts. Thank you, sir.

The Cuairman. Allright, Dr. Dempsey.

Dr. Dempsry. Mr. Chairman, and members of the subcommittee,
we have prepared a few charts which illustrate some of the points that
were made in the Secretary’s testimony and which can perhaps serve
as an epitome of the principal points that he made.

As he pointed out, of the total number of deaths in the United
States in the last year for which we have a full accounting, there were
1,187,558 which were ascribable to heart disease, cancer, and stroke.
These represent 71 percent of all of the deaths that occurred during
that year.

To repeat his statement about the economic costs of these diseases,
the direct costs of patient care, of hospitalization, and the economic
cost to the country through lost productivity have been estimated at
$31.5 billion for 1962.

Senator Yarsoroucu. Mr. Chairman, may I ask a question here?

The CuarrMan. Certainly.

Senator YarroroucH. Dr. Dempsey lists $31.5 billion as the annual
cost of cancer, heart disease, and stroke. You are not including in
that, I assume, the ultimate costs for care of people? You are count-
ing in that only the loss of productivity for their productive years?

Dr. Demesry. That is correct. We are counting the cost of care
during that year only, not the forward cost.

Seantor YarsoroucH. That is just 1 year’s care?

Dr. Dempsey. And the loss of productivity.

Senator YarsoroucH. You are not projecting to the future and
adding it in?

Dr. Dempsey. No, sir.

Senator Yarsorovucu. It would cost just that much in 1 year?

Dr. Dempsey. Yes, sir.

Senator Yarrorover. $3114 billion.

Dr. Dempsey. Yes.

Senator YarBoroucu. Thank you. It is about 5 percent of our total
gross national product of $625 billion a year roughly. ‘ Roughly 5 per-
cent of the whole gross national product of the United States is the
cost for 1 year of heart disease, cancer, and stroke.

Are you considering in there people in their productive years or are
you including in this people who have passed their productive years?

Dr. Dempsry. No, sir, we have made allowance in computing the
costs for those people who were past the age of 65 and, therefore,
would not be productive.

DenDtOr Yarrorovueu. You didn’t count those not in their productive
years?

Dr. Dempsey. Yes, sir. We have also eliminated housewives and
have placed no value on their services although their services actually
are of some value.

Senator Yarsoroucn. I think when you left out housewives you left
out one of the most valuable elements in our society.

Dr. Demrsry. I agree with you.

Senator Yarsorouen. I think this illustrates how modest these fig-
ures are when we get an explanation how this $3114 billion is arrived
at, people under 65.

 
 

COMBATING HEART AND OTHER MAJOR DISEASES 47.
al Dr. Dempsey. Yes, sir. : oe
Senator Yarsoroven. And only for that 1 year and not including
housewives ? os
Dr. Dempsey. Yes, sir. - .
ey Senator Yarsoroven: : [think it.is.a very modest figure, It is low,
at it isnot high. If you included housewives this figure would be much
ve higher than 5 percent of our gross national product ?
Dr. Dempsry. We believed if we erred we should do so on the con-
od servative side.
re Senator Yarsoroveu. Thank you for an explanation of the basic iB
6. data that went into this computation. i
1g Dr. Dempsey. The medical complex which we have discussed is a t
device that will coordinate various resources as they exist in our system
Sy of medical care today. This:system includes medical schools, research
iC centers in which clinical and laboratory research is done, and the:hos-
ut pitals in which patient care is delivered. All of these would be co-
ordinated for delivering patient care, for implementing further re-
search, and for improving training.
These complexes would provide for the latest advances in diagnosis
a and treatment. It would make these advantages available to physi-
n cians and to the institutions in which physicians work. All of this
7 would be provided for people who would be in a stated geographical
area. i
e The components of the complex consist basically of a medical school 4

and the related departments “in’ the parent university, the teaching

schools. It would include clinical research centers—that is a can-
cer research center, a stroke center, a heart-disease research center
which would be established: in:relationship to the major medical in-
stitutions. All of these in turn. would be related to stations for the
diagnosis and treatment of heart disease, cancer, and stroke and other
diseases in community hospitals throughout the geographic area. I

will expand upon that point in a later chart.

: The grants that would be provided under this bill are of two kinds.

) First, the grant for planning which the Secretary mentioned, and sec-
ond, after the planning had been accomplished, a grant for operation
of the complex. This latter grant.could be used for the support of the
activities listed in this chart—for staff, for renovation, for construc-
tion, for equipment, services, ‘research, training, and especially for
increasing the accessibility of improved patient care.

The benefits that we believe would be derived from these complexes
are primarily that they would save lives, they would also improve the
training of physicians and specialists, they would improve the way
in which new knowledge would be discovered and brought to bear upon
medical practice, and they would have a great virtue in that they would
promote efficiency within the community by eliminating duplication
and by using efficiently the very scarce highly trained manpower that
we have, oo

A diagram such as this might perhaps indicate some of the relation-
ships we have been discussing. In the center is the medical center con-
sisting of the university medical school, teaching hospitals, and re-

 
48 COMBATING HEART .AND. OTHER MAJOR! DISEASES

search institutes. In a community surrounding this center the radius
of which might be as much as a hundred ‘miles or more, a number of
community hosiptals exist. In these community hospitals, stations
would be established for stroke, for cancer, or for heart disease.

A large community hospital might have stations for all three of
these hae or even for four or five, if other major diseases are in-
cluded.

Senator Yarsoroven. This would:be something like an emergency
ward for accidents, there would be a place for a person to be taken in
the hospital. If they were brought there with one of these diseases,
would it be for research, would it be.actual treatment or research?
What would be the nature of those strokes, cancer, and heart centers
in a hospital? oe

Dr. Demprsry. To a degree they would support the emergency ward,
but especially they would provide equipment and the knowledge of
specialists who would be stationed in the hospital and who would be
available as consultants for the voluntary staff of the hospital.

I have some prepared testimony, Mr. Chairman, which will bear
upon the question Senator Yarborough has asked, and I could elabo-
rate on it later by giving a hypothetical case example. I believe this
would make the matter clear, Senator. +: .

Senator Yarsorovan.. Yes. payee

The Cuarrman. All right.

_ Dr. Dempsey. These stations operate as a kind of network among
themselves, tying the individual community hospitals together so
that knowledge can flow from one to another or patients can be trans-
ferred: from one to another and so that the special abilities of one
hospital can be utilized through the ‘channels established by these
stations—each one of them coordinated by the center. The special
equipment and special knowledge of any one hospital would be more
widely available than is the case when the relations between com-
munity hospitals remain haphazard as they are at the present.

For example, a patient with a stroke‘is admitted to hospital A
which has a cancer station. Although the specialist in the cancer
station certainly would not be a specialist in the area of stroke, he
could refer the physician who admitted the patient to the stroke
expert in a neighboring station and thus provide information that
the physician would not otherwise have: He would also be able to
refer back to the medical center for consultation wherever advisable
and possible. .

Such a complex as we have described does not necessarily follow
State lines. There are many metropolitan areas in which a city or
metropolitan region is divided into:two or more States. This has
been shown diagrammatically here by a hypothetical State line; the
medical school and some of the hospitals are in one State, and some
of them could be in the neighboring States. The geographical region
described makes as large an accommodation to the location of people
as it is possible to make. Sa

Mr. Chairman, this is the end of the charts.. As I mentioned I do
have some prepared testimony.

(The charts referred to previously follow :)

 
ases,

 

 
 

COMBATING HEART AND OTHER MAJOR DISEASES

ANNUAL |
COSTS | $31.5 BILLION
HEART

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AND |
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A REGIONAL MEDICAL COMPLEY
COORDINATES RESOURCES:

MEDICAL SCHOOLS
CLINICAL RESEARCH CENTERS
HOSPITALS

PATIENT CARE

CLINICAL RESEARCH
TRAINING

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
i  _

52 COMBATING HEART: AND OTHER MAJOR DISEASES

A REGIONAL MEDICAL COMPLEX
“PROVIDES:

 

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COMBATING HEART AND OTHER MAJOR: DISEASES 53

COMPONENTS OF A
REGIONAL COMPLEX

UNIVERSITY

MEDICAL
SCHOOL
CLINICAL

AFFILIATED
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DIAGNOSIS TREATMENT
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54 COMBATING HEART AND OTHER MAJOR DISEASES

 

 

 

STAFF

 

 

RENOVATION
EQUIPMENT

SERVICES
RESEARCH
TRAINING

IMPROVED
PATIENT CARE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
COMBATING HEART AND OTHER MAJOR DISEASES: 55

BENEFITS =
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GREATER
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56 COMBATING HEART AND OTHER MAJOR DISEASES

    

 
  

 

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COMBATING. HEART AND OTHER ‘MAJOR - DISEASES OT

The Cuairman. Suppose you proceed with your further testimony,
Doctor.
Dr. Dempsey. Mr. Chairman and.members of the subcommittee, it
is @ special pleasure for me to present this to you and to support leg-
islation to advance that part of the President’s health message deal-
ing with multipurpose regional medical centers. Our.recommenda-
tions are embodied in the proposed Heart Disease, Cancer, and Stroke
Amendments of 1965, S. 596, introduced by the distinguished chair-
man of this committee.
I was privileged to serve for a time as a member of the President’s
Commission on Heart Disease, Cancer, and Stroke, and am pleased
that some of its recommendations were included in the President’s
health message. Secretary Celebrezze has indicated how the present
bill proposes to carry part of these objectives forward. He has
stressed the fact that improved care can be made available to larger
numbers of people by the organization described as a medical complex.
It should also be stressed that this primary purpose of the bill—
greater availability of better care—is best accomplished in environ-
ments and in institutions where research and teachings are also pro-
ceeding concurrently. The three faces of medicine—teaching, re-
search, and patient care—must coalesce into one image if the full po-
tential of each is to be realized, :
The proposed complexes represent a sound organization. In its
report, the President’s Commission noted that the proposed regional
centers “would be established where possible in conjunction with a
major existing medical institution” and that the proposal “represents
an outgrowth and extension of an already successful program of the t
National Institutes of Health.” :
The clinical research center program, now in its sixth year, has pro-
vided evidence that patient costs have not been oppressive, that the
clinical research and training programs carried on in the centers have
been well accepted by the hysicians and institutions with which they
are associated, and that a background of successful management pro-
cedures is now available. The proposal for establishing medical com- 4
plexes therefore rests upon a foundation of experience and com etence.
Since the proposed bill deals with three or more categorical iseases, :
each of which is of major interest to at least one of the National ;
Institutes of Health, a word is necessary as to possible duplication and, :
conversely, as to coordination. The existing categorical programs |
carried out by the respective Institutes have flourished during the
past two decades and have thoroughly proved their great value in

 

 

gorical approach.

_ The scientists, supported by a grant from the Heart Institute, par-
ticipate in the intellectual life of the university, and all science is the
better for it. Biochemists, cytolo ists, or pharmacologists studying
the cardiovascular system have made important contributions to their

own and to other disciplines or specialties, Indeed, a drug which was
one of the first tranquilizers, now so important for mental health
programs, was discovered by a scientist searching for a drug having

certain desired effects on blood vessels. The record now shows abund-

 
ae

58 COMBATING HEART AND OTHER MAJOR DISEASES

antly that funds to support categorical activities have helped greatly,
not hindered, the broad advance of the health sciences.

A second point to be made concerns the relation of this program to
the already existing Institutes. At the outset, one must emphasize
again the primary purpose of the medical complex bill: To make avail-
able better care for more people. To reach this goal, research must
be supported, and that is the primary goal of the categorical In-
stitutes.

Other programs, such as those in the Bureau of State Services, are
concerned with the provision of health services. However, any pos-
sible duplication can easily be prevented through coordinative proce-
dures prescribed in regulations, such:as-those which have long-been
used by the NIH and the National Science Foundation. co

In any event, support of.aetivities whereby university medical cen-
ters, with their concentrations of highly specialized physicians and
equipment, will more widely be available to patients in an entire region
is new and does not overlap with existing programs. As in the case of
the proposed organization itself, administration of this program rests
again on a foundation of experience and competence.

Certain aspects of the program, especially those relating to the
development of diagnostic and treatment stations in community hos-
pitals, represent evolving relationships among the Federal Govern-
‘ment, teaching and research institutions, and the Nation’s system of
community hospitals. The evolution of this relationship should be
closely watched and evaluated continuously as experience is gained.
We regard the support of these stations, therefore, to be in the nature
of a demonstration, to be carried out under regulations prescribed by
the Surgeon General as provided in section 906 and to be rigorously
reevaluated as required by section 907 of the bill.

Since the urgent need for extension of care into the community. will
stimulate medical schodls, research institutes, and other local institu-
tions to much greater than normal effort, it seems necessary to provide
matching funds of up to 90 percent ’6£ the cost of required renovation
and construction. As the program evolves, the ratio of matching funds
for construction and renovation as well as for operational costs, should
be reexamined and reevaluated in the light of experience.

Mr. Chairman, Secretary Celebrezze and I have thus far spoken in
generalities rather than in specifics as to how a complex might be
formed and how it might be used. As its very name denotes, a com-
plex is a complicated arrangement. It can appear in different guises
toa patient, a practicing physician, a medical administrator, or a civic
leader. T should like to describe how a complex might come into being
and how it might function in some typical situations.

Let us assume that there is a city with a population of 600,000 near
a, State line and with about the same number in the surrounding sub-
urbs. Within a radius of 100 miles there are 3 other cities of perhaps
100,000 population each. The entire population of the region is about
2.5 million people.

The central city has a university and. a medical school, a university
teaching hospital, and several hospitals having 200 or more beds. Two
of these (children’s and V-A hospitals)‘ are affiiated with the medical
school. Two of the other cities have one 450-bed hospital each, and the
third has two 300-bed hospitals. There is also a State chronic disease

 
 

COMBATING HEART AND OTHER MAJOR DISEASES 59

hospital of 800 beds in the area and numerous small, 50- to 100-bed,
community hospitals.

PLANNING THE MEDICAL COMPLEX

The university, the medical school, or the medical center in the core
city assumes initiative in the planning and future development of the
regional medical complex. The first step is the organization.of an
advisory group representing knowledgeable and interested lay and
professional citizens who live and work in the geographic area. Mem-
bership in this advisory group might include medical educators, hos-
pital administrators, practicing physicians, research scientists, indi-
viduals involved in urban: planning, individuals from health or :wel-
fare departments, and other community leaders.

This advisory group would assist a staff located at the university or
medical school in the initial planning of the regional medical complex
and in the preparation of an application for a grant to assist in plan-
ning this program. The initial application for planning funds would
describe the existing institutions, agencies, and programs which would
participate in the formation of the medical complex. It would also
describe the relationships between these institutions necessary for the
successful operation of the network, the geographic area and popula-
tion base to be served}:and other’ factors. : .

After review of the application by the National Advisory Council
on Medical Complexes, approval of the application would result in
a grant that would assist the detailed planning, contractual negotia-
tions, and other activities essential to the initiation of a program of
this scope.

DEVELOPMENT OF THE MEDICAL COMPLEX

The medical complex would evolve gradually over a period of time
as specific components are added. The ultimate goals, in the par-
ticular illustration presented here, involve development of a cancer
clinical research center at the chronic disease hospital that has been
developing an interest and expertness in the problems of cancer.

A stroke clinical research center will be connected to the university-
teaching hospital where the neurologists, neurosurgeons, and vascular
surgeons have been carrying on active research programs and where
is now located an active rehabilitation service much interested in the
retraining of stroke victims. A heart disease clinical research center
is planned for development in 1 of the 9 general hospitals in the core
city: 1 hospital, with 850 beds, has recently expressed an interest
in affiliating with the medical school. It currently has a satisfactory
teaching program with approved internships and residencies in sev-
eral specialties. The department of medicine at this hospital has a
full-time cardiologist who has been doing some independent research
on a rather small scale in heart disease in addition to his other re-
sponsibilities in the hospital. About 20 diagnostic and treatment sta-
tions in this regional medical complex would be placed in several of
the voluntary hospitals located in the core city, the 3 or more men-
tioned in 3 medium-sized. cities of 100,000, and a few in the hospitals
in the geographic area with 100 beds.

In a few of the largest hospitals, there might be both a heart disease
diagnostic and’ treatment station and a cancer diagnostic and treat-

 

 

 

 
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60 COMBATING HEART AND OTHER MAJOR DISEASES

ment station. At the State chronic disease hospital, in addition to
the cancer clinical research center, there would also be a cancer diag-
nostic and treatment station to which hospitals with less than 100 beds
in communities not very distant could send their patients.

The main ingredient in the regional medical complexes is the will-
ingness and desire of individual people, and the programs and agen-
cies which they represent, to work together in an effort to improve the
health services in the area and increase their accessibility by bringing
to bear the energies and competencies of medical educators and bio-
medica] research scientists in order to enhance the overall quality of
patient care. Facilities and equipment are, of course, important. In
this hypothetical regional medical complex, it would be necessary to
carry out renovation and to provide equipment in order to develop the
cancer clinical research center in the State chronic disease hospital.
In the case of the heart disease center, the voluntary general hospital
within the core city would have to undertake new construction on the
hospital ground but this would be related to its currently planned
expansion program.

Young physicians, who have recently completed their specialty train-
ing, would be designated to head the stations located in the community
hospitals. Each of these would be a member of the medical faculty ;
each would participate in the university’s teaching and research ; each
would assist in the educational program provide by the hospital for
its interns and residents; and each would arrange clinical conferences
and other seminars through which the hospital’s staff would learn new
procedures and information known at the medical center but not yet
applied at the local hospital. Such continuing education of the staff,
and such participation in teaching and research, assure that the system
can constantly improve and renew itself.

Mr. Chairman, I think this gives some indication of how Senator
Kennedy's concern might be met. The participation of these stations
with medical schools would serve as an avenue through which the man-
power to staff the station would be available. At the same time, it
should be said that the program, as outlined here, would not provide
all the added medical manpower which we will need in future years.
These must be provided through other kinds of programs carried out
in the medical schools themselves.

As examples of improved medical care, I would like to point out that
benefits that derive to patients from access to any component of a
medical complex can be dramatic. Consider the following hypotheti-
cal case:

A 47-year-old schoolteacher suffered a heart attack. He was imme-
diately admitted to hospital A in his community by his physician. His
course was satisfactory until the third day in the hospital when his
heart stopped beating. Because of a training program in the man-
agement of cardiac arrest, which had been conducted by personnel
from the heart diagnostic and treatment station in hospital B in the
same community, the staff in hospital A had been taught proper emer-
gency procedures. In this situation, an intern applied electrodes to
the patient’s chest and literally shocked him back to life. A second
episode of severe irregularity m heartbeat, and its subsequent arrest,
occurred a few hours later. After a second resuscitation, a cardi-
ologist was called into consultation and, subsequently, the patient was
referred to the heart disease clinical research center in another city.

 
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COMBATING HEART AND OTHER MAJOR DISEASES 61

Therein, diagnostic studies led to the decision to implant wires con-
necting the patient’s heart to an electronic, artificial pacemaker which
would stimulate his heartbeat. The subsequent management of this
patient required the working together of the specialists and scientists
in the heart disease research center, the specialists in the diagnostic
and treatment station, and the patient’s own physician.

Lest it be thought that this hypothetical case is too artificial, I
might say that one of the Nation’s leading professors suffered just
such a series of attacks a few years ago. His heart stopped 14 times
in the course of it. He is a ive, well, and functioning today as a
result of the care that he could get in one of the major clinical centers
of the country of which he happened to be a member.

Senator Yarsoroucu. Dr. Dempsey, without that care, would any
one of those heart stoppages have been fatal?

Dr. Dempsey. It would have.

Senator Yarsoroueu. He would have died 14 times if those special
cares had not been available?

Dr. Dempsey. Yes,

Senator Yarsoroven. He would have died 14 times?

Dr. Demrsry. This outdoes the “proverbial cat.”

Senator Yarsoroven. I think you will have difficulty in finding a
more dramatic case than that.

Dr. Demrsry. The regional medical complex also permits sharing
the resources represented by facilities and equipment. Techniques for
monitoring patients’ heartbeats, through the use of miniature FM
transmitters carried by patients and receiving and recording equip-
ment located in a research center, now exist and permit more accurate
management of therapeutic procedures than was formerly possible.
The medical complex offers the network for expanding this competence
and resource to more physicians and to their patients.

Not only the patient, but the doctor as well, will benefit from the
improved services available through the complex. Consider the case
of a physician whose patient is ospitalized in order to carry out
diagnostic studies concerned with a small growth on her thyroid

gland. These studies led the physician to conclude that his patient
had cancer of the thyroid. He referred her to a surgeon for consulta-
tion. The surgeon felt that, because of the patient's age, high blood
pressure, and rather severe lung disease, she would not tolerate sur-
gery. Accordingly, he suggested that the physician refer his patient
to the cancer diagnostic and treatment station. At this station, by
virtue of its connection with the cancer clinical research center, the
physician was put in touch with a research physician trained in nuclear
medicine and licensed by the Atomic Energy Commission to admin-
ister radioactive iodine 131—an alternative to surgery in the treatment
of certain patients with thyroid cancer. Without the availability of
such a resource, many patients in the same situation either would be
forced to travel great distances to large teaching centers or their phy-
sicians would have to rely on less adequate procedures.

Because of this experience, the physician learned of the resources
available in the complex. Later, when another patient in his prac-
tice had a child with a congenitally deformed heart, he was able,
through the cancer specialist who had initially helped him, to meet
the cardiologist at the heart disease clinical research center. The

43-669—65——_5

 

 

 

 

 

 
ean enn nana

62 COMBATING HEART AND OTHER MAJOR DISEASES

experimental diagnostic and operative procedures being developed
there permitted an operation which completely restored the child to
health. The physician had been assisted to accomplish something
otherwise impossible.

Examples such as there could be multiplied indefinitely. Each
would indicate how the organization of the complex aided people.
Patients would receive better care, physicians would receive improved
assistance, both would benefit from the availability of equipment other-
wise too new or too expensive for ready accessibility. The increased
efficiency brought about by large-scale community planning and effec-
tive use of resources would benefit the population at large.

Mr. Chairman, I believe the proposed legislation will go far toward
improving accessibility of high-quality patient care. I earnestly rec-
ommend it for your favorable consideration.

Thank you.

The Cuarrman. Dr. Price, is there anything you would like to add?

Dr. Price. No. I do not have any prepared testimony, Mr. Chair-
man. I will be pleased to assist in answer questions, sir.

The Cramman. Dr. Dempsey, where in the Public Health Service
would you locate responsibility for the administration and operation
of the proposed regional network ?

Dr. Dempsey. This has not been completely determined, Mr. Chair-
man. As I indicated in my testimony, there exists in the Public
Health Service, particularly in the NTH, a background of competence
and experience in managing a similar kind of program. The bill
calls for this determination to be made by the Surgeon General, and
he has, as I understand, a small task force which is now studying the
various aspects of the bill.

The Cruamman. The Commission discussed the matter but did not
pinpoint it in one place, did it?

Dr. Demrsry. No, sir. The Commission felt that the administra-
tive management of a program had best be left to administrative de-
termination. Although many members of the President’s Commis-
sion had personal opinions on the subject, the Commission as a whole
believed that it should not push too far into the area of prerogatives
of the Secretary and of the Surgeon General. :

The Cxatrman. But there was much comment about NIH, wasn’t
there, and reference to the experience and background of NIH?

Dr. Dempsey. Yes, sir.

Secretary Crtesrezze. If I may direct myself to that question since
it is an administrative question on it-——

The Cuatrman. Yes.

Secretary CuLeprezze (continuing). We haven't determined, we
discussed it briefly yesterday, as to where in the Public Health Service
this would be handled. There are strong sentiments and strong rea-
sons for putting it in NIH.

On the other hand, we think of the National Institutes of Health pri-
marily as a research function, so that the question of just exactly
where it will be put has not been determined at this time, Mr. Chair-
man.

There are strong sentiments for having it in NIH because of their
basic knowledge and in the handling of it.

 
 

 

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COMBATING HEART AND OTHER MAJOR DISEASES 63

On the other hand, we have always identified NIE primarily as a
research bureau. We will give it strong consideration.
The Cuamman. You a:

h Te considering the matter very carefully
now ?

Secretary Ceczprezze. Yes, sir.

The Cyaan, Dr, Dempsey, what did the Comm
mend as a 5-year cost of establishing such a network ?

Dr. Dempsry, My memory is that it was in the vicinity of a billion
600 million dollars. This is in the report of the Commission.

The Cuarrman. We will get that figure from the report.

Dr. Dempszy. Sir?

The Cuamman. Doesnt that figure appear in the report?

tT. Vemrsey. Yes. This is the cumulative sum over a 5-year period

for all components of the medical complexes as we have outlined
them.

The Cuarrman. How many regional centers did the Commission
recommend ?

Dr. Dempsey. Over a 5S-year period, in the neighborhood of 30
complexes,

The Cuarrman. The Commission recommended over 80?
Dr. Dempsey. Yes. As I remember, there were 30 complexes con-
taining 60 categorical centers. The figures appear in the report.

The Cuairman. In the report of the Commission ?
Dr. Demrsry. Yes,

The Cuarrman. How
hospitals, do you recall ?

Dr. Dempsey. There were between 500 and 600, as a I remember.

The Cuamman. 500 or 600, That information would be in the re-
port of the Commission ?

Dr. Demrsry. Yes, sir. In general, the ratio was about, 20 stations
to 1 of the complexes, as I remember. On the average, it was felt that

this was about the proper number. Yes, I see that the Commission’s
report called for 150 stations for heart dis

for stroke. That would be 450. I am so
high in my memory.

The Cuamman. 450, Now,
affiliated with medica] schools?

Dr. Dempsry. The hospitals nearby medical schools are affiliated to

various degrees, Each medical school has one or more, sometimes
many, closely affiliated hospitals which are ordinarily designated as
teaching hospitals. In addition many medical schools have less

ission recom-

many diagnostic and treatment stations and

to what extent are existing hospitals

ting them to attract interns and residents,

The medical schools in my experience are bein
for affiliation with the community hospitals to
are unable to respond at present.

The Caarrman. Is there any figure, any percentage figure, as to
what percent of our hospitals are affiliated with medical schools?

r. Dempsry. I am sorry, I wouldn’t know. There are about 7,000
hospitals in the United States. There are 87 medical schools. At

g besieged by requests
a degree to which they

 
   
 
  
   
   
  
 
 
   
 
 
 
   
  
 
 
  
 
    
  
  
   
 
 
 
  
 
  
  
 
 
 
 
 
 
 
 
  
  
   
   
  
  
  
 
   
  
  
  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
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64 COMBATING HEART AND OTHER MAJOR DISEASES

most there would not be more than 400 or 500, I would think, of the
hospitals that. were closely related to medical schools, so it would be
a small percentage.

The CHAIRMAN, Well, as you have indicated, hospitals not affiliated
with medical schools have the most difficulty, do they not, in recruiting
residents and interns?

Dr. Demrsey. Yes, sir. You brought out the same point in your
opening statement. concerning the improvement of medical care in the
Veterans’ Administration. Everything that you said in that state-
ment applies equally well to the community hospital which does have
a connection with a teaching institution as opposed to one which does
not.

The Cuarrman. Doctor, could you give us some idea of the cost of
organizing, establishing, and operating a regional medical complex,
for instance, how much would you need for planning, how much for
the training of personnel, how much for construction, how much for
administration ?

Dr. Dempspy. I am sorry, Mr. Chairman, it is very difficult to answer
your question at this time with any precision. We have some rule-of-
thumb estimates that would indicate that the cost of a total complex
such as the one that I have outlined in my testimony, might be some-
where in the vicinity of $10 to $15 million a year as a fully formed,
fully functioning activity.

owever, the provisions of the bill call for individual community
institutions to make application for funds. Until we have such con-
crete applications with somewhat harder estimates than we have as
yet, it is not possible, I think, to be too definite as to individual costs.
Tt is partly for this reason that the development of stations, we think,
should be regarded in the light of demonstrations until some greater
amount of experience is gained.

The CyammMan. You would have to get that experience to have a
more definite idea as to what the operating cost would be?

Dr. Demesry. I also neglected to add that we are aware of the fact
that a large institution in a very densely pulated area with already
excellent facilities may find it possible bo bern a complex almost full
blown from the very beginning.

In another location it may be possible for a complex to begin on a
smaller scale with only some of the component parts assembled. The
institution could then build and grow on this beginning. Obviously
both the construction and operating costs would be very different in
the two situations, and yet in order to obtain the regional distribution
which we desire, it may be essential to place a complex in a location in
which at the very beginning there is only minimum competence.
Again, considerations such as these illustrate the difficulty of making
hard and fast financial estimates at the present time.

The Cuatrman. Can you foresee now how many of these regional
medical complexes might be established in the next 5 years?

Dr. Dempsry. I would hope to take at least a shot at the Commis-
sion’s recommendation of somewhere in the vicinity of 30. This is,
again, a somewhat diffuse estimate until we get our feet wet with
actual experience.

The Cuarrman. Senator Javits.

 
COMBATING HEART AND OTHER MAJOR DISEASES 65

Senator Javirs. Thank you very much, Mr. Chairman. I shall be
brief. I have another subcommittee meeting also going at this same
time.

Mr. Secretary, will you give us your reasons for fixin the first year
authorization at $50 million and not fixing any authorization for the
succeeding 4 years?

Secretary Cerxprezze, I think Dr. Dempsey touched on that just a,
moment ago. You must recall that this report came out in December
of this year at a time when all budgets were in, and it was our feeling

then present a program which would ft the pattern rather than try to
guess, and it would be only a guess at this stage, or make commitments
at this time which might be detrimental to the size of the program
ater, :

We thought of it carefully and, as a matter of fact, I am surprised
we came in with any kind of legislation because, as I say, this report
was Just finalized in December o last year, and we are just in February
now.

Also the other question which is parallel with this, the Commission
recommended much higher percentages in certain categories than we

$291.7 million, which is an increase of $23.7 million, the Commission
still recommended a higher increase.

© are now evaluating whether to present a supplementary budget
or not and that question hasn’t been determined yet, but I think basi-
cally, Senator, it was because the report was just out and we haven’t
really had an opportunity to go into it in depth.

Senator Javrrs. The difference, of course, is instead of being be-
fore us you would be before the Appropriations Committee once the
bill left here. I would be personally in favor of fixing authorized
limits for each of the years of the program rather than to let it go out
open ended without some consideration by this subcommittee. I don’t
believe that the final figures ought to be fixed solely on the matter, on
the question of money. I think they ought to have a relationship to
our interest in the viability of the program and its objectives,

So, I hope we will have your help, Mr. Secretary-——

Secretary Ceresrezzn. Yes; well, of course——

Senator Javrrs (continuing). Of trying to give us limits for the
other years.

Secretary Crrzprezzn, Of course, the chairman of the Appropria-
tions Subcommittee is the same chairman of this subcommittee.
Senator Javirs, I think the fact that the personnel of the appro-

mittee should be entitled to evaluate and establish what it considers to
be the proper limits for the program.

May I ask you, Mr. Secretary, on the matter of the objectives and
purposes of this plan which you have before us, have you and your
people arrived at any estimate as to what this could mean, I emphasize

 

Essie aaa ba Si

 
eae

66 COMBATING HEART AND OTHER MAJOR DISEASES

each word advisedly, “this could mean,” in terms of cutting down the
incidence of deaths attributable to these major diseases as this, in, let
us say, the 5-year span of the program. Have you evaluated any per-
centage that you estimate we could cut of the deaths attributable to
these particular diseases if we went ahead with this program as you
have laid it before us for the 5-year period ?

Secretary CrLeprezze. Bearing in mind the language of the Com-
mission, without knowing to any degree of certainty whether a person
lives or dies but: using the language of the Commission, it was their
feeling that a substantial proportion of these people who have died
could have been saved.

Now, when we get down to basic percentages, Dr. Dempsey, did the
Commission have any estimates ?

Dr. Dempsey. There were some estimates. They lead to very large
numbers. There are—as the Secretary pointed out in his testimony—
several hundred thousand unnecessary deaths per year, equal to the
population of a large city. It is, as you know, very difficult to be
definite in such a projection, and one may indeed be accused of sensa-
tionalism in giving such a figure, sir.

There are, however, estimates to indicate the magnitudes that we
are talking about. ‘There are some 15,000 women who die——

Senator Javirs. How many ?

Dr. Demrsny. Fifteen thousand women in the United States die of
cervical cancer, and the best evidence is that nearly all of these are
preventable and curable. All of the ravages of rheumatic heart disease
with its attendant mortality and morbidity which in many ways is
more important perhaps to our Nation than the mortality itself, can be
prevented today.

The fractions, percentages, or actual numbers are substantial—
20 or 80 percent of the deaths that come from these diseases are pos-
sibly preventable. I wouldn’t care to make a more accurate estimate
than that.

Senator Javits. So you would put it, just for the sake of order of
magnitude, 20 to 30 percent saving in lives which as I just added up in
1963, represents 1,186,000 deaths from heart disease, cancer, and
stroke. Let’s make it as light as possible. You estimate the possibility
of saving 20 to 80 percent of those lives through this program as a
possibility ?

Dr. Dempsey. Yes, sir.

Senator Javrrs. It is very important that we have some concept and
order of magnitude of it.

Secretary Criesrezze. As I stated in my opening statement, Seator,
citing the importance of narrowing this gap between research work
and actual application, I used the example of polio. When we
think just several years ago polio was running in the thousands upon
thousands and because of the immunization and other programs, this
year I think it is down to—last year it was 125 cases, not in thou-
sands; that gives you some idea of the advantages when you can get
scientific knowledge to the people.

Senator Javits. The figures you gave us show that 250,000 to 300,000
lives might conceivably be saved by this program. What you are
doing in this legislation, of course, is bridging the gap between the
patients and the research. You have found, I gather, that the Federal

 
 

the
let

of
re
se

be

S-

 

 

COMBATING HEART AND OTHER MAJOR DISEASES 67

Government must in a major way help to bridge this gap because
there is apparently much more of a lag between the research and the
patient under present circumstances than there ought to be in the
national interest. Isn’t that the essence of this presentation?

Secretary CeLeprnzze. That is ri ht.

Senator Javrrs. And that of the ommission ?

Secretary Cenesrezzn, Yes,

Senator Javrrs. I have just two other very brief questions, Mr.
Chairman.

We notice that you call for a report by the Surgeon General accord-
ing to section 907 on June 30, 1969, and yet we notice from Dr. Demp-
sey’s testimony very strong emphasis on evaluation of this program,
for example, he Says at page 5:

The evaluation of this relationship should be
continuously as experience is gained.

Would you say that we would not be taxing you unduly if we called
for an annual report by the Surgeon Genera] ?

Secretary Cereprezzn, It can be done because actually we are talk-
ing about an overall report. Interim departmental reports come in
constantly on evaluation but we could do it. I think that a report
after the first year or about the middle of the second year after we
have had actual operating experience would be useful but a first year,
report would possibly merely reflect. the mechanism we are setting up,
but we could do it.

Senator Javrrs. Mr. Secretary, give us your best advice on reevalu-
ating the provision of section 907 now that I have raised the question.

ive us your best advice, we don’t want to tax you but I do notice
that Dr. Dempsey himself emphasized the continuous evaluation. Give
us your best judgment.

ecretary CeLeprezzr. I think that on the initial part of the pro-
gram it would need a minimum of 2 years,

First of all, you do have a selling job to do to get the communities
interested.
Senator Javits. So you would call for a report 2 years after?
Secretary Ceresrezzn, Two years after, I think would be sufficient.
enator Javits. I have one other question which you may or may

not wish to answer because it may involve a whole complex of Govern-
ment policy.

If you don’t wi
it for the record.

I notice we are faced with Senator Long’s amendment with respect
to discoveries, and so forth, which may result from these research
operations. Now, personally, I have some very grave doubts about
our wholesale acceptance of that formula in every bill ‘as to whether
it is really productive or counterproductive. And I would greatly
appreciate it if we began to get from individual departments and in-
dividual programs the specific evaluation of whether or not it is the
most desirable in the national interest to have this rather sweeping

closely watched and evaluated

sh to answer it now please say so and you can supply

clause with respect, to discoveries or patents or processes as the result
of the research. This calls for

the general public.”
If they are in any way, if they are produced in the course of re-

search work which is done wi

health

there “being made freely available to

e with Government, Federal Government

 

 

 

 

 

 

 

 

 

 

 
68 COMBATING HEART AND OTHER MAJOR DISEASES

Secretary Czneprezze. Are you referring to patent rights, 1s that
what you are referring to, the patent rights provision ?

Senator Javits. That is right. That is an amendment which is
before us already and undoubtedly faces the committee or on the
floor. I do think we ought to have a critical evaluation of the depart-
ments with respect. to this matter.

Secretary CeLeprezze. We can furnish that to you at a later date.

Senator Javrrs. Will you do that?

Finally, you don’t have to answer this right off the top of your head
that you do not have in this legislation the recapture provision for
facilities which are furnished under this legislation if they cease to be
used for the purposes furnished which you have in other legislation
like the Public Health Service Act, the Mental Retardation Act, and
so on.

Would you also advise us whether it is or is not desirable 2

Secretary Crieprezzp. Yes. The reason we didn’t put it in is be-
cause construction is a very minor part of the bill. The others deal
primarily with construction, that is the other legislation.

Senator Javirs. It may be equipment and so on. Would you re-
evaluate that and give us your best advice.

Thank you.

The Cuatrman. Senator Yarborough.

Senator Yarrorovucn. Mr. Chairman, in view of the lateness of the
hour I have very few questions. I think some of these questions were
answered as the witnesses testified. I do want to ask this, Mr. Secre-
tary, and also Dr. Dempsey. The $50 million asked in the first year,
of course, will not do this job. That is just a pilot program, just to
start, and this overall job of getting—I take it your prime priority
is this—to all of the doctors, medical personnel of all types and the
hospitals of this country information that is already known in the
great research centers, is that one of the first tasks ¢

Secretary CELEBREZzZE. Yes.

Senator Yarsoroucn. And the other is to get the information
where it. can be used in treatment of the people?

Secretary Cxteprezze. Most of the time now will be spent on
planning.

Senator Yarsorovert. First will be planning, the 50 million?

Secretary Crnesrenze. You will get very little results in the first
year because it requires planning to get these groups together, and at
that time we will be in a much better position to come in with tighter
estimates for second, third, and fourth years.

Senator YarsoroucH. Next year, after you can tell us what you
actually need to spend the money after you have planned it?

Secretary Crreprezze. There are some areas, Dr. Dempsey has
testified about it, there are some areas in the Nation today which will
be easier to pull together because they have complexes and these com-
plexes will, of course, be much further advanced and much. easier
to plan for because they have the existing facilities and we can move
ahead. But in a vast majority of other areas we have got to do the
proper planning and I think we need sound planning of what we are
trying to accomplish to provide information to come up with realistic
figures for the years 1967, 1968, 1969, and 1970.
 

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COMBATING HEART AND OTHER MAJOR DISEASES 69

Senator Yarsoroucu. Mr. Secretary, you and Dr. Dempsey contem-
plate 30 projected centers which would have a complex of medical
schools, hospitals, and so forth, to provide for the type of coordinated
center that you have described, you would necessarily have a large
population base to have already in existence to have these medical
schools and hospitals.

You are basing this mainly in big population centers?

Secretary Cermprezze. Yes. On the other hand, we have a great
many areas where there is no medical school. We are not just scratch-
ing them from the slate. In the event there is no medical school, then
the diagnostic and treatment centers could be coordinated with the
existing hospitals in that particular area.

Senator Yarsorouen. If you had a large population area, you would
need a medical center just the same to get this information out to all of
the hospitals?

Secretary Crteprezze. On the other hand, Senator, we will try
under the Health Professions Act to aid more medical schools.

Senator Yarsorouan. I notice the largest 30 cities of the United
States im 1960 embrace populations of 400,000 and over.

Mr. Chairman, J ask to put in the record this table of the population
of cities in the over-400,000 class.

The Cuairman. Without objection, we will put it in the record.

(The table referred to follows :)

Cities with estimated population of "400,000 and over on January 1, 1964
[In thousands]

Phoenix, Ariz__--.---...-___ 510.6| Kansas City, Mo--____.--___ 531.6
Los Angeles, Calif.....-._.___ 2, 677.7! St. Louis, Mo.._______--_____ 720. 1
San Diego, Calif-.--...-_____ 639. 2; Buffalo, N.Y_-.-..--_-.-_____ 516. 4
San Francisco, Calif.___.______ 745.3| New York, N.Y ..__-_.__-__ %, 741.2
Denver, Colo_-.---------.____ 523. 8| Cincinnati, Ohio_-_-_._-_____ 499. 9
Washington, D.C.__-.________ 777. 6| Cleveland, Ohio_..___________ 869. 7
Atlanta, Ga__---. 510. 0| Columbus, Ohio..-..--_______ 514, 6
Chieago, Tl. 3, 534. 5| Philadelphia, Pa____.._______ 1, 986. 8
Indianapolis, Ind__.._-_______ 514. 0| Pittsburgh, Pa_....-._______. 578. 0
Louisville, Ky_-.....--____ 400.9; Memphis, Tenn__.___________ 546. 8
New Orleans, La_.__-..______ 652. 2; Dallas, Tex ..--..---.-_- 781.3
Baltimore, Md_.-_._________ 933. 1| Houston, Tex____.___._______ 1, 055. 7
Boston, Mass_.-.-_....______ 659. 7| San Antonio, Tex__...___.___ 653. 7
Detroit, Mich..-....-_______ 1, 614, 1| Seattle, Wash.__._.__________ 567.1
Minneapolis, Minn. _._._____ 473. 5| Milwaukee, Wis______________ 764. 6

Source: Sales Management, June 10, 1964, by Julius W. Allen, Chief Economics Division.

Senator Yarsoroven. Doctor, would this heart disease diagnostic
and treatment station be used for only severe cases? Would all cases
be sent to the centers or would you just have severe emergency cases?

Dr. Dempsry. No, sir. The station would consist of a place in a
hospital in which there is specialized apparatus of value in, say, heart
disease, and in which there would be people who had expert knowledge
in heart disease. These people and this equipment and these facilities
would be available to assist any physician in the hospital with any
patient who came into the hospital. “The degree to which they would
assist and participate in the management of any particular case
would vary from zero to very active involvement. But it would actu-

ally benefit all patients in the hospital and indeed in the area who had
heart disease.

 

 

 

 

 
pee 70 COMBATING HEART AND OTHER MAJOR DISEASES

Senator Yarsoroven. Well now, after the centers are set up, would
the administrative bodies which now grant permission to doctors to
practice in hospitals be the same that would determine access to the
facilities of these regional medical centers?

r. Dempsey. The specific answer to your question is “Yes.” There
is nothing in the bill which it is planned to alter the responsibilities of
the governing boards of any hospital. The one possible exception to
this statement is that in the planning arrangements made by the in-
stitutions, they would voluntarily agree to accept the station, and to
place on the staff of their hospital the designated physicians referred
from the medical complex to the station, but this would be a voluntary
arrangement made by them, not one imposed on them.

Senator Yarsoroteu, Due to the lateness of time I won’t explore
that further now, Doctor, but it might be a proper matter for further
exploration in the future.

notice you were on the Commission that studied this matter.

r. Dempsry, Yes, sir.

Senator Yarsoroccu. We now save in the field of cancer one person
in three but a few years ago only one in four was saved who had can-
cer. You have a ‘number of instances where the percentage saved
might be increased markedly.

r. Dempsey, Yes, sir.

Senator Yarnorocen. And I take it from the nature of the recom-
mendations that Sou are very optimistic about the number of those.

ere is one that I doubt You are as optimistic about—it says lung
cancer can be sharply reduced by reducing cigarette smoking. I think
that is one area where You weren't quite as optimistic, Doctor,

Dr. Dexpsey. We ha ve the problem of human nature, sir.

Senator Yareorocen. Thank you. Mr. Chairman.

The Cuamnan, Senator Kennedy of Massachusetts?

Senator Kexxepy of Massachusetts. I would like to say for the rec-
ord I strongly favor this legislation. and the purposes which it is
trying to accomplish, Mr. Secretary. and I appreciate your testimony
this morning.

I would like to ask just a few questions. if Icould. You may have
Sone over these questions while I Was at my other committee meetings

Could you give us at least some idea of what you might look forward
to in the next 5 years, as far as the number of these centers to be located
in these regional areas?

Did you cover that earlier this mornng?

Secretary CELEBREzzp. We covered that. Senator

Senator Keyyepy of Massachusetts. You covered that this morning.
I would like to ask if You have covered this in your testimony, Mr.
Secretary. The proposed legislation would authorize the appropria-
tion of $50 million for fiscal year ending June 30, 1966, and such sums
as may be necessary for each of the rext 4 fiscal years.

I was wondering if you could g.ve us the amounts which we might
be able to expect would be fortheaming and requested through your
Department in this next period of z:me?

Ss

 

ecretary CELEBREzzE. I answered that earlier.
enator Kennepy of Massachusezrs. I see.

cee es
ee ne

COMBATING HEART AND OTHER MAJOR DISEASES 71

Secretary Cetrprezzx. The basic reason was that the report came
out in December of last year, the report has only been available about
2 months.

Senator Kennepy of Massachusetts. I can’t hear you, Mr. Secretary.

Secretary CeLesrezze. I am sorry.

The basic reason, I explained to Senator Javits, who asked the same
question, was that the report came out in December of last year.

Senator Kennepy of Massachusetts. I see.

Secretary Cutmprezze. So, of course, it has only been out a short
time, and it was our thinking that before recommending appropria-
tions for the second, third, and fourth years, that we would use this
$50 million primarily now for planning and for demonstration and
at the end of that time we would be in a much better position to come
in with realistic figures for the second, third, and fourth year basically.

Senator Kennepy of Massachusetts. Mr. Secretary, do you know
how many centers you are going to have in the next year, and in the
next 4 or 5 years?

Secretary CeLeprezzp. We are talking in terms of about 32 centers.

Senator Kunnepy of Massacusetts. Let’s use those centers. You
are talking about 32 centers. What will it cost to run these centers?

Secretary Crieprezze. Well, that may vary depending upon what
the existing facilities are as you establish these centers because there
are some cities that already have medical facility complexes into which
we could move. Others would require an expenditure of perhaps very
little for construction or for renovation, expenditures for the purchase
of equipment, expenditures for staffing and maintenance.

Senator Krnnepy of Massachusetts. What were the estimates; could
you give us some idea as to the range of these figures? If you are
talking about 32 centers in various sections of the country, I think
there must be at least some figures by which you would be able to
determine what the cost will be and what you are going to need for
appropriations.

Secretary Cetesrezze. I was thinking that the $50 million that we
asked for

Senator Kennepy of Massachusetts. Maybe I am not making myself
clear.

I understand this authorization and what it is going to be used for.
My question is, What is going to be the amount that this program is
really going to cost over this next period of years with respect to
the 32 centers that are going to be located in the different regions of
the country ?

Secretary CeLeprezze. My answer was that we would be in a better
position to answer that once we have established the three or four
complexes that we are talking about under the $50 million, using
Hane as rather a demonstration project to come in with more realistic

gures.

Senator Krnnepy of Massachusetts. Well, Mr. Chairman, I sug-
gest that we should try to find out the financial commitment of this
program. I think this is an area which is a matter of considerable
concern. It is to me. I support this concept and support this pro-
gram, Mr. Secretary,

Secretary CrLesrezze. I think that it would be unrealistic for the
administration to come in on second-, third-, and fourth-year appro-

 

 
(eee

72 COMBATING HEART AND OTHER MAJOR DISEASES

priations without gaining basic experience at least for 1 year on de-
tailed planning and how fast we can move in these centers.

Senator Kennepy of Massachusetts, Well, Mr. Chairman, I would
only like to suggest that I think that it may be difficult to defend this
on the floor of the Senate for those who are not sympathetic to this pro-
gram. We are not going to be able to be any more responsive to these
questions without the projections. I would like to reserve the right to
pursue this matter at a later time.

The CHarrMan, Certainly.

Senator Kennedy of New York?

Senator Kennepy of New York. Thank you, Mr. Chairman. 1 just
want to listen to the testimony.

The Cyaan. If you have any questions, we would be happy to
have you ask them.

Senator Kennepy of New York. Thank you.

Senator Yarsorovcu. Dr. Dempsey, is the Public Health Service
hospital in Galveston, Tex., affiliated with the University of Texas
Medical School in Galveston ?

. Dr. Demrsny. May I refer that to Dr. Price?

Dr. Price. It is not affiliated, sir, in the sense in which many commu-
nity hospitals are affiliated with medical schools. On the other hand,
there is a very close relationship between it and the medical school at
Galveston. Teaching is conducted in our hospital. Some of the mem-
bers of our staff participate in the staff activities of the medical school,
and I think for all practical purposes one might say that there is a
program affiliation, although it is not a formal affiliation in which the
medical school participates in the staff management of the hospital.

Senator Yarsoroucn. Of course, one is a State medical school, and
one is a Federal Government hospital, but they do work very closely
together, don’t they ?

Dr. Price. This has been true fora number of years,

Senator Yarsoroucu. And the University of Texas is the oldest
medical school in the State of Texas. You are familiar with that 2

Dr. Price. I know it is an old one,

Senator Yarsorovcu. Do you think the order to close down this
Public Health Service hospital at Galveston, because it has a rated
capacity of only 79 beds and a caseload of 134 a day, is going to help
the medical complex there in Galveston ?

Dr. Price. I think the development. of a medical complex based on
the medical school at Galveston 1s an issue of somewhat different, mag-

in the area to know how important this one hospital of the Federal
Government might be to the development of such a complex.

Senator Yarsoroueu. Mr. Chairman, in the interest of time, I will
not pursue the matter further at this time. But on future occassions
I will, when we have other witnesses.

The Cuarrman. Anything you would like to add, Mr. Secretary ?

Secretary Cereprezzz. No.

The Craimman. Anything further you would like to add, Doctor?

Dr. Dempsry, Ni 0, Sir.

Senator Yarsorovau. Mr. Chairman, I want to commend the wit-
nesses for their appearance, . I know it is going to cost money in the
future, and Iam prepared to support it. I hope we will pass this leg-

 
 

COMBATING HEART AND OTHER MAJOR DISEASES 73

islation, and you will go full steam ahead with the development of
these centers.

The Cuamman. I certainly want to thank you gentlemen and
strongly commend you for the very excellent testimony you have
brought us this morning, and I am sure you will give careful considera-
tion to the remarks of the Senator from Massachusetts, Senator Ken-
nedy, with reference to this matter of costs because, naturally, that
will be a question that will be recurring not only this year but through
the years as long as this program is going forward. .

You have brought us some very fine, most excellent testimony, and
we deeply appreciate it. We certainly want to thank you for it.

Thank you. ,

The Carman. Dr. George Wolf. Dr. Wolf, you are president
of the Association of American Medical Colleges, and vice president
of medical and dental affairs at Tufts New England Medical Center.

Dr. Wor. That is correct, sir. .

May I introduce my colleagues. Dr. Robert Berson, on my left,
who is executive director of the Association of American Medical Col-
leges; and Dean Thomas Turner, who is dean of Johns Hopkins Uni-
versity Medical School, and president-elect of the Association of
American Medical Colleges.

The Cuarrman. We are glad to have you all here today.

Senator Kennepy of Massachusetts. I would just like to extend
a word of welcome to Dr. Wolf from my State of Massachusetts. He
is well qualified to talk on this subject and has, I am sure, some very
helpful observations on this legislation. I want to welcome him, and
extend to him the best wishes of the committee, and the same to the
honored gentlemen who come with him this morning.

Dr. Wour. I would like to have Dr. Berson make a statement.

STATEMENT OF DR. ROBERT BERSON, EXECUTIVE DIRECTOR, AS-
SOCIATION OF AMERICAN MEDICAL COLLEGES; ACCOMPANIED
BY DR. GEORGE WOLF, PRESIDENT, ASSOCIATION OF AMERICAN
MEDICAL COLLEGES; AND DR. THOMAS TURNER, PRESIDENT-
ELECT, ASSOCIATION OF AMERICAN MEDICAL COLLEGES

Dr. Berson. Mr. Chairman, with your permission, we would like
to make a very brief statement, in view of the Jate hour, and expand
that a little bit in writing in the immediate future.

As you can imagine, it would be easier for us to speak to this measure
if we were also talking about S. 595, the Health Professions Educa-
tion Assistance Amendment of 1965 because this is so much of the same
package, and there is a sharp limit to how much anyone can speak for
all of the medical schools at this moment, because in the brief period
since the President’s Commission reported and this legislation was
introduced, we have had an opportunity for only a few hours of dis-
cussion of this important legislation among representatives of all the
schools.

Actually, stated very broadly, the objectives that the President set
forth under the headings of “ trengthening the Nation’s Health Fa-
cilities and Services, Manpower for the Health Services and Health
Research, and Research Facilities” in his message to Congress are the
objectives of the medical schools of this country which they have been

  
  
 
 
 
 
 
 
 
 
 
 
  
 
 
  
   
 
 
 
 
  
 
 
  
  
 
  
 
 
 
 
 
 
 
  
 
  
 
 
 
 
  
 
   
 
  
 
   
  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

74 COMBATING HEART AND OTHER MAJOR DISEASES

ursuing for many decades. We continue to support these objectives
wholeheartedly, and it is wonderfully encouraging to have such a clear
statement of them by the President, now supported by legislation that
has been introduced. . .

The medical schools and their teaching hospitals and affiliated in-
stitutions have played a crucial role not only in educating medical
students, which used to be about all they did, but also in training
many workers in allied health professions in perfecting our great
system for training physicians and clinical investigators, advancing
knowledge through basic and clinical research, and applying it to the
problems of patients in the operating room, at the bedside and in the
clinics.

The tremendous role the Federal Government has played in this
through many agencies, articularly the Public Health Service, and
the National Institutes oF Health is very well known to your commit-
tee. You are responsible for so much of it that we do not need to
elaborate that at this time.

The first point we want to em hasize is when you consider pro-
posals of the magnitude of this bill, it makes it imperative to recog-
nize that our system of providing medical care in this country is inter-
dependent, although it is heterogeneous and not highly organized,
and we do not usually think of it as a system.

One simply cannot expect the fulfillment of pledged services to pa-
tients without support of and thoughtful consideration for the edu-
cational system that underlies it.

Now, about the legislation itself, we support the purposes set forth
fully, with the reservation that we do not think they can be achieved
unless we do give adequate consideration to the whole basic operation,
the whole basic system.

The medical schools and the related institutions which make up the
medical center, have become the resources to which patients with spe-
cially complicated Pee are referred for study and treatment, and
they are increasing: y effective in this role.

"he words of Dr. Osler that you quoted earlier have really been
taken seriously. Incidentally, he was one of the earlier presidents of
the association that Dr. Wolf now presides over and, as you know, he
played a fundamental role in the development of the Hopkins for which
Dr. Turner is responsible at this time.

They have been taken seriously, and they have been wonderfully suc-
cessful all over the country, and it is perfectly logical and natural to
try to extend the influence of these institutions and improve the ways
they can cooperate with other hospitals, with the medical profession,
for the better interest of their patients.

Now, naturally, the medical schools would hate to see any vast dis-
ruption of the patterns that have been proven successful in the past—
evolution, yes, but not sudden disruptive change.

The members of the medical profession of this country are largely
the alumni of our medical schools, so we have a natural interest in the
pattern continuing to be one in which the individual physician can
achieve maximum effectiveness as well as appropriate professional
satisfaction.

It has been well demonstrated that it is highly effective to bring
together people who are doing research that is basic, but is also per-

 
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COMBATING HEART AND OTHER MAJOR DISEASES 75
tinent to clinically important problems, with clinical investigators
studying these problems and applying their results to the treatment of
patients as well as training younger people in the field.

A few independent autonomous institutions have developed which
are highly effective in doing this, but there are many other concerted
efforts which have developed as fully integrated parts of teaching hos-
pitals or medical schools, and they have been equally or more success-
ful.

Some of the categorical research centers which developed as rela-
tively isolated institutions, have been even more successful after they
developed close ties with the medical school and the medical center
developing in their area.

We are firmly convinced that the categorical research centers to be
developed under this legislation in the future should be intimate parts
of medical schools or medical centers and staffed by members of the
aculty.

Ni OW, a number of medical schools have had a good bit of experience
in trying to perfect regional arrangements that are rather similar to
the intentions of this legislation, and they have found it a rewarding
and a difficult business.

It has made it very clear that the relations between institutions and
the individuals involved are delicate and complex, and it is also pain-
fully difficult to procure and maintain an adequate supply of man-
power for this mission. It is simply imperative that careful planning
and thorough discussion and understanding precede the activation of
any regional complex that is to receive substantial support under this
program.

Hasty activation of any such regional complex before adequate staff-
ing and facilities are available, and thorough agreement are reached,
will accomplish little, and do a lot of damage.

Each regional complex will have immediate impact on the medical
school and the medical center involved, The success of the regional
complex would be dependent upon the continued success and grow-
ing effectiveness of that medical school and medical center, and the
development and success of one regional center will have immediate
repercussions on other medical schools, and it may make it easy for
the center, the complex, that is making progress to make even more
progress by recruiting personnel at other medical schools and medical
centers that need it.

We think that the role of the National Advisory Council, as provided
in this legislation, is extremely important. So far as the bill specifies
who should be on it, it seems good, but we would also urge that it
always include at least one member who has had experience in being
responsible for the whole of a medical school or a medical center.

Now, back to the manpower business again: The 88th Congress took
some very substantial steps, and they are helpful, but we are convinced
that a great deal more needs to be done. As this subcommittee knows so
well, for 15 years or more, the association has been concerned about
the escalating demand for medical manpower, and the painfully slow
progress we are making at meeting that demand.

It seems to us that the success of this program and of a good many
other programs that will be before this session of Congress are de-
pendent on our making progress with the manpower problem.

     
    
 
  
  
  
    
 
   
  
  
 
   
   
  
   
 
  
  
   
   
   
  
  
   
  
  
   
    
   
  
   
 
  
    
 
   
 
  
   
 
   
  
 
 
   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

76 COMBATING HEART AND OTHER MAJOR DISEASES

We, of course, would like to say more about that when you are con-
sidering appropriate legislation.

Now, it is necessary, I think for us to emphasize the imperative need
for attention to the manpower problem, but that does not mean that
we are not for the purposes of this legislation. It is tremendously en-
couraging that it has been proposed by the President and is being con-
sidered by the Congress as a part of national policy, and it seems very
likely that if it is handled on the basis of careful and through planning,
development when resources are adequate for the purpose, it can
achieve its high purposes without disrupting the rest of our complex
system of education, research, and medical care.

This, of course, only if we give adequate attention to the basic prob-
lems of the educational system which would be appropriate under other
legislation.

Mr. Chairman, it might be useful if Dr. Wolf would make any sort
of comment he wanted, and then Dr. Turner, and then we would be
delighted to try to respond to any points you wanted to raise.

The Cuarrman. Dr. Wolf.

Dr. Wotr. I would like to describe very briefly something that I
happen to be connected with that Dr. Dempsey has mentioned in a
variety of public utterances, and that is the Bingham Associates Fund
which is part of the Tufts Medical Center in Boston.

About 20 odd years ago a Mr. Bingham, a wealthy person in Maine,
gave some money to a group of men, trustees, so that they could do
something for medical care in the State of Maine, and what they have
done over the years now has had many of the elements of the proposed
program and, I think, has been quite successful.

A very few, brief examples: One, they now have developed ‘a series
of TV tapes for postgraduate education of the physician, and this is
Se into the educational TV network in Boston, and going up into

aine.

They have also provided funds for hospitals to get directors of
medical education in their smaller community hospitals, and in this
way have encouraged the development of an internship and residency
program.

In addition, medical students have gone out from Tufts to the
smaller hospitals and gained community experience. ‘

They have also paid for part of the salary. of a physician who is
director of rehabilitation at a small hospital in northern Maine.

Then, finally, they have cooperated in providing consultation serv-
ices to hospitals in Maine in the areas of nursing, X-ray technology,
clinical laboratory, dietetics, record-room library technique, and so

orth. '

This program has been flexible over the years. It has been very
small, of course, but I believe has been successful.

Dr. Turner?

The Cuarrman. Dr. Turner. ,

Dr. Turner. Thank you very much, Mr. Chairman.

T think all of us recognize the very fine quality of the President’s
Commission’s report. It should be noted, however, that this bill im-
plements only.a few of the recommendations in that report and, as

enator Kennedy, I believe, suggested earlier this morning, we cannot
help but feel that S. 595, for example, is intimately tied into this pic-
ture. We have only limited manpower, which is in short supply, and

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COMBATING HEART AND OTHER MAJOR DISEASES 77

we are asking them to do more things and to be better trained, and
eventually you come to a point where you simply cannot do these
things without more individuals todothem. Thank you.

The Cuamman. You feel then than S. 595 and S. 596 are comple-
mentary one to the other, do you not, Dean?

Dr. Turner. I certainly do, sir; and I might even go a little bit
further and say 597 which provides better library facilities must be
considered in this picture, too.

The Cuatrman. These three in a way constitute a kind of tripod,
do they not?

Dr. Turner. I certainly agree.

The Cuamman. If you are going to do the job we have been talking
about this morning to accomplish these ends, we need all three, do we
not

Dr. Turner. I entirely agree with you.

The Cuamrman. Do you gentlemen have any suggestion as to where
you would put the responsibility in the Department of HEW for the
administration of these proposed networks?

Dr. Berson. Senator Hal, our association has not gone into this
very far, and I am quite sure that there are elements of this that are an
administrative decision and must be made by the Secretary or the Sur-
geon General.

There is one concern that I would express, and that is that however
it is administered, the competence that has ‘been gained in the Heart
Institute, the National Cancer Institute, and other institutes become
involved that this competence and experience be used as a fundamental
part of the making, of the decisionmaking, as to what to do.

Now, this could be done by a variety of administrative mechanisms,
but I think it would be a shame if this number of years of very success-
ful experience were not made use of in some way.

The Cuamman. You strongly feel that from your experience, do
you not, Doctor?

Dr. Bzrson. That is right; that is my personal opinion.

The Cuatrman. Your experience, too, Dr. Wolf; and your exper-
ience, too, Dr. Turner?

Dr. Turner. Yes, Mr. Chairman. We cannot forget we worked
nearly 20 years with the National Institutes of Health in a most ex-
cellent relationship with the medical schools, and this does not mean
that there are not other administrative mechanisms that. will work,
perhaps, just as well, but I think this historical fact must be taken into
consideration.

The Cuamman. Senator Yarborough.

Senator Yarsorouau. Dr. Berson, I am very sympathetic to your
suggestion that 1 of the 12 members of the National Advisory Coun-
cil on Medical Complexes represent the medical schools.

However, the law provides that these 12 people shall be leaders in
the field of the fundamental sciences in the medical sciences and pub-
lic affairs; 1 is to be the Surgeon General, 1 is to be an outstand-
ing person in the treatment of heart disease, 1 in the treatment of
cancer, and 1 in the treatment of strokes, which makes 4. One
from the medical schools would make five.

Now, I say I am sympathetic to that, but the hospitals say they
want a member, the research institutes want one, and we will soon

43-669— 65——6

  
 
 
 
 
 
 
  
  
  
   
 
 
 
 
  
  
 
 
 
 
  
 
 
   
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  

 

 

 

 

 

 

 

 

 

 

 
78 COMBATING HEART AND OTHER MAJOR DISEASES

run out, and we won't be able to get that broad spectrum of leaders
in the whole field of medical sciences and public affairs.

I do think that the basic institutions that teach medicine ought to
have some representation.

Dr. Berson. Senator, of course I was not thinking of representa-
tion. I was thinking of the background experience and viewpoints.
and this might be found in men who had had the responsibility for
a medical center as a whole, and a few of these men hare a background
as hospital administrators. But my point is that the law provides to
have experts in these subject matter fields.

Now, presumably these men have spent their professional life in
those fields, not necessarily responsible for the broader aspects of the
institution.

So I would say not necessarily a dean, but someone who has a real
background of experience of a responsibility of that magnitude, medi-
cal school, or medical center.

Senator Yarporover. You do recognize that we have a problem of
how to utilize this limited manpower that Dr. Turner has so graphical-
ly described here where many of those men are already teaching and
engaged in research at the same time?

Dr. Berson. Yes.

Senator Yarsorouau. Thank you.

The Caiman. Senator Kennedy.

Senator Kmnnepy of Massachusetts. I have no questions. I would
just like to underscore what the presentation indicated which, I think,
you observed so accurately, Mr. Chairman, about the interrelationship
of these programs and of the pending legislation. I certainly think
this is worth considering. .

The Cuamman. In other words, we have got to move forward on
all fronts.

Dr. Berson. That is right.

Senator Kennepy of Massachusetts. It does not lessen the impor-
tance of this legislation in any way.

Dr. Berson. Oh, no.
aia Kennepy of Massachusetts. And I think all of us realize
this.

The Cuarman. That is correct.

Senator Kennepy of Massachusetts. And I appreciate your observa-
tions on it.

Dr. Berson. Thank you very much.

The Cuairman. Anything else you gentlemen would like to add?

Dr. Brrson. No, sir. We would like to submit a written report in
a few days.

The Cuarrman. Very good. That would state officially the position
of your association ?

(The statement referred to follows:)

PREPARED STATEMENT FOR THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES Con-
CERNING 8, 596, HEART Disrasz, CANCER, AND STROKE AMENDMENTS OF 1965

The Association of American Medical Colleges greatly appreciates the oppor-
tunity to present its views on this important legislation. We would find it easier
to speak clearly for the association if we were discussing both S. 596 and the
legislation dealing with the needs for manpower, 8. 595, Health Professions Edu-
cational Assistance Amendments of 1965. And the degree with which anyone can

aan
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COMBATING HEART AND OTHER MAJOR DISEASES

79

speak for all the medical schools is sharply limited by the fact that, in the short
interval since S. 596 was introduced, it has been possible to have only a few
hours discussion of this legislation by the executive council and the institutional
members of the association.

Our views on this specific matter will be easier to understand if we first say
a few words about the general intent and objectives set forth by the President

in his message to Congress titled “Advancing the Nation’s Health.”

Stated broadly, the objectives the President set forth under the headings
“Strengthening the Nation’s Health Facilities and Services” ; “Manpower for the
Health Services,” and “Health Research and Research Facilities” are the objec-
tives the medical schools of this country have been pursuing for many decades.
We continue to support those objectives wholeheartedly. It is wonderfully en-
couraging that the President has endorsed those recommendations so strongly
and that your committee is in the process of considering this and other legislation,
especially 8, 512, §. 595, and 8. 597, which will do so much toward achieving them.

The medical schools, their teaching hospitals and affiliated institutions have
played a crucial role not only in educating medical students, but also in train-
ing many workers in allied health professions ; in perfecting our great system
for training physicians and clinical investigators ; advancing knowledge through
basic and clinical research and applying it to the problems of patients in the
operating room, at the bedside and in the clinics. The tremendously important
role the Federal Government has played in this grand development through
several agencies, especially the Public Health Service and the National In-
stitutes of Health, is well known to you and needs no elaboration at this time.

The first point we want to emphasize is that considering proposals of this magni-
tude makes it imperative to recognize that our system of providing medical
care is interdependent, although it is heterogenous, not highly organized and
not usually discussed as a “system.” One cannot expect the fulfillment of
pledged services to patients without support of and thoughtful consideration
for the educational system that underlies it.

Concerning 8. 596, Heart Disease, Cancer, and Stroke Amendments of 1965,
specifically, we support the purposes set forth, and we think they can be carried
out only with proper attention to the “system” as a whole.

The medical schools and related institutions which make up medical centers
have become the resources to which patients with specially complicated prob-
lems are referred for study and treatment and are increasingly effective in
this role. It is a logical and natural extension of this background to continue
to perfect the ways that medical schools, teaching hospitals, and related neighbor-
ing institutions can cooperate with each other, with hospitals at some distance,
and with the medical profession for the better interests of their patients. The
members of the medical profession of this country are largely alumni of the
institutional members of the association so we have a natural interest in the
pattern of medical care continuing to be one in which the individual physician
ean achieve maximum effectiveness for his patients and appropriate professional
satisfaction.

It has been well demonstrated that it is highly effective to bring together
people doing research that is basic and pertinent to clinically important prob-
lems (such as heart disease, cancer, stroke, and several others) with clinical
investigators studying those problems and applying the results to the treatment
of patients as well as training specialists in the field. A few independent and
autonomous institutions have developed which are highly effective in doing
this. The accomplishments of our great clinics devoted to one “category” of
disease or to rehabilitation are so well known ta your committee there is no need
to elaborate on them. I do want to point out that some of them have been
even more successful after they developed close ties with a medical school.
It is clearly desirable for these established centers to continue to evolve in a
way appropriate for their own setting. And it seems worthy of some emphasis
that other such concerted efforts have developed as fully integrated parts of
teaching hospitals or medical schools and that they have been equally
successful.

We are firmly convinced that the “categorical research centers” to be devel-
oped under this legislation in the future should be intimate parts of medical
schools or teaching hospitals, staffed by members of the faculty, rather than
isolated and independent institutions.

A number of medical schools have had experience in trying to perfect regional
arrangements for the orderly referral of patients to the medical center: the

     
  
 
 
 
 
 
 
  
  
  
 
 
 
    
  
 
 
  
  
  
  
  
  
   
  
  
 
 
  
  
   
  
  
   
  
    
  
 
   
   
   
  
 
  
   
  
  
 
  
   
   
 
  
 
 
  
  
  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
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80 COMBATING HEART AND OTHER MAJOR DISEASES

establishment of specialized diagnostic or treatment stations in hospitals at
some distance and the transmission of new knowledge to practicing physicians.
The examples of Albany and the University of Kentucky were cited by Dr.
Dempsey.

Eleven years ago John Deitrick wrote:

“While medical schools and their teaching hospitals were encountering these
serious financial difficulties, the public demand for their services was increasing.
Medical centers had proved their value in terms of improved medical service.
The concept of a medical center rendering many types of medical service had
been promoted by several medical schools. Tax-supported schools had generally
rendered some direct medical services to their communities or to their States, but
they. were constantly being asked to expand this service as the public grew
to expect direct and supervised medical care from the medical school.

“The new philosophy is illustrated in a report published by the regents of one
State university which included the following statement: ‘University personnel
and activities constitute many resources that are of potential importance to our
community welfare. Consequently, the medical schoo] has extended its inter-
ests beyond the limits of its classrooms to the end that its many resources
may be made of maximum use to the people of our State.’ This medical school
supervised or had affiliations with 14 hospitals whose primary function was
patient care. One private medical school specifically stated that one of its
major objectives was a community medical-care program.

“The philosophy, propounded by national organizations and leaders in the
health professions, soon reached the level of the Federal Government. In 1948
a report to the President by the Federal Security Administrator stressed the
point that financially the medical schools were unable to meet the need of the
Nation for physicians, and at the same time promulgated the need for large
medical centers, with a medical school becoming the hub of each center. The
President was advised that the Nation’s total health resources could best be
utilized by a program of Federal-State-community action to develop a system of
hospitals and health centers closely integrated with a medical school and medical
center in their respective regions, to provide smaller nearby hospitals with
various services and professional personnel for patients who required special
eare.

* * * * * * *

“The concept of expanding the influence and responsibility of medical schools
for patient care was discussed in 1951 in the publication entitled ‘Financial
Status and Needs of Medical School,’ which was a preliminary report by the
Surgeon General’s Committee on Medical School Grants and Finances. It
stated:

“The entire problem of extending the influence of medical schools is be-
coming of increasing importance. Active regional programs in New England,
New York, Michigan, Virginia, and other areas demonstrate the weight attached
to these plans by many medical educators and medical administrators. The
rapid growth of hospital facilities under provisions of the Hospital Survey and
Construction Act will increase the demand for leadership and direction from
medical schools.

“ce * * About 30 deans reported to us that a shortage of general funds is
the major barrier to the development of these activities * * *. It is clear that
an expanding concept of the function of medical schools as part of the community
is evolving out of the initiative and experience of the schools themselves. These
experiments have proved to be productive, and we foresee a growth of this
movement.’ ?

“Obviously these statements represent a radical change in the fundamental
concept of the function of a medical school. The medical schools, organized
originally as educational institutions, are developing into medical service centers
with constantly expanding responsibilities in the health field. Not only does
the public expect these institutions to set standards of medical care, but in
addition it expects them to provide and supervise the hospital care for large
population areas as well as for national medical-service programs.” ?

1 Federal Security Agency, Public Health Service, Report by the Surgeon General’s
Committee on Medical aor pants and Finances,” pt. I, ashington, D.C., U.S. Govern-
ment Printing Office, 1951, p

2 “Medical Schools in the Gaitea States at Mid-Century,” by John E. Deitrick, M.D.,
and Robert C. Berson, M.D. :

 

 
 

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COMBATING HEART AND OTHER MAJOR DISEASES 81

Additional current examples would include Tufts and the Bingham Associates,
New York University, the Universities of Michigan, Ohio, Wisconsin, Kansas,
Iowa, Rochester, and others. In some instanceg the initiative has come from
the medical school and in others has come from other groups and the medical
school has responded,

This experience makes it clear that the professional and institutional relations
are complex and delicate. It also makes it clear that it ig painfully difficult to
procure and maintain an adequate supply of trained manpower. A functioning
region! complex, as recommended by the President’s Commission on Heart Dis-
ease, Cancer, and Stroke, would make the efforts of the practicing physician more
effective, but the development and Operation of the “stations” in each hospital
and the “categorical research center” will require a marked increase in trained
manpower,

It is simply imperative that. careful planning and thorough discussion and un-
derstanding precede the activation of any “regional complex” that is to receive
substantial support under this legislation. Such careful planning can also help
to avoid unnecessary duplication of facilities, equipment, and services with its
great cost in money and scarce personnel, so the provision of grants for such
planning is probably the best feature of the legislation, Hasty activation of any
such “regional complex” before adequate Staffing and facilities are available

and thorough agreements reached would accomplish little and might do much
damage,

Advisory Council provided by this legislation always include some individuals
who have had experience in carrying the responsibility for medical schools or
medical centers ag a whole. And it also seems imperative that the role of the
National Advisory Council be changed from “consultation” to “advice” and that
the legislation make it clear the Surgeon General is not to award grants that
have not been approved by the Council,

The Association of American Medical Colleges has not taken 4a position on
which portions of the Public Health Service should administer thig program
and probably will not do so. From my Own experience it would seem wise for
this administrative decision to be left to the Surgeon General and the Secretary
of Health, Education, and Welfare. I do think it would be wise for the program
to make use of and build on the long and successful experience of the National
Heart Institute and the National Cancer Institute, particularly in relation to
the “categorical research center” portion of each complex.

The 88th Congress took Some substantial steps to aid in increasing the supply
of trained manpower in the health fields but we are convinced that much more
heeds to be done. As this committee knows So well, the Association of American
Medical Colleges has long been gravely concerned ag to whether there will be
enough trained manpower to meet the growing demand. The present prospects
are that the number of physicians who have graduated from medical sehools in
this country wilt continue to decline in relation to the population. The success
of this program is absolutely dependent upon an increased supply and appropri-
ate distribution of trained workers and so is the success of other proposals before
the Congress in this session. We would like to say much more about this when
legislation dealing with health Inanpower is being considered.

Having expressed our reservations, I want to add that I think that, with sound
planning and proper attention to the system of providing research, education, and
service as a whole, the problems which concern us can be overcome and progress
toward better medical care for everyone can be greatly helped by this legislation.

I would urge the passage of this legislation along with the other legislation

to implement relevant recommendations the President made in his inessage to
Congress.

Dr. Berson. Yes; it will, but it is not different from what we have

said this morning.
The Cyaan, I did not think it would change.

 

 

 
 

82 COMBATING HEART AND OTHER MAJOR DISEASES

Now we have Dr. Carleton B. Chapman, of Dallas, Tex., president
of the American Heart Association, and professor of internal medicine,
University of Texas, Southwestern Medical School.

Doctor, I have a telegram from you, sir, in which you said you would
like to have with you today Dr. James Warren and Dr. Robert Wilkins,
past presidents of the American Heart Association, and Mr. Jesse Fill-
man, member of the board of directors of the association, and Mr.
Rome Betts; are they here with you thie morning?

Dr. Cuapman. Yes, sir; all except Dr. Wilkins who could not come

The Cnairman. Do you have all those who are available?

STATEMENT OF DR. CARLETON B. CHAPMAN, PRESIDENT, AMERI-
CAN HEART ASSOCIATION; ACCOMPANIED BY DR. JAMES V.
WARREN, PAST PRESIDENT, JESSE R. FILLMAN, MEMBER, BOARD
OF DIRECTORS, AND ROME BETTS, EXECUTIVE SECRETARY,
AMERICAN HEART ASSOCIATION

Dr. Cuapman. Yes, sir. If I may, I will introduce them.

On my right is Mr. Fillman, who is a member of our board of di-
rectors. Heisa lawyer, and he comes from Boston.

Also on my right

The Cuamrman. You mean you let lawyers in your association ?

Dr. Cuapman. Oh, yes, sir. We are a voluntary health association.

The Cuarrman. I think that will particularly appeal to members
of this committee. Most of us are lawyers, you know.

Dr. Cuarpman. Also on my right is Dr. James Warren, who is a
past president of the American Heart Association and currently
professor of medicine at the Ohio University School of Medicine.

On my left is our executive secretary, Mr. Rome Betts, whose
executive offices are in New York.

The Cuamrman. We are delighted to have you.

Senator Yarporouen. Mr. Chairman, at this time I would like
to welcome to this committee Dr. Carleton Chapman, president of the
American Heart Association. I see we have other “presidents from
Texas” on this agenda also. We have quite a complex of presidents.
We are very proud of them, and we are proud to have one before this
subcommittee at this time, and we are glad to welcome you here before
this subcommittee under the leadership of this great chairman,
Senator Hill.

It is a personal pleasure for me to see people from Texas coming
here supporting this medical legislation. That was not exactly the
situation 7 years ago when I first came to this subcommittee.

The Cuairman. There has been a little change of heart. I guess
the American Heart Association had a lot to do with it; didn’t it,
Doctor?

Dr. Cuapman. I certainly like to think it has.

- The Cuarrman. We are certainly glad to have you. You may
proceed in your own way.

Dr. Caapman. Thank you.

I am honored to have the opportunity to serve as spokesman for
the American Heart Association in connection with the proposal—
S. 596—to establish regional medical complexes for research and
treatment in heart disease, cancer, stroke, and other major diseases.

 

 
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COMBATING HEART AND OTHER MAJOR DISEASES 83

Our organization regards the proposal as one of the most Significant
pieces of health legislation ever to come under consideration in our

country and we support its major objective without qualification. That
objective, as we understand it, is—

* * * to afford to the medical profession and the medical institutions of the
Nation * * * a more abundant opportunity of making available to their patients

the latest advances in the diagnosis and treatment * * *

especially of heart disease and stroke, which are the areas of our
special concern and competence. This general aim, in fact, has been
an important goal of the American Heart Association for many years.

At the outset, gentlemen, permit me to point out that the American
Heart Association is a voluntary health agency and a public service
organization. Our reason for being, and our main justification, is the
fight against diseases of the heart and blood vessels in particular and
the preservation of the health and the vigor of our Nation, speaking
more generally.

Our membership is made up of about 40,000 of the Nation’s leading
public-spirited laymen and about 35,000 physicians (generalists and
specialists) who are Interested in circulatory diseases. We view this
Important group of diseases as a public health problem of major
magnitude and complexity, and have mobilized all sorts of skills,
talents, and intellects in our efforts to cope with it, By the same token,
we have called in many of our qualified members, both medical and
nonmedical, in studying the bill before us and in preparing this testi-
mony, which we have presented. But we would like to say, too, we
have no ax to grind in offering it.

We appear before your subcommittee solely in the public: interest
and in the hope that we can make some contribution to wise and
effective legislation in the health area,

There were many points in the proposal (S. 596) that were of
interest to us; so many, in fact, that we elected to take up only the
main ones in our presentation this mornings. We have relegated
details about wording, and an official resolution by the board of di-

the President’s Commission on Heart Disease, Cancer, and Stroke, to
an appendix to the main body of our report. But with your per-
mission, we would like to place an appendix and resolution in the
record.

The Cuairman. We will have that appear following your testimony
in full inthe record,

(The information referred to appears on pp. 91-92.)

Dr. Cuapman. Thank you, sir.

In our view there are several aspects of the proposal (S. 596) that
are of critical importance, and some of which will lead us to make
overlapping of some of what has gone before.

By far the most important and pressing, we believe, is that which
relates to staffing and training, and the need for trained personnel,
in general, the role of the medical schools, in particular,

the proposal to establish regional medical complexes is enacted
large numbers of highly trained people—physicians and nonphy-
siclans; medical and paramedical—will be needed to staff them, At
present, these people are not available in sufficient numbers and there
is only one source from which they can come: the medica] schools and

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iii ™~

84 COMBATING HEART AND OTHER MAJOR DISEASES

their affiliated teaching hospitals which, taken together, are defined
in the bill as medical centers.

It follows inescapably, therefore, that if the proposal (S. 596) is
to succeed, its most immediate effect must be to strengthen and expand
the role of the medical schools and affiliated hospitals in the training
of physicians and other health personnel. Without such people in
adequate numbers, no amount of physical construction, or any other
provision, can make the proposal to establish regional medical com-
plexes even begin to approach its goals.

In this connection, let me point out that the modern American
medical school, as you know, sir, characteristically a regional institu-
tion, operates training programs in depth and at many levels. It is
not only concerned with providing the training required for the M.D.
degree; it also, mainly through its clinical departments, trains interns,
and residents; physicians seeking specialty training, and other post-
graduate groups. The trend today is toward more and more clinical
training, much of it highly specialized, after the M.D. degree is at-
tained. And this trend is not solely due to the requirements of spe-
cialty groups themselves; the Academy of General Practice, in fact,
recently announced that it favors at least 2 years of training after
a young physician completes his internship. The trend toward in-
creased training after the internship will, however, be emphasized
and accelerated if the proposal to set up regional medical complexes
is passed by Congress.

Senator Yarsorovcn. May I interrupt there?

The Cuarrman. Yes.

Senator YarsoroucH. Doctor, this question I should have asked of
Dr. Berson, and if he is still here I might direct it to both: We worked
very actively on this subcommittee in the past Congress to pass the
Health Professions Educational Assistance Act of 19638. Do you think
that is being implemented fast enough, the money is forthcoming,
medical schools being approved or the applications for new buildings
or renovated buildings at existing medical schools being processed
fast enough?

Dr. Crapman. I have a view on it, sir, but I would like to defer
to Dr. Berson on that point, if he is still here.

Senator Yarporoveu. Could I interrupt at this point? Dr. Berson,
what comment. do you have on that?

Dr. Berson. Senator Yarborough, I think about as fast progress is
being made as you can expect. It is a very complicated business, and
it involves site visits to many, many institutions.

All of us in the medical schools as well as in the Public Health
Service, hope that the next meeting of the Council can reach decisions
on a number of more applications, and there is every indication that
they will be able to do so.

Senator YarsoroueH. Is the actual amount provided for student
loans, $5 million for fiscal 1964 and $10 million for fiscal 1965 being
made available, has it been made available?

Dr. Berson. Yes.

Senator Yarsorouen. Is it being made available?

Dr. Berson. It is being made available; yes. The timing was un-
fortunate because I have heard Surgeon General Terry mention get-

ting the appropriation after the school year started, which made it
very difficult to proceed fast enough.

 
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COMBATING HEART AND OTHER MAJOR DISEASES 85

Senator Yarzoroveu. Because of the long session we had the past
vear.

Dr. Berson. Yes.

Senator Yarsoroveu. We hope to remedy it this year.

Is there enough money for the student loans?

Dr. Berson. ‘No.

Senator Yarsoroueu. I hope you gentlemen ask for it.

The Cuamman. Doctor, may I ask you one question: You spoke of
the Council, you mean the Council onthe Health Professions Educa-
tional Assistance Act?

Dr. Berson, That is correct. They are scheduled to have meetings
in the relatively near future, in a few weeks now, and there is every in-
dication they will be able to consider a large number of applications
and make definitive decisions at that time.

Senator Yarsorovey. Dr. Chapman, pardon my interruption of
your testimony, but your testimony, in addition to that of Dr. Turner
and the man who preceded you, makes it clear all the time that for
these centers to work you have got to have more personnel, and it takes
a long time to train them. I think the Nurses Training Act we passed
in the last session of Congress will be helpful in this.

Dr. Cuapman. Right, sir.

In view of what we have been saying, and Dr. Berson as well, it is
not surprising that the framers of the proposed bill put the medical
schools and their affiliated hospitals (the medical center) squarely in
the middle of the regional medical complexes. It could hardly be
otherwise, in view of the vast importance of the medical center train.
ing programs—broadly defined to which I have already made refer-
ence.

But at the present time these training programs are not producing
enough graduates to meet the needs of the program the proposal would
set in operation. To establish such a system without first seeing to
the expansion of clinical training facilities might, in effect, do more
harm than good. It would dilute our existing supply of trained
clinical personnel and might well lower, instead of elevating, existing
standards of diagnosis and treatment. To give young physicians
additional training after internships in the areas encompassed by the
proposed bill requires elaborate staffing and planning. Our medical
schools and their hospital groupings, in order to meet the needs for
staff of the proposed complexes, will have to enlarge their senior clini-
cal teaching staffs and provide a greatly increased number of clinical
traineeships for young physicians who happen to be ready for them.
Our medical centers will also have to expand their facilities for train-
ing other types of personnel—nurses and various technicians, for ex-
ample. And such expansion of training facilities can hardly be
achieved overnight.

It might be well, parenthetically, for funds provided by grants in
the first year under the bill, if it is enacted, to be used in some measure
for the complicated planning that the expansion of training facilities
will inevitably require, and we are glad in this connection to note the
interest in planning grants shown by the Secretary’s testimony earlier
today.

In a few sections of the country, it may be possible to set up pilot
projects at the outset, each to consist of a medical center, categorical

 
86 COMBATING HEART AND OTHER MAJOR DISEASES

research institute, and station for diagnosis and treatment. Sue
projects, if carefully planned and operated, may within a few yea
yield very valuable guides that are applicable to the Nation as a whol

In essence, then, we believe that the proposed bill should be so de
signed and administered as to encourage and assist our medical school
and their affiliated hospitals to expand and upgrade their clinical train
ing programs, beginning as soon as possible. This should be the firs
objective of the bill; the first item in an orderly sequence of develop
ment which can, we believe, enable the proposal to contribute impres
sively to the improvement of the health of the Nation.

Turning to another item, an item which our groups within the Hear
Association considered the next most important, we urge in th
strongest terms, and with all deference to previous testimony, that the
regional complexes proposal, if it becomes law, be administered as
part of the National Institutes of Health,

We make this recommendation not only because we have utmost con.
fidence in and respect for the National Institutes of Health and for
the men who direct. them, but, even more significant, the Institutes col.
lectively represent a splendidly constructed system, built up over more
than a decade and ideally suited for the implementation of the regional
complexes proposal. This, after all, the complexes proposal, that is,
rests very critically and predominantly as has been pointed out, on the
continuing recruitment and training of highest level clinical personnel.
At the Federal level, the National Institutes of Health can rightly
claim expert knowledge of this particular function, and we believe this
attribute can be turned to splendid account in the administration of
the regional complexes proposal.

In addition, the established traditions of the advisory councils of
the National Institutes of Health have been widely accepted and, we
think, universally respected in the N ation. And, just as important,
the categorical nature of the National Institutes of Health still further
qualifies them, in our considered opinion, for administering the re-
gional complexes proposal, an important segment of which is also
categorical,

We wish to make it very clear that, in making this strong recom-
mendation, we are well aware of the splendid tradition and the out-
standing service of others arms of the U.S. Publie Health Service.
The Heart Association, in fact, has cordial relations with them, as well
as with the National Institutes of Health, and cooperates with them in
humerous activities. We have plans for broadening and extending
such cooperation, especially on questions concerned with the relation
of environment to circulatory disease of all sorts. But the regional
complexes proposal is concerned with the provisions of clinical care
and training and this, viewing the problem in depth, puts it firmly and
squarely alongside the National Institutes of Health. It would, we
believe, be a fundamental error not to utilize this ideally-suited body
for the administration of the proposed regional complexes.

Our discussion groups considered many other questions in connec-
tion with administration of the proposed complexes but we realize that
we cannot claim to be experts on the intricacies of the possible and the
impossible in Federal administrative practice. The suggestion was
made that the National Advisory Council for Regional Complexes be
attached directly to the Office of the Director of the National Institutes
 

 

 

 

COMBATING HEART AND OTHER MAJOR DISEASES 87

of Health, and we submit the suggestion for consideration but without
a strong recommendation.

We would, however, consider this suggestion desirable if it should
prove to be administratively feasible. It was also noted that as the
proposed bill is now worded, the Surgeon General may appoint a Na-
tional Advisory Council but is not actually required to do so. And
the Council, if appointed, is merely advisory to the Surgeon General.

It follows that the Surgeon General may, if he wishes, award a grant.
that has been specifically rejected by the Council. We believe this to
be unwise. We recommend that the wording be altered so that the
Surgeon General must a point a National Advisory Council and must
have Council approval before he can award a grant under the bill.
He should, however, retain veto power over prior positive Council
action, in our opinion.

The Cuatrman. Would you please state that reason again.

Dr. Cuapman. We think the Surgeon General should have the au-
thority to veto a recommendation for an award under the bill, but that
he should not-be able to make an award if the Council has actually
projected it.

The Carman. Unless the Council has made the recommendation.

Dr. Cuapman. That is right.

The Cuamman. He can veto the recommendation but he cannot act
without the recommendation ; is that.it?

Dr. Cuapman. Exactly, sir. This is exactly the way it is in the law
we are most familiar with, in the Institute Law, the Heart Institute.

The Cyarman. It is that way in the Heart Act.

Dr. Cuarman. Yes, sir.

Finally, we take note, Mr. Chairman, of the provision for 9-to-1
matching for construction or built-in equipment (S, 596, p. 3, lines 9-
15). We recommend that the 9-to-1 requirement be deleted and that,
under the proposed bill, it should be made possible to pay the entire
cost of construction, or of built-in equipment, from grant. funds.

In support of this recommendation, we can only repeat an argument
which, although very important and often stated, never seems to have
had much effect, and that argument is a matching provision, even at
the 9-to-1 level, will tend to exclude qualified but underfinanced medi-
cal schools and affiliated hospitals from full participation in the pro-
gram and, we think, we believe, is contrary to the intent of the pro-
posal. It would, in fact, aggravate existing discrepancies between our
best and our worst clinical care and training facilities.

We wonder if it might not be possible for the grantee to offer the
Jand on which a structure is to be built as his contribution. In many
cases, the value of the land will be well over 10 percent of the total
cost of the structure and, in addition, the land may well appreciate in
value as the structure is used.

The Cuatrman. Land is absolutely essential, of course.

Dr. Carman. Yes, sir. But at the moment the grantee is required
to supply the land. This is our whole point. Even if this suggestion
proves to be unworkable, we still very much hope that the final bill

will provide unmatched funds for construction in regional complexes.

In conclusion, sir, the American Heart Association is very much in
agreement with the main objective of the proposal (S. 596) which is
basically to make it possible for the Nation’s physicians to provide our

 

 

 
Nee eee eee eee een

88 COMBATING HEART AND OTHER MAJOR DISEASES

people with the best possible diagnosis and treatment of heart disease
and stroke.

For the proposal to accomplish this high aim, the development must
proceed according to an orderly sequence; and the first step is, beyond
any question, in our view, to expand and improve the clinical training
programs of our country’s medical schools and affiliated hospitals.
Full development of categorical centers and community stations must
inevitably be delayed until the people to man them are available.

The Heart Association, having worked intimately with the National
Institutes of Health and other arms of the U.S. Public Health Service
for many years, believes very strongly that the regional centers pro-
gram, if enacted, should be administered through the National In-
stitutes of Health by its own National Advisory Council.

Finally, the American Heart Association urges that nonmatching
funds for construction and built-in equipment be made available for
the proposed regional complexes.

And that, sir, is all of our prepared testimony. We shall be glad
to expand it, or to try to answer questions, if you wish us to do so.
But first, I should like to thank you very much on behalf of the Amer-
ican Heart Association for giving us the opportunity to present our
views on this extremely important health proposal.

The Cuarman. We certainly thank you. You have brought us a
very splendid statement. In fact, your statement was so fine that you
answered the questions that I had in my mind.

Senator Yarborough, any questions you have, sir?

Senator Yarsoroveu. Dr. Chapman, I congratulate you and your
associates because this shows a very thorough study of this bill. “You
have come up with concrete proposals.

Let me ask you, aren’t the National Institutes of Health primarily
concerned with research ?

Dr. Cuapman. Well, they are concerned with research; yes, sir.
But they also, of course, have had by virtue of this very thing very
intimate contact down the years with medical schools. They are
the groups within the Public Health Service with whom the medical
schools have intimate contact and for this reason since the medical
schools are a central focus in the proposal to establish regional medi-
cal complexes, we feel it would be vastly more efficient to have the
NIH administer it.

Senator Yarsoroven. The problem that worries me is whether you
won’t take primarily what are research institutes and turn them into
mere administrators and have them become primarily an administra-
tive agency.

Dr. Carman. The only answer I can give you, of course, is to
point out that the clinical center is part of the National Institutes
of Health at Bethesda, and it gives them a very strong clinical arm,
and we believe a very marked understanding of clinical training pro-
grams.

The Crarrman. May I ask a question in connection with that?
The National Institutes not only make grants but also enter into the
contracts with the medical schools in the matter of medical research,
and in the field of fellowships and training; isn’t that true?

Dr. Cuapman. Yes, sir; it is very true. It is one of their more
important functions.
 

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COMBATING HEART AND OTHER MAJOR DISEASES 89

Pray Cuairman. In the field of training and in awarding fellow-
ships.

Dr. Cuarman. Yes, sir; that is right.

I wonder, sir, if Dr. Warren might have something more to add.
This is a very important question.

The Cuamman. All right, doctor.

Dr. Warren. Yes, I was going to point out that, of course, the
NIH is particularly involved with research, but it is very deeply
in the training and, as I understand the original Heart Act, it strongly
states this, so that I would agree thoroughly with Dr. Chapman.

If I may, I have just two brief additional points.

The Cuamman. Go right ahead.

Dr. Warren. The Heart Association has in addition reviewed the
bill S. 597, I believe on medical libraries -—

The Cuarrman. Yes,

Dr. Warren (continuing). And has voted to support it. We feel
that it is a very important part of this package that we have talked
about earlier today.

Just a personal comment: In my position at Ohio State University,
we have a regional program involving what we often call satellite
hospitals in Ohio, something like the Albany program mentioned
earlier, and we found a great eagerness of hospitals to enter into this,
and we feel it is very successful and it is a step in the direction that
we have been talking about.

The Cuamman. In other words, you pioneered in this field.

Dr. Warren. I think I reluctantly would have to say that Albany
did some of these things first, and we have picked it up.

The Cuatrman. The work you have done in a way has been some-
what pioneering ; has it not ?

Dr. Warren. Yes; I think so.

We have a very vital two-way radio program to staff physicians, I
think it is something like 35 hospitals in Ohio, that once a week dis-
cuss various medical diagnostic and treatment problems,

The Cuamman. Senator Yarborough.

Senator Yarporouen. Dr. Chapman, you say:

In essence, we believe the proposed bill should be so designed and administered
as to encourage and assist our medical schools and their affiliated hospitals to
expand and upgrade their clinical training programs.

Now, I strongly support S. 595 and S. 597, and worked on the
Health Professions Act and N- ursing Act. But. it seems to me this
act has a somewhat different purpose. I will not take time to recite
its purposes, but if you look at section 900, the purposes of this act
affect the medical schools. But the purposes in no way imply that
this law is more important. We need those programs, and we need to
push them, and we are very conscious of the shortage of medical per-
sonnel. We have had this over the years. We have had testimony on
the number of doctors per 100,000 population, and all those shortages ;
and it seems to me the main purpose of this act is to take the medical
knowledge you have already accumulated in these research centers, in
the big hospitals, and through this kind of complex get that knowledge
down to the average practitioner, to the small hospital in a small town,
everywhere. Jam thinking of a typical city of 200,000 population in
my home State with five hospitals; one of those hospitals is a city-

 

 
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90 COMBATING HEART AND OTHER MAJOR DISEASES

county hospital, one is a private hospital, very finely endowed by pri-
vate grants, some are church-related hospitals. I am not certain
about their administration, but I doubt that there is close coordination
among them as this bill contemplates in either the stroke or heart
disease or cancer areas.

Doctors, of course, know each other and refer patients and call in
experts in the field, but not to the extent this law contemplates.

It seems to me this contemplates a different kind of thing, which is
to get to the quantum of knowledge you have now through this, what
was it, 1,800,000-word index,

T am reminded that the president of the Encylopaedia Britannica
told me in 1962 that so great was the explosion of knowledge and
learning in this country m the past two decades, they had to change
10 million words out of 3314 million words in the Encyclopaedia Bri-
itannica. Never in the history of mankind has there been such a rapid
change of words in the language to explain the scientific and techno-
logical life for the average man.

So it seems to me we have a. little different purpose in this act,
although the need is as great for this medical education, and we hope
that administratively they will carry out what we legislatively have
directed that they do.

I hope the Bureau of the Budget does not cut the money off after
we appropriate it. That is one sore spot around here.

Dr. Cuapman. L understand it. This is the purpose of this bill, as
we understand it, too. But what it would require us to do in terms of
manpower—and this is the reason we put the emphasis where we have—
we could not do at the moment. For example, in our own State, if Dal-
las or Houston undertook to set up consultative services for a large
number of community hospitals and satellite stations, we would be very
hard put to supply these people at the moment. In fact, we could not
do so.

This is why we have felt that we should put the emphasis on clinical
training at a higher level. It is at a level which we think has been
somewhat neglected under previous arrangements; and this is why we
have felt it absolutely necessary to place this emphasis where we have.

Senator Yarsoroucn. You and your association have certainly come
forward with some stimulating recommendations here, and we con-
gratulate you for having studied this bill.

The Crairman. Anything else you gentlemen would like to add?

Dr. Warren. I might just add, as I have been sitting here, I am
sure that probably over half of the advanced clinical training of
specialists in heart disease, cancer, and stroke, must be supported
through the NIH in one way or another.

Now, as Dr. Chapman and you, Senator Yarborough, have alluded
to, that much of this is research-oriented, and we have a sort of gap,
no way available now for the support of a young doctor who has had
his basic medical school internship training but wants to go on just
to be a better heart specialist, a better cancer specialist, but not neces-
sarily an academician, a member of a research or full-time medical
school team. There is a very sizable area of deficiency of available
funds for training, and I would say personally that this would supply
a very much needed help in this area.

The Cuatrman. Very well.

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COMBATING HEART AND OTHER MAJOR DISEASES 91

Senator Yarporoven. The young doctor faces generally, after years
of medical school and internship, a financial crisis, for most families.

Dr. Warren. Most of them are married and have two or three
dependents by this time and, as I saw in one of the magazines recently,
most of them moonlight a little bit.

Senator Yarsoroucu. I read that article, too. It isa regrettable
situation that there is not more financial support to permit those with
those proven talents to devote their time to research. I agree with you.

The Cuairman. Is there anything you would like to add?

Mr. Berrs. Mr. Chairman, there is just one personal word that I
would like to add here. I revert to some of the comments made. by
Senator Kennedy of Massachusetts when he was attempting to gain a
more precise idea as to the sums that may be required when this goes
into its second through fifth years of operation.

Again personally endorsing the objectives of this act, and reverting
to Dr. Chapman’s own testimony with regard to the wisdom of pilot.
activities in this direction, with particular emphasis on training in or-
der that the manpower may be produced for this larger thrust into the
30 or more centers, it does seem to me that at the outset there could
be greater thought given to the fiscal limitations which may be re-
quired in order to launch this program successfully on its way, and
in order that there may be this precision of definition that I believe
the bill presently lacks.

The Cuatrman. Is there anything you would like to add, sir?

Mr. Firman. Unusual as it may be for a lawyer, I have nothing to
add, Mr. Chairman.

The Cuatrman. Well, they say the smart lawyer knows when he
has won his case, and therefore he does not continue talking; is that
right ?

Mr. Firuman. That is right.

The Cuairman. Gentlemen, you have certainly given splendid tes-
timony. We not only congratulate you but we express to you our deep
appreciation. We want to thank you very, very much.

(The material referred to previously follows :)

APPENDIX I

RECOMMENDED CHANGES IN Worpine (8. 596)

Page 2, line 15: the op
portunity.

Page 6, line 4: to be changed to read: application therefore end as recom-

mended. by the National Advisory Council and approved by the Surgeon General.
[Insertion in italie.]

Page 6, line 21 and 22: Delete provide for the designation of and insert desig-
nate,

Page 7, line 1: Change to read: complex,
tives of organizations, [Insertion in italic.]

Page 7, line 9: Change to read: with and as advised by the Council, ete. [In-
sertion in italic] -

Page 7, line 16: Change to read: application therefore and as recommended
by the National Advi.

visory Council and approved by the Surgeon General, ete.
[Insertion in italic.]

Page 9, line 5: Change the word may, to shall, To read: approval of the Seec-
retary, shall appoint, ete.

Action of the board of directors of the American Heart Association, January
9, 1965:

portunity to be changed to read a more abundant op-

, Which usually includes Trepresenta-

Voted: To endorse the objectives of the Report of the President’s Commis-
sion on Heart Disease, Cancer, and Stroke:

 

 

 
CEEE eee eee eT ee

92 COMBATING HEART AND OTHER MAJOR DISEASES

Further voted: To authorize the President, Carleton B, Chapman, M.
to make whatever arrangements may be appropriate to Present constri
tive Support and criticism regarding specific Proposals to Congresg and e
ments of Federal units ;

Further voted : That this action Specifically includes authorization to wo,
in closest Cooperation with the American Cancer Society.

The Cuamman. N. ow, Dr. Murray Copeland, of Houston, Tex,

Come around, Doctor.

ou are president of the American Cancer Society. Will you brin,
Dr. Diehl with you?
‘octor, you are associate director of the University of Texas M. D
nderson Hospital & Tumor Institute; is that correct, sir?

Dr. Corenanp, Yes, sir.

Senator Yarsorovan, We are honored to have another presidenj
of a Texas institution presented to the subcommittee,

Dr. opeland, we are proud of the fact that your work has been such
that the specialists in your work over the Nation have elected you
president of the American Cancer Society.

e Cuamman, Doctor, we are happy to have you here and we are
happy to have our old friend—and when I use the word “old” it has
nothing to do with age, but he has been a friend of the committee for
many years—Dr. Dieh] with you. We are glad to have both of vou

Dr. Corenanp, Thank you, Senator Hill and Senator Yarborough,

I am pleased to be here to represent the American Cancer Society,
the eading voluntary organization in this country dedicated to the
control and eradication of cancer. I am also associate director and
general surgeon, Department of Surgery, of the University of Texas

D. Anderson Hospital & Tumor Institute of Houston, Tex.

Tam glad to have Dr. Diehl with me to answer appropriate questions
which might arise.

Because of the short prior notice relative to the Opportunity to tes.
tify, the officials of the American Cancer Society feel that only a gen-
eral statement can be offered at this time, without commenting in depth
on some of the concerns which arise in the minds of some of us relative
to certain facets of the proposed bill.

At the first opportunity, sir, the proposed bill wil] be presented to
a broader Spectrum of the responsible membership of our society, and
the consensus of opinion obtained from a study in depth can be given
to the subcommittee, by written statement and Mr. Chairman we
should like to do so. .

I should like to introduce at this time also ‘a statement which was
prepared and issued by the American Cancer Society adopted by the
board of directors of the American Cancer Society on J anuary 22,1965,
without reading it except to say this, sir: That the American Cancer

ociety views the report of the President’s Commission on Heart Dis-
ease, Cancer, and Stroke as an effective instrument in focusing atten-
tion on goals in cancer control to which the American people can
rightly and sensibly aspire, The Commission has given the public a
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yancer
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COMBATING HEART AND OTHER MAJOR DISEASES 93

thorough analysis of problems and bold suggestions for action, sir.
The Cuarrman. We would be happy to have both statements appear
in full in the record at this point.
Dr. Corrianp. Thank you, sir.
The Cuamman. Thank you.
(The prepared statement referred to follows :)

PREPARED STATEMENT OF THE AMERICAN CANCER SocreTy

The American Cancer Society views the report of the President’s Commission
on Heart Disease, Cancer, and Stroke as an effective instrument in focusing
attention on goals in cancer control to which the American people can rightly
and sensibly aspire. The Commission has given the public a thorough analysis
of problems and bold suggestions for action.

As general recommendations are being translated into legislative proposals,
it will be necessary to have further expert consultation and advice in shaping
specific policies and programs. The society has had many years’ experience in
techniques of cancer control... Its committees of physicians, scientists, and
informed laymen will always be available to work with those charged with the
responsibility of implementing the Commission’s proposals. In this, as in other
legislative matters affecting cancer control, the society will of course continue
its long-established practice of providing expert testimony at congressional
hearings and before administrative bodies and its advocacy of the principle of
governmental support in private institutions under private control in this field.

The board of directors feels that staff and volunteers should read and discuss
the Commission report with care. Its sections on cancer give a striking picture
of the seriousness of this disease and the importance of mounting a massive
attack on it.

If our country achieves the Commission’s major objectives of the best in
diagnosis and treatment for all cancer patients, of more and better trained phy-
sicians and scientists, of greater support for cancer research, will strengthen
the cancer control movement to which the American Cancer Society is dedicated.

The imaginative concept of the vastly increased attack with Government funds
on cancer is largely focused in areas where the American Cancer Society has
not had the funds to meet the needs it has long pointed out. The traditional
program of the society as a voluntary opinion leader, as a public and profes-
sional educator, as a catalyst in organizing services for cancer patients, and as
a sponsor of research, will be even more vital to insure the full effect of this
increased cancer control movement.

As Federal funds increase, the greater the need will be for private funds,
Such funds will be needed to assure that private institutions remain private
and to meet the added burdens of increased medical care as more patients seek
increased care stimulated by the Président’s message on health. The need to
organize people on a voluntary basis—for their own protection and to help
others—will remain until cancer is finally brought under control.

ADDITIONAL STATEMENT BY Murray M. CoreLanpD, M.D.

After discussion with the Legislative Committee of the American Cancer
Society, I am again expressing the general support of the objectives of the bill
in intensifying and broadening the attack on cancer. This support is based upon
the experience of the society in research, education, and service, and the avowed
purpose of the bill not to interfere with the existing patterns, methods or financ-
ing of professional practices of patient care. We would be opposed to the use of
any of the funds for the payment of the cost of hospital, medical or other care
of patients except incidental to research, training or demonstration, and we be-
lieve that the emphasis on the private institution and practitioner must. be main-
tained in the future.

We support the provision of the bill requiring some matching funds for con-
struction grants as consistent with the established practice and the experience of
the past, and to insure the support and participation of the private institution
and practitioner.

There are already established over a thousand tumor clinics under the leader-
ship of the American College of Surgeons, and there exists a wide distribution
among private practitioners of significant and modern diagnosis and treatment
in the cancer field. The development of the program envisioned by this bill must
43-669— 65-7

  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
  
 
 
 
 
  
 
 
 
 
 
 
   
  
  
 
 
 
 
 
 
 
  
 
  
 
  
 
  
 
  
 
 
 
   
  
  
 
 
ee enna ecenec cence ee

94 COMBATING HEART AND OTHER MAJOR DISEASES

be careful to utilize these existing facilities and to enlist their cooperation and
support, because as the experience of the American Cancer Society has demon-
strated, progress in the control of cancer can only be accomplished through the
cooperation and support of the private practitioner and professional societies.
Through experience and history we have learned that fast and accurate progress
in the control of a serious disease can best be accomplished through the concen-
tration of effort on the specific disease alone rather than through the “whole man
approach.” For this reason we recommend that the inclusion of “other major
diseases” in the title and purposes of this bill be deleted, and that the entire
fund and administrative energies concerned now be concentrated upon heart
disease, cancer, and stroke.

The bill and program outlined under the recommendations of the President’s
Commission sprang from the ongoing programs in the field of heart disease,
cancer, and stroke so well developed by the National Institutes of Health. Within
the framework of its councils are the men best qualified by experience, knowledge,
and training to advise and shape the extension of the program into the fields of
education and patient care included in the new concept of regional complexes.
Most of the specialists consulted have indicated that this new program should
rely heavily on the existing councils. We join in this opinion and recommend.
that at least six of the members of the new National Advisory Council on Medical
Complexes be selected by the Surgeon General from the membership of the Ad--
visory Councils of the National Institutes of Health. It is recommended that
two each be selected from the Cancer Advisory Council, the Heart Advisory
Council, and the Council on Neurological Diseases and Blindness, with know]l-
edge in the field of stroke. In this connection we would like to reemphasize the
position of the American Cancer Society that the program of the National Cancer
Tnstitute is, and will continue to be, of vital importance, and that the support
for that program must be enlarged.

: We believe the committee should recognize that specialized institutions referred
to in this bill as categorical research centers, now in existence are performing
much of the program which is envisioned in this bill and in the cancer field have
been the source of much of the strength of the present. progress against cancer.
We recommend, therefore, that in the language of the bill it be made clear
that they can furnish essential planning and administrative leadership in
regional complexes, and that they are furnishing and should continue to furnish,
the type of teaching and training of manpower which is particularly necessary
for the successful functioning of the proposed complexes. There do exist areas in
which such manpower can best be planned for through teaching institutions
not directly affiliated with medical schools. For this reason we recommend fhat
the definitions of the bill be broadened to make this concept clear by amending
section 902(b) defining medical centers to read as follows: .

“(b) The term ‘medical center’ means a medical school or a specialized institu-
tion for post-graduate medical training and one or more hospitals affiliated
therewith for teaching, research, and. demonstration purposes.” .

We also feel that the local advisory council envisioned by the bfll as a part of
the planning and functioning of the Medical Complex is vitally important
and its membership should be included in the application for its grant, and not
be left to future creation after the grant. We also feel that the language of the
pill in section 903, subsection (b) (4) should include representatives of voluntary
health agencies and professional societies which will be vitally concerned-in the
planning and carrying out of the program, as well as representatives of organ-
izations and institutions and members of the public.

Dr. Copenann. It is interesting to note that in preparing proposals,
the President’s Commission categorically identified the dimensions
of the problems concerned with heart disease, cancer, and stroke; pin-
pointed the national needs in attacking each of these disease processes,
which accounted for 71 percent of the deaths of the country in 1963;
examined the resource potential for combating these diseases and,
finally, made recommendations designed to bring together the best
in categorical medical care and the best in medical. research, region
by region, across the country.

As the general recommendations of the President’s Commission are
being translated into lecislative proposals, the American Cancer
Society, with its many years of experience in cancer control, welcomes
the opportunity to work with those charged with the responsibility

-
 

COMBATING HEART AND OTHER MAJOR DISEASES 95

of implementing the President’s proposals through S. 596, and its
companion bill H.R. 3140. In this, as in other legislative matters af-
fecting cancer control, the society will continue the long-established
practice of providing expert testimony at congressional hearings
and before administrative odies, and will continue its advocacy of the
principle of governmental support in private institutions under pri-
vate control in this field.

If our country achieves, through this proposed legislation, the ma-
jor objectives of the best in diagnosis and treatment for all cancer
patients; of more and better trained scientists; and of greater sup-
port for cancer research, this will strengthen the cancer control move-
ment to which the American Cancer Society is dedicated.

It seems to us to be a corollary that all of organized medicine must be
heavily involved, through the interested medical schools and associated
hospitals; the categorical cancer hospitals and tumor institutes, many
of which have university connections outside the medical schools; |
and appropriate community hospitals. |

The American Cancer Society feels that the proposed bill envisions
a significant forward step in developing and coordinating new con-
cepts in medical care for the victims of major diseases, but the bill, it
seems to us, does not appear to provide for the careful correlation of
the spectrum of activities cited in this new program with those of the
National Institutes of Health. I believe Senator Yarborough has
given an answer to this. The specifics sometimes does not necessarily
encourage passage of legislation. The American Cancer Society
hopes that any new legislation will strengthen the vitally important
National Cancer Institute program, as well as the other established
cancer hospital and tumor institute center programs. Examples of
such institutes are: the Memorial Sloan-Kettering Cancer Center, New
York City; the Roswell Park Memorial Institute, Buffalo, N.Y.; the
M. D. Anderson Hospital & Tumor Institute, Houston, Tex.; the
Children’s Cancer Research Foundation, Boston, Mass., and others.

These institutions are making valuable contributions to cancer
research, contributing to the care of cancer patients and to the grad-
uate training of physicians in the highly specialized techniques of
cancer treatment.

Already, the cancer hospital and tumor institute centers, as well
as individual interested medical school cancer programs, are func- j
tioning adequately for the purpose of becoming the heart of major
medical facilities, as envisioned in the proposed bill. These on-going
so-called medical complexes can be utilized immediately in shoring up
cancer activities in community hospitals seeking such aid, thus mak-
ing the best in modern medical care readily accessible to increasing
numbers of people suffering from cancer.

The categorical intent of the President’s Commission report seems
clear to us, and we hope that the legislative act. will incorporate the
gigantic opportunity to emphasize suitable specific approaches to con-
quering the three major killers of men today; namely, heart disease,
cancer, and stroke, and not dilute the present legislation with explora-
tions into programs for other diseases until the parameters of the pres-
ent recommended program are established and progress in the control
of the three great killers is apparent. This is not to say that there
comes 2 day the program may be elaborated in many directions,

The definitions of “regional medical complexes,” “categorical re-
search centers,” and “diagnostic and treatment stations” should be

   
Hee eee ee

96 COMBATING HEART AND OTHER MAJOR DISEASES

carefully reexamined, to be sure that all currently adequate major
medical facilities will be properly evaluated and utilized in the new
program. For example, nonmedical school connected, categorical
hospital and tumor institutes should be included as being at the heart,
of certain of the complexes. By this, sir, I refer to this diagram in
which we have large letters “Medical School” at the top and “Patient
Care” at the bottom. We should like to see categorical nonmedical
school, connected institutes, cancer or heart institutes, and the like
should they be available as the heart of the complex and have the ap-
propriate authority to carry out the mission.

The Cuarrman. Doctor, if you have that chart modified, we will be
glad to put it in the record. You don’t have to do it now, furnish it
to us at a later date.

Dr. Corenann. Yes, sir; thank you, sir.

(The charts referred to above follow :)

A REGIONAL MEDICAL COMPLEX COORDINATES RESOURCES:

 

SELECTED UNIVERSITY CONNECTED
MEDICAL SCHOOLS | 101 secon catty a
CENTERS

 

 

 

 

 

Q (2

TEACHING ano AFFILIATED
HOSPITALS

for

 

 

 

 

 

PATIENT CARE

CLINICAL RESEARCH
TRAINING

DOCUMENT }----_ Revision of 3rd chort in the port folio of chorts in Dr. Dempsey’s
testimony os suggested by Dr. Merray M. Copelond, President of
the Americon Concer Society in his statement on Senote Bill 594
before the Subcommittee on Health of Committee on Lobor and
Puolic Welfare, February 9, 1965.

ee _ pee

 

 

 

 

 

 

 
 

    
   
   
 
  
 
 
 
 
  
 
 
 
  
   
 
   
  
 
  
  
   
  
    
  
  
  

COMBATING HEART AND OTHER MAJOR DISEASES 97

   

 

 

    
   

 
      
 
 

   
  

 

 

 

new Components of a Regional Complex
heart

at SELECTED ang ee
edical MEDICAL SCHOOLS | or HOSPITAL and RESEARCH INSTITUTE
Noa

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BASIC TEACHING

and

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DIAGNOSIS ans TREATMENT
STATIONS

 

 

 

DOCUMENT 2--..~ Revision of 5th chart in the port folio of chorts in Dr. Dempsey’s
testimony (bearing on same subject) as suggested by Dr. Murray M. Copeland,
President of the American Cancer Society in his statement on Senote dill
596 before the Subcommittee on Health of Committee on Labor and Public
Welfare, February 9, 1965.

Dr. Copztanp. The American Cancer Society wishes to place em-
phasis on filling the need for additional trained personnel to carry out
the research, educational, and service intent of the legislation, and
hopes that the provision of such personnel will be given a top priority
in the implementation of the program, and indeed we were pleased
today to hear, I think, the very adequate discussion on these points.

The proposal of grants for construction and initial equipment of
new buildings; expansion, remodeling, and alteration of existing
buildings is a forward-looking one, and deserves every consideration
for those institutions demonstrating a real need for improved physical
facilities to carry out the mission. We feel that the stewardshi of
this legislation is rightly placed within the Office of the Surgeon Gen-
eral and strongly recommend that the hands of his Office should not
be tied by requiring the appointment of a council or commission out-

smprey's side of the framework of the National Institutes of Health.

ident of
Bill $96

or and
 

Ty

98 COMBATING HEART AND OTHER MAJOR DISEASES

We suggest that enabling legislation could permit the appointment
of an advisory body to the Surgeon General within the council
mechanisms of the National Institutes of Health using the appropriate
current advisory councils as adviser to this new council charged with
specific responsibilities of the new program. We also feel that the
majority of the members of the proposed new council should be in-
dividuals who are outstanding in the study, diagnosis and treatment
of heart disease, cancer, or stroke. .

We are hopeful, also, that the centers, stations and major medical
facilities proposed in the bill will have important roles, not only in the
treatment but also in the prevention of cancer; and much cancer can
be prevented. Concerning this, the President’s Commission states:

It seems apparent that the reduction of cigarette smoking offers great pos-
sibilities for the prevention of illness, disability, and premature death in this
country, with regard to both cancer and cardiovascular disease.

This refers to the leading cause of cancer deaths in this country to-
day. In fact, from the projections of my epidemiological section of
the American Cancer Society, we are convinced that more than 50,000
cancer deaths annually in the United States are attributable to ciga-
rette smoking.

The President’s Commission further states that :

A network of smoking control clinies should be provided to assist those who
desire to give up smoking.

Clearly, the prevention of cancer is vastly preferable to even the best
cancer diagnosis and treatment, We hope, therefore, that smoking
control clinics, as well as other cancer prevention measures, will be
an important responsibility of the proposed new program.

As Federal funds increase, the greater will be the need for private
funds. Such funds will be necessary to assure that private institu-
tions remain private, and to meet the added burdens of increased
medical care, as more patients seek increased care, stimulated by the
President’s Message on health. The need to organize people on a
voluntary basis—for their own protection and to help others—will
remain until cancer is finally brought under control,

__ And, sir, I should like to repeat, in completing the statement, that

May I, Senator Hill, ask the privilege of turning this over to Dr.
Diehl for any statement he might like to make, sir?

The Crarrman. Dr. Diehl, we would be happy to have you make
any statement you think essential.

Dr. Drext. Thank you, Senator Hill. I collaborated with Dr.
Copeland in the preparation of his statement so what I would have
said is incorporated with his testimony.

However, it occurs to me
points. One is to emphasize what Dr. Copeland has stated about
the important role that specialized cancer institutes, which are referred
to In this bill as categorical institutes, have made in cancer research,
cancer education, and the care of cancer patients—a role that is rather

 

 
ne

COMBATING HEART AND OTHER MAJOR DISEASES 99

unique in cancer. There are few if any similar institutes in the field
of heart disease. . - ;

In his testimony, Dr. Copeland mentioned institutes of this type
which have been pioneers.and leaders in cancer research, training, and
service. Such institutions can and should play a vitally important
role in carrying out the purposes of this bill. In fact, these specialized
centers could well be a major focus for the special training of physi-
cians in the diagnosis and treatment of cancer.

Another point that I would like to make is that cancer differs also
from heart disease and stroke in another regard. That is that there
are physicians, internists mostly, who are essentially heart disease
specialists, and. neurologists, and rehabilitation specialists who are
concerned with the field of stroke. .

On the other hand, several specialists are concerned with the di-
agnosis and treatment of cancer. Most cancer patients are cared for
by the general surgeon, but cancers of the female genital tract are
handled primarily by the gynecologist; cancers of the blood system,
like leukemia, are handled primarily by the internist or the pediatri-
cian, and so forth. In addition, other specialized individuals are in-
volved in the treatment of patients with cancer. For example, radia-
tion treatment by highly specialized radiotherapists and the adminis-
tration of drugs by specialized chemotherapists are important in the
treatment of many patients with cancer.

One of the reasons that special cancer institutes and centers have
developed is that they bring together teams of such specialists,

These are a couple of points that I would emphasize as important
considerations in the development of this program.

The Cuamman. Certainly you and Dr. Diehl have been most help-
ful here this morning.

Senator Yarborough?

Senator Yarsoroven. It is a very helpful recommendation, Dr.
Copeland, and I believe some of the first I have seen reducing to a prac-
tical level what to do about smoking.

The Surgeon General has warned people; we have had all kinds of
warnings. I heard last night on a television broadcast that in England
they have prohibited thea vertising of tobacco on television and radio
and are considering prohibiting its advertising in newspapers in the
immediate future. That becomes more difficult in America than Eng-
land where they have the BBC, and have a completely Government-
owned broadcasting system. But you recommend a network of smok-
ing control clinics which should be provided to assist those who desire
to give up smoking.

J think we have a big problem before they reach the point that they
gotoaclinic. I fear that you would have relatively a small percentage
of oursmokers. I think we would have some kind of nationwide shock
treatment to the body politic as a whole over this danger.

After the Surgeon General’s report, smoking went down, but the
sales are now up to an alltime high.

I think if every cigarette smoker would read two paragraphs out
of your statement every morning—if we could induce him to do that—
that would be more helpful than many other things I have heard
suggested.

 
ee

100 COMBATING HEART AND OTHER MAJOR DISEASES

But you have a suggestion: You are in favor of doin something.
The very existence of these clinics would have some beneficial effect, I
feel certain.

Thank you for your appearance here and for patiently waiting.

Thank you, Senator Hill, for a very fine hearing.

The Cuamman. We have had an exceptionally fine hearing this
morning, and certainly you gentlemen have contributed much to this
hearing. We deeply appreciate your splendid statements here and the

information and thought that you both brought with you. We are
gratefulto you. Tha you very, very much.

Dr. Copetanp. Thank you. .
The Cuairman. The subcommittee will now stand in recess until to-

morrow morning at 10 a.m. .
(Whereupon, at 1:30 p.m., the subcommittee recessed, to reconvene

at 10 a.m., Wednesday, February 10, 1965.)

 

 
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We are

until to-

convene

 

 

COMBATING HEART DISEASE, CANCER, STROKE, AND
OTHER MAJOR DISEASES

 

WEDNESDAY, FEBRUARY 10, 1965
U.S. Senate,

SUBCOMMITTEE ON Ha.rx oF THE
Comarrrer on Lagor AND Pusric WELrFarz,
Washington, D.C.

m.,
4232, New Senate Office Building, Senator Lister Hill (chairman of the
subcommittee) presiding.

Present: Senators Hill, Yarborough, Pell, Kennedy of Massa-
chusetts, and J. avits, members of the subcommittee, and enator Ken-
nedy of New York, member of the full committee,

Committes staff members present : Stewart E. McClure, chief clerk;
John §S, Forsythe, general counsel ; Robert. W. Barclay, professional

of your committee here with you this morning, and I am going to ask
you now to present the members of your committee, and then after that
we will have a brief statement by Senator Kennedy, and then I will
ask you to proceed in your own way if that is agreeable,

to the committee. We are very proud of his discoveries in Texas in
the treatment of heart disease’ and the successful techniques he hag
developed. I think it well to state at this point that some of those
discoveries were made not with the support of all of his colleagues
in the profession, He had to fight sometimes singlehandedly as

these new techniques to a point of proven success and perfection. It is

surprising to me how many people I hear around the world who know

of your work. I have been asked about your work in Europe and

have been asked about it in Israel. It is known all around this earth

in medical circles and we are very proud you are a resident of our
tate.

Tam happy to welcome you here,

101

 

 

 

 
ee

102 COMBATING HEART AND OTHER MAJOR DISEASES

The CHamman, If you will let me, Senator Yarborough, I cer-

tainly join with you in all of the very fine and richly deserved things

STATEMENT OF DR. MICHAEL E, DeBAKEY, CHAIRMAN, PRESI-
DENT’S COMMISSION oN HEART DISEASE, CAN CER, AND STROKE

Dr. DzBaxery. Thank you very much, Senator Hill and Senator
Yarborough, you are always gracious and kind. Iam deeply appre-
ciative of your kind remarks,

Senator ill, we have here on the panel some of the key members of
the President’s Commission on Heart Disease, Cancer, and Stroke. I
would like to introduce them.

On my left hers is Dr. Sidney Farber, who was not only a member
of our Commission but who was the Chairman of the Subcommittee
on Cancer of our Commission.

On my right, Dr. Irving Wright, who is the Chairman on the Sub-
committee on Heart Disease of our Commission.

Dr. John Stirling Meyer, sitting on his right, who is one of the
distinguished heurologists of this country, indeed of the world, not
only a member of our Commission but also Chairman of the Subcom-
mittee on Stroke,

Next to him is Dr. Howard A. Rusk, who, of course, is known
throughout the world for his pioneering work in rehabilitation, was

hairman of our Subcommittee on Rehabilitation of the President’s

ommission,
These men are here with me to testify before your subcommittee
on S. 596 ® are delighted to have this Opportunity and we are

very grateful to have you allow us to speak on behalf of this bill.
he Cuairman, Dr. DeBakey, I may say we are not only happy to
have you but we are very much honored that you are here,
Senator Kennedy, I believe you have a statement you would like to
make at this time,
Senator Kennepy of Massachusetts. Yes; I have,
T, first of all, would like to extend my very good wishes to Dr.

Pioneer in the chemical control of cancer. I feel that this subcom-
mittee is particularly fortunate to have his participation, and the
wealth of experience that he has brought to this problem.

Mr. hairman, with your permission and with the permission of
the subcommittee, I would like to read a short statement on my views
on this bill.

The Cuarrman. You go right ahead, Senator.

 
i

7 COMBATING HEART AND OTHER MAJOR DISEASES 108
ch, I cer- Senator Kennupy of Massachusetts. With your permission I
ed things would like to express my support for S. 596 and particularly compli-
vileged to ment the chairman on the development. of this legislation and the
done and excellent hearings which he has been conducting here. I know some-
ome very thing of the needs and the problems to which this legislation is di-
ppose you rected. I have watched the magnificent work of Dr. Farber and the

children. We, in Massachusetts, have a special pride in this Children’s

|, PRESI- Cancer Research Foundation, as it is formally called, because it was
TROKE developed through the voluntary contributions of many thousands of
People, and because it was the first institution of its kind devoted

Senator specially to childhood cancer problems and research. It ig also a
y appre- pioneer in the chemical control of cancer, and I believe that the opera-
| tions of this foundation will serve as an excellent prototype of the
mbers of regional cancer centers contemplated by this bill.
troke, I As cancer crusade chairman in Massachusetts 4 years ago, I had
i the opportunity to observe the suffering and disillusionment created
member by this terrible disease, but more, I saw what success could be achieved
mmittea through early diagnosis and treatment, and by the use of the latest
techniques. ‘This is the point of this legislation. We must bring the
he Sub- latest in detection and treatment methods and equipment out to the
people. What we can learn, and will continue to learn, in Boston,
» of the | we can share with other regions whose research and treatment have
rld, not | not developed as far,
Subcom- The problem of heart disease and stroke lend themselves to the
regional complex approach. Time is of the essence in a majority of
known cases, and immediate skillful treatment is often the difference between:
on, was life and death. The therapy and rehabilitation following the heart
sident’s attack or stroke, both medical and. psychological, is crucial. I have.
Seen personally the progress that can be accomplished in this area of
mittee treatment. This progress must be made available to as many serious
we are cases as we can reach, and the research must be accelerated to find ways
I. | to arrest these diseases long before they become a problem.
ppy to We are grateful to Dr. Rusk, who is here today, and who has been
so helpful in his excellent work with my father. I am sure that Dr.
like to Rusk appreciates the importance of this legislation in connection with
the rehabilitation of patients.
| The regional approach to the diagnosis and treatment, provided by
0 Dr. this bill, will give us a broad study of the many variations of heart
ts, not problems. The increasing excellence of computers and other elec-
in so tronic equipment will give our researchers a major lift in analyzing
these problems, recommending the treatment, and setting the course
of the toward new research.
> first With these regional medical centers and diagnostic and treatment
s the stations wired into our medical university complexes, we can convey
com- basic information over thousands of miles to experts in Boston, and
1 the in other large cities, and special treatment can be immediately recom-
mended. This is one of the great advantages to a coordinated re-
on of gional network of medical diagnostic and treatment centers, Modern
riews electronics, much of which has pioneered in my State, has moved

rapidly and effectively into the field of medicine. It has eliminated
much of the guesswork and trial and error of diagnosis and therapy.
By bringing the latest in electronic and other medical equipment

 

 
 

1 104 COMBATING HEART AND OTHER MAJOR DISEASES
out to regionally spaced medical centers, we will save many more
te contribute immeasurably to the human security of our commu
ye and gain giant strides in coordinating information and research
k I know something of the need for regional medical centers ;
I area of Massachusetts and New England. We are very fortun:
6 having Harvard, MIT, Boston University, and the many won
Pp hospitals in Boston.
It is the type of center we must build throughout many other
$ in this country. We must use every available medical facilit

have, including existing veterans’, mi itary and Public Health Sx
hospitals, and we must coordinate these facilities through elect
devices, through cooperative staffing, through the dissemination «

¥ latest information, and through a continuing process of cons
C tion and improved maintenance.

Last week, on the Senate floor, Mr. Chairman, I called for a reg

t economic development program for New England. I recommen

¥ thorough review of this region’s hospital and medical facilities

services, with a view toward providing the latest in psychiatric,

C cal, and surgical care, diagnostic, and special treatment units,

0 hospitals beds, including nursing care units, for every sectic

area. The developing fast access road system in southern New |

¢ land, and an improved and expanded road system in northern

England can provide for a reasonable spacing of these medical ce
to accommodate broader regions of people.

In Massachusetts there are a number of areas outside the M

r politan Boston complex which are in substantial need of a regi

medical complex. Some of these concern Cape Cod, the Berks

an.

t the northeastern, western, and southeastern sections of the State.

« objective in a New England regional program would be to encou

( the development of these centers through the greater allocation of §
and Federal assistance and planning.

( With this legislation, we are particularly concerned with our

1 most serious diseases, and here we are correct in emphasizing an at
on these problems, as a first step. I am hopeful that, as time goe:

] we can accelerate this program measurably into many other il
areas. I feel that we are embarking here on one of the most vital

1 progressive approaches in medical treatment and science ever

tempted. We must do everything we can to make it work. Wemu
particularly mindful of the fact that our medical demands are inc1
ing substantially, and with the increase in hospital and medical
grams more people, who need treatment will seek it out, and der
} it. It is our responsibility to a healthy and secure America, to
that this medical service is provided to all of our citizens.
The Crarrman. Thank you, Senator. Senator Robert Kenne
Senator Kennepy of New York. Thank you, Mr. Chairman, I
want to welcome Dr. Rusk, Dr. Wright, and Mr. Folsom to this:
committee and introduce them. They are three citizens of whom 1
York is very proud and I think the country is very proud. As Sen:
Kennedy of Massachusetts said, we owe a particular debt to Dr. R
who has worked with the family for a long period of time but I wat
to come before the subcommittee and particularly welcome these t]
very eminent and prominent citizens of my State. I know that
members of the Panel have contributed tremendously to the health |

| __
COMBATING HEART AND OTHER MAJOR DISEASES 105

ro 1; well-being of our country, but I wanted to particularly point out the
re aves, citizens from my State of New York. Thank you.
h. , _ (The statement of Senator Kennedy of New York follows:)
nate in STATEMENT OF HON. ROBERT F. KENNEDY, A U.S, SENATOR FROM
nderful THE STATE OF NEW YORK
1 areas Mr. Kewnnepy of New York. Mr. Chairman, I would like to address
lity we a brief statement to the subcommittee concerning my interest in this
Service bill, S. 596 designed to combat. heart disease, cancer, stroke, and other
tronic major diseases. The deliberations of the Subcommittee on Health are
. of the of concern to all citizens of the country, for when 71 percent of all
nstruc- deaths in the Nation are caused by the diseases under discussion,
almost no family evades their scourge. Citizens of New York must
egional be additionally concerned because of the particularly high incidence
nded a of death from heart disease on the east coast revealed in the statistics
es and presented by the President’s Commission. Yet all statistics inade-
medi- quately describe the personal tragedy suffered by those individuals
s. and afflicted by the diseases, .
a As so eloquently indicated in the Commission’s report, these per-
+ Ene. sonal losses perhaps might be more philosophically acceptable if they
n New were solely diseases of old age. But the facts presented by the Com-
centers mission show that this is not the case. For example:
More than 128,000 of the 285,000 people who died from cancer
Metro- in 1963 were under 65.
sional More than 25,000 of the people who died from cancer in 1963
shires were under 45.
- Ou Cancer is either the first or second largest killer of children.
surage between land 14. ;
F State Stroke is the fifth rargest killer of people under 65.
Of the deaths caused y heart disease 28 percent occurs to peo-
- three ple under 65.
attack The high incidence of these diseases, articularly cancer, among the
08 ON | young means that. we are losing peop e who may not have reached
‘TIness their most productive periods of activity or are being struck down
il and in the prime of their lives, For these individuals, as well as for the
or at- many individuals reaching the period of their lives when they can
ust be: enjoy the fruits of retirement, we owe a full-scale attack on these
creas- ao. of the four horsemen of Apocalypse—heart disease, cancer,
and stroke.
| Dro; The report on the Commission indicates clearly that medical re-
to see search is beginning to provide some of the answers to the mysteries

of these illnesses. We are now able to effect cures that would have

nedy ? been impossible just a few years ago. Some of the recent develop-
L just ments In surgery and medicine include:

5 sub- | Drugs to relieve hypertension related to heart disease.

New Direct heart surgery to repair damage or defects.

nator New techniques for the early detection of uterine cancer.

Rusk Chemotherapy for the treatment of cancer.

anted Early detection of the symptoms of stroke,

three New rehabilitative techniques for stroke victims.

t all These developments offer hope to those who are able to receive the
hand proper diagnosis and treatment from physicians who are aware of

these recent medical developments.

 

 

 

 

 
 

106 COMBATING HEART AND OTHER MAJOR DISEASES

Implementation of the recommendations in the Commission’s re-
port concerning further research will undoubtedly lead to the develop-
ment of new techniques and treatments. These developments will.
offer hope to those who face death from these diseases under the pres-
ent stages of medical knowledge. We must not only continue the
support of medical research that has been so ably initiated by the
distinguished chairman of this subcommittee, Senator Hill, but we
must also increase our support in those areas that the committee has
recommended.

However, as I understand it, the three recommendations of the
Commission that are embraced in S. 596 are designed primarily to
bridge the gap between the fund of research knowledge that we have
developed on heart disease, cancer, and stroke and the patient of the
average practitioner who would like to receive the benefits of that
research tomorrow.

‘These recommendations provide for—

1. Regional centers concerned with either heart disease, cancer,
or stroke, conducting clinical investigation, teaching local prac-
titioners, and patient care.

2, A national network of diagnostic and treatment stations
aimed at bringing the highest medical skills within the reach of
every citizen.

3. Medical complexes based on university medical schools where
advanced medical equipment, teaching, and the school’s research
activities would be available to doctors affiliated with the regional
centers and the diagnostic and treatment stations.

The report of the Commission indicates that the regional centers
and the diagnostic and treatment centers are “oriented toward high-
equality services in connection with a specific disease (which) will
greatly increase the accessibility of the best in medical practices across
the Nation.” The establishment. of medical complexes would enable
existing medical centers to expand their existing resources to aid in the
creation of the regional centers and stations. As I understand it, the
regional centers, the stations, and the medical complexes to be created
under the provisions of S. 596 will bring to the average practitioner
the latest information from our medical research efforts and better
prepare him to aid the citizen suffering from one of these diseases.
The results of such a union of medical knowledge and everyday medi-
cal practice can produce dramatic effects on the vital statistics of death.
This union has the potential to significantly lengthen the lives of many
Americans alive today. I can assure you that the citizens of New
York are interested in S. 596 because it affects them directly.

I think it is important that the purposes of S. 596 be made clear, for
although the bill authorizes a sum of $50 million for fiscal year 1966,
the Commission’s report recommends a total of $1,580 million for the
purposes I have described during the next 5 years, broken down an-
nually as follows:

 

 

 

 

Millions
Fiscal year 1966___ $149, 25
Fiscal year 1967 230. 85
Fiscal year 1968 354. 025
Fiscal year 1969 7 406. 650
Fiscal year 1970 ane -- ---- 4389.45

 

ee
 

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Millions
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354. 025
406. 650
439. 45

 

COMBATING HEART AND OTHER MAJOR DISEASES 107

A. program of this size is a major step in making the benefits of
medical knowledge available to all. I believe that there is some con-
fusion about the purposes of S. 596, as to whether it is designed pri-
marily to place an emphasis on bridging the gap between research and.
medical] service or whether it is primarily designed to further research
on heart disease, cancer, and stroke. I know the Subcommittee on
Health will remove this confusion during the course of these hearings.

The Cuairman. We are happy to have you here, Senator.

I may say, I have a telegram here from General Sarnoff which I
shall read into the record:

I regret very much that previous important engagements involving a number
of people prevent me from accepting your invitation to appear before your
committee on Wednesday morning, February 10. As you know I was a member
of the President’s Commission on Heart Disease, Cancer, and Stroke and par-
ticipated in its deliberations and in the preparation of its report to the Presi-
dent. As one of the laymen on the Commission I was deeply impressed with the
careful analysis of the problems involved and the recommendations developed
by the professional and skilled medical members of the Commission.

I strongly endorse the proposals in that report for a national effort to conquer
the dread diseases of heart attack, cancer, and stroke, and to make existing
medical knowledge and skills more widely available to its victims. While the
value of good health and productive life cannot be measured in dollars, it is
nevertheless clear that a substantial reduction in the destructive effects of these
diseases will save much more than the cost of the recommended program and,
therefore, will contribute to the economy as well as the health of our Nation.

Davip SARNOFF.

Now, Dr. DeBakey, we will be happy to have you proceed, sir.

Dr. DeBaxey. Thank you, Senator Hill.

The Cuatrman. May I say that since we started, our good friend
and. very distinguished member of our committee, the Honorable
Marion Folsom has come in and he has been with us many times in
the past and has always been tremendously helpful. He was most out-
standing as a Secretary of Health, Education, and Welfare and we are
happy to have him here today.

STATEMENT OF DR. MICHAEL E. DeBAKEY—Resumed

Dr. DeBaxey. Senator Hill, let me say, too, that we of the panel
here are delighted he is with us today, and want to express our grateful
appreciation to him as a member of the Commision, the President’s
Commission, because he brought to the President’s Commission not
only his wisdom but a wealth of experience in matters relating par-
ticularly to the health of this Nation.

I would like to speak in support of this bill along with my associates
here on the panel, Senator Hill, based upon the studies of the Presi-
dent’s Commission embodied in its report to the President.

When the President first met the Commission after establishing the
Commission he told the Commission among other things that. two-
thirds of all Americans would either die or suffer from these three
dread diseases, cancer, heart disease, and stroke, and unless we do some-
thing about it, this would continue or even increase based upon the
evidence we had available to us.

He said to the Commission, “I expect you to do something about it.”

The Commission accepted this challenge, regarded it as of the ut-
most seriousness and immediately went to work to try to find out what
could be done about it: The results of its study are embodied in its

 
  
  
   
  
 
  
 
  
 
 
 
 
 
 
 
  
 
 
 
  
 
 
 
 
 
 
 
 
  
 
 
 
 
  
 
 
 
 
  
 
  
 
 
   
 
  
  
  
  
 
 
 
 
 
  
  
 
 
 
  
 
  
 
 

 

 
 

108 COMBATING HEART AND OTHER MAJOR DISEASES

report. The Commission had about 9 months to make an intensive
study of these matters. It divided itself up in a number of subcom-
mittees, the chairman of some of these subcommittees are here on this
panel and will speak a little later about their findings.

There were 166 experts brought to the Commission’s hearings,
45 such were held, over 7,500 pages of testimony prepared involving
literally millions of words of testimony, data collected and analyzed
some of which has never been available previously.

On the basis of these intensive studies during this 9-month period
the Commission made a number of specific recommendations, indeed,
there were 35 specific recommendations, which the Commission be-
lieved with deep conviction would make a real impact upon ways
and means of reducing these diseases and perhaps ultimately con-
quering them.

Some of these recommendations, and particularly the most impor-
tant innovative aspects of these recommendations are embodied in
S. 596 and it is for this reason we are here to testify in support of
S. 596 because it is concerned with the establishment of regional cen-
ters and complexes.

In our report.to the President on this particular problem we indi-
cated that this should be projected over a 5-year period, that the plans
for the establishment of these centers would take a certain amount of
time to develop, and to produce a truly national network as we en-
visioned the establishment of these centers in their efforts, in the effort
to make a real impact upon these diseases.

This group of recommendations embodied in this bill projected the
establishment of a national network of regional heart disease, cancer,
and stroke centers for clinical investigation, teaching, and patient
care in universities, hospitals, and other institutions across the coun-
try. We made certain projections for the number of centers for each
year, and indicated the estimated cost of these centers over the first
year would be $87.5 million and a total of $841.7 million for the devel-
opment of 60 such centers over a 5-year period. These were the pro-
jections that we made on the estimate that we had based upon the best
information we obtained from the best experts in the country on all
aspects of this problem. :

I believe, Senator Hill, that this Commission made, perhaps, the
most exhaustive survey of this subject that has ever been made. - Cer-
tainly it was able to collect data that was never available before and
was able to get the consensus of the most: knowledgeable people and
the most knowledgeable organizations concerned with these problems,
such as the American Heart Association and American Cancer So-
ciety and similar health organizations, as well as leading proponents
in these fields.

Now, each of the subcommittee chairmen of these key recommenda-
tions embodied in this bill are here, along with Mr. Folsom and I
should like to call upon them to testify particularly in regard to the
material which they have available and the information they have in
support of this.

Incidentally, I might call attention to the fact that the Commission
prepared its report in two volumes. The first volume embodied the
total set of recommendations, and the recommendations. regarding
the regional network are of course in that volume, .
sive
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COMBATING HEART AND OTHER MAJOR DISEASES 109

The second volume which will soon appear is a much more volumi-
nous volume. It provides the documentation in support of the recom-
mendations and I have here before me the preprints to give you some
idea of the total documentation that will be available in the second
volume which provide, I think convincing support for these recom-
mendations.

May I now call upon Dr. Sidney Farber, who was the Chairman
of our Subcommittee on Cancer and who headed that Subcommittee
in all of its deliberations and provided a report from that Subcom-
mittee which underlies the recommendations in the Commission’s
report.

The Cuarrman. Dr. Farber.

STATEMENT OF DR. SIDNEY FARBER, CHAIRMAN, SUBCOMMITTEE
ON CANCER

Dr. Farser. Mr. Chairman, it is a great privilege as well as a
pleasure to appear before you today. I want to thank Senator Ken-
nedy of Massachusetts for his kind words, and say here how happy
Tam as a citizen of Massachusetts to see him a member of this impor-
tant subcommittee concerned with health, and how well remembered
he is in Massachusetts for the great leadership he gave the crusade for
cancer just 4 years ago.

The Subcommittee on Cancer had in its membership Dr. R. Lee
Clark, the director of the M. D. Anderson Cancer Hospital in Texas,
Senator Yarborough, whom you know very well.

Senator Yarsoroucn. Yes, I know Dr. Clark very well. He comes
from a third or fourth generation of educators in "Pexas. His ances-
tors and immediate relatives include people who have founded uni-
versities, which have grown into great universities and they also
include college presidents in our State. He is another distinguished
member of one of the most distinguished families the Southwest has
ever been graced by. He has done very fine work in the Anderson
Tumor Clinic at Houston. You are familiar with its work, I know,
from your great knowledge of cancer in America.

Dr. Farzer. He gave us authoritative help throughout all of our
deliberations as did all of our Subcommittee, Dr. Frank Horsfall,
president, Sloan-Kettering Institute, part of the Memorial Institution
of New York, Dr. Charles Mayo of the Mayo Clinic, Dr. Jane Wright,
one of the professors of New York University and in charge of cancer
chemotherapy in her service. There were also several very knowledge-
able and dedicated lay people; Gen. David Sarnoff was a member of
this subcommittee; Mrs. Florence Mahoney, who is well known for her
tremendous contributions to medical research and health; Mr. John
Carter, the distinguished editor and Mr. Emerson Foote, who has
concerned himself deeply with matters of health and medical research
for many years.

This subcommittee made recommendations, Mr. Chairman, and
gentlemen of the subcommittee, which are embodied in the report of
the Commission in part I, and now in part II to which Dr. DeBakey
made reference. It is my privilege in representing this portion of the
Commission to give hearty endorsement to this report and to present
its recommendations as printed to the subcommittee. I will not go
into detail about them.

43669658

 
 

110 COMBATING HEART AND OTHER MAJOR DISEASES

I should say at once that the report of this subcommittee, as indeed
the report of the entire Commission, would not have been possible with-
out the support which the Congress through the Appropriations Com-
mittees of the Senate and House has given to the programs of medi-
cal research and health in general for many, many years. Your dis-
tinguished leadership, Mr. Chairman, has made its impact upon the
course of medical research in this country, and has been responsible
for the great growth of the National Institutes of Health. These re-
search programs in the National Institutes of Health and in other
governmental agencies which carry on medical research and give sup-
port have made possible the acquisition of new knowledge and the pool-
ing of knowledge in a manner which was never possible before. On
the basis of these great contributions of the National Institutes of
Health and the other governmental agencies concerned with research
in the Public Health Service and outside the Public Health Service,
we are in a position to make recommendations which otherwise would
not be possible.

In the main the recommendations as described in the bill which you
have proposed, are those which we are supporting today. There will
be opportunity, we understand, for other portions of the Commission
report to be considered later.

Specifically we are recommending in cancer the creation or expan-

sion of 20 cancer regional centers as part of medical complexes or asso-
ciated with either medical schools, universities, specialized cancer insti-
tutions, or research hospitals all brought together, pooling their ener-
gies, their knowledge, their resources to do something which we have
never been able to do before.. Implicit in this recommendation is also
the creation of 200 stations for cancer which will be connected with
these regional centers.
- The purpose of all of this is very clear. What we want to do is,
first of all, make available all of the knowledge concerning cancer
which is available in those institutions which are carrying on the
greatest amount of research and which are giving to patients every-
thing that research can bring at the present time. This is not today
the case for all patients. The figure of 300,000 Americans who will
die of cancer this year is well known to you. This represents a figure
which would be very much greater if not for the great advances in
medicine and in surgery and laboratory sciences of the last 20 to 25
years, but the figure is still too high because we are saving only one out
of three patients with cancer. Thirty years ago we were saving one
out of five. So, we are doing much better.

I would give a conservative estimate which represents the thinking
of our panel on cancer, that if these regional centers were operating
today, we would be able to save 100,000 Americans who are going to
die of cancer this year. This figure is based upon the certainty that
such a Regional Cancer Center network throughout the country would
make possible far earlier diagnosis, more effective utilization of the
methods of proved value available today, and the application of new
knowledge from the research laboratories without delay. I want to
emphasize that this is not possible today because of the lack of re-
sources to make this Regional Cancer Center network possible.

The purpose of these Regional Cancer Centers is to bring this know]-
edge in diagnosis, treatment, and research to the assistance of every
s indeed
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COMBATING HEART AND OTHER MAJOR DISEASES 111

doctor in the country who has a patient with cancer, This program
is created to assist the doctor in the care of his patient by bringing
resources and manpower and equipment and in knowledge which are
not presently available in usable form to every doctor in the count

various specialties of cancer care and treatment and various aspects
of medicine, surgery, and laboratory science necessary for both for pa-
tient care as well as progress leading to the discovery of the causes of
‘cancer and new methods of diagnosis and treatment.

And finally, these centers will set u
through stations which will be situated in un
munity hospitals of 300 beds or so in strategic parts of the country.
Through these hospital stations the doctor will be in constant touch
with the centers,

Senator Hill will recall for a number of years, when I have had
the privilege of appearing before his Appropriations Committee, I
have made this recommendation of setting up of institutions which
‘would have the same kind of organizational pattern and power as that
in the splendid National Cancer Institute in Bethesda but in inde-
pendent institutions throughout the country.

I think that, Mr. Chairman, I shall not carry this any further at this
time.

The total cost for over a 5-year period is put in our Commission
booklet for the stations as some $i ili

sinning of a new era, of a new era in the treatment of human beings
with cancer in this country.

With the chairman’s permission I take this opportunity to define
the terms used in more detail.

1, The Regional Cancer Center can be a part of a medical complex,
‘or it can be an independent institution associated with a medical
school, a university, or an already existing cancer institute or hospital-
research institute cancer complex. Close association with existing
medical resources in all other fields of medicine is desirable. This can
‘be through a university, or through a medical school, or by association
with a number of institutions concerned with research, teaching and
training, demonstration and care of the patient. Experience both
abroad and in this country has demonstrated how effectively the many

isciplines and approaches to the cancer problem can be brought to-
gether in a cancer Institute, or in a cancer hospital and research insti-
tute combination. Such organizations bring together in one location
all the skills, knowledge, and techniques of medicine, surgery, and the
laboratory sciences required for the solution of the many problems of

J care of the patient
with cancer.

  
 

_

112 COMBATING HEART AND OTHER MAJOR DISEASES

The Regional Cancer Center would be an expansion of this cancer
institute development, such as is seen in the M. D. Anderson Hospital
and Cancer Research Institute in Houston, the Memorial Sloan-Ket-
tering Cancer Hospital and Institute in New York, the Roswell Park
Cancer Hospital and Institute in Buffalo. These are the largest in
the country. There are more than 15 others which may be described
in terms of varying degrees of completeness as cancer institutes,
including the Children’s Cancer Research Foundation in Boston,
which is devoted primarily to research and care in the field of leuke-
mia and other forms of cancer in children.

The Regional Cancer Center would represent an expansion of this
type of hospital-research institute by strengthening the basic research,
the preclinical research, and the clinical investigation already present
to a strong degree in a few cancer institutes in the country, and by pro-
viding both more adequate facilities and more stable support for the
care of patients who are under clinical investigation while receiving
optimal treatment and who make possible the training of scientists
and cancer specialists and demonstrations of the optimal forms of
treatment. The expansion which the center would provide will include,
in addition, provisions for consultation with the 200 cancer stations,
and through them the community hospitals, and through them the
doctor in practice. New methods of communication will be possible by
special support in such centers. The centers will assume the obligation
of being available to any doctor in the country at any hour of the day
or night for consultation, diagnosis, and treatment. Such cancer
research centers accept as their goal and function the mobilization of
total resources of science and medicine for the benefit of patients with
cancer now alive and for the eradication of the many problems of
cancer.

These cancer research centers may be in parts of the country where
there is no intimate connection with universities or medical schools,
following patterns already established in the relationship of medical
institutions to one another. Special arrangements can be made to uti-
lize the existing strength of universities, medical schools, and special-
ized cancer institutions for the staffing of these centers, for the training
of students, scientists, and doctors in the many fields of science and
medicine applied to cancer, and for the pooling of knowledge.

In the case of cancer, the existing Cancer Institutes have already
proved the certain of success of an expansion into Regional Cancer
Centers with even more meaningful connections and associations with
universities, medical schools, and other medical institutions.

9. The diagnostic and treatment cancer stations will be located either
in university hospitals, or in community hospitals with 300 beds or
more, which either have or will develop cancer registries. Wherever
there is a community need not yet met, special consideration should be
given to the development of stations so that patients will not have to
travel too far from their own communities. The stations will be pro-
vided with additional staff required to provide the best in diagnostic
services available today, and also to provide the expert care of the
patient with cancer. Doctors who are expert in radiology, radio-
therapy, chemotherapy, special diagnostic techniques, and the various
branches of surgery which bear on cancer will be available. The cancer
stations will be in constant contact with the Regional Cancer Centers

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COMBATING HEART AND OTHER MAJOR DISEASES 113

and will, in turn, be in communication with community hospitals and
with the doctors in practice. The stations, therefore, will serve as part
of a network of facilities available for the programs of clinical investi-
gation carried out with other Regional Cancer Centers.

The special knowledge of biostatisticians and epidemiologists in the
centers, and the availability of computer facilities in such centers will
make possible the creation of experimental designs for clinical investi-
gation as well as the storage, retrieval, and analysis of data for the
entire network system.

Thank you, Mr. Chairman.

The Cuamman. Thank you.

Dr. DeBaxry, Thank you, Dr. Farber.

Senator Hill, I would now like to ask Mr. Folsom if he would make
his remarks now because I understand he has another appointment a
little later.

As I indicated earlier, Mr. Folsom brought to the Commission a
great deal of wisdom and experience in dealing with these matters

and he was of tremendous value and support to the Commission’s
deliberations.

STATEMENT OF MARION B. FOLSOM, DIRECTOR, EASTMAN
KODAK CO.

Mr. Forsom. Thank you. Mr. Chairman, it is a great pleasure for
me to appear before your subcommittee again. I recall the cordial
relations which I had with you, Senator, while I was Secretary, and
also with your committee.

It is my privilege to serve on the President’s Commission and also
on its Manpower Subcommittee. I have a prepared statement which I
will file but I would like to make my remarks orally.

The Cuammay, All right.

Mr. Secretary, we will have your prepared statement appear in full

in the record at this point and you may make any further statement
you see fit, sir.

(The prepared statement of Mr. Folsom follows :)

STATEMENT OF MARION B. FoLsom, Director, Eastman Kopak Co., FoRMERLY
SECRETARY OF HeattH, Epucation, anp WELFARE—1955—-58

It is a great pleasure for me to appear before your committee again and to
discuss this bill designed to carry out some of the recommendations of the
President’s Commission on Heart Disease, Cancer, and Stroke. It was my
privilege to serve on this Commission and on its Manpower Subcomuittee.

The two recommendations relating to this bill read as follows:

“The Commission recommends that a broad and flexible program of grant
support be undertaken to stimulate the formation of medical complexes whereby
university medical schools, hospitals, and other health care and research agencies
and institutions work in concert.

“The Commission recommends a special program of incentive grants to com-
munities to stimulate the development of a system for the planning and coordi-
nation of health activities.”

The following excerpt from the Commission's report indicates the need for
better planning and coordination of health facilities and services in loca]
communities—

“Manpower and facilities for the delivery of top-quality health care are in
short supply in virtually every community. Therefore, the efficient use of exist-
ing resources is imperative. Yet in many communities the reverse is actually
the case. Instead of coordination, there is duplication of services and facilities
in some areas, while serious gaps exist in others.

 

 
eee rey ee

114 COMBATING HEART AND OTHER MAJOR DISEASES

“There may be several large general hospitals, furnishing more beds for acute
care than can possibly be utilized by the community. while serious shortage
exist in beds for long-term care and programs for the those patients who can
best be cared for in their own homes. Seyeral hospitals may possess costly
equipment—such as cobalt devices for cancer care. or heart-lung machines—
each being used only once or twice a week. Teams of highly skilled people
required to work with this equipment are also standing idle.

“A beginning response to these problems can be seen in a few of the Nation's
more progressive and active communities.

“Such endeavors are of the utmost importance if we are to realize our aspira-
tions for programs that will have maximum impacts on heart disease. cancer,
and stroke. Independent and often competing activities of hospitals, health
departments, and medical practitioners—each working in isolation and often
at cross purposes—are not in the best interest of the consumers of health sery-
ices, the health profession, or the Nation.”

I gained the impression from my 8 years association with the Public Health
Service that one of the greatest needs in the whole health field today is for
sound community planning of hospitals and other health facilities. This im-
pression has been reinforced by my experience since leaving Government serv-
ice. I haye been spending a good part of my time. both before and after my
retirement, in this health and hospital field. For several years T have served
as chairman of the Patient Care Planning Council of Rochester and Monroe
County, and also as chairman of the planning committee for the 11-county Roch-
ester Regional Hospital Council, Thus. I have had practical experience in trr-
ing te put plans into operation. For some time I have heen serving on the Fed-
eral Hospital Council. For the past 2 years I have been Chairman of the Na-
tional Commission on Community Health Services, whiech—with grants from
foundations and the Public Health Service—is engaged in a 4-year program to
stimulate the organization of community health planning agencies.

Last year I was appointed by Governor Rockefeller chairman of a small
committee with the difficult assignment to make recommendations for a better
control of hospital costs.

So, you see, I have had an opportunity to study, as a layman, general hospital
and health-care problems from several different angles and have visited quite
a few cities and talked to many experienced persons in connection with these
activities.

In my opinion, we have a long way to go in meeting the broad objective
of providing the best of medical care, including preventive care, to the popula-
tion. regardless of income. Due to the progress of medical research and medi-
cal science, we have learned much in recent years, but our problem now is to
apply widely the information we already have. To meet this objective. we
probbaly will have to spend a higher percentage of onr gross national product
on. health and medical care than we have in the past. It is now 6 percent, com-
pared with about 4 percent 20 years ago. The trained health manpower will
be limited for some years, although the potential manpower will be adequate.
Hence, it is necessary for all those engaged in this health field to make every
effort to conserve resources and the scarce manpower. and to get the most ef-
fective use from both through the elimination of waste. unnecessary duplica-
tion, and to adopt the most progressive management methods.

People are naturally greatly concerned over the sharply rising costs of hos-
pitalization—in New York State daily hospital charges have risen at an aver-
age of 8% percent per year during the last 4 years. A high percentage of this
increase in cost has been due to uncontrollable items. such as hospital wages
and salaries catching up with those in other fields. more expensive treatment,
Services, and equipment, brought on by the great advances in science and medi-
cine in recent years, all of which require more highly trained personnel. Due
to the rise in incomes and the widespread use of prepaid insurance, a larger
percentage of the population are using hospitals.

One important factor in the increased cost has been the lack of planning in
facilities and services which are needed to provide the various levels of care.
In a typical city you will find that there is an excess of acute heds and cenersl
overntilization of the acute general hospital which, of course. is the most ex-
pensive facility; and a shortage of long-term care, extended care, and self-care
facilities, which can be constructed and operated at a considerably lower cost and
often better suited to the needs of the patient. The acute beds can also be re-
lieved by greater use of ambulatory and out-patient services and organized
home care.

   

 

enn
 

 

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COMBATING HEART AND OTHER MAJOR DISEASES 115

s for acute Another cause of increased cost is the competition and lack of cooperation be-
| Shortages: tween hospitals, resulting in unnecessary duplication of expensive facilities and
S who can: Services, and scarce manpower. In many of these hospitals, with small use of
SESS costly the facilities, the quality of care is apt to be below that of other hospitals.. In
nachines— many cases, management methods of hospitals have not kept up with the great
led people progress in business management in the field of training, development, and

utilization of personnel, data processing, statistical controls, communications,
e Nation’s: ete.

. To meet the situation and provide high-quality comprehensive health care,
ur aspira~ there is real need for better communitywide planning of all health facilities and
e, cancer, services. The planning agency should be established to coordinate existing
1s, health health facilities—both governmental and voluntary. It should study the actual
and often needs in order to prevent duplication. It should study future needs in order to.
alth serv- fill any gaps. And it should obtain community agreement on the facilities that
. are needed. It could minimize costly duplication of partly used personnel and.
ic Health See that scarce skilled manpower is used in the most effective way.
lay is for A number of examples could be cited of effective programs of coordinated

This im- community health planning, several having been financed in part by grants from
lent serv- the Public Health Service under the Community Facilities Act. But perhaps I
after my should give you some practical examples from our Rochester experience.
ve served In 1961 we organized the Patient Care Planning Council, initially to determine
1 Monroe the allocations of funds from a joint capital campaign for the seven hospitals,
ity Roch- and then to serve as a health planning and coordinating council for the county.
ce in try- With the assistance of the local medical society, we arranged for 28 physicians
ithe Fed- to make a scientific survey of the patients in about half of the beds in the hos-
the Na- pitals, in order to determine the type of facilities they needed. We found that
nts from a substantial number of the patients did not, for medical reasons, need to be in-
ogram to an acute general hospital but could have been taken care of in out-patient de-
partments, extended-care, long-term, or self-care units, doctors’ offices, or at
a small home. As the result of this study, we reduced considerably the number of acute
a better general beds the hospitals had requested. Instead, three hospitals will con-
. struct so-called extended-care units for the convalescence and rehabilitation of
hospital patients who do not need all the services given in the acute beds—the units to
7 quite be constructed and operated at a much lower cost. As the result of these
ese changes, we were able to devote a much larger part of our funds for moderniza-
bijective. tion, replacing several old buildings with modern wings and equipment,

. ula After the successful capital campaign, we continued our efforts to coordinate.
Gone di- the health facilities to provide better health care with less duplication and work.
ow is to Much had previously been accomplished in obtaining cooperation of the hospitals
‘ive, wa by the regional hospital council and of the health agencies by the council of social
many agencies,
oe With the combined efforts of the councils, the hospitals, physicians, and health
7 er will agencies, the following has been accomplished in recent years:
lequate The hospitals have participated in joint purchasing for a number of years;

@ every. The hospitals agreed upon the most urgent needs for two capital funds
nost ef after thorough study;

: The county medical society encouraged hospitals to organize utilization
luplica- committees :
of hos- Five hospitals are constructing a centralized laundry, with borrowed funds
n aver- to be amortized from charges, rather than use funds from the community
of this capital drive; .

wages The council worked out a program for transfer of the municipal hospital
tment to the University of Rochester Medical Center, with savings to the city ;
1 medi. The council obtained agreement to abandon County Tuberculosis Hospital

. Due with transfer of patients to nearby State hospital with available beds, with
larger: considerable savings to the county ;

The council is now working out an agreement between the county and the.
ing in medical center for medical care of patients in the county infirmary ;
f care. | An organized home-care program has been developed for patients trans-
eneral | ferred from hospital ; . ;
st ex- A mental health council has been organized to coordinate the activities of
f-care yaarrecy in the mental health field, including the integration of the State
| ospital;
penne The council arranged for one general hospital to add in-patient psychiatric:
nized unit and to combine with three agencies to set up and operate an out-patient:

clinic;

   

 
 

116 COMBATING HEART AND OTHER MAJOR DISEASES

Based on a bed survey which indicated that 30 percent of its medical and
surgical patients could be taken care of in a self-care unit, one hospital is
converting part of its facility for such a unit. It is estimated that the
operating cost per bed will be reduced by 38 percent.

The council is now endeavering to develop a program for coordinating use
of special laboratory equipment ;

The community college has established a preclinic nursing course for the
first year of the hospital’s diploma school program and a 2-year associate
degree course. One hospital abandoned plans to construct a new nurses
dormitory and its diploma school program.

The council is now developing a long-range plan for health facilities in
the community.

We still have much to do.

It is difficult to measure the improvement in health or the dollar savings
resulting from these activities to obtain better control of hospital construction,
facilities, and utilization, and closer cooperation of various health agencies.
I have, however, made three comparisons between Rochester and three other
New York cities—Buffalo, Syracuse, and Albany. The Biue Cross agency in the
Rochester area covers 73 percent of the population compared with 40 percent
in the three other cities. The in-patient-days per thousand Blue Cross members
in 1963 for the three other cities were considerably above Rochester. The com-
bined Blue Cross and Blue Shield premium in these three cities was also con-
siderably above that of Rochester.

From my experience, I am very optimistic over the possible accomplishments
by community health planning councils. We are hoping that the findings of the
National Commission and the experiences of the few communities which are
doing a good job will stimulate many communities to set up such councils.

The “medical complexes” proposed by the President’s Commission would be-
come a valuable part of a community health planning and coordinating council.
For example, the University of Rochester Medical Center has been very helpful
in our planning efforts and already has an affiliation with three community
teaching hospitals. Only recently, the Center completed arrangements with one
of the hospitals under which one of the faculty members will be the full-time
chief of medicine at the hospital, with reimbursement for his salary to the
Center. This will enable the hospital to attract interns and residents who can
be rotated to the medical center, and be helpful to both institutions in their
training and research activities. If similar arrangements could be made for
several staff officers in all the teaching hospitals, and if the other plans contem-
plated in the “medical complex” proposal were adopted, there would be great
opportunity for improvement of medical care in the community. There would
be closer cooperation between the hospitals and less likelihood of unnecessary
duplication of expensive special facilitieis, which could be concentrated in the
Center where better care could be provided. There would be better opportunity
for the staff in the other hospitals to keep in touch with new knowledge and
practices, and for attracting more physicians to the seminars and special classes
and lectures at the Center.

I therefore see how a “medical complex” would be of great value to us in the
Rochester community. It would also be helpful in the 11-county area, where we
are now conducting a demonstration project for areawide planning, under a
grant from the Public Health Service.

I would, therefore, heartily endorse Senate bill 596, which would authorize
grants to communities for setting up such “medical complexes.” For communities
which are not as far along as we are in Rochester, funds would be provided to
develop a plan and to set up the planning council.

I have a few comments on the provisions. It would seem to me that there
should be specific provision that the local health department be included in the
local council supervising the program. I assume they would be, anyhow. Should
not the State health department be brought into the picture, also, at least on a
consulting basis?

As far as expenditures for construction are concerned, should it not be speci-
fied that they be coordinated with the Hill-Burton and other Federal-State plans?

As these complexes are intended to be demonstration projects with the pre-
sumption being that Federal grants will be made only for a limited period, should
it not be indicated that 10 pereent specified for local contribution is intended as
a minimum and that greater local contribution is contemplated in most cases?
If substantial contributions are not obtained, it may be difficult to continue the
project when the Federal grants close.

Se
 

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COMBATING HEART AND OTHER MAJOR DISEASES 117

Thus it is important that the Provisions be kept broad, as they are, particularly
in the provisions of other major diseases, and that the medical schools be given
all possible freedom to develop their own programs of education, patient care,
and research, and that flexibility be permitted for communities.

A sound growth of medical complexes would, of course, require many more
highly trained doctors, who are already in short supply. It is thus very impor-
tant that Congress consider the several measures advocated by the Commission

I would also suggest that action be taken on the Commission’s recommendation
that there be an additional program of “grants to communities to stimulate the
development of a system for the planning and coordination of health activities,”

Mr. Fotsom. I would like to read an excerpt from the Commission’s
report.

The Cuarrman. All right, sir.

Mr. Fotsom. About the better planning and coordination of health
facilities in local communities; it reads:

Manpower and facilities for the delivery of top-quality health care are in short
supply in virtually every community. Therefore, the efficient use of existing
resources is imperative. Yet in many communities the reverse ig actually the

case. Instead of coordination, there is duplication of services and facilities in
some areas, while serious gaps exist in others,

There may be several large general hospitals furnishing, more beds for acute
care than can possibly be utilized by the community, while serious shortages exist
in beds for long-term care and programs for those patients who ean best be
eared for in their own homes, Several hospitals may possess costly equipment—

with this equipment are also standing idle.

beginning Tesponse to these problems can be seen in a few of the Nation’s
more progressive and active communities.

Such endeavors are of the utmost importance if we are to realize our aspira-
tions for programs that will have maximum impacts on heart disease, cancer,
and stroke. Independent and often competing activities of hospitals, health
departments, and medical Practitioners—each working in isolation and often at
cross purposes—are not in the best interest of the consumers of health services,

the health profession, or the Nation.

I gained the impression when I was down here with my 3-year asso-
ciation with the Public Health Service that one of our greatest needs
in the whole health field was sound community planning of hospitals
and other health facilities

This impression has been reinforced by my experience since leaving

overnment service. I have been spending a good part of my time
recently in the health and hospital field.

or several years I have served as chairman of the patient care

planning council in Rochester and also chairman of the planning
committee for the Rochester 11 county regional hospital council.
So, I have had practical experience in trying to put these plans in
operation.

I find a number of cities have nice plans but very little has been
done about putting them into operation. I have also been Serving on
the Federal Hospital Council here which makes grants under the

Community Facilities Act to communities to assist in its planning
efforts.

  
  
 
   
    
 
  
 
 
 
   
 
 
 
  
   
 
  
  
  
  
 
 
 
  
    
  
 
 
 
   
 
  
 
 
 
 
   
   
 
    
   
  
  
 
 
 
  
   
  
  
 
 
 
  
 
   
 
  
 
  
 
 
 
  
   
 
 
 
 

118 COMBATING HEART AND OTHER MAJOR DISEASES

For the past 2 years I have been chairman of the National Commis-
sion on Community Health Services which, with grants from founda-
tions and from the Public Health Service, 1s engaged in a 4-year pro-
gram to stimulate the organization of community health planning
agencies.

Only Jast year I was appointed by Governor Rockefeller as chair-
man of a small committee with a difficult assignment to make recom-
mendations for better control of hospital costs. So you see I have had
an opportunity to study as a layman these general hospital and health
-eare problems from several different angles.

I have visited quite a few cities and talked to quite a number of
-experienced people in this field.

In my opinion we have a pretty long way to go yet in meeting the
broad objective of providing the best of medical care including pre-
ventive care to the population. Due to the great progress we have
made in medical research and medical science we have learned very
much in recent years but our problem now is to apply widely the in-
formation we already have.

The trained health manpower, which our manpower committee
-studied, will be limited for some years. It is going to take some time
to train enough people to do an ample job. Hence, we have got to do
what we can to conserve our scarce manpower and also conserve our
‘resources, which means we ought to get rid of as much waste as we
scan, unnecessary duplication, and adopt the most progressive manage-
‘ment methods for the hospitals.

HOSPITALIZATION COSTS

People are very greatly concerned now about the sharply rising costs
-of hospitalization. In New York State we find that the daily hospital
charges are rising at the rate of 814 percent a year. That is the aver-
_age of the last 4 years. A high percentage of this has been due to un-
controllable items because we must catch up in wages and salaries with
_other fields. We have had to use much more expensive equipment.
‘We have much more highly trained manpower in order to take advan-
tage of all the advances which have been made. Also, many more
people are using hospitals than before because of the increasing stand-
ard of living and the widespread use of prepaid insurance.

On the other hand, one important factor in this increased cost has
been the lack of planning of facilities and services which are needed to
provide the various levels of care. As the Commission pointed out in
this extract I just read, in a typical city you will find an excess of acute
beds, the most expensive type of facility, and general overutilization
because of the lack of other types of facilities such ‘as long-term care,
self-care facilities. These other facilities could be operated at con-
siderably lower cost and also constructed at a lower cost. In many
cases they are better suited to the need of the patient.

Also the ambulatory and outpatient services can be used more, also
greater use can be made of organized home care.

Another cause of increased costs is the competition and the lack of
cooperation between hospitals resulting in unnecessary duplication of
expensive facilities, and also duplication of scarce manpower.

Now, in many of these hospitals with a small use of these facilities,
the quality of care is probably below that of the other hospitals.
 

wr

   
   
  
   
 
 
  
 
 
  
 
 
  
   
    
  
  
 
  
 
 
   
  
    
  
  

 
 
 
 
  

COMBATING HEART AND OTHER MAJOR DISEASES 119
ommis- ‘We also find that in many cases management methods of hospitals
founda- have not kept up with the great progress of business management such
ar Pro- as in the field of training and development and utilization of man-
lanning power, data processing, statistical controls, communications, and so

. orth.
3 chair- COMMUNITY HEALTH PLANNING
recom-
ive had To meet this situation and provide a high quality of comprehensive
health health care, there is a real need for better communitywide planning of
all health facilities and services in the community.
iber of Now, a planning agency should be established to coordinate the ex-
isting health facilities, both governmental and voluntary. They should
ng the study the needs of the communities and try to make plans for future
ig pre- needs to try to fill in the gaps and should minimize costly duplication
e have of partly used personnel and see that scarce skilled manpower is used
d very in the most effective way.
the in- A number of examples could be cited but I thought you might be
interested in what we have been able to do in Rochester as a practical
mittee application in the last few years. We have had in Rochester for a
e time number of years a regional hospital council which was financed a num-
, to do ber of years ago by one of the foundations. We have had the experi-
ve our ence of cooperation between the hospitals which has not existed in other
as we communities,
nage- In 1961 I was asked to be chairman of an allocation committee to
allocate the funds which we were going to raise for a capital drive for
the hospitals. I found that the request was going to be several times
more than I knew we could raise. As chairman of the allocations com-
mittee, I felt I would have to make most of the decisions; as the other
y costs members of the committee were representatives of the hospitals. We
spital organized a patient care planning council with the top people in the
aver- community, the president of the medical society, the head of the Com-
fo un- munity Chest, and the Council of Social Welfare Agencies, etc., as
5 with members of the committee.
ment. The first thing we did was to make a survey of a thousand beds, se-
dvan- lected _on a scientific basis, to be studied by a group of 28 doctors
more brought together by the medical society to study the patients, the needs
tand- of the patients in those beds, and to see what type of facilities they
needed.
t has We found that as far as the medical patients were concerned 23
led to percent of the patients occupying these acute general beds shouldn’
ut In have been there. They should have been in other types of facilities
acute or at home. As a result of that we decided we didn’t have to expand
ation the acute beds of the city as much as the hospitals had recommended.
care, We cut down their request considerably.
con- Instead of that, three hospitals are putting in what we call extended
nany care units, for people needing rehabilitation, convalescent. services, peo-
al ple not quite ready to go home—but who do not need the services of
81SO an acute hospital. We think the units can be built at half the cost.
ke of We used a motel-type construction and operated at half the cost of
x 0 f acute beds.
ed As a result of that we were able to use a good part of our money for
7 modernization. We tore down five or six old buildings and are putting
HAS, up new buildings with modern equipment and getting more for our

 

 
 
  
  
 
 
 
 
  
 
 
  
 
  
 
 
 
 
  
   
  
  
 
 
 
  
 
 
 
 
 
  
 
  
  
 
 
 
 
 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

iii —

120 COMBATING HEART AND OTHER MAJOR DISEASES

money. This isa joint hospital drive, by the way, that all the hospitals
got together on.

In most cities each hospital is on its own. Asa result they are apt
to duplicate facilities and add the type of beds not needed rather than
modernize existing facilities.

Now, I thought you might be interested in the other things we have
been able to accomplish; so I am going to read a list of what we have
been able to do in the last few years with the help of the medical
societies, the medical school, the regional hospital council, and the
Council of Social Agencies.

The hospitals have participated in joint purchasing for a number of
years. The hospitals agreed upon the most urgent needs for the two
capital funds drives we have had in the last 10 years. The county
medical care for the patients in a county infirmary where we find that
committees. Five hospitals are constructing a centralized Jaundry
with borrowed funds to be amortized from charges rather than use
funds from the community capital drive. The council worked out a
program for transfer of the municipal hospital to the University of
Rochester medical center with savings to the city. The council obtained
agreement to abandon the county TB hospital and transfer the patients
to a nearby State hospital that had plenty of beds available thus effect-
ing a large savings to the county. We are now working on an agree-
ment between the county and the medical center to provide medical
care for the patients in the county infirmary. We find that the quality
of medical care is very low in the infirmary and this will greatly
improve it.

Organized home care has been developed for patients transferred
from hospitals. We found half of these didn’t need to go in the hos-

itals and we can provide that care at $10 a day compared to $40 a day
in the hospital.

A mental health council has been organized to coordinate the activ-
ities of agencies in the mental health field, including integration of
the State hospital in the community with 3,000 beds.

The council arranged for one general hospital to add an inpatient
psychiatric unit and to combine with three agencies to set up and
operate an outpatient clinic.

Based on a bed survey which indicated that 30 percent of medical
and surgical patients could be taken care of in a self-care unit, one
of the hospitals is converting part of its facilities for such a unit. We
can operate that at about a reduction of 38 percent over the acute beds.

We are now endeavoring to develop a coordinated program for the
use of special laboratory equipment.

Our community college established a preclinic nursing course for first
year of the hospital’s diploma school program and 2-year associate
degree course. The results of that were that one hospital abandoned
plans to construct a million-and-a-half-dollar nursing home dormitory
and its diploma school program.

We also are now developing a long-range plan for health facilities
of the community. We still have quite a little to go but we are getting
fine cooperation in bringing about these various improvements in the
health care and cutting out duplication.

Tt is difficult to measure the value of this and the dollar savings
but because of the better control we have had of hospital utilization
  

ospitals

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COMBATING HEART AND OTHER MAJOR DISEASES 121

and closer cooperation I made a comparison with Rochester and the
three upstate New York cities who haven't done much in this field—
Buffalo, Syracuse, and Albany. I find that the Blue Cross agency in
Rochester covers 73 percent of our population as contrasted with these
other cities where only 40 percent are covered.

The inpatient days per thousand of Blue Cross members shows the
utilization of the hospitals in these three other cities is considerabl
above that in Rochester. The combined Blue Cross and Blue Shield
premium in these three other cities is over 40-percent higher than that
of Rochester.

From my experience I am very optimistic, therefore, of the possible
accomplishments from these community health planning councils.
We hope to get the findings of the National Commission and experi-
ences in a number of communities will stimulate many other commu-
nities throughout the country to set up these councils.

Now, in getting down to this legislation, these medical complexes
proposed by the President’s Commission will become a very valuable
part of a community health planning and coordinating council.

For instance, in the Rocester area, the University of Rochester Medi-
cal Center has been very helpful in our planning efforts. Only recently
the Center completed arrangements with one of the hospitals under
which one of the faculty members will be the full-time chief of medi-
cine in this hospital with reimbursement for his salary to the center,

This will enable the hospital to attract internes and residents who
can be rotated to the medical center.

SOLVING STAFF PROBLEMS

One of the difficulties of many hospitals now is they can’t attract
internes, but by a tie-in with the medical center it will be much easier.
This is also going to help both institutions in training and research
activities.

If a similar arrangement could be made as we contemplated in these
medical complexes so there will be several staff officers in these commu-
nity hospitals furnished by the medical center, and with the other plans,
there would be better medical care in the community. There would
be closer cooperation between the hospitals and less likelihood of un-
necessary duplication of expensive equipment which would not be
used very much in these other hospitals.

There would be a much better opportunity for the staff in other
hospitals to keep in close touch with new knowledge that a medical
center would have. You could have also more physicians interested
in continuing courses given by the medical center. So I can see where
a medical center would be of great value to us not only in Rochester
but in the whole Rochester area, in the 11-county regional hospital area
which we are engaged in planning for.

I would, therefore, heartily endorse this Senate bill 596 which
would authorize grants to communities for setting up medical com-
plexes and these coordinating and planning committees,

SUGGESTED AMENDMENTS

T have only a few comments to make on the provisions of the bill.
It would seem to me that there ought to be specific provision that the

 

  
  
 
 
 
  
   
  
 
  
  
 
 
  
 
   
    
  
   
  
 
 
 
  
   
   
   
  
 
  
  
  
 
 
 
 
    
  
  
 
 
  
 
 
 
 
  
   
 
 
 
  
 
 
  
  
  
  
 
  
 
  
 
 
  
   
Also, I think it ought to be Specified that these expenditure;
Construction should be coordinated with the Hill-Burton and
Research Facilities Acts and other Federal-State Plans. In 09
words, there ought to be a pretty close coordination so you won't
unnecessary duplication, I think it ought to be Specified in the
that this should be brought about.

8 these complexes are intended to bea demonstration project m
or less for a limited period, I wonder whether we shouldn’t ask

28 On the size of tho communities and how they are organized anc
how different &toups get together so I would certainly endorse keeping
this as flexible aS possible, . ;

NEED To EXPAND MEDICAL, MANPOWER

Now, of course, this means, if you have & wide growth of these
medica] complexes, You are going to have to have more highly trained
octors and already they are in short supply. So I think it is impor-
tant that Congress consider the several] other measures advocated b

we find that a large percentage of the students in medical schools come
from families with income of over $10,000. A lot of good potential
Material is in the other 8TOUDS We are not ta ping now. J would think
these scholars Ips would be ver » Very helpful in that area,

Iso I think we should expand our program for tants to com-

munities to stimulate the development of these Planning and coordi-
nating committees,

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COMBATING HEART AND OTHER MAJOR DISEASES 123:

The Cyatrman, Thank you, Mr. Folsom, for your most interesting
and informative statement, We appreciate it very, very much.

Dr. DeBakey ?

r. DeBaxey. I also want to express my thanks to Mr. Folsom for-
his testimony here,

Next, I would like to ask_—_

he Cuamman. Senator Kennedy ?

Senator Kennepy of New York. I understand Mr. Folsom has to:
leave. Could I ask him Just one question? JI thought your statement
was very helpful and interesting. I was just wondering based on your:
experience and the efforts that you made in this field, could you just
tell us what you think the relationship between the centers and the-
stations to NIH and the Public Health Service should be?

RELATIONSHIP WITH NIH

Mr. Fotsom. Well, I have been thinking lately about how the tieup:
ought to be here. The NIH now deals with the medical schools all
the time on research, and the Bureau of State ices i i ith
medical schools also, I understand, under the Research Facilities Act.
Tt also makes grants to hospitals and communities for i

So, I would think it might be better tied in with the State service
organizations, in the Public Health Service, rather than N TH, although
there should be a close relationship.

Senator Kennepy of New York. The emphasis really should be
then on making sure that the information that is uncovered and which
was mentione earlier brought to the attention of the local doctors and

lives could be saved. This is a mechanism, a suggestion, of the best
way of getting that knowledge out to the communities,

From my experience, I think it could be done. It would be very
helpful and could be done fairly rapidly, too, in communities already
set up to do it. But there are so many communities that haven’t made
much effort in planning so a good part of this money the first year
will go for planning to getting agencies set up and instructed on how
to go about it.

Then they could actually set. the stations up and most of the stations
would be located, of course, in existing community hospitals. The
university medical center would serve as the base and as a regional
center. I think that is what we contemplated.

Senator Kennepy of New York. Thank you very much.

The Cuarrman. Senator Yarborough ?

Dr. Farber, do you want to make some comment on that?

  
 
  
   
 
  
  
   
   
  
  
   
  
 
  
 
 
  
  
 
 
 
 
  
  
   
   
  
 
  
   
 
 
   
  
  
  
   
  
  
   
  
  
  
 

124 COMBATING HEART AND OTHER MAJOR DISEASES

Dr. Farser. With your permission, Mr. Chairman, I understand
what Mr. Folsom has in mind, and J agree with him certainly as Sena-
tor Robert Kennedy has mentioned that the uncovering of knowledge
and getting it to the doctors is of tremendous importance here. But
I would like to make a point here that I did not make clearly before,
and that is that these centers will make possible the kind of medical
research in clinical investigation which is not possible today on the
scale that is required, not only in the field of cancer but in heart disease
and in stroke, and in many other diseases, too. Research on it will be
an extremely important part of this, and it is this research as well as
the training which I associate with the National Institutes of Health,
with the aid of any other governmental agencies or any other parts of
the Public Health Service that are required, but the research must be
emphasized greatly.

Mr. Forsom. I might say I think it is wise to leave the decision in its
relationship within the Public Health Service here entirely to the Sur-
geon General to work out because there must be very close coordination
between these two elements.

The CHARMAN. Senator Yarborough, do you have some questions?

Senator YarBorovucn. Mr. Folsom, I want to comment on this recom-
mendation for an expansion of the Health Professions Education Act
and the Nurse Training Act and also your additional recommendation
that career programs be stimulated in community colleges. I might
add junior colleges for training medical and dental technicians to help
the higher trained medical doctors and the dentists.

In the hearings on this Health Professions Education Act the testi-
mony indicated that it took about $25,000 to educate a young doctor,
and that less than 5 percent of the families of the United States were
financially able to finance that education. As you pointed out, that is
just automatically excluding from medical education the overwhelm-
ing majority of the people of the country unless they have outside aid.

T have a question or two back when you were exp aining the coordi-
nated action in Rochester and how much it saved there, I know two of
those actions were that the council got the University of Rochester
Medical Center to take over the municipal hospital, the city hospital,
he you were successful in getting the State to take over the county

ospital. ‘

Apparently you did not lessen the medical treatment but the city and
county there were able to shift this off to other governmental agencies.

SAVINGS REALIZED

Mr. Forsom. In the case of the medical center we had always had a
close tie-in there. But the city was incurring quite a deficit. We were
able to get the deficit wiped out before the university would take it over
mainly because we got the welfare department to pay what it should
have been paying all along for the welfare patients.

Senator YarsoroucH. Now, if you get the county TB hospital taken
over by the State, is this really a true figure that you saved that much?

Mr. Fotsom. No. What we did there was—

Senator Yarsoroucu. Somebody pays for it.

Mr. Fousom. Thirty miles away there was a State hospital with

plenty of beds available for these patients. We had been operating this
 

wr

   
  
 
 
 
  
  
 
 
  
  
  
 
  
 
 
  
   
  
  
 
  
  
 
  
 
 
  
  
 
   
   
 
 
   
 
 
  
 
  
  
   
  
 
  
   
  
  
  
   
  
    
   
  
 
 
   
  
  
 
 
 
 
  
 
 
 

 

COMBATING HEART AND OTHER MAJOR DISEASES 125
stand county hospital with the patient load going down steadily with no
Sena- reduction in staff, in fact, an increase in staff. So the patient could be
ledge cared for at a much lower cost at the State hospital and the county

But really saved about a million dollars. .
efore, . The State has not increased its cost anything like that much.
dical Senator Yarsorovucu. In other words, you are not giving this as an
n the illustration of how one governmental unit shifts from one to another
isease but a savings by coordinated action. : oo
ill be Mr. Fousom. Yes. ‘This had been considered for several years but
ell as nobody had been able to do it. With the top leadership in our council
ealth, we convinced the authorities what an overall savings there would be.
rts of We think we are giving better care at a much lower cost. _
ist. be Senator Yarsoroveu. Thank you, Mr. Folsom; thank you, Mr.
i. Chairman. 8
in 1ts Mr. Fousom. .I might say the reason I have to leave I have to testify
Sur- before Congressman Celler’s committee. 4
ation The Cuairman. We certainly appreciate your presence, Mr. Folsom,
| and I want to thank you very much.
ons? Mr. Forsom. I am very glad to be here.
com- The Cuarrman. Thank you, sir. ;
1 Act Dr. DeBaxzy. Senator Hill, before asking Dr. Wright to continue
ution at this point, I would like to amplify just a bit some aspects of the
Light legislation and its purpose at least as we conceive it since I think the
help question has been raised—Senator Kennedy raised the question a
. moment ago—as to what takes the major thrust of the legislation, I
esti- think it is important to recognize, first, that this legislation provides
ctor, an opportunity to extend an effort and a direction of development that
were is already in operation, Senator Kennedy.
at is While it is true in a sense that this constitutes the most innovative
elm- aspects of the recommendations of the President’s Commission in estab-
aid. lishing this concept of a regional network, it is new only in that sense.
rdi- It is not unrelated to programs, on-going programs. It is, I think, in
0 Of fact, so closely related that it is an outgrowth of the going programs.
ster It is the natural extension to a great degree of the developments and
ital, the fruits that have come out of the National Institutes of Health re-
nty search and training activities, and the concepts of the centers which
are already in operation su ported by the National Institutes of Health
and largely thrust upon the medical community through that means.
cles. - So, this type of legislation is new only in respect to providing a
further extension of this total concept. 1 think actually it is derived
from this background of activity, and the long experience that has now
developed over this period of time beginning with the establishment
ad & of the National Institutes of Health and particularly the categorical
ihaahi institutes in combining the research, training, and now patient care,
ver so intimately interwoven in most centers that have been in operation
uld that it is difficult to disassociate one from the other. The reason one
kk can provide the highest degree of skill and knowledge in patient care
oh? in such centers is because research and training are an integral part in
. It. ,
So, I think it is important to understand this concept, that this is not
ith just an extension of patient care and making available the best knowl-
7 edge. It is not just an extension of research, clinical research, and. it
nls is not just a means of providing training. It is the best mechanism of
43-669—65—_9

  

 
 

126 COMBATING HEART AND OTHER MAJOR DISEASES

combining all three. Anyone who has had experience in a medic
center, such as most of us, and, of course, many others whom we co!
sulted, has recognized the importance of this particular objective ar
that this is the best means of achieving this goal.

It is the best means of providing the best in research and particular
in clinical research, the best means by which it is possible to bring tl
knowledge gained from basic medical sciences to the bedside and 1
translate that knowledge into diagnosis and patient care. It is also tl
best means for providing training for the practitioners who will ult
mately provide this care, and it is the best means of expanding the bas
sciences in these general areas.

So, I think it is important to recognize that this is not just the thru:
of medical care.

Senator Kennepy of New York. Thank you. That is very helpfu
I just gathered from the earlier testimony and looking into this legi
lation to some extent and the background that there had beem som
deficiencies in the being able to get the information which has bee
developed by all of you to the bedside and to the local doctor and
gather that in the field of cancer from your own testimony and I kne
there had to be some emphasis on that. I didn’t mean to imply
thought research should be less or we hadn’t been doing a great des
in any or all of these fields but I just thought we should really foct
some attention on that point so it is quite understood. It is ver
important.

Dr. DeBaxey. It is very important and I am glad you did bring |
out. But I just wanted to emphasize this concept underlying th
centers and its relationship to the experience we have gained in th:
regard.

enator Kennepy of New York. Thank you very much.

Dr. DeBaxey. May I now ask Dr. Wright to present his testimony}
Mr. Chairman?

The Cuamman. Dr. Wright.

STATEMENT OF DR. IRVING WRIGHT, CHAIRMAN, SUBCOMMITTE
ON HEALTH

Dr. Wricur. Senator Hill, and members of the committee, it is
real pleasure to be before you again. I have had the experience i
previous years and I hope have made a minor contribution to you
efforts in the field of health. .

The Subcommittee on Heart Disease was made up of Dr. Samu
Bellet, professor of cardiology at the University of Pennsylvania; D:
J. Willis Hurst, professor of medicine at Emory University; Dr. Pav
Sanger, distinguished surgeon from Charlotte, N.C.; Dr. Taussig
Johns Hopkins, with whom you are all very familiar, I am sure, fo
her distinguished work on congenital heart disease; and the sta:
member, Dr. John Turner, who contributed markedly to the work o
this Committee.

My own experience has been in practice, in the teaching of medicin«
and research mostly on a clinical level at Cornell University. I hav
also been president of the American Heart Association and a member o
the National Advisory Committee for Heart Disease for one term an:
for part of another term.

 

 
 

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COMBATING HEART AND OTHER MAJOR DISEASES 127

I mention this to indicate that I have had a rather broad experience
and have been interested in these problems, not just since the inception
of this Committee but during my entire professional life of more than
& quarter of a century.

The Subcommittee on Heart Disease has presented to you its report.
Tn essence this is my statement, based on the efforts of the entire Com.
mittee. I should like to summarize it and perhaps make comments
on certain aspects of this report in order to conserve your time. It is
all available for your perusal.

The Cuamman. We will have it appear in full in the record,
Doctor, in its appendix.

Dr. Wren. This report has already been submitted. It is entitled
“The Report of the Subcommittee on Heart Disease.” This will
appear in the second volume of the report of the Commission.

We are strongly in favor of general principles outlined in the bill
as it has been drawn up and submitted to us. ‘There are certain points,
however, that appear to be worth while discussing.

The concept of the regional complex and the center working as a nu-
cleus with radiated stations throughout a geographic area is involved.
We hope all areas in the country would eventually be covered. This
concept is a very valid one, but it is a long-term project. It is impor-
tant to get it underway now because it won't be very long before we

right now. It will take planning, it will require development of man-
power at every level. Physicians, of course, are the key personnel,

ub we must have more nurses, and more laboratory technicians.
Electronics technicians are now being declared essential to medical
progress, a field that medicine hasn’t really done very much about
developing at all. Yet the future of medicine is going to be tied into
this new discipline. We need physical therapists, occupational thera-
pists, and rehabilitationists,

We need many more trained workers in the social sciences who are
sincerely. interested in sick people, not in abstract theories. The plan
is a broad one, and it is a long-term one. But in order to get off the
ground, this type of bill must be implemented soon,

The Heart Disease Subcommittee has recommended that a total of
25 centers be established during the next 5 years. The total amount
of money involved in this will be approximately $166.2 million.

This is a very conservative estimate. It has been felt by some that
we were being too conservative in terms of the cost per center, but we
tried to be honest in our estimations. Once a center is established, indi-
vidual investigators within that center may, if they wish, a ply for
special research and other grants which would supplement the basic
grant once the center organization is ready to use extra funds to
advantage.

The Heart Disease Subcommittee felt there was a need for 160 new
heart stations. The concept of the station as adopted by the entire
Commission really came from the development of heart stations in
many hospitals during the past 15 or 20 years.

0, this is not an idle dream. Stations are, in fact, in operation in
many centers, including Cornell. They have served as a nucleus for

  

  
  
   
  
 
 
  
  
   
  
  
 
 
 
 
 
  
   
   
  
  
  
 
  
 
  
  
  
 
  
  
   
   
  
 
 
 
 
 
  
 
  
  
 
  
  
   
 
  
 
 
 
  
 
  
  
 
   
     
 
  
   
 

128 COMBATING. HEART AND OTHER MAJOR DISEASES

stimulation and interest, much better care of the patient, and continu-
ing education to the doctors on the staff who are not heart specialists.
They come to the station to see the electrocardiograms, to discuss the
problems of the patient with the specialists working in the station.
This is a most important form of continuing physician education and
is vitally important. ey ;

In terms of the question that Senator Kennedy addressed to Mr.
Folsom, it is my belief that.the centers and the regional complexes
would best be related directly to the NIH, because they are going to
be vitally concerned with research projects, and the NIH organization
is experienced in this.

The Cuamman. Doctor, if I. might interrupt, isn’t what you are
proposing in a sense an addition to the programs we have conducted
through NIH?

Dr. Wrieut. This is correct.

The Cuarrman. Building on and enlarging them?

Dr. Wricurt. This is correct.

This implies a need for NIH to be reoriented so that there will be
more interest and more support for care of patients and for the train-
ing of local physicians into this program. Otherwise, the NIH pro-
gram has been superbly administered in the past. This new concept
should be developed to a greater degree.

The stations that. are located in major centers should probably be
under NIH, but stations out in the rural and small community areas
may be, for practical purposes, oriented to the Bureau of State Services
of the heart disease control program. Here there will be an absolute
need for a cooperative effort working with the volunteer agencies such
as the American Heart Association to coordinate the facilities in the
area and devleop stations of the highest possible standards.

This Committe has also recommended development of laboratories
at a State level for the standardization of certain types of laboratory
tests, such as the culturing of streptococci in the rheumatic fever pro-
grams (not available generally but terribly important) or the stand-
ardization of prothrombin tests to aid in the control o anticoagulant
therapy. This bill should be broadened to include these laboratories
for standardization. They should frequently be closely coordinated
with stations at local levels. :

The stations we contemplated, 160 in number, would start with 30
the first year at a cost of $1114 million. The total over 5 years would
be estimated to cost $117,500,000. That is a 5-year project, and it is
contained in the report of the Commission.

It is vitally important, that.the practicing physician be made to feel
important in this program. He should be graded up, not graded down,
and his continuing education and participation is essential to the suc-
cess of any program of this nature. If we do not succeed in fostering
his education, if we do not keep it constantly up to modern scientific
ideas, he will soon become obsolete, even though he goes through the
motion of practicing. This we must avoid in any such program, there-
fore, grants to the community hospitals to continue live, active educa-
tional programs are essential to the fulfillment of this program. We
are trying to get modern care to the patients. How do we achieve this?
It must be through. the local physicians. ‘This is important. It
should be emphasized and. it should never be forgotten for one moment,

 
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COMBATING HEART AND OTHER MAJOR DISEASES 129

The Cuarrman. Doctor, Senator Javits advises me he has another
meeting that he must attend, and he is going to have to leave us, and
he has a question or so he would like to ask you.

Dr. Wrieur. Yes, sir.

Senator Javirs. Doctor, may I apologize, but the immigration sub-
committee on which I sit is having its opening hearings on immigra-
tion right now with the Attorney-General. I would like to join my
colleague, Senator Kennedy, in welcoming the New York members of
the panel. I understand he did that when he introduced you to the
subcommittee, which I greatly appreciate and ask you just these two
questions.

One, it seems to me that the bill does not go as far as the report, and
in terms of the facilities which are to be created,

Nonetheless, is the panel favoring the bill as being the best in this
imperfect world, or does the panel feel, if any of us are so minded, that
we should insist on bringing the bill up to the report ?

Dr. Wrieur. In answer to that question, I believe that there are
certain aspects which—some of which, I have already mentioned—
which should be included in the bill, and which are part of the rec-
ommendation of the Commission. I think that we must strengthen
it in some aspects. For example, we need more finances for training.
If we don’t train people we will not have the manpower to man this
program. They run parallel. Mr. Folsom also made one or two
suggestions which I thought were worthy of considerations by the
committee, — ,

Senator Javits. We will go over the testimony and take very seri-
ously the areas in which you feel the bill needs te be upgraded. "I cer-
tamly will and I am sure others will. .

Dr. DeBaxey. Senator J. avits, may I simply state after 9 months
of study by this Commission, and thesé are all members of this Com-
mission, of course it is perfectly natural for us to feel that the bill is
deficient in the areas in which it did not meet the Commission’s recom-
mendations, and I would say very definitely to you in answer to your
question that we would like to see the bill conform more closely to the
recommendations of the President’s Commission.

Senator Javrrs. May I make a suggestion, gentlemen. After read-
ing your testimony if you find that you have not sufficiently, in your
judgment, pinpointed exactly the items with reference specifically to
the bill that you feel ought to be amended, it is requested that you
put in writing a memorandum specifically pinpointed to the sections
of the bill as to what you believe should be done. I ask unanimous
consent, Mr. Chairman, that this memorandum may be made part of
the testimony. ,

The Carman. Without objection that memorandum will appear
in the record, including your testimony this morning.

Senator Javrrs. I have just one other question.

I am very deeply interested as others of us in the question of nar-
cotics addiction. Did the Commission give any consideration to how
any work in narcotics could be tied into their efforts? -

For example, was such consideration given either as to research or as
to any combination of research and clinical training or any combina-
tion of research and outpatient training? One of the appalling things
about narcotics addiction is that mighty little is being done about the

  
 
   
  
   
 
 
 
 
 
  
  
   
  
 
 
  
 
  
  
 
 
 
 
 
  
  
  
  
   
 
 
 
  
   
 
 
 
  
 
 
 
  
 
 
  
 
   
 
 
 
 
  
  
 
  
  
 
  
  
  
 
  
 
  
  
 

130 COMBATING HEART AND OTHER MAJOR DISEASES

basic question of either cause or cure, and I just wondered whether you
gentlemen gave that any consideration.

Dr. Wrieut. I don’t think anyone with any knowledge of medicin
or knowledge of what is going on in the world today could say any
thing but be in complete agreement with your statement of the impor
tance of narcotic addiction.

The Commission did not consider this as one of its items because th
Commission as given to us by President Johnson was specifically fo.
heart disease, cancer, and stroke.

It is true that people with cancer and people with some types of vas
cular diseases have so much pain that addiction is something that w
have to guard against at all levels, and I think most physicians dc
But there is not the real essence of the problem of narcotics, and_
think this should be a matter of a separate bill and a separate stud
of major importance, if I may say so.

Senator Javrrs. Thank you very much. Thank you, Mr. Chairmar
I deeply appreciate your courtesy.

The CHamRMAN. xu right, Doctor.

Dr. Waientr. I was discussing the relationship of training to re
search problems. I would like to mention here, if I may, just one sec
tion of our report. This is on page 14 and thereafter, in which it point
out that the NIH budget has only been increasing at the rate of 4-
or a little more—percent per year. The National Heart Institute buc
get was decreased by $15 million last year.

I would like to place in the record that an increase of 4 to 6 percer
in the budget per year for the development of a really aggressive re
search program is completely unrealistic. This is what it costs to kee
what you have going. Once you are embarked in a research projec
as I have been, and Dr. DeBakey and others in this group, you find ot
that the cost of equipment is going up, and the cost of salaries goes up-
more than this; annually you fight to have well-trained people. The
have to be paid more as years go by just like everyone else in industr
or professional life. Therefore, 4 to 6 percent is a totally inadequat
addition. The estimates of the Advisory Heart Council, a most at
thoritative body, runs considerably higher, closer to 20 percent. Th
is required at this point when we are trying to develop a national pr
gram of this magnitude.

The fact that the National Heart Institute has been budgeted in suc
a way that training programs have been markedly curtailed mstea
of being increased is a matter which should be completely revise:
A marked increase in training grants should immediately |
authorized.

The trainee programs and research fellowship programs of the NI
have been confined primarily or almost completely to those who a:
training for basic type research. Now we are going to need a very lars
number of physicians who are trained for clinical or applied researc
and the care of patients in the special areas of heart disease, cance
and stroke. Therefore, we should emphasize the importance of esta
lishing funds for clinical traineeship so that we develop thorough
well trained teachers and practitioners in these areas to take positio:
of leadership in stations and in centers

The Cuatrman. Doctor, I think you will find that the Nation

Institute on Mental Health has carried on this very training y
speak of.

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COMBATING HEART AND OTHER MAJOR DISEASES 131

Dr. Wricur. Yes, sir; they have,

The Cuarrman. But they have not done it in the Heart Institute; is
that correct?

Dr. Wricut. That is correct. The Heart Institute, the Cancer Insti-
tute, and the Nati i

tional Institute of Neurological Diseases and Blind-

€ Commission also recognized the need for developing scholar-
ships for young men who want to go into medicine. I want to second
that heartily. “The development of the doctors of the future should
not be on the basis of family finances, it should be on the basis of the
capability of the individual. This, however, should not be on the basis
of grades alone but should also include consideration of evidence of
character suitable for the exacting standards of this profession,

en they succeed in getting through the medical school they also
face the need for specialized training to be leaders in these major fields
that cause more than 70 percent of the deaths in this country. We
have to provide manpower if we propose to develop great facilities,
This is vital.

The Carman. I would certainly agree with you, Doctor, and I
think for the record I should say that in the last several years the Con-
gress has appropriated more money for NIH—for the Institutes, and
the NIH—has Invested, shall I say, more money than has been used—
they have had surpluses; the cause of those surpluses I am not pre-
pared to go into at this moment but we have given them more money
than they have used in the last several years,

r. Wrigur. Yes, sir. This is true’ in a sense but the Bureau of
the Budget gets inte the act,
he CuarrMan, Undoubtedly ; yes, sir.
Dr. Wricut. And the NIH does not actually have as much money to
use as Congress appropriates and intends to Be used for this purpose.

The Cuarrman. You speak of a very unportant factor when you
speak of the Bureau of the Budget, Doctor.
. Wricut. Yes, sir.

he Cuarrman, ery important.
just want to make the record clear, though, that Congress had

appropriated these funds that had not been expended.
r. Wrieur. Yes, sir.

The Cuairman. I like the word invested. You would agree with
me?

Dr. Wricut. That isa very good word.

The Cuaran, Invested:

Dr. Wrigur. May I make two further points and then conclude my
statement, sir?

The Cuarrman, Yes,

tion. The medica] profession is literally overwhelmed by the thou-

sands and thousands of medical articles that appear monthly in this
country and abroad. Some of them aren’t worth reading but many

of them are and to particular individuals they are the lifeblood of
intellectual progress,

  
  
 
 
 
 
 
  
   
    
   
 
  
  
    
  
 
  
  
  
 
  
   
  
  
  
 
 
  
 
 
  
  
  
     
   
 

132 COMBATING HEART AND OTHER MAJOR DISEASES

 

Therefore, we must develop a way to resolve this problem into a
crystallized form so that the physician or medical scientist at every
a get the meat out of the total mass of material that is pub-
ished.

And lastly, I speak particularly for Dr. Helen Taussig in this but I
am in complete agreement, more interest must be shown in the de-
velopment of animal research facilities.

In the past animal research has too often consisted of housing the
animals in a shed or a barn under very poor conditions. They develop
all kinds of diseases. Frequently nobody knows what the diseases
are except they kill off a lot of experimental animals often ruin-
ing great research programs. Some of the diseases are known, many
are not understood. It is high time that in our program development
we must allow funds for modern animal care. If we are going to
carry on research with animals it is no good if half the control ani-
mals die off because they get infected, in unsterile quarters.

I now conclude by pointing out that what is learned elsewhere in
the world in medical research can be applied to American citizens.
Therefore, international research and international relations in the
field of medical sciences is absolutely essential for us to get out of the
world’s total information the maximum benefit that can be applied to
the American public.

Thank you very much.
~ The Cuarrman. Thank you.

- Dr. DeBaxey. Thank you, Dr. Wright.
T would like to now call on Dr. Rusk to testify next.

STATEMENT OF HOWARD A. RUSK, CHAIRMAN, SUBCOMMITTEE ON
_ REHABILITATION, PRESIDENTS COMMISSION ON HEART DIS-
_ EASE, CANCER, AND STROKE

Dr. Rusk. Senator Hill and gentlemen, I, too, am grateful for the
privilege of testifying before your subcommittee. J was Chairman
of the Rehabilitation Subcommittee and on my Committee were Mr.
Folsom, and Mrs. Harry S. Truman. ,

We met with every other subcommittee in addition tq many hearings
with specialists from all over this country.

We were told by President Johnson that this Commission should
investigate the problems of heart disease, cancer, and stroke in three
areas: research, training, and service. My particular interests and
that to which rehabilitation is dedicated is service to the patient—
somebody who has been too late for research as far as he is concerned.
Our program is designed to train him to live the best life he can with
what he has left. As you well know, in this modern concept, this pro-
gram started in 1943 with the amendment to the old Vocational Re-
habilitation Act, and has grown very rapidly during the past decade
because of the great understanding and support of the Congress in
this program.

The most heartening thing to me personally that came out of this
Commission report was the fact that every subcommittee unanimously
said that any complex or station has to be underpinned by a compre-
hensive rehabilitation service for the benefit of the patients who have

 

 
 

sm into a
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ut is pub-

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ress in

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COMBATING HEART AND OTHER MAJOR DISEASES 133

reached maximum improvement and for whom prevention has not
been possible.

In order to provide. this, the Subcommittee addressed themselves
to this broad problem—to a review of what we have and what we
would need—to provide these services over the next 5 years. oo,

I would like to give three short illustrations. Rehabilitation in
cancer has been sadly neglected in the past. The numbers rehabilitated
under the Federal-State vocational rehabilitation programs have been
infinitestimal because we have been so concentrated on the needs in
orthopedic and neurological problems.

One evidence of the great need of rehabilitation for the cancer
patient is that the colostomized patients formed an organization called
Colostomies Anonymous in order to share with each other the knowl-
edge they had gained the hard way. .

We had this brought to us very vividly within the last 4 weeks in
our own institute when two patients were referred to us by Memorial
Hospital. They were said to be the second and third patients in
medical history to have survived an operation known as hemicolec-
tomy. These individuals had cancer of the bladder that had spread
into the pelvis and they were given one of two alternatives—3 months
to live in pain, or an operation that, if the disease had not spread to the
upper glands, then half of the body would be amputated just above
the pelvis.

The first man, a presser and tailor, chose to be operated and half
of his body was amputated. He survived and he came to us about 4
weeks ago. He is now sitting up in a special plexiglass shell. He
works in the gymnasium 2 or 3 hours a day. My prosthetic colleagues
tell me that they feel that legs can be made for him so that he can
ambulate, drive a car, and the head of his union hag already promised
him a job.

The second came to us 2 weeks ago, a 42-year-old schoolteacher with
the same condition, who also survived and who we think can be re-
habilitated back into life again. ,

In rehabilitation of stroke cases we have had considerable experi-
ence. We can’t rehabilitate an individual with such brain damage he
can’t remember today what he was taught yesterday, or those with
such severe heart damage that they can’t take on the added exertion,
or those with uncontrollable malignant hypertension. But take the
rest, and the answer is “Yes.” A recent analysis of 3,000 patients has
shown that 87 percent can be taught to meet the needs of daily living,
and 35 percent can do some kind of gainful work and the average age
of this group was 63.

We are very heartened by what can be done for these patients and
the same is true of the patients with heart disease.

Our program comes on after the stitches are out and the fever is
down, when the patient recovers from his coronary and has to go back
toanew job. We feel that we can bea halfway house to find out what
he can do within the limits of his cardiac capacity so that he can’t
harm himself but become a productive citizen.

I think in the past it has been demonstrated many times that re-
habilitation, which we now talk about as the third phase of medicine
is not only good medical and social practice but it also is sound eco-
nomically because we have been able to show over and over again

  

  
  
  
 
   
 
 
  
 
 
 
 
 
  
 
 
 
 
 
  
 
 
 
 
  
  
  
 
 
  
 
 
 
  
  
 
 
 
  
  
 
   
  
  
 
  
 
 
 
  
  
 
 
  
 
   
 
  
  
 
  
 
 
 
  
 
 
 
 
 
 
 
  
 
 
 
 

134 COMBATING HEART AND OTHER MAJOR DISEASES

that for every dollar invested $5 come back in Federal income tax
alone in the first 5 years after the individual was rehabilitated. V
have been able to show the same thing in hospital costs which we
fundamental to Mr. Folsom’s presentation—that a large number
these individuals can be gotten out of acute hospital beds, moved
other facilities or taken home, taken care of at home with a fracti
of the cost. ,

In order to provide these services, the commission made seve!
proposals, divided into two sections. One group will require n
legislation, including a new program of project grants to pay part
the costs of projects to expand vocational rehabilitation programs wi
the objective of increasing the number of handicapped persons 1
cationally rehabilitated.

Now, President Johnson in his health message pointed out that 1:
ear we broke the record and rehabilitated 120,000 disabled perso:
hat is great. It was 40,000 in 1945. “My 1966 budget will prop

increased funds to rehabilitate an additional 25,000.” ‘That is we
derful, too, but when you realize there is a backlog of more than 2 m
lion and when we get 250,000 new cases a year you can see that —
are not making great, progress very rapidly, and this is primarily d
to the fact we don’t have the people and we don’t have the faciliti

The other points requiring new legislation I will summarize: T
first would allow us to take patients 6 months or longer to try
determine their rehabilitation potential. You can’t examine peoy
and in 3 days or 30 days tell who can and who can’t. This is a re
tively simplo thing which would, I think, get a great many peo}
back into productive life again.

Then grants for construction of rehabilitation facilities and wor
shops, and last an authorization for Federal financial participation
activities which are financied by local public funds as well as St:
public funds, which we feel would broaden the base of this progr:
tremendously.

The price tag on the program recommended under present law,
expand programs to reach more heart disease, cancer, and stro
victims, would come to $1214 million a year, or, around a $78 milli
total with gradually increasing increments over a 5-year period. U
der the new legislation I have outlined, it would require $10 million t
first year, and $15 million for 4 successive years or a total of $1
million approximately to do this total job.

I think one of the most important things in this bill that I wot
like to reemphasize, that my colleagues have all spoken of, is provi
a nucleus for continuing education of the physician which is func
mental if the level and quality of medical care is not only to be ma:
tained but improved.

As far as the bill S. 596 specifically is concerned, I think it is 1
fortunate there is no mention of rehabilitation m the bill. The rep
has shown the action of the subcommittees and our recommendatio
the necessity for underpinning all of these various programs by
comprehensive rehabilitation service and I think this should be
stated.

I think also in the recommendations fer the Advisory Council 1
bill should include someone skilled in, and dedicated in, the field
rehabilitation.

 
 

wT

COMBATING HEART AND OTHER MAJOR DISEASES 135
taxes The Crarmsan. Doctor, may I interrupt you there?
- We Dr. Rusk. Yes.
| were The Cuatrman. Woe are supposed to have another bill on this whole
er of matter of rehabilitation and f hope we can have that bill from the
ed to administration. I can assure you if we don’t get an administration
ction bill, we still will have a bill.
Dr. Rusx. Thank you, sir.
vera] I would just like to conclude by saying that we have to have more
new people in this field. We are shorter, I think than any other field in
rt of medicine. We feel that we are a service to the other specialties in
with medicine. We are excited about this opportunity for service because
> VO- i it broadens the present regional rehabilitation center Pp m which
last | you and your committee established some 6 years ago and which has
as i i

ons. i that: these complexes are designed to go forward in heart disease,
pose cancer, and stroke.

ron- ank you very much,
mil The Cuairman. Thank you.
ine (The prepared statement of Dr. Rusk follows :)
ue
he STaTEMENT oF Howarp A. Rusx, M.D.
8
to Mr. Chairman, thank you for the Privilege of appearing before the com-
J, mittee as a member of this Panel today. I am happy to offer the following
pie statement for the record in connection with these hearings,
la- For anyone deeply concerned with improving diagnostic, curative, and re-
3le habilitative care for the American People, the bill before the committee is of
tremendous importance. J know that the committee has before it a complete
k citation of the statistics Surrounding these three diseases and the tragic inroads
: ~ they are making into the health, well being, and productivity of the American
n people.
te I should like to highlight the opportunities we now have to create expanded
and modern rehabilitation programs to deal with disabilities resulting from
m

‘At present several Government agencies are doing valuable work to assist
0 practitioners, hospitals, local, and State agencies to provide more and better
re rehabilitation for the disabled people they serve, Among these are the Voca-
" tional Rehabilitation, Administration, the Public Health Service, the Children’s
Bureau, and others. I believe this bill, if enacted, will fortify all of the work

being done by these agencies.
e The proposal to establish a series of regional medical complexes for research,
3 teaching, and patient care for heart disease, cancer, and stroke patients can
have far-reaching effects in our efforts to secure new knowledge, elevate
the quality of care, and greatly augment our supply of well-trained experts

habilitation into these complexes, I hope the committee will make clear the
importance of doing this. It would be a tragedy if thousands of young physi-

 

the rest of their professional lives.

In relation to these proposed complexes, the Commission also recommended
that the special rehabilitation research and training centers now in operation
in several places in the country be expanded to permit them to operate at their
full potential. 1 presume this proposal ig being considered—and I hope favor-
ably—by the Department of Health, Education, and Welfare with a view to

 
Neen een eee ee eee neeeneen eee ee nnn ey

136 COMBATING HEART AND OTHER MAJOR DISEASES

ices. This should be an essential part of complete diagnostic and treatment
Service; it also becomes the vehicle by which these patients, upon discharge, can
be regularly integrated into the community rehabilitation programs, including
the Nation’s network of State vocational rehabilitation agencies. This post-
hospital care is a critical need for large numbers of heart disease, cancer, and
stroke patients. We must have better provision for this kind of aftercare
in the community, both for those who will be capable of employment later and
for those whose objective is a satisfactory functional and social life,

The bill also provides for a National Advisory Council on Medical Com-
plexes. I urge the committee to make specific provision in the bill for at least
one of the members to be a person who is outstanding in the rehabilitation of
heart disease, cancer, or stroke patients,

Again I thank the committee for promptly considering this important legis-
lation which is certain to be an outstanding contribution to the improvement of
the health and well-being of the American people.

The Cuarrman. Dr. DeBakey.

Dr. DeBaxey. Our next witness is Dr. Meyer.

_Senator Hi. I would like to say that he is not only one of the
distinguished and pioneering men in this field, but I might say that
his subcommittee brought out beautifully the striking example of the
gap that exists today in the knowledge available, for example, in this
field of stroke, and the application of this knowledge or the lack of
application of this knowledge to a large segment of patients suffer-
ing from this disease.

STATEMENT OF DR. JOHN STIRLING MEYER, CHAIRMAN, SUBCOM-
MITTEE ON STROKE, PRESIDENT’S COMMISSION ON HEART DIS-
EASE, CANCER, AND STROKE

The Cuarrman. Dr. Meyer.

Dr. Mryer. Senator Hill, it is a great honor to appear before your
subcommittee.

I would like to testify in strong support of this bill, S. 596, in gen-
eral, and particularly as it applies to the program of stroke.

The Stroke Subcommittee included Dr Howard Rusk, who is
presently here today, and we had appear before us representatives
of all those people in the United States who are considered to be
expert in the stroke field. These included Dr. Houston Merritt, of
New York; Dr. Denny-Brown and Dr. Charles Kane, of Boston,
Mass.; Dr. Champ Lyons, of Alabama; and, of course, Dr. DeBakey
himself, because not only is he expert in the field of vascular surgery
elsewhere in the body, but also in the treatment of strokes.

Our Stroke Committee report is submitted here as part of the testi-
mony, and it is the part from volume II which is fairly extensive.

The summary of what I would like to bring in testimony today, sir,
is that stroke is a neglected field. I do not think there is a more
neglected area in modern medicine. . ;

lot of people do not know what a stroke is. A stroke is an inter-
ruption of the blood supply to the brain. It may be due either to
hardening of the arteries with a thrombosis or blood clot with ocelu-
sion, or it may be due actually to a rupture, with a hemorrhage into
the brain. It is very common.

Now, I will give you some idea of the magnitude of the stroke prob-
lem in a minute, but the important message I want to get across today
is that this is a preventable and a treatable disease, and it is only in
 

 

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large, can
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COMBATING HEART AND OTHER MAJOR DISEASES 137

the past decade. that we have come to realize that this is not only a
preventable and a remediable disease, but it-is ‘also’ a diagnosable
disease in the warning state before you have a catastrophic occlusion.

In my opinion, one of the greatest clinical discoveries in modern
medicine in the past 10 years has been the recognition of the warning
stages of strokes. It is probably as revolutionary as the recognition
of angina as the warning of a heart attack, and we realize now how
terribly common these little warning strokes are, and that something
can be done about it.

This includes medical as well as surgical treatment, and with the
modern advances of arteriography, which are the outlining of the
blood vessels to the brain by dye, and taking X-ray pictures we can
confirm the diagnosis with extreme accuracy, and it turns out that
about two-thirds of the cases have lesions or trouble in the blood ves-
sels in the neck which the surgeon can get at very easily. This came
as a big surprise to all of us, even though we had been working in
this area for many years, we did not realize how common this was.

We are also coming to recognize, by the application in a small way
of pilot programs such as are recommended in this bill, how frequent
is the association of hypertension, a treatable condition, with stroke.

Eighty percent of cases with stroke have hypertension and this, of
course, is a treatable condition, and will prevent strokes.

Diabetes is another commonly associated disease with stroke. We
also know now of drugs which will increase blood flow to the brain
in patients with stroke, and in the past decade we have come to recog-
nize the value of surgery in the treatment of this condition for the
first time.

A word about the magnitude of the problem. This is an immense
public health problem: the field of stroke. There are over 400,000
new cases of stroke each year in the United States, and this is a gross
underestimate. ’

Of these, at least 200,000 die. There are at least—and this again
is a gross underestimate—in my opinion, 2 million cases of stroke in
the United States who are disabled at the present time. -

Now, the cost to our Nation is enormous for the care of this type of
disability as well as the loss of work capability in people often in the
most productive period of their lives, oo

What are our plans in this bill to do something about this problem ?
We want to provide a national network of centers and stations that
are expert in the. diagnosis, treatment, and preverition of strokes.

First of all, the centers: We want to provide by this bill 15 regional
centers located primarily in university or medical centers which will
be established over a 5-year period ata cost’ of $85.5 million, approxi-
mately. This is not a lot of money when you think of what it can do.

We also propose 100 community stations at a cost: of about’ $77.75
million over a 5-year period. ae ct

These stations can often be‘ combined’ with the heart stations that
were mentioned by Dr. Wright in order-to share facilities and save

money. Tt is this type of organization, an aspect that éan be pro-
vided by our experts in the Public Health Service of the Federal Gov-
ernment, to conserve money, facilities, and manpower that Mr. Fol-

som alluded to earlier.

   
 
 
  
  
  
  
 
 
     
  
 
 
  
 
  
 
 
 
  
  
  
   
  
 
 
 
 
  
 
  
   
 
 
 
  
 
  
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
  
 
  
  
 
  
   
 
  
  

   
 
 

138 COMBATING HEART AND OTHER MAJOR DISEASES

Now, I want to make clear the difference between a center and a
station. A center is primarily concerned with research, determining
new causes of diseases, and improving our knowledge of prevention,
diagnosis, and treatment.

The stations are primarily concerned with development of commu-
nity resources to provide the best. possible medical care and _applica-
tion of knowledge which Senator Kennedy stressed as being so
important.

Now, you can well ask will these work? Well, I can tell you they
will work. We have got three centers for stroke in the United States
today. I am fortunate in having one of them in Detroit at Wayne
State University.

Dr. Irving Wright, on my left, has another one at Cornell, and there
is another one in Minnesota, under Dr. A. B. Baker.

Now, there is no question that these stroke centers are working ex-
tremely well. They are supported by the U.S. Public Health Service,
and we have learned a great deal.

We have a collaborative study in the surgical treatment of stroke
that has been chaired both by Dr. DeBakey and Dr. Champ Lyons. (I
am the secretary) and we know now on the basis of 3,000 to 4,000 cases
what to expect from various types of treatment of stroke, and I myself
in my own institution now have data on 150 cases of randomized,
surgically treated cases compared to medically treated cases.

We can now show data which is getting to the level of statistical
significance where certain forms of surgery can be proven to be valu-
able in this disease. Furthermore, we have another randomized, con-
trolled study of medical treatment which shows the vasodilator com-
pounds may be valuable in the treatment of acute stroke on the basis
of purest scientific statistical data, which is the best type of data one
can possibly have. This is what these centers will make available.

Now, a word about organization: I submit to you that these centers
related to research and investigation are best organized and under the
supervision of the National Institutes of Health, using an extension of
the existing double review principle of an advisory council and study
review committees or scientific committees.

-I would submit, sir, in my. opinion that the stations, the stroke
stations, should be related jointly to a committee of the National In-
stitutes.of Health and the Bureau of State Services: working coopera-
tively.

The point is this is.not a.competition for power or control. It isa
united effort to improve the health of our country and it is a great
responsibility.

I wonder if I might just. mention one word about manpower and
then, sir, I will be finished.

Naturally, we are all concerned about manpower because we are all
short of experts in medicine. The whole of medicine is understaffed,
we know that, we want to improve the men available in medicine, and
that is being discussed.today.

Dr. Rusk has pointed out the shortage of personnel in rehabilita-
tion. This is true in neurology, which happens to be my specialty ; we
are short of neurologists.

But I do not believe this program in this bill is going to create any
manpower shortage. What it will do in the stroke field is that the
 

 

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iter and a
terminin
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f commu-
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you they
ed States
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ervice,

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00 cases
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centers
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re all
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and

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any
the

hese. patients are already being taken care o
and it will not alter the present pattern. of medic
States, but make it more efficient.

Thank you, Mr. Chairman.

he CHarrMan, Talking about the manpower question, Doctor,
if I may ask you, did you have the Opportunity or did you give con-
sideration to the question of salaries for your Federal staffs? I am
thinking particularly in terms of NIH now. @ have lost so many
good men, as you know, at NIH, and due, I think, in large measure
to the inadequacy of the salaries. Did you consider that ?
r. werER. Dr. DeBakey will answer that.
The Cuamman, All right, Doctor.
Dr. DrBaxnry, Senator Hill, I can speak about that. Ihave spoken
about this matter before your committee previously.
he Cuamman. That is right.

Dr. DeBaxry. You will find in the Commission’s recommendation
a strong proposal in regard to this mat

ter, strongly recommending
that this need be met,

here could be no question about the fact that there is urgent need
in the opinion of the Commission members, because they made a very
strong appeal in their report to the President that this need be met.

I think it is extreme y important that an effort be made to pro-
vide adequate salaries at sufficient levels to compete with ongoing
salaries for these people. This, I think, constitutes an important
element of the total program because, without these people to hel
administer and develop this program, it will have great difficulty in
being implemented property. I think it is an extremely important
int.

f by the physicians
al care in the United

report, did you?

r. DeBaxry. We gave great emphasis to this in our r

ave in previous testimony before your committee.
The Cratrman. Yes; I know that.

Dr. DeBaxzy. In that testimony I have pointed this out on a num-
ber of occasions. think this is an- urgent problem.

e Cuarrman. I quite agree with you. Iam glad yow used that
word “urgent.” Tt certainly is urgent. We are losing more and
More people all the time due to this inadequacy of the salary level ; is
that not.true?

Dr. DeBaxey. That is exactly correct.

e CHatrman, Deetor, let’ me ask you this: Could you give us
Some estimates of the cost of operating a: regional medica] complex ;
what would be the first-, second. third-, fourth-, or fifth-year course:for
the 32 regional medical compl

exes recommended by your Commission ?
Dr. DzBaxny, Senator Hill, in our Commission’s.recommendations
Wwe proposed a total of 19-regional centers in heart disease, cancer, and
stroke during the first year at a cost of $87.5:million,

OW, We projected: our program. over 4 S-yea,

eport, and I

  

  
 
 
 
 
  
 
   
   
 
   
   
 
 
   
    
 
  
   
  
 
 
 
  
 
  
 
  
 
    
   
  
  
 
 
  
   
  
   
  
  
   
 
 
  
 
 
   
   
   
 
   
 
 
 

i el ——————

140 COMBATING HEART AND OTHER MAJOR DISEASES

- This is because we recognize that this type of program in the mag-
nitude envisaged would require time to develop. You could not get
all of this entire regional network covering the entire country of
regional complexes, centers, and stations developed in 1 year or 2 years,
but over a 5-year period we would hope to have the numbers that
we stated. That was the best estimate that we could come to from the
studies we gained. LS

So that over a 5-year period we would hope to develop some 60
regional centers, and 550 total stations at a cost of—we are including
the medical complexes at a cost of—$1.6 billion over the 5-year period.

The Cuarrman. Over the 5-year. period ?

Dr. DeBaxry. That is right. Now, in this respect we would hope
that this bill would lead. to that development. I want to say very
clearly, Mr. Chairman, that we are strongly in support of this bill as
it is written here. There are a few, perhaps, modifications in word-
ing, as has been indicated, that might be made to strengthen it, but we
would like to see this bill endorsed and approved by.Congress because
it does provide the basic need to get this program started.

And while, in the opinion of the Commission members here, it may
not meet the full need, it does begin the program, and we would hope
to see it started, certainly in the manner in which it is indicated here.

We have indicated in our Commission report to the President what
we estimated would be the total need over a 5-year period, including
what we estimated to be the cost.

It is obvious, too, that the average cost of one of these centers may be
developed from the figures we gave, but this would vary because of the
local needs. One place might cost maybe $1 million to get a center
started and operated, whereas in another place it might cost as much as
$3 or $4 million, but the average total cost is indicated in the budgets
we have proposed as estimates of needs.

The Cratrman. What were the two modifications you addressed
yourself to, Doctor?

_ Dr. DeBaxey. Well, one of the modifications I would hope that we

indicated is that we believe, as we indicated in the Commission’s rec-
ommendations, that in the National Advisory Council on Medical
Complexes be established. In this bill, S. 596, this is indicated in per-
missive language, but we would like to see it definitely established. We
would like to see this done because we believe that the experience of
the National Institutes of Health in this program—and I think it is
important to recognize that this experience has been extremely help-
ful in bringing us to this point—it has really brought us to this point,
at which it is possible now to develop this program. Were it not for the
work of the National Institutes of Health in establishing the support
of medical institutions in this-country, both for research and training
and in establishing clinical research centers as well as special research
centers of other types, we. would not be in the position today:to mount
a program of this kind.

I think it is important to recognize this program is not unrelated to
well developed and highly successful ongoing programs, as is indicated
by the report of the: President’s:Commission. There are other specific
recommendations that are:made to support these ongoing programs and
to expand them and develop them further, and I would hope, Mr. Chair-
man, that this bill will not be recognized as completely unrelated to
other activities.

 
 

   
  
 
  
  
 
  
  
  
  
  
 
 
 
  
  
  
 
 
 
 
 
 
 
 
  
  
 
  
   
 
  
 
  
 
 
  
 
  
  
  
 
 
 
  
  
  
   
  

a

3 COMBATING HEART AND OTHER MAJOR DISEASES

 

14]
the mag- I think it is important to recognize that there are other supporting
d not get mechanisms that will need additional funds:as we have indicated,
untry of just cite as. an illustration, Mr. Chairman, the recommendation
r 2 years, we make about the library. Here, for example, is one important aspect
bers that of the under inning of effort that is necessary to mount this pro-
from the gram, and to Eeep it going and to develop further knowledge which, of

course, will be applied at a later date.
Some 60 The Cuamman. Some of your recommendations can be carried out
neluding under existing law, is not that true?
r period, Dr. DeBaxny, Absolutely; and I think this is very important to
Tecognize, and indeed in the report to the Presideni’s Commission
ld hope we bring this out... There is no need for legislation for many of the
ay. ve Programs that are already in operation. They simply need to be ex-
s bill as panded, to be emphasized further, to be developed further.
1 word- There is need for legislation, and there is need for this specific bill,
but we and itis extremely important t at we recognize that his bill will make
because it possible to develop this regional network. Without this bill I doubt
. seriously that we could ever mount this program,
it may © -HAIRMAN. Do you have something to add, Dr. Farber?
d hope v. #ARBER. Tam in hearty agreement with Dr DeBakey. He stated
1 here. this very clearly,
t what at is new about this that we cannot do without this bil] is this
luding regional network which starts a totally new kind of activity which is
directed toward the expansion and extension of what we have been
1ay be oing through the N. ational Institutes of Health until now But this
of the network has a, very specific goal, a purpose, which is not implicit in
center anything else that is now presently supported from other sources,
ich as © VHAIRMAN. Well, now—_
dgets Dr. DeBaxny, Mr. Chairman, I would like to take advantage of this
Opportunity which you have offered us to present a supplement
essed € Carman, Todo what, sir ?
Dr. DeBaxnry. To present a supplemental Statement should you
it We like for it to appear in the record later,
rec- The Cuamman, Good. We would be happy to have you do that.
lical Dr. Wright, you had something ?
We r. Wrieut, Lest there be Some apprehension in some quarters re-
e garding this development of the regional complex, I would like to re-
e of emphasize the point made by the committee repeatedly that, for the
it Is Most part, these complexes ‘are to be built within the structure or
elp- Closely associated with the structure of the leading medica] centers and
Int,, schools of the country and not as a separate institute,
the he Cuarrman, ' Ys, Well, you are going to take advantage of
ort and use to the maximum, I'take it, what wenow have?
ng Dr. Wriaur. That is right. .
rch The Cuairman. We have a lot of good Programs, do we not?
mt DrBaxpy, Absolutely, ,
The Cuamman, We had a former king come all the way from
to Europe over here to a medical center, I have seen the time—no, I
ed have not seen the time, but I have read about the time when he would
fic have gone to Berlin or Vienna, or maybe Paris or London or even,
rd perhaps, Edinborough ; is that right?
e Tt. DeBary, Yes.” oO
(0

 
 

The Cuarrman, Have you seen the time, Doctor?
43--669—65 10

    
 

ell ] |

142 COMBATING HEART AND OTHER MAJOR DISEASES

I withdraw that. Now Doctor, as I foresee this. program here, the
two big questions we are going to have in the consideration of this
legislation, I am not thinking entirely of this committee, but. 1 mean
on the floor of the Senate, and as it progresses. through the House of
Representatives and the committee over there, and everything, one
is going to be this matter of what is it going to cost? That isa very
easy question to ask, and a very pertinent question, too, and the other
is going to behow is it going to be administered ¢

What are you going todo? You heard former Secretary Folsom’s
testimony this morning. It would seem to me that certainly most of
this administration should be and ought te be in connection. with the
NIH, is not that true? Would that be your thought as the Chairman
of this Committee?

Dr. DeBaxer. Well, I would say this in that regard, Senator Hill.
The NIH has had an extraordinary experience in dealing with the
medical scientific community of this country. It has been an extremely
successful experience.

It has promoted the level of medical care as well as the level of medi-
cal science in this. country to its present position of eminence.

Indeed as a consequence of these developments in medicine greater
advances have taken place during this period than in all previous
recorded history. This has been largely due to the support and the
activities and the kind of organizational development that has taken
place in the National Institutes of Health.

For this reason and because this program is so intimately related to
the ongoing programs of the National Institutes of Health, with the
exceptions that you pointed out, I would think it ought to be extremely
closely integrated with that program, if not immediately and directly
under that program.

The Cualrman. Just as.in the matter of physical rehabilitation,
we know what has been done by the Office of Vocational Reha-
bilitation—

Dr. DeBaxzy. Yes.

The Cuairman (continuing). Under the leadership of Dr. Rusk,
Miss Mary Switzer, of course, and you would want to make maximum
use of the knowledge-and experience you gain there by working right
with the Office of Vocational Rehabilitation; is. that. cérrect ?

Dr. DeBaxex. Exactly.

The Cuamman. Do. you gentlemen. have any further thoughts to
suggest. on this. matter on. the: administration of these programs?

Dr. DeBaxey. Well, we.can—we have already indicated, I think,
for the: most. part, what. our feelings ars.in this regard. We show in
the President’s Commission. in general our regard for this. If you
would like, we can present to you a supplemental statement in. this

regard.

The Cuarrman. I wish you would do that, Doctor, because,.as I say,
the two questions that are going to-be asked as-this:legislation proceeds,
are the question of administration and the question of the cost.

Dr. DeBaxey. We.can. specifically point to those two questions in
our supplemental statement..

The Cuarrman. Good.

(The supplemental statement referred to follows:)

 
a, <a

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ons in

 

COMBATING HEART AND OTHER MAJOR DISEASES 143

SUPPLEMENTAL STATEMENT SUBMITTED. By Dr. MicHAEL E, DEBaxkrEy

Hon. Lister HILt,
U.8. Senate, Washington, D.C.

Dear Senator Hi: As Chairman of the President’s Commission on Heart
Disease, Cancer, and Stroke, I appreciate the opportunity to further clarify sev-
eral questions which were raised during the hearings on February 10 on 8. 586, the
bill you introduced to implement the President's. proposals in the fields of cancer,
heart disease, and. stroke,

We regard these proposals, embodied: in S. 596, as an excellent beginning toward
the ultimate goal which President Johnson clearly enunciated in his historic
health message of January 7, 1965, to the Congress. In that message, President
Johnson said:

“Today we are. challenged. to meet and master the 3 killers which alone
account for 7 out of 10: deaths in the United States each year—heart disease,
cancer, and stroke. The Commission on Heart. Disease, Cancer, and Stroke has
pointed the way for us toward that goal.”

Thus, in giving our strong support for the passage. of this bill, we can repeat
the statement we made to the President in submitting our Commission report to
him that it is our “deep conviction that. its. immediate implemenation will not
only narrow appreciably the spectrum of.our ignorance, but will contribute to the
saving of thousands upon thousands of American lives now needlessly sacrificed
to those three deadly enemies of mankind.”

Early in the deliberations of the Commission, its 28 members resolved that
we would make no major recommendations unless they were accompanied by
specific price tags. We realized the difficulties involved in that decision and the
burden it would place upon our technical staff, but we strongly felt that it would
be irresponsible to present to the President and to the Congress major recom-
mendations in these areas without indicating our best estimates of what they
would cost.

We also made a considered decision, after much deliberation at several Com-
mission hearings, that it. would. be equally irresponsible to present just a 1-year
estimate of the costs of our proposals. As we stated a number of times in the
Commission report, the fight against. these three major killers of mankind will
not be won overnight. We therefore voted to present 5-year cost estimates wher-
ever possible, realizing that to. go much. beyond the fifth year would involve us
in more speculation than precisiom..

On. pages 78. to 83 of the first volume of the Commission report, there are
specific cost estimates of every one of the major recommendations we adopted
at the final Commission meeting last fall. (See app. B, p. 295.)

On page 79 of the report there is.a specific breakdown of the 5-year costs of
establishing a. network of regional: medical complexes. The 5-year cost is esti-
mated: at.$1.6. billion. This: overall estimate: is further broken down into the
specific yearly costs of the complexes and their component parts—the regional
centers.and the diagnostic and treatment stations.

We. do not regard these cost estimates as absolutely rigid or immutable. They
are the best estimates: we. could come up with. after making: several. national
surveys of prototype: centers.. The estimates are, however, the Commiassion’s best
judgment after 9 months. of study. and 7,500. pages of testimony garnered from
close to: 200 witnesses: representing: all segments of the medical and scientific
community.

We realize that. the:executive:amd legislative: branches of our National Govern-
ment must make their own: independent evaluations of the importance and
validity of these: recommendations. We folly understand. that there are many
other worthy programs competing for support out. of our total Federal tax
revenues: but we maintain, as' we pointed: out on page 27 of the report, that the
$42. billion which: these: diseases cost.our economy each year mandate a sizable
offensive to cut down thése losses. We had the valuable assistance of the
President’s Council of Econemic Advisers: and of many of the Nation’s. most
distinguished economists in: developing these estimates. A good deal of this
eeonomic matertal. wilk appear: in: volume 2: of: the Commission report.

A second major question: raised at the hearings: concerned. the.strueture for the
administration of the regional medical complex program.

The 28-member Commission gave this matter a great deal of thought, and its
conclusions are outlined im several. sections:of volume 1 of. the report.

  
  
 
  
   
  
 
  
  
  
 
  
 
  
 
  
 
  
 
 
  
  
 
 
 
  
  
  
 
 
  
 
 
 
  
 
 
 
 
 
  
 
 
 
  
 
 
 
 
 
 
  
a

 

144 COMBATING HEART AND OTHER MAJOR DISEASES

The overwhelming majority of the Commission: Members felt that the regional
medical complex program should be tied closely to the ongoing activities of the
National Institutes of Health. For example, on page 29 of the report, the Com-
mission recommends an Advisory Committee on Regional Centers and it further
suggests that the recommendations forthcoming from this Committee be trans-
mitted to the appropriate NIH Advisory Councils to aid these Councils in. making
recommendations to the Surgeon General regarding applications for regional
centers. The intent-here igs quite clear. The Advisory Committee on Regional
Centers should be closely tied into, and call upon, the vast knowledge and experi-
ence of the existing NIH Advisory Councils in the fields of heart disease, cancer,
and neurological diseases,

- On page.31 of the report, there is a very clear statement that “the proposal for
categorical research centers for heart disease, cancer, and stroke represents an
outgrowth. and extension of an already successful Program of the National

in various parts of the Nation.” .
The present NIH Clinical Research Center program, while relatively small in
scope, is a prototype of the major innovative thrust of the Commission’s report

asked to appropriate $198 million for NIB training activities, the great bulk
‘of which fall into the clinical area. Furthermore, the President has recom-
mended $54 million for NIH fellowship programs,

Many of the members of the Commission have served, or are now Serving,
on various ‘NIH advisory councils. In drawing up the final Commission re-
port, they were deeply aware of the unparalleled experience of the National
Institutes of Health in working with universities, medical schools, independent
research institutions, and hospitals in the fields of research, training, and
the delivery of a high quality of patient care.

The consensus of the vast majority of the ‘Commission—that the National
Institutes of Health be given the major responsibility for the administration
of the regional medical complex program—wag endorsed at the Senate hearings
‘by: the American Heart Association, the American Cancer Society, and the
Association of American Medical Colleges.

The American Heart Association, which is composed of 35,000 physicians

for the implementation of the ‘regional complexes proposal. This, after all,
rests very. critically and: predominantly as has been. pointed out, on the con-

 

Segment of which is also categorical.” :
Speaking for the 28 members of the President's Commission on Heart Disease,

Cancer, and Stroke may I: express to you, and to the members of the Senate

Labor and Public Welfare Committee, our deepest appreciation for the op-

 
nal
the
ym -
her
ns-
ing
nal
nal
ri-
er,

for
na]

its

coo Pa re et Ot I e E

fe

 

COMBATING HEART AND OTHER MAJOR DISEASES 145

portunity to appear before you and to explain our detailed proposals for a
major offensive against the three diseases which remain as the major threats
to the health and well-being of Americans of all ages.

If you need any additional material I, or my fellow members of the Com-
mission, would feel privileged to supply it.

Sincerely yours,

. : MICHAEL EH. DEBAKEY, M.D.
The Cuamman. Senator Yarborough.
Senator Yarsoroven. Mr. Chairman, I have several questions. In

view of the time, I would like, instead of asking one witness several

questions, just to range these questions up and down the panel here.

Dr. DeBakey, and you gentlemen on the panel, I want to express my
appreciation for your action in coming here. I cannot visualize all the
demands upon your time that you have left but, knowing the few
experts there are in these fields, I know of the tremendous demand
upon your time—day and night, at every hour, at every minute. You
ae to allocate and do a certain percentage of what is requested
of you.

I realize—pulling you out away from this practice and from these
supervisory duties and all the many tasks you have—what it means

or you.

We appreciate it very much and I wish 20 Senators were listening
here. It is our task, as this small group on this subcommittee, to try
to carry through to the full committee some feeling of this urgency
that you have given us about the need for this. I think what we
have, of course, 1s just a token in the bill. I am thinking of pages 78
through 88 of your report here and what you recommend is needed. I
am thinking, in that context, we ought to do that. We are appropriat-
ing, in this Government, $50 billion a year for defense—$47 to $50
billion. This year it is about $6 billion for space. I have heard a
good many complaints that the space sciences are bleeding scientists

rom other fields and I think that even what you recommend here
sounds large to many Members of the Congress. But, when we con-

sider all of the billions we are pouring into space and defense, it is a

modest amount. I would like to see all of it appropriated and we

will do what we can.

Now, you, I know, with your great demands on your time, might be
limited but the organizations and associations to which you belong—
of which you have become presidents—I want to make a suggestion or
two about their efforts.

Difficult as our problem is in the Senate, it is much easier than the
problem in the House of Representatives or with the Bureau of the

udget.

Under the leadership of this great and distinguished chairman,
who has been on this committee for more than a quarter of a century,
T have been on the Subcommittees on Education and on Health, for
just 7 years. I have seen the great progress that has been made in
those 7 years under his leadership, and not merely in health but in
education, because the two fields overlap, as has been pointed out here
in so many instances.

For example, when we got the Health Professions Act through, that
relieved some of the burden on the National Defense Education Act
loans because the loans are larger to a medical student than a student
under the National Defense Education Act.

  
 
  
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
  
 
 
 
 
 
   
  
 
 
  
 
 
 
 
 
 
 
  
 
 
 
 
 
   
 

146 COMBATING HEART AND OTHER MAJOR DISEASES

So there is overlap in the two subcommittees.

We get bills out of this subcommittee and, under the leadership of
this distinguished chairman, through the full committee and through
the Senate and it is generally trimmed down there. That is nothing
compared to what we strike when we hit the House of Representatives.
That is the real meat ax and they chop down. I have sat on these
conference committees year after year where the Senate fights. I
have seen the time when every Member of the Senate was fighting in
the field of education, both Democrats and Republicans, for more
liberal appropriations and more liberal authorizations and, right
across the table from us, every Member of the House, both Democrat
and Republican, was voting to cut it down.

So we ask for help at the other end of the Capitol. Our jurisdic-
tion stops at a line right through the center of that dome.

In the east front extension there is one room down on the floor
below the main rotunda where the conference committees meet and the
line, right through the center of that table, is through the east and
west—through the center of the Capitol—and half of it is on the
House side of the Capitol and half is on the Senate side.

Now, after we get this authorization, we have great frustrations
from the Bureau of the Budget. We get messages year after year
from all administrations asking for glowing things.

Then the Bureau of the Budget comes along and cuts the life out
of them. They say they cannot cut our appropriations but they turn
around to the department and say, “You can’t spend what is appro-
priated,” so it is further whittled down. You will get more reason-
able treatment in the Senate than you do in the House and the Bureau
of the Budget so, despite all your sacrifices and time to come here,
we ask for your help in these two other branches of the Government.

Dr. Farber, your statistics state that of 300,000 who die of cancer
each year, 100,000 might have been saved Are those 100,000 the
ones who might have been saved with medica] knowledge now known
if you could get this medical knowledge into the hands of every
practitioner and every small hospital, every clinic, all over the land?

Dr. Farger. Senator Yarborough, yes; that is what I meant.

This would include earlier, far earlier diagnosjs than is now the
case so the surgeon has a better opportunity; greater application of
radiotherapy of the most modern kind and the use of chemical agents
in combination with radiotherapy and with surgery.

If we could combine early diagnosis with these new modalities
of treatment, I feel certain that the reduction would be of the order
of magnitude that I have mentioned. This is a considered statement.

Senator YarsoroueH. What percentage of the radiotherapy being
administered today, in your opinion, is by technicians who are ade-
quately trained in radiotherapy for cancer application ?

Dr. Farser. I cannot give you an exact percentage, but I can say
this: There is a great shortage of highly skilled men in the field of
radiotherapy. This has been recognized by the National Cancer Insti-
tute and the National Institutes of Health in the creation of a program
to train many more radiotherapists and radiobiologists.

This is one of the great shortage areas so that, first, there are not
enough trained men to do all of the radiotherapy which we would like
in the finest manner. There are not enough institutions with the

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COMBATING HEART AND OTHER MAJOR DISEASES 147

proper therapeutic weapons in radiotherapy to carry this on. This
is one of the areas which we hope would be remedied by the creation
of these 20 centers and the 200 cancer stations.

Senator YarnorovucH. Due to the fact of the lack of coordination,
is it not true, out over the Nation, there are centers where there are
no properly trained people in the treatment of radiotherapy for
cancer and a man, who just generally handled X-ray machines,
applies the X-ray to the spot?

Dr. Farser. That, indeed, is correct, Senator. I agree with you.

Senator Yarsorovueu. I could pursue that further but I will not.
I think we all know what we have in mind on that point and I think
it pinpoints the necessity—one of the many necessities—for this pro-
gram not only for the modest amount we put in this bill, in an effort
to try to get something passed, but in the broader aspects of your
report.

i have a question. I want to commend you for getting this report
and the staff in getting this report in a readable format. Will the
others be similar ?

Dr. DeBary. Yes.

Senator Yarporoucu. Let me recommend that it be in readable
format. The wider the dissemination we have of this information,
then the better the prospects for speedier enactment of this program
and the speedier use of it.

Dr. DeBaxry. Thank you, Senator. I think you would be inter-
ested to know that we attempted to give wide dissemination of this
report and I have been tremendously heartened, as every member of
this Commission, by the very favorable response that we have re-
ceived about this report, both from the lay and the medical scientific
communities of this country. It is perfectly obvious that the recom-
mendations of this report are recognized as being needed, and urgently
needed, and strongly supported.

There is hardly a day goes by that I do not receive a telephone call
or a letter from institutions wanting to know what they could do about
applying for a center.

Senator Yarsoroucn. Thank you, Dr. DeBakey.

The Cuarrman. Can I ask a question right there?

Senator Yarsorouen. Yes.

The Cuarrman. Doctor, would not you like to have the reports of
these subcommittees printed asa part of this hearing?

Dr. DrBaxery. Yes, we would like very much to have that.

The Cuamman. You do that. Be sure we have copies.

Dr. DeBaxey. I will see that you get copies.

The Cuamman. Reports of each one of your subcommittees, so we
can have them printed asa part of this hearing.

(The documents referred to appear as appendix A on p. 171.)

Dr. DeBaxey. I think the information and data available in the
subcommittee reports, as I have indicated previously, some of which
have never been available before, that have been compiled here, is of
tremendous value, and many aspects of the planning stage that will be
necessary later.

Senator Yarsoroven. These committee reports that we print have
tremendously valuable information in them. Sometimes it is not recog-
nized at the time. The members or ex-members throw their reports

 
  
  
  
 
  
  
 
 
  
  
  
  
  
  
  
 
 
  
  
 
 
 
 
  
 
 
  
 
  
  
  
 
  
  
  
 
  
  
  
 
 
 
 
 
  
  
 
 
 
  
   
  
   
 
 
 
148 COMBATING HEART AND OTHER MAJOR DISEASES

away. The office is so cluttered they cannot keep them and they bi
come scarce. I looked at a report last night, a report by Presider
Roosevelt when he had a Commission on American Architecture, an
the report was printed as one of our green-backed documents. The
were lost or thrown away, and now it costs $5.25 to get a copy of tha

Architects recognize that many farsighted men had recommend:
tions and they use the report. So while we will print this as a doct
ment, I hope you gentlemen will print it in a form that the publi
will read and we will read ourselves out of this fine print. I like th
attractive way in which this is gotten up.

Since all of you are engaged in education as well as in your specia
ties you know the problem you have in getting people to look at ir
formation.

Dr. Wright, you said one big problem is getting the cooperation c
individual practitioners, to get away from their fear that these centel
are going to have Government medicine of some kind, and I think ths
is a very important thing. Do you not think it is important also |
we are to get this early diagnosis that Dr. Farber has talked abou
we have to have the cooperation of the medical profession, the ind
vidual practitioner, who is out practicing alone?

Dr. Wricur. This is terribly important, Senator, and it makes |
possible to apply already known knowledge with real tangible result

As Senator Hill and perhaps other members of the committee knov
we have been interested in the treatment of coronary attacks with ant
coagulants for a good many years.

Just as a tangible result of this, I would like to mention the figur:
that have just appeared substantiating our findings. These wei
figures obtained by a 3-year study conducted by the British Medic:
Research Council.

Among the men who were in the study under 55 years of age, tk
death rate was 14 percent in those receiving anticoagulants, as con
pared to 26 percent for those not receiving anticoagulants.

Repeated heart attacks in those under 55 years of age, occurred i
those treated with anticoagulants in 15 percent. In the untreated case
the same 3-year period, 62 percent developed additional heart attack
It is an increase of four times. :

If we consider this in terms of hundreds of thousands of patient
the difference between 15 as against 60 percent, can really produc
an impressive impact on the problem. In patients over 55, the di:
ferences were not so great. There was a difference between 17 an
33 percent. These are the latest available figures based on a ver
careful study conducted in the British Isles.

This is just an example. If we have such information, and tt
physician in practice can apply it, and he has laboratories that I
can depend upon, checking with the standardized laboratories I mer
tioned, the whole pattern of this type of treatment in a communit
can be changed. The community may be a small or a large one.

Senator Yarsoroucu. Dr. Wright, your statement earlier about tk
international aspects and the need for getting this information tran:
mitted between nations was brought home forcefully to me some yea
ago as a practicing attorney.

I had a sunstroke case and in trying to find information, a medics
doctor was advising me, who was doing research, that the only plac
ee

COMBATING HEART AND OTHER MAJOR DISEASES 149
ey be- he could find information where research had been done or collected
sident and printed was in a British medical journal of statistics they kept
e, and in the Euphrates area in Mesopotamia during World War I, when

They they were losing so many men to sunstroke, they began to collect it
f that. and studied the figures.
enda- That was printed, and it was the only place where it was printed.
docu- It was not updated. It was in the late 1940’s, and I found it in a
public British medical journal.
€ this Dr. Wrieut. This is a common experience. Any effort that is made
. to curtail the application of funds and resources for studies elsewhere
ecial- in the world is shortsighted.
at In- We should emphasize international studies and communication and
increase them because, what is developed elsewhere is applicable to
on of the American public. We ought to take advantage of this. There are
nters excellent and highly productive research people all over the world.
‘that If we have good contacts with them, we get their results years before
so if we might otherwise.
bout, Senator Yarsoroven. Dr. Wright, on page 33 of your report where
indi- your recommendations for expenditures are stated, I am referring to
. the sixth, seventh, and eighth columns on undergraduate training,
es it National Institutes of Health, for graduate training grants, and in
alts. the third, clinical fellowships and investigatorships. You would spend
now, more money there than on any of the other categories, I noticed.
inti- Dr. Wricut. The others are essentially in operation.

Senator Yarsorovau. This is the big gap then ?
ures | Dr. Wrient. But the clinical fellowships have never been developed
vere | at all, so we would be starting from scratch here and, therefore, we
ical need more funds to get started in these areas.

| Senator Yarsoroucu. In the panel yesterday some people men-
the tioned moonlighting, some people doing this work often having to do
om- | work on a night job in order to earn a living. I assume this is more
. ‘ acute in this area because of lack of programs.
| in | Dr. Wrieur. It certainly is important. I think they ought to be
ISOS doing their moonlighting learning more medicine rather than driving
ks. buses or something like that.

Senator Yarsoroucu. I agree with you.
its, Dr. Wricur. Buses are important for public transportation but for
ice a person who is a highly trained individual preparing for a profes-
if- sional career, this is not the kind of moonlighting he ought to be doing.
nd Senator Yarsoroucn. Absolutely. Let me ask you, Does not this
ry take more years of training than most of the space sciences? Our

scientists working in space?
he ‘Dr. Wricur. If you include the total education, actually today when
he a man starts in undergraduate arts college he really has to be beginning
n- to prepare himself for a medical career. If he is going to be efficient
ty about it, he must take mathematics and chemistry and physics, biology,
and allied subjects to prepare himself. There are 4 years.
1e If he has 4 years of medicine, there are 8 years. Ifhehasa residency,
S- there are at least 3 years more. There are 11 years.
rs Then if he should go into training to become a specialist in his field
the total is 18 or 14 years. We must have funds to pay these people
il enough. By that time they have families and other responsibilities,

e and they should lead a normal life.

 
 

150 COMBATING HEART AND OTHER MAJOR DISEASES

Senator Yarsoroueu. I am hopeful that our committee——

Dr. Wricut. I hope we will develop this plan and get it operatis

Senator Yarsoroues. I hope our committee will in the bill befc
it is finally through bring out all you have requested in those fiel
We will see what success we have. Atleast we will never pass it unl
we bring it out of our committee and make a fight for it on the floor
the Senate.

Dr. Wriaut. Thank you, Senator.

Senator Yarsporoucs. You have my help on this, Mr. Chairman.

You mention that experimental models of hearts have already be
tried in man. That has been temporary while an operation was
process or have you actually implanted a whole experimental model
a heart in a man?

Dr. Wricut. I would like to ask Dr. DeBakey to speak on this
this point, since it ig more in his field than in mine.

Senator Yarporoues. Dr. DeBakey.

Dr. DeBaxey. Specifically I can speak about this authoritative
since that refers specifically to a clinical case which I had. This
not an artificial heart to replace the heart but rather to suppleme
the heart. There are programs now being supported by the Natior
Heart Institute, and we, among others, are involved in this resear
program, and I can tell-you from the experience that we have had th
this is a feasible objective. An artificial heart both to replace the fur
tion of the heart in terms of its pumping mechanism and to suppleme
that function, i.e., to support it temporarily, constitute a feasible c
jective which we are intensively investigating ; and there are a numb
of us who believe that if we can promote this program as intensive
as we would like, bringing all the skills and knowledge from the oth
physical sciences, particularly engineering, electronics and the like, th
we can perfect a model that can be used and applied to human bein;
Actually we are now able to apply them in experimental animals, n
on a permanent basis, but we can put them in experimental animals a1
replace the function of the heart quite effectively for a short peri
of time.

We would hope to have this within the next 5 years, but it w
require a far greater expansion of effort than we are putting into it
the present time. ‘

Senator Yarsoroveu. Or it will require more research money
well as manpower.

Dr. DeBaxey. Exactly.. To be able to bring the skills and knov
edge of other sciences inte this program, which we are unable to «
now as we would like.

Senator Yarsorovuen. A corollary question: You state, Dr. Wrig!
that kidneys, livers, lungs, and recently lungs, have been transplant
into man from primates or from man to replace diseased orgat
Have you transplanted entire hearts into a man?

Dr. DrBaxry. Well, there has been one done, one case that 1
know about. We personally, I personally, have not, and we have n
in our institution, but there has been one that has been done which w
only successful for a short period of time.

Senator Yarsoroven. An entire heart from a primate?

Dr. DeBaxrey. Yes.
ng.
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COMBATING HEART AND OTHER MAJOR DISEASES 151

Dr. Wricur. Wasn’t the problem in part due at least to the fact
that the size of the heart of the primate was not adequate for man?
That was one of the things.

Dr. DeBaxey. Of course, the more fundamental problem still exists.
There is the problem of the rejection phenomenon. This is a funda-
mental problem which has not been completely solved. We can sup-
press this in certain areas. We have patients of our own, as well
as others, with transplanted kidneys now going well over a year, and
these people are leading a reasonably normal life, and working and are
rehabilitated.

How long we can keep this going we do not know, but there are more
hopeful signs about this all the time. This is why, in a sense, research
must undergird this whole effort.

Senator Yarsoroucu. Dr. Meyer, while you were testifying you said
400,000 new stroke cases a year. Is this percentage in relation to the
entire population increasing each year, declining, or is it stationary,
the percentage of people with strokes a year? What is happening
there?

Dr. Meyer. If you analyze the data as an overall trend in the U.S.
population, stroke is increasing. However, if you take certain seg-
ments of the population there is some promising news. Males, for
example, around the age of 65 in the past decade who have been re-
ceiving control of their blood pressure, the incidence of stroke in this
particular treated group is decreased.

Now, that is my interpretation of the statistics. I could tell you
that the answer to your question is that the overall incidence is going
up of strokes, but there is a certain group in which it is going down,
and there is some argument about why, and I think it is because of con-
trol of blood pressure.

Senator Yarsoroucn. Of course, with increasing longevity of people
you will have more strokes.

Dr. Meyer. That is true.

Senator YarsoroucH. If we limited this to people under 75 or under
70, is the percentage of strokes increasing in that group ?

Dr. Meyer. Yes, but in the younger age group, there is some evi-
dence, sir.

Senator Yarsoroucu. Say 75?

Dr. Meyer. In this particular, if you don’t mind, if I take it down
a decade below that, below 65——

Senator YarporoucH. Sixty-five.

Dr. Mryer. With the management of hypertension in the young
group the incidence is decreasing, I think, not increasing.

Senator Yarsoroucu. Dr. Rusk, the $148 million that you mention,
is that for rehabilitation clinics alone for 1 year or the full 5 years.

Dr. Rusk. That is the full 5 years on the two programs, the legisla-
tive one and, the increased appropriations for ongoing programs, in
training primarily.

Senator YarsoroucH. That was not in this report.

Dr. Rusx. No. It isin the backup document in detail.

Senator YarsporoucH. That will be in the record.

Dr. Rusx. It includes the support of these four new facets of the
legislation that, hopefully, will come in a special bill.

One point that has not really been mentioned in the testimony is that
in the report the recommendations for certain bioengineering activi-

 

 

 
eee eee

152 COMBATING HEART AND OTHER MAJOR DISEASES

ties, some specifically in the field of rehabilitation and others in the
general field of instrumentation, I think all of us realize every day
that there needs to be closer cooperation and understanding and re-
search between the biologist, physician, and the engineer, and we find
this especially true in our field in the development of new devices and
material and so forth.

We have patients now totally paralyzed, arms and legs, who, be-
cause of the artificial muscle and by eletronic or carbon dioxide motiva-
tion are carrying on full-time jobs where their brain is needed and
their hands are not.

I think that this is one very great area of the future so far as
research and development is concerned.

Senator YarnoroucuH. Thank you, Dr. Rusk. ;

Gentlemen, I want to mention one point which has been discussed
some, not publicly like this, but I think that we might as well bring
it out, about this bill. ;

There have been some fears expressed by people connected with
some of the great clinics of the country that this bill as now written
rather straitjackets them, that the medical schools will have a grip
on them, and some people connected with these great clinics point
out in the earlier stages of cancer research that medical schools would
do little about it, would hardly take patience, especially if it was
thought to be incurable. They would not give them a bed. These
great research institutes over the country have added a great deal,
and of course, you know better than I what they have done.

I won’t take time to try to recite any of that, but I just mention
this point because this is being talked about, and I would like to ask
for your recommendations, not immediately but in the solution of this
before we come to consider this bill, to be certain that there are such
safeguards that you will have their full cooperation in the passage
of the bill.

Dr. DeBaxery. Well, Senator Yarborough, I think if one carefully
reads the bill there isno limitation in this regard.

Senator YarsoroueH. Pardon me.

Dr. DrBaxey. I say if one carefully reads this bill it does not
restrict the centers to these institutions. It names a number of differ-
ent kinds of institutions, and I would think the most important
element in developing a regional center is the potentiality and, par-
ticularly in terms of personnel available that are in that center for
that purpose.

Senator Yarsoroveu. I think, perhaps, that was accentuated by
some of the charts exhibited during the hearings showings that medical
schools and other things had no place for these institutes, which they
list as a factor in this complex.

Dr. Rusk, in this rehabilitation you mentioned the work on re-
habilitation earlier, people who have had cancer cures, cured by
amputations of considerable portions of their body. Is there a saving
of money with this, when you take the amount of money to rehabilitate
these people? Have you saved money for the economv? This is a
pretty hard, coldblooded question. You have saved a man, you re-
habilitated him for his life but we have had that, question asked us.
Are you actually saving money for the economy when you do this?
It isnot my question but people have asked us this question.
 

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COMBATING HEART AND OTHER MAJOR DISEASES 153

Dr. Rusx. We have had figures from last year that 19 percent of
those rehabilitated were on public assistance or in public institutions
before they were rehabilitated and returned to work. After the aver-
age cost of rehabilitation was less than a year’s welfare payment,
which was a continuing thing that went on year after year.

These two gentlemen that I spoke of, which is the most radical
example I could have given you, are in their early forties. I think
both of them will go back to work. It is going to cost not too much
to rehabilitate them except in the development of the new type of
prosthesis, but I will give you an example of this.

Hight years ago we had a boy brought up from Bolivia with no
arms and legs. We developed legs for this child and taught him to
walk. Heis now in junior college in California.

But because we invested the money, because these legs were de-
veloped, when the thalidimide babies came—5,000 of them in Germany,
and thank God we had only a handful here—we had legs that could
be the pattern for the fitting of these children. So it is not just what
you invest in these two patients, it is what you invest in all the patients
coming on for the future. I think you have to say, too, what is the
price tag on human life.

Senator Yarsoroucu. Well, I was asking this question which has
been asked about taxes. Actually taking these people off relief rolls,
would not there be a saving of money from the standpoint of the
public tax roll?

Dr. Rusx. A terrific saving. As I pointed out, for every dollar
spent, $5 come back in Federal income tax alone in the first 5 years of
rehabilitation.

Senator Yarsoroven. Money comes back by taking these people off
relief and making them viable portions of the whole community life.

Dr. Rusx. That is correct.

Senator Yarsoroucx. Dr. Wright, there is one more thing—time has
run out—you touched on this more than anybody. In enlisting the
efforts of the practicing physicians, how would these arrangements
work between the diagnostic stations and the medical complexes? I
do not want to prolong this, but if you would just tell us briefly.

Dr. Wricut. Yes. It seems to me that the station is the key area to
bring thisabout. The station should provide one to five people who are
really knowledgeable in an speciality. They should act as a focal
point of education, continuing education in’ the community service
area.

But there attitude makes a big difference. If they adopt the atti-
tude that the doctors, the practitioners cannot continue to follow and
care for their cases, this sets up a very bad relationship, and could do
more harm than good.

If they take the attitude that “we are providing you with a service,
Doctor, and we will help you with your patients in any way that we
can do so, you bring the patient in, we will do the electrocardiogram,
we will help you with fluoroscopy, we will help you to interpret, we
will help you with the basic treatment. If your patient should have
to go to a hospital for open heart surgery, we will help you, and when
the patient comes back, he is your patient,” the impact of the program
is entirely different and implemented then with a good spirit.

 

 
Nee eee

154 COMBATING HEART AND OTHER MAJOR DISEASES

At every level we should bring this spirit about. Otherwise, the
whole program can really get fouled up in a small community.

The Commission has rightly taken the attitude that we must help
the practitioner apply modern medical science to the care of patients,

Dr. DeBaxey. Senator Yarborough, may I just add, in respect to the
role of the private practitioner, that we consider him to be an active
participant in this program. We believe that this program provides
one of the best educational mechanisms for keeping him up to date
with what is going on in medicine, and keeping him up to date
with the most recent up-to-date knowledge in these special fields, He
will then have a better opportunity to maintain his continuing edu-
cation.

Senator Yarsorovan. Dr. Wright pointed out earlier the danger
of that individual practitioner becoming obsolete in his own profes-
sion if he did not keep up.

Dr. DeBaxey. That is right.

Dr. Wrieut. I think one of the biggest challenges to medical edu-
cators today is the prevention of early obsolescence of their gradu-
ates and this means that at medical school level and from then on the
students and the graduate doctors must be inculcated with the concept
that their education never stops, it cannot stop. They must be tied
into a continuing educational process in order to avoid this, in order
to provide them with the tools, the intellectual as well as technical
tools, to equip them to give the best service.

Senator Yarsoroucn. Dr. Farber.

Dr. Farprr. May I add one word here to another aspect of the
relationship of the doctor in practice to all of this? If you scratch a
doctor you find a frustrated research man, and this will afford an
opportunity for the doctor in practice to help in the gathering of
vitally needed information concerning the action of drugs and chemi-
cals, for example, working as part of an experimental design created
by the regional center and the medical complex in association with
all of the other regional centers and medical complexes in the country,
and the NIH, let us say, through the station to the community hos-
pital, to the doctor in practice, and that doctor in his way will not
only have a chance to have a continuing education by giving his
patients the benefit of something which is new which he otherwise
could not give them, but he has an opportunity also have the satisfac-
tion of contributing to the acquisition of new information.

Senator Yarsoroven. Thank you.

Dr. Rusk indicated he had something to say.

Dr. Rusx. I just wanted to mention that the second volume, the
backup document of the Subcommittee on Communications, has gone
into this in great detail, including a program of the new transitorized
type of apparatus which lays back 8 millimeter films and some of
which have already been eveloped, so this is a postgraduate course
for doctors that can be made available to them right in their office,
which is also a part of the thinking and the planning and the recom-
mendations. That is detailed in volume IT.

Senator Yarsorover. That will enable that doctor to be as modern
as the most modern hospital.

Dr. Rusk. Carry on right in his own office a continuing postgradu-
ate program.

as
I et ts

COMBATING HEART ANp OTHER MAJOR DISEASES
wise, the

Senator Yargoroucn. [ congratulate you, gent]
iby:

emen, on the achievye-
ment, your leadership, and f

or your taking those achievements and
nust help trying to broaden that which you know so it would benefit the whole
‘patients, people, and as Dr. Wright said, humanity.
ect to the ank you very much for the time you have taken to educate us
an active here. We hope we can transmit some of this to the Seante,
provides The Cuamman. I think they demonstrated this morning they are
p to date mighty good educators,
to date enator Yarsorover. I think so, too.
Ids. He Dr. DeBaxry, Senator Hill, may I say as a final word to express on
ng edu- behalf of all of us here and on behalf of the medical scientific com-
munity in this country that we should like to express our grateful ap-
danger preciation to you, Senator Yarborough, and to other members of your
profes- Committee for the yeoman work that you have done in providing the
leadership and the strong support for these humanitarian goals. We
eeply appreciate it.
sal edu- © CHAIRMAN, Dr. DeBakey, Dr. Farber, Dr. Meyer, Dr, Wright,
gradu- and Dr, Rusk, we certainly feel deeply grateful to you for the mag-
1 on the nificent work, dedicated work, that you all have done on this Com-
concept MIssion.
be tied As Senator Yarboro gh has said, it is not only service to our people
. order here in America, but it 7s @ service to all o mankind, and surely we
chnical want to thank you an

hat you have brought us here this morning. Weare deeply grateful to
of the you, Thank you very, verymuch. Than ou.
atch a At this point in the record I will place a list of the members of the
rd an President’s Commission on Heart Disease, Cancer, and Stroke. Fol-
ng of lowing that exhibit will appear a number of communications and state.
hemi- ments that have been received to date.
‘eated (The exhibits referred to follow :)
with Mermberrs op THE PRESIDENT’s Commission ON Heart Disease, CANCER, ANp
mtry, STROKE
- hos-
| not CHAIRMAN
x his , Dr. Michael ¥, DeBakey, professor and chairman, Department of Surgery,
wise Baylor University College of Medicine, Houston, Tex,
|
sfac- MEMBERS
Dr. Samuel Bellet, professor of clinical cardiology, Graduate School of Medicine,
University of Pennsylvania, Philadelphia, Pa.
the Mr, Barry Bingham, editor and publisher, Louisville Courier-Journal, Louisville,
y.
rone Mr. John M. Carter, editor, McCall’s magazine, New York, N.Y,
ized Dr. R. Lee Clark, director and surgeon in chief the University of Texas M. D
sof | Anderson Hospital & Tumor Institute Houston, Tex.
~ r. Edwa - Vempsey, former dean, School of Medicine, Washington Uni-
irse versity, St, Louis, Mo. Resigned on September 28 1964, to become special
fice, assistant to the Secretary (health and medical affairs), U.S Department of
ym- Health, Education and Welfare, Washington, D.C
r. Sidney Farber, director of research, Children’g Cancer Research Founda-
tion and professor Harvard Medical School, Boston a
orn tT. Marion § Fay, former President and dean the Women’y Medical College
of Pennsylvania Philadelphia a.
lu- r. Marion B. Folsom 7

 
156 COMBATING HEART AND OTHER MAJOR DISEASES

Mr. Emerson Foote, former chairman of the board, McCann-Erickson, Inc., Ne
York, N.Y.

Gen. Alfred M. Gruenther, immediate past president, American National Re
Cross, Washington, D.C.

Dr. Philip Handler, professor and chairman, Department of Biochemistry, Dul
University Medical Center, Durham, N.C.

Mr. Arthur O. Hanisch, president, Stuart Co., Pasadena, Calif.

Dr. Frank Horsfall, Jr., president and director, Sloan-Kettering Institute f
Cancer Research, New York, N.Y.

Dr. J. Willis Hurst, professor and chairman, Department of Internal Medicin
Emory University School of Medicine, Atlanta, Ga.

Dr. Hugh H. Hussey, director, Division of Scientific Activities, American Me
ical Association, Chicago, Ill. Resigned as of September 5, 1964, to becon
special consultant to the Commission.

Mrs. Florence Mahoney, cochairman, National Committee Against Mental Iilnes
Washington, D.C.

Dr. Charles W. Mayo, emeritus staff surgeon, Mayo Clinic, Rochester, Minn.

Dr. John 8S. Meyer, professor and chairman, Department of Neurology, Way!
State University College of Medicine, Detroit, Mich.

Mr. James F. Oates, chairman of the board, Equitable Life Assurance Societ
New York, N.Y.

Dr. E. M. Papper, professor and chairman, Department of Anesthesiology, Cc
lege of Physicians and Surgeons, Columbia University, New York, N.Y.

Dr. Howard A. Rusk, professor and chairman, Department of Physical Medici
and Rehabilitation, New York University Medical Center, New York, N.

Dr. Paul W. Sanger, surgeon, Charlotte, N.C.

Gen. David Sarnoff, chairman of the board, Radio Corp. of America, New Yor
N.Y.

Dr. Helen B. Taussig, emeritus professor of pediatrics, Johns Hopkins Uz
versity, Baltimore, Md.

Mrs. Harry 8. Truman, Independence, Mo.

Dr. Irving S. Wright, professor of clinical medicine, Cornell University, Med
cal College, New York, N.Y.

Dr. Jane C. Wright, adjunct associate professor of research surgery, New Yor
University School of Medicine, New York, N.Y.

U.S. SENATE,
Hon. Lister HIttr, February 12, 1965.
Chairman, Subcommittee on Health,
Committee on Labor and Public Welfare,
U.S. Senate, Washington, D.C.

Dear Lister: I am very much interested in the hearings you are now conduc
ing on S. 596, to establish a realistic plan to combat heart disease, cancer, strok
and other major diseases. I am familiar with the report of the President
Commission on which the present legislation is based, and I commend you f
introducing 8S. 596, and for so promptly holding hearings on it.

The American people, I am confident, will strongly support and apprecia
any practical program to help reduce the toll these diseases now take. Hea:
disease, cancer, and strokes are responsible for over 70 percent of the deatt
in this country. Because of them close to $30 billion is lost each year in pr
ductivity and in taxes due to premature disability and death. Their contro
and eventual elimination, will be one of the greatest boons which could come 1%
mankind.

We must continue to open up every possible line of research which will d
velop new scientific knowledge to combat these diseases, and to make availab
to all people in all parts of the country the new and existing lifesaving knowledg
we possess. We must do this without interfering with present medical patterr
or professional practices, or with the administration of existing hospitals. S. 5¢
has been drafted skillfully to meet all of these criteria.

I am particularly enthusiastic about the provisions of the bill to establis
32 multipurpose regional medical complexes throughout the country. Such con
plexes would bring the latest methods of prevention, diagnosis, treatment, an
cure of major diseases within the reach of millions who do not now have thes
benefits.
 

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COMBATING HEART AND OTHER MAJOR DISEASES 157

It is my understanding that these new complexes will be associated with
medical schools, teaching hospitals, medical centers and other already estab-
lished public or nonprofit institutions. I would like to make known, therefore,
in these first congressional hearings on the multiple-purpose regional medical
complexes, the interest of the University of Utah Medical School, with its new
teaching hospital, in being selected as the site of one of the complexes. The
qualifications of the school for such a selection are unquestioned. ;

The College of Medicine of the University of Utah is the only functioning
medical school between Denver and the Pacitic coast, and between the Canadian
and Mexican borders. It has established an enviable reputation for excellence
in all three major phases of medical school activities; namely, education, re-
search, and patient care. It is already participating in a considerable degree
in regional aspects of medical education and care, especially through its post-
graduate medical education division and through participation of its faculty in
meetings to evaluate the standards of care. It is a logical, natural site for a
medical complex of the type contemplated in this bill. The location of such
a complex at the University of Utah Medical School would simply be expanding
and making more effective the work already being done there, and make it pos-
sible to reach more people not only in all of Utah but in several surrounding
States.

I have been in touch a number of times about this proposal with Dr. Kenneth
B. Castleton, dean of the Utah Medical School, and he has assured me of the
great interest of the school in the proposal, and in having a possible role in
it. He feels, as I do, that through it the schools could render an even greater
service to the people of the area.

In closing, let me stress again my support of S. 596, and to offer my assistance
in getting action on it in the U.S. Senate at the earliest possible date.

Sincerely,
Frank E. Moss.

AMERICAN HospiTraL ASSOCIATION,
Washington, D.C., February 16, 1965.
Hon, Lister HILL,
Chairman, Committee on Labor and Public Welfare,
U.S. Senate, Washington, D.C.

Dear SENaToR HILL: This statement expresses the views of the American Hos-
pital Association and its recommendations in respect to 8. 596, Heart Disease,
Cancer, and Stroke Amendments of 1965. This bill amends the Public Health
Service Act so as to add a new title IX for the purpose of establishing regional
medical complexes for research and treatment in heart disease, cancer, stroke, and
other major diseases.

The American Hospital Association applauds the overall purpose of this bill
and the intent of the Federal Government to support further major efforts in an
overall attack on these major killer diseases. The hospitals of America are, of
course, acutely aware of the effects of these diseases upon individuals, their fami-
lies, and the Nation. The entire health field, along with the Federal Government
and the public, has been making substantial efforts in the alleviation of suffering
caused by these diseases. We see this bill as a means of focusing national atten-
tion in a coordinated manner upon heart disease, cancer, and stroke, and we
support the purpose of this legislation.

Before commenting in particular on sections of the bill, we wish to project the
image we have as to the detailed means of implementing the purposes of the leg-
islation. We believe it is essential that such an overall view be clearly under-
stood by everyone at the outset. A group of prominent and widely experienced
health administrators met and assembled all information available and discussed
the bill in detail and the implications which the bill seems to have for both imme-
diate and long-range health care in the United States. As we have summed up
the primary function of this legislation, it is {o establish a bridge between the
science of medicine and its full application to the care and treatment of patients.

ORGANIZATION

Appropriate organization essential to carrying out the purposes of the bill is
paramount. Three levels of health facilities are to be included in each individual
overall demonstration, In combination these facilities and services are seen as

43-669—65——11

 

 
 

—_

158 COMBATING HEART AND OTHER MAJOR DISEASES

comprising a “regional medical complex.” The medical school and the medical
teaching hospitals affiliated with the school form a “medical center,” which is the
nucleus. This nucleus is seen as assuming primary responsibility in the advance-
ment of the program’s intent throughout the entire regional medical complex.
There are at present 80 medical schools in the country, and there are approxi-
mately 200 hospitals affiliated with these medical schools.

The second level in the régional complex, referred to as a “categorical research
center,’ we interpret as comprising the nonaffiliated approved teaching hospitals,
of which there are approximately 600. These hospitals are teaching centers with
medical intern and residency programs. They are the major source for the edu--
eation of professional nurses and the primary sources for the teaching of many
other of the health disciplines.

The third level in the regional complex is referred to as the “diagnostic and
treatment station.” In large measure these stations would be the smaller hospit-
als spread throughout the Nation. They provide a focal point for medical care
and treatment in smaller communities and make possible the concentration of
services and facilities in behalf of the community in the most economic fashion.
There are approximately 6,000 of these smaller hospitals.

The above combination of facilities comprises the potential for the program
in large measure. The complex would provide a means for funneling the pro-
gram out into the largest number of health facilities and through them to the
public as a whole.

We believe it is well at the outset to start with a limited number of carefully
nurtured total regional medical complexes and in keeping with what we believe
to be the purpose of the bill to limit the program to only carefully selected cases
in the disease entities to be included. Emphasis would be only upon those cases
which would be benefited by the various newer and promising types of treatment.
Thus, the present program would make available the very latest advances and
would bring the fruits of medical research to a limited number of patients at the
outset.

We believe, however, it would be a mistake not to appreciate the enormous
public pressure that will grow for the broadening of the program. In this
regard, we see the intent of the bill to go far beyond the present limited cate-
gorical research program of the National Institutes of Health. At the start,
the program would be directed toward demonstration of patient care related
to training and research. The point we would emphasize is that the publie’s
expectation for expansion of the program to much more complete patient care
demonstrations should be kept in mind.

At the time the Federal Hospital Survey and Construction Act was started in
1946, a coordinated hospital system was visualized. The organization and co-
ordinating aspects of that system were in some ways very much like the pro-
gram which is now being considered in 8. 596. The coordinated hospital system,
as visualized under the Hospital Survey and Construction Act, failed to material-
ize. Major reasons for this failure were a lack of any primary disease focus
which would tend to stimulate coordinated efforts, a lack of financing directed
toward coordination, and various aspects of human factors involved in such a
coordinated program. We believe, therefore, that the provisions of this bill
will go far to remove various problems encountered in the past.

The Federal Government is at the present time providing financing and stimu-
lation to regional planning of health facilities. Such endeavors are being
organized rapidly throughout the country. These planning groups could well
be helpful in accomplishing the purposes of the regional medical complexes
proposed in this bill.

ADVISORY GROUPS

The bill proposes that advisory groups will be established for each regional
medical complex. We have tried to visualize the most effective organization
of such groups so as to accomplish the desired purposes of the bill. To be
effective, the advisory group should be representative of each of the component
levels of the regional medical complex. This will provide importantly for joint
effort and cooperation of the medical school hospital group, the large teaching
nonaffiliated hospital group, in the smaller hospitals in outlying areas. Most
importantly, it will avoid the possibility of total domination by the medical
schools in the complex which could well frustrate the total purpose of the
program.

We believe the function of the advisory group is most important to the suc-
cess of the whole idea, and we have therefore given particular thought to the
 

iS

the medical
which is the

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COMBATING HEART AND OTHER MAJOR DISEASES 159

n perhaps veto bower. In the third approach,
the advisory group might be established 80 as to have statutory authority

) Projects and programs. The bill, we believe,
Provides only for an advisory group.

to us, however, that this program
is moving very slowly and the total amount of funds appropriated by the Con-
; i al accomplishments, We note that legisla-
tion has been introduced to assist.in the financing and Operation of medica}
schools,

Adequate numbers of well-trained professional nurses are also of fundamental
importance to the successful accomplishment of the program, The Nurse Train-
ing Act of 1964, which Congress passed last year, should be helpful in relieving
the Professional nurse shortage,

The Federal Government has for sever

the training of qualified
portance,

al years been assisting materially in
practical nurses and this sroup is also of great im-

we would hope that support will be fortheoming, It should be possible to in-
crease Substantially the effectiveness of already existing medical manpower
through intensification of refresher training and of Specialized training for

Selected physicians. We hope this will be given particular emphasis in this
program as it develops under S. 596.

FINANCING

: é ancial burdens placed on special-
ized departments of hospitals.

The disease entities visualized for care under this bill i
procedures carried on in hospitals today. They cannot, therefore, he considered
in terms of the usual or average costs of providing pati i
emphasize very strongly, therefore, that for all of those
for research training and care in the various units of t
plex that the Federal Government commit itself to paying fully for all the
services required by this group of patients, Too often the experience with
Government research programs hag developed problems because of widely

i ini & costs, which costs are research
We feel that all three costs must
f this program.
SPECIFIC COMMENTS AND RECOMMENDATIONS ON 38. 596
Section 900. Purposes

We are pleased that this section would provide for “
addition to heart disease, cancer, and stroke with appr

he regional medical com-

other major diseases” in
opriate controls provided

 

 

 

 
160 COMBATING HEART AND OTHER MAJOR DISEASES

elsewhere in the bill. There are various concurrent diseases which may affect
patients’ treatment, and it is well to have this provision in the bill.

Section 901. Authorization of appropriations

On page 3, line 1, we urge that the word “hospitals” be inserted immediately
following the words “research institutions’. Though it no doubt is intended
that hospitals will be included in the broad language, inasmuch as it is in hos-
pitals where the prograin is in the main to be carried on, it is important to name
them specifically in the bill.

In subsection (b), page 3, line 10, we believe the word “or” appearing between
the words “planning” and “other activities” should be changed to “and”. This
is necessary, we believe, to make perfectly clear that both planning and other
activities in connection therewith will be included under the grant.

In subsection (c), page 3, line 16, we strongly urge that this paragraph be
rewritten as follows:

“Funds appropriated pursuant to this title shall be available to reimburse
fully the cost of hospital, medical, or other care of patients (as determined in
accordance with regulations) incident to research, training, and demonstration
activities,”

This rewording conforms to the suggestion we have already made that the
entire cost of the services to patients accepted under this program be paid for.

Section 902. Definitions

In subsection (d), page 5, as we have previously discussed, we would urge
that to the fullest extent possible the smaller hospitals in the country be utilized
as “diagnostic and treatment stations.” It is at this level that, in large part,
the disease entities to be included in the program will be detected. We recom-
mend, therefore, that paragraph (d), page 5, line 2, be amended by inserting the
phrase ‘‘the hospital or unit thereof” instead of the phrase “of a hospital’.

Section 903. Grants for planning and development

In subsection (a), page 5, line 24, following the words “research institutions”
we urge the insertion of the word “hospitals”. We believe this is essential in
order to avoid unnecessary construction, In several areas of the country, med-
ical schools do not own and operate their own hospitals; and to accomplish their
purposes, they make arrangements with one or more existing hospitals in the
area. We believe it would be unwise to force medical schools under these
circumstances to construct their own hospitals. As previously mentioned, we
believe the bill expects hospitals to be a primary entity in carrying out the
program and it is essential, therefore, that they be named specifically.

Subsection (b) (2), (8), and (4), page 6 refers to “the applicant.” The bill
contains no. definition of an applicant. It is not clear whether an applicant
must be the medical center or whether it may be a clinical research center or a
diagnostic and treatment station or whether it could be an entirely separate
corporate entity. There are examples in the country of such entirely separate
corporate entities functioning at the present time.

We would urge that provision be made for an “applicant” to be any one of the
three components of the complex provided so long as all the requirements in

respect to forming the complex and establishing the necessary advisory com-
mittee are met.

Section 904. Grants for establishing and operation of regional medical complexes
In subsection (a), page 7, line 11, immediately following the words “research

institutions’, insert “hospitals”. .Again we believe this is essential in order
to give recognition to their primary function in the proposal.

Section 905, National Advisory Council on Medical Complexes

In subsection (a), page 9, line 5, we urge that “may” be deleted and the word
“shall” be inserted. It is essential, we believe, that there be no doubt whatever
as to the requirement for the appointment of the National Advisory Council.

In subsection (a), page 9, line 11, following the words ‘“‘the medical sciences”,
insert “hospital administration”. Since most of the pregram will be carried
out in hospitals, there should be assurance that an appropriate authority in
hospital administration be included; and for the same reason, we believe that
in line 15 at the end of the sentence there should be added: “and one shall be
outstanding in hospital administration.” At the present time, the bill provides
 

lay affect

nediately.
intended
is in hos-
. to name

between
”. Thig
nd other

sraph be

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stration

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Cause of cancer and the seconda

cancer as well as better methods for early detection and improved treatment

Kennetu WILLIAMSon,

Associate Director, American Hospital Association.

 

STaTeMEnr oF THE AMERICAN Den tat AssocraTion

billions, Any commitment to the total health
of our people that the Nation makes mu
Substantial amount of
of these diseases whi

discover even better methods to contai
Yavages,

legislation is not solely because of

-being of the American people. In relation to
the research and treatment cent

ers concerning heart disease, the dentist has
a vital professional concern for some forms of this disease, particularly that
known as bacterial endocarditis. This type, involving damage to the valves
of the heart, sometimes occurs because of infection in the mouth. Cooperative
efforts in educating the medical and dental professions as to preferred methods
oing on for some time between the American

research centers devoted to cance
given to oral cancer,

The incidence of oral cancer in the United States ig approximately 30,000
new cases per year. As of 1965, it is estimated by the American Cancer Society
that 9,000 persons are dying each year from this manifestation of eancer, In
studies made as to the site of cancer, only the breast, lung, and uterus were

found to havea higher incidence rate than does the mouth.

What is even more serious is that the 5-year survival rate of oral cancer
is worse than that for cancer in any other part of the body except the lungs
and stomach. After 5 years, only 29 percent of those afflicted with oral cancer
survive.
uO Further, many of those few who do survive, live on at great cost. Deformities,

ff any, and other undesirable changes resulting from the treatment for cancer
of the breast, lung, uterus, stomach, and prostate can be successfully handled
‘So that society in general is unaware of the physical changes in the individual.

i i In many instances, deformities
ent of an acceptable appearance.
eating or speaking when the tongue or the floor
of the mouth has been nece; i - There is a sudden and shocking
loss of dignity and sense of stability for such people and severe psychiatrie

In many instances, these people are
ed of their lives not because of the cancer so much
as from the impact of its consequences,

Considerable research is being conducted today in an effort to find the primary
ry factors relating to lung, breast, and uterine

in the form of radiation, surgery, and chemotherapeutic agents.

 
  
 
  
   
 
 
    
 
  
  
 
 
 
  
 
 
   
  
   
  
   
  
  
 
 
  
 
   
   
  
   
    
  
  
  
    
  
  
  
 
  
 
  
  
  
 
 
 
  
   
   
 

>

162 COMBATING HEART AND OTHER MAJOR DISEASES

envisoned in 8. 596 could and should be charged with substantial respon-
sibility in this field. Most men conversant with oral cancer have great hope that
the tragically low survival rate could be dramatically and swiftly raised through
more widespread application of early detection and improved treatment methods.
At the same time, the disfigurement that now so frequently accompanies treat-
ment can, in some way, be minimized or even eliminated.

The American Dental Association, then, is deeply sympathetic to the goals of
8. 596. But we would at the same time like to urge in the strongest possible
manner that the establishments authorized in S. 596 be planned in such a way
that they serve our people’s total health and that the considerations raised in this
brief statement not only be given careful consideration but be acted upon.

Tue AMERICAN Puntic HEALTH Association, Inc.,
Washington, D.C., February 10, 1965.
Hon. Lister Hirt,
Chairman, Senate Convmittee on Labor and Public Welfare,
New Senate Office Building, Washington, D.C.

Dear Mr. CHainMan: The American Public Health Association along with
you has been pointing out for several years the serious facts recently highlighted
in the report of the President’s Commission on Heart Disease, Cancer, and
Stroke. We applaud the recommended dramatic crash approach to these major
causes of death, and we are grateful to see that universities and medical schools
are to be involved in the fight in a direct way. They have much to offer, and we
in public health have long wished for their greater participation in community
health much as universities have for decades participated in agricultural
programs.

We have some misgivings about the mechanisms of application of services to
communities as proposed. in the legislation since apparently the network of public
health agencies (both official and voluntary), which have long been repressed by
low budgets and most recently by fragmented and sporadic support, appears to
have been overlooked.

I am convening a small group of individuals experienced and especially com-
petent in the delivery of health services to review this question of methods
of providing services. This review will be done quickly but thoroughly, and
hopefully I will be able to forward to you suggestions to further improve this
highly desirable legislation before it is finally enacted.

Respectfully yours,
Berwyn F. Marrison, M.D.,
Exceutive Director.

 

AMERICAN MEDICAL ASSOCIATION,
Chicago, Ill., February 18, 1965.
Hon. Lister Hm,
Chairman, Committee on Labor and Public Welfare,
U.S. Senate, Washington, D.C.

Dear SENATOR Hitt: The American Medical Association wishes to express
its appreciation to the Senate Committee on Labor and Public Welfare for making
available to it an opportunity to appear on February 9, 1965, at the hearings on
8. 596, the “Heart Disease, Cancer, and Stroke Amendments of 1965.” We regret
that we found it necessary to inform you that we could not present the associ-
ation’s views at that time. Because of the short notice given of the hearings,
it was not possible to accord this important legislation the proper measure
of consideration which it warrants.

We are sure that this committee must appreciate the tremendous significance

of the legislation before it. The purposes of it, namely to assist in combating
heart disease, cancer and stroke, and other major diseases, are most laudatory.
The eradication or control of such diseases, as well as of all other medical afflic-
tions of man, has been, and continues to be, an active concern and goal of
medicine,

We deem it imperative that S. 596 be given consideration commensurate with
the significant impact which it could have upon the course of medicine and upon
the health needs of our citizens.
 

 

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COMBATING HEART AND OTHER MAJOR DISEASES 163

‘The association has initiated steps within its organization to give to S. 596
a most careful analysis of its intent and the manner in which it is sought to
be implemented and achieved. We eannot urge too strongly to this committee
that this legislation raises considerations with far-reaching ramifications and
with a potential of far-reaching effects upon the Nation’s health needs. The
course to be charted must represent the most judicious employment of the Na-
tion’s medical resources.

Sincerely,
F. J. L. BLasincame, M.D.

GELVIN-HavuaHEy CLINIC,
Concordia, Kans., January 14, 1965.
Hon. Frank Carison,
U.S, Senate, Washington, D.C.

Deak Franx: In reviewing the many comments from newspaper articles and
television speeches of future plans of the Johnson administration in establishing
funds for clinical research in cancer and arteriosclerotic diseases, it is the desire
of our group to establish such a research program.

Dr. Haughey and I established the Gelvin-Haughey Clinic in 1951. Our long-
range planning and thinking was to provide patients, as nearly as possible, a
complete diagnostic medical center. This has been accomplished in part by the
addition of 11 doctors, most of whom are board certified in the following spe-
cialties: Thoracic and urological surgery, obstetrics and gynecology, internal
medicine, gastroenterology, and pediatrics.

On November 1, 1957, the Gelvin-Haughey Clinic was accepted as a full mem-
ber of the American Association of Medical Clinics and has been a member in
good standing since that time with several doctors acting on the national ereden-
tials and membership committees.

Reports from the Kansas State Hospital Association show that the St, J oseph
Hospital, Concordia, Kans., has been among the five leading hospitals in the
State of Kansas in the number of cancer cases diagnosed and treated in the past
5 years. From these reports you can readily see we are ideally located gZeo-
graphically for a research center.

I wish to make this information available to you for future reference. If
appropriations are made available for clinical research, this information will
be in your files and will be available to the interested committees with your
usual good support. Any further information which you feel would be desirable
or advantageous, I will be more than happy to furnish.

Most sincerely yours,
E. R. Geivin, M.D.

 

UNIVERSITY OF MINNESOTA MEDICAL ScHOOL,
DEPARTMENT oF PHYSICAL MEDICINE AND REHABILITATION,
Minneapolis, Minn., February 9, 1965.
Senator Lister Hit,
U.S. Senate, Washington, D.C.

Dear SENATOR Hitt: As your committee begins considering legislation for
diagnosis and treatment of heart disease, cancer, and stroke, I would like to
bring to your attention one of the most serious problems we face in trying to
build better rehabilitation services for the disabled people of this country.

Our medical schools across the country, with only rare exceptions, are con-
tinuing to turn out thousands of young physicians who have gained no real
comprehension of modern rehabilitation services and what they can mean to all
of the disabled and chronically ill patients they will be caring for during their
professional lives as physicians. Even our most highly rated medical schools
provide little or no teaching of medical rehabilitation in the 4 years of medical
school. The almost total emphasis on pathology and diagnosis of acute disease
leaves the graduating medical student unprepared to care for the millions of
‘cases of chronic diseases which can be improved by rehabilitation. It is only
the few physicians who decide to go into physical medicine and rehabilitation
as a specialty who have an opportunity, as part of their formal medical educa-
tion, to learn about medical management and continuity of medical care. Unless
something is done aggressively to overcome this deficiency at this crucial stage
in the development of physicians generally, we are going to continue to face

 

 
 

164 COMBATING HEART AND OTHER MAJOR DISEASES

almost insurmountable (and largely unnecessary) obstacles in coping success-
fully with the problems of severe disability among the American people.

I have inquired of the Vocational Rehabilitation Administration about their
current efforts in support of undergraduate medical training in rehabilitation.
Some time ago they undertook an extremely modest program to secure at least
token attention to the indoctrination of medical students in rehabilitation con-
cepts. At present they are making annual grants for this purpose to some 65
medical schools and of this number over 75 percent of these grants are less than
$30,000. In a few other schools their support goes as high as $100,000 a year,
which brings this vital teaching to a level which is a little closer to the practical
requirements for this important undergraduate teaching. You may recall that 2
years ago I and Dr. Frank H. Krusen recommended to your committee that
teaching grants of $200,000 per year be made to selected schools and that the
number of grants be increased over the years as medical schools reorganized the
curriculum so that they would be able to provide adequate teaching of medical
rehabilitation.

I know that you are quite familiar with the President’s Commission’s proposal
to establish 32 regional centers for teaching, research, and services for heart,
cancer, and stroke patients. Certainly this represents a laudable effort to
advance diagnostic and curative medicine which will benefit untold thousands
of patients. However, unless these centers encompass the teaching, research,
and services for comprehensive management, including rehabilitation, they will
fall far short of meeting the goals proposed by the Commission, and medical care
will still remain inadequate for millions of disabled patients. In these three
diseases we have an outstanding example of how it is possible to so focus our
interest on diagnostic medicine that we completely fail to grasp the dimensions
of these diseases in terms of the disability they produce.

In particular, these proposed regional centers should be located at medical
Schools and should be focal points for teaching medical students the principles
and techniques of rehabilitation while they are learning the other phases of
diagnosis and care of heart disease, cancer, and stroke patients. This is an
opportunity we should not miss. I should like to recommend that the bill which
you and your committee report should include specific provisions for the Voca-
tional Rehabilitation Administration to support an expanded program of under-
graduate medical education in rehabilitation and to start immediately toward
building this support on a level of $100,000 annually for all of the medical schools
with whom the Vocational Rehabilitation Administration presently has such a
grant relationship. In doing this we should give priority to those medical schools
which have or will have a direct affiliation as one of the proposed 32 regional
centers for heart disease, cancer, and stroke. Our objective should be to give
this kind of support to every medical school as fast as they are able to organize
and carry out the proper undergraduate teaching curriculum in rehabilitation.

Furthermore the support to each of the established regional rehabilitation
research and training centers should be increased to $1,500,000 annually so that
they may expand their training of faculty members needed in other medical
schools, provide leadership in the development of a comprehensive rehabilitation
program. and in the aggregate represents a research effort in rehabilitation and
chronic disease comparable to that of the named Institutes of the National In-
stitutes of Health at Bethesda.

The amount of funds involved here is not great in comparison with the size of
the investments we are making in other aspects of health research and teaching.
It can, however, have a major and continuing impact on the ability of our Na-
tion’s physicians to do a much better job for their patients who become disabled
from iniury or the many chronically disabling diseases.

I deeply appreciate the many wonderful things you already have done to ad-
vance medical care in this country, and I hope you will find it possible to take
this important forward step,

With all good wishes, I am,

Sincerely yours,
Frepertc J. Korrxe, M.D.,
Professor and Head, Department of Physical Medicine and Rehabilitation,
 

_

   
  
  
 
 
 
 
 
  
  
 
 
 
 
 
 
 
  
 
  
    
  
 
  
  
  
 
 
 
  
  
  
  
  
 
 
  
 
  
  
  
  
 
    
 

 

COMBATING HEART AND OTHER MAJOR DISEASES 165
eSss- AMERICAN PHYSICAL THERAPY ASSOCIATION, :
New York, N.Y., February 9, 1965.
heir Senator Lister Hitt,
‘ion, Chairman, Senate Committee on Labor and Publie Welfare,
east U.S. Senate, Washington, D.C.
con- Dear Senator HILL: The American Physical Therapy Association, as the sin-
> 65 gular national professional organization for the more than 12,000 physical thera-
han pists in these United States, has basic concern with the health and well-being of
ear, our citizens. In this context we have vital interest in the Heart Disease, Cancer,
ical and Stroke Amendments of 1965 (8. 596) and request that this letter be read into
it 2 the record of the hearings on this bill currently being held by Senate Committee
hat on Labor and Publie Welfare.
the The American Physical Therapy Association supports and endorses the provi-
the sions of 8. 596:as essential to meeting the needs for rehabilitation of the millions
cal of our citizens afflicted by heart disease, cancer, and stroke, as well as other major
diseases,
sal This association through its constituent members has for more than 44 years
rt, provided specialized high quality treatment services, for both inpatients and out-
to patients, afflicted with crippling diseases, and has been the predominant allied
ds medical profession involved with the rehabilitation of persons with strokes.
ch, Physical therapists have contributed through basic and clinical research to the
ill body of knowledge concerning the evaluation and treatment of the stroke victim.
Te Furthermore, they have extensive experience in conducting and participating in
ee training and demonstration activities in this area.
ur For the aforestated reasons the American Physical Therapy Association makes
ns the following recommendations concerning S. 596:
1. That the regional medical complexes be established in areas in which ap-
‘al proved schools of physical therapy exist. If no such school exists in a region,
es that consideration be given to the development of a physical therapy school in
of association with the medical school.
in 2. That consideration be given to the requirement that physical therapy be
oh represented in the designation of regional advisory groups.
a- 3. That the provisions for construction of facilities as defined in section 902(f)
r- include the physical therapy service departments and physical therapy training
d facilities.
Is 4. In view of the fact that participation and cooperation of physical therapists
a is essential to the success of the proposals contained in 8. 596 and inasmuch ag
Is physical therapy is one of the leading medical sciences involved in the treatment
iL of heart disease, cancer, and strokes, we recommend that the Surgeon General
e be advised to appoint a member of the American Physical Therapy Association
e to the National Advisory Council on Medical Complexes.
l. We hope that these recommendations will receive the serious consideration of
a your committee.
t Sincerely,
l Mary Evizaseru Kos, President.
)
[

List or Screntirrc Parers Pusrisuep BY Dr. Henry G. HADLEY, AND ON. FILE
IN THE COMMITTEE FOR THE Use or ITs MEMBPERS IN CONSIDERING 8. 596

The Reason for the Failure of Cancer Research.

. The Krebiozen Episode and Cancer Research.

. Environment and Micro-Organisms in Neoplastic Disease.
Micro-Organisms, Cellular Immunity, and Neoplastic Disease.
Serological Reactions and Neoplastic Disease.

. Bacterial Immunity and Neoplastic Disease.

. Evolutionary Theory and the Etiology of Cancer.

Cancer and Plant Tumors.

9. Cybernetics, Micro-Organisms, and Neoplastic Disease.

10. The Correlation of Bacterial Immunity With Neoplastic Disease.

GO US OTe OF bo

 

AMERICAN Heart Assocrarion, INnc.,

New York, N.Y., February 24, 1965.
Senator Lister Hirt,

Charman, Committce on Labor and Pubic Welfare,
Senate Office Building, Washington, D.C.

Dear Senator Hirt: The American Heart Association recently offered testi-
mony before the Subcommitee on Health on 8. 596 (regional medical complexes)

  
 

166 COMBATING HEART AND OTHER MAJOR DISEASES

and was grateful for the opportunity of placing its views on record. We hope
you will advise us if there is any other action we can appropriately take.

Meanwhile, I am taking this opportunity of acquainting you with the com-
position of the study commission I appointed for the purpose of examining the
bill (S. 596) and establishing the main points of our testimony. It consisted of
the following members:

Dr. Robert Glaser, chairman, Affiliated Hospitals Center, Inc., Boston.

Dr. Robert Wilkins, professor of medicine, Boston University Medical School,
Boston.

Dr. James VY. Warren, chairman, Department of Medicine, Ohio State University,
Columbus.

Dr. A. McGehee Harvey, professor of medicine, Johns Hopkins University, Balti-
more.

Dr. Sherman M. Mellinkoff, dean, UCLA Medical School, Los Angeles.

Dr. John R. Hogness, dean, University of Washington Medical School, Seattle.

Mr. Jesse R. Fillman, Choate, Hall & Stewart, Boston.

Dr. Houston Merritt, vice president for medical affairs and dean, Columbia Col-
lege of Physicians and Surgeons, New York.

Mr. Philip P. Ardery, Kentucky Home Life Building, Kentucky.

Dr. Lindsay BE. Beaton, Tucson.

Dr. Francis L. Chamberlain, clinical professor, University of California School
of Medicine, San Francisco.

Dr. Carl V. Moore, professor of medicine, Washington University, St. Louis.

Mr. Quigg Newton, Commonwealth Fund, New York.

Dr. Elvis J. Stahr, Jr., president, Indiana University, Bloomington.

Dr. Carleton B. Chapman, professor of internal medicine, Southwestern Medical
School, University of Texas, Dallas.

Mr. Rome A. Betts, executive director, American Heart Association, New York.

The group convened in Boston on February 6, each member having studied
the bill and other relevant material thoroughly beforehand. The main lines of
the testimony were evolved after a session lasting about 6 hours. I should add
that each member dropped everything and came to Boston on little more than
24 hours notice. After the meeting in Boston, we obtained the approval of our
legislative advisory committee by telephone. The testimony we oflered on Tues-
day, February 9, was thus based on very competent advice and careful study.
I doubt that a more knowledgeable and highly motivated group of men could
have heen found in the Nation for the purpose.

Please be assured of our continuing interest in the legislation (S. 596 and
8. 597), and of our appreciation for the courtesy the subcommittee showed us.

Yours sincerely,
CaRLETON B. CHAPMAN, M.D., President.

 

CANCER CARE OF THE NATIONAL CANCER FOUNDATION,
New York, N.Y., February 15, 1965.
Senator Ronert F. Kennepy,
U.S. Senate,
Washington, D.C.

Dear Senator KENNEDY: Thank you for your letter of February 8 concerning
the work of Cancer Care in relation to the proposed amendment to the Public
Health Service Act.

At your suggestion, I have reviewed the report of the President’s Commission
on Heart Disease, Cancer, and Stroke and S. 596 and found that these documents
deal thoroughly with the goal of curing and rehabilitating the cancer patient by
means of research, training personnel, diagnosis, and treatment. No considera-
tion is given, however, to meeting the needs of those who will die of cancer each
year. This omission is understandable is view of the fact that the program of
Cancer Care is unique and, regrettably, was not represented on the Commission.

During the several months or years that a patient with advanced cancer may
live, his family ean be destroyed by financial and emotional strain. This is par-
ticularly true is the middle-income group, where a previously productive family
ean be reduced to public welfare status. In the 20 years of its existence, Cancer
Care has gained the experience that enables us to help these families retain
their integrity. dignity, and productivity.
 

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COMBATING HEART AND OTHER MAJOR DISEASES 167

Cancer Care was called on to serve 10,555 persons last year in the metropolitan
area of New York City, which included 3,671 patients and 6,884 family members,
Financial grants amounting to $535,079 were given to provide necessary serviees
in the home. These Services include medical homemakers, housekeepers (for the
care of children), nurses, bedside equipment, transportation for medical treat-
ment, and the cost of prescribed medications, When care at home was not fegsi-
ble, some of these grants were used to supplement nursing home costs.

An additional $235,752 was Spent for counseling and guidance,

Funds must be provided for research directed toward the cure of cancer. We
must face the fact, however, although it is painful to do so, that a cure is. many
years off,

More than 300,000 people in the United States will die of cancer this year.
Without assistance, Inany of the families of these patients will lose their inde-
pendence and become an economic liability.

I find nothing in the terms of S. 596, or in the report of the Commission, to
indicate that the needs of the advanced cancer patient and his family have been
considered.

I would, therefore, strongly recommend that provision be made for the millions
of American families who must face this disea

Se in the years to come.
I appreciate your Interest and your awareness of this problem.
Sincerely yours,

Henry J. HEIMLICH, M.D., President.
NEw RocuHELLE, N.Y,

 

PREPARED Srarextenr OF WaRREN ZEPH LANE, M.D.

To amend the Puble Health Service Act to
cancer and stroke,

Senator Hill, distingui

Subcommittee on Thermog-
ravhy of the American Cancer Society.

My purposes in appearing before the committee is to place in persnective the
aspirations of the non

-profit community hospital. Since World War II the aug-
mentation and educational ungrading of the staff of the community hospital;
the expenditures by trustees for capital develo

pment; the enlargement of en-
dowment funds; and the progressive planning and construetion in collaboration
with the Hill-Rurton Act has produced a progressive program of local and re-
gional hospital improvement.

When the Commission’s report is carefully read, recommendations are made
which seem to fit the qualifications of many community hospitals. But, the
community hospitals, in order to shorten the timelag between conceptual and
‘development ‘work for medication

S and procedures and instrumentation need
further supnort. The ultimate consumer, the patient, wants to know and needs

In order to aceomplish this reduction
aeute short-term patient care cannot h
There are many reasons for this, bu

in the time lag the current income for
é expended on research and development.
t the overriding factor is that the rapid

i stigators tend to congregate in the
university and teaching hospital complexes, These ‘points are not criticism,
they are used to demonstrate the plight of the community hosnitals that may
be trving to encourage staff activities for medical investigation and postgraduate
edueation.

The program that we have attempted to implement at the Norwalk Hospital
mav serve as a grassroots example:
(1) A 20-vear flexible plan for orderly develonment bas

ed on population growth
and public communications was established in 1951.

  
  
  
 
  
  
  
 
 
 
 
 
 
 
 
 
  
  
  
 
   
  
 
 
 
 
  
  
 
  
    
  
   
 
  
  
   
  
  
  
 
 
 

 
 

SS

168 COMBATING HEART AND OTHER MAJOR DISEASES.

(2) The annual giving plan with a full-time director and staff, charged with
the development of fund procurement, was accomplished. This staff prevents
the necessity of expensive fund drives. In 13 years it has produced $9 million
at a cost of 6.5 percent of gross income from over 30,000 individual gifts. More
than 165 other community hospitals have adopted the annual giving plan de
veloped by the Norwalk Hospital.

(3) Professional staff requirements for certification and education were en-
larged and defined.

(4) A research laboratory was established. Since opening for work in Octo-
-ber 1968 it has—

{a) Been responsible for coordinating basic research in infrared themog-
raphy for 18 institutions over the United States.

(b) Been responsible for the original work in developing an instrument
which may have application in ‘the surgical treatment of coronary artery
and peripheral vascular arteriosclerotic disease .

(¢) Performed more than 2,000 infrared thermograph examinations which
may lead to a method for localization of cancer.

(d) Accomplished the isolation of a dialyzable substance in the blood
serum of patients with rheumatoid arthritis,

These are outstanding examples of programs which are related to clinical
medicine. :

In international programs:

{1) Since 1953 we have trained interns and residents from 26 nations.
Many have gone on to university centers for board certification in various
specialties,

(2) We have participated with various applied science firms in the nego-
tiation of a total ecological development program for Kenya. This latter
program includes a “reversed flow” medical training program for physi-
cians, nurses, and technicians which will train Kenyans in the principles
of American medicine. When fully funded and implemented we expect to
make this program a model for underdeveloped nations everywhere.

I am sure that the same types of work can be claimed by many other hospi-
tals, but my purpose is to demonstrate what is feasible with our present support.
Therefore, I would like to make the following recommendations to the committee
for consideration when amending the law:

(1) Provide for a category of funds which are to be reserved for grants
to community hospitals for research and development and postgraduate medi-
cal education, This should include capital funds and discretionary funds for
personnel, supplies, and equipment. Certain prerequisites for safeguarding,
application should be specified such as (a) minimum space requirements, (db).
program definition, (c) house-staff participation, (7) science-fair winners par-
ticipation, and (¢€) review by a committee of the hospital and staff and trustees.
In this way we may be able to generate a great deal more interest from the
premedical and high school students in a mutual learning process. :

- (2) Provide for travel and housing for qualified physicians,: nurses, and,
technicians from underdeveloped nations for a minimum of 2 years. During
this time they could be exposed to the grassroots of American medicine. On
return to their countries, this should be followed up by the cross-fertilization
of the “reverse flow” process in. which American personnel will spend 1 year
in that country seeing to it that the new-found knowledge does not become
diluted or forgotten. In the process. the problems of the underdeveloped coun-
try will be learned at firsthand. It is my belief that family allowances should
be included for both categories. :

(83) Provide subsidies for accredited foreign medical schools provided they
will accept American students who qualify. In this way we may encourage the:
“reverse flow” to start with the original educational process. Also, the expense.
may be somewhat less than enlarging our present medical education program
too rapidly with loss of excellence in the process. .

Finally, I should like to say that if the public sector provides some support
for programs such as this the private funds will increase locally when the:
ultimate consumers begin to realize the benefits. Thank you for your con-.
sideration.
  
 
  
  
   
 
   
   
  
  
  
 
 
  
  
 
  
   
   
 
 
 
 
 
 
   
  
   
  
  
  
   
  
  
 
 
  
  
  
  
   
  
  
  
  
  
  
   
  
 
 
 
   
  
  
 
 
 
 
  
 
  
  
 

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COMBATING HEART AND OTHER MAJOR’ DISEASES 169

U.S. Senatn,
COMMITTEE ON PuBLIC Works,

February 24, 1965. ,
Hon, Lister Hirt, : .

Chairman, Committee On Labor and Public Welfare,
‘New Senate Office Building, Washington, D.C.

__ Dears Senator Hite: Attached pease find a letter addressed to me from Dr.
‘William L. Simpson, scientitic director, Detroit Institute of Cancer Research,

In this letter Dr, Simpson expresses his views on S. 596. Lf at all pussible I
would appreciate the inclusion of Dr. Simpson’s letter in t
hearings in 8. 596 so that his views may receive consideration when the Sub-
‘Comnittee on Health prepares to “narkup” the bill,

With all good wishes,

Sincerely,

Pat McNamara, U.S. Senator.

Detroit INSTITUTE oF CANCER RESEARCH,

: Detroit Mich., February 20, 1965. .
Hon. Patrick Y. MoNaMara, :

Senator from Afichigan,
Old Senate Office Building,
‘Washington, D.C.

‘Dean Mr. McNaMara: It is a source of much regret that I have learned so
recently that public testimony was being taken on Senate Bill 596, which was
introduced by Senator Lister Hili to implement recominendations of the Pregi-
dent’s Commission on Heart Disease, Cancer, and Stroke,

As the scientific director of the Detroit Institute of Cancer Research, one of
Jess than a score of categorical institutions devoted to basie and clinical research
in the field of cancer in the United States, I find that the wording of this bill
departs significantly from the recommendations of the President’s Comnuission on
Heart Disease, Cancer, and Stroke in several important and undesirable ways.

In the first place, the primary emphasis on development of huge “medical
complexes” built around medica) schools is unrealistic for most sections of the
country and will block the possibilities for immediate progress based on the
knowledge developed in existing categorical institutes to deal with the specifie
diseases named. The inclusion of “other major diseases” in addition to heart
disease, cancer, and stroke, makes the program so diffuse that gains against the
three named diseases would surely be delayed through dissipation of the total
effort. There is no careful study to justify this broadening of the bill beyond
the diseases so carefully documented by the distinguished group of scientists and
citizens who made up the President’s Commission.

I urge that the committee, of which you are a member, seriously consider
amending the bill so as to take full advantage of the opportunity to push ahead
quickly with the fight on cancer by recognizing the leading roll that ean be
played by institutions already committed to basic and clinical studies on that
disease. I urge that you recognize the broad experience of the several National
Institutes of Health in administering research funds and place administrative

responsibility for implementation of the President’s program within the National
Institutes of Health,

If there is any way in which I can be of assistance to
in evaluating the potential effects of this le.

of the city of Detroit and the State of Michi
eall, :

you or to the committee
zislation, especially on the people
gan, I shall be at your service upon
Sincerely yours,

WILLIAM L, Siupson, M.D.,
Scientific Director.

 

 
 

170 COMBATING HEART AND OTHER MAJOR DISEASES

Wayne State UNIVERSITY,
Detroit, Mich., February 16, 1965.
Hon. Lister Hm,
Chairman, Labor and Public Welfare Committee,
Senate Office Building, Washington, D.C.

Dear Senator HILL: We have read with interest the report of the President’s
Commission on Heart Disease, Cancer, and Stroke (vol. 1, December 1964). We
understand that Senate bill 596 introduced in the 1st session of the 88th. Congress «++
seeks to implement certain of the recommendations of the Commission.

The establishment of regional medical complexes for research and treatment
in heart disease, cancer, stroke, and other major diseases is of particular interest
to us in that we are all concerned with the development of a teaching, research,
and service medical center in Detroit. Wayne State University has begun the
building of a teaching and research center designed to accommodate entering
classes of 200 medical students. This has been made possible by collaboration
of the midtown Detroit hospitals; Harper, Grace, Woman’s, Children’s, and the
Rehabilitation Institute with the university. The purposes of the center clearly
fit into the patterns outlined by the provisions of S. 595, S. 596, and S. 597.
The Housing Commission, the Planning Commission, the Health Comission of
the City of Detroit, the five voluntary hospitals and the university have worked
together for many years to bring the medical center to its present state. Our
objectives are excellence in the areas outlined by S. 596, as well as in all other
fields which relate to our several teaching, research, and service functions.

The bills now under consideration hold much promise for the developnient of
an important public health and educational resource in Detroit. The under-
signed represent some of the organizations vitally interested in the medical
center and what it may bring to almost 4 million people in our immediate area.
We invite your special attention to these bills and to our interest in them as
sound methods by which the recommendations of the President's Commission
may be implemented. We also assure you of our willinguess to testify before
your committees if you think this is desirable.

JEROME CAVANAGH,
Mayor, City of Detroit.
Joun J. HANLON,
Health Commissioner, Detroit and Wayne County.
Ray Eppert,
Chairman, Citizens Committee, Detroit Medical Center.
LEONARD Woopcock,
Chairman, Board of Governors, Wayne State University.
CLARENCE HILBERRY,
President, Wayne State University.
ERNEST GARDNER,
Dean, School of Medicine, Wayne State University.

 

ANN ArRBor, Micu., February £7, 1965.
Senator Pui A, Hart,
Washington, D.C.:

The University of Michigan respectfully urges your support of Senate bills 595,
596, and 597 which can help us to improve and expand our already distinguished
programs in medical education. The proposed support and assistance to students,
faculty, libraries, and schools are necessary to meet the demands of the people
for improved health, and to our ability to do our share.

President Hartan Hartcuer,
The University of Michigan.

The Cuarrman. The subcommittee will now stand in recess.

(Whereupon, at 12 :55 p.m. the subcommittee recessed subject to the
eall of the Chair.)
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APPENDIX A

SUBCOMMITTEE REPORTS OF THE PRESIDENT’S COMMISSION ON
, HEART DISEASE, CANCER, AND STROKE

REPORT OF THE SUBCOMMITTEE ON Heart DISEASE

(Dr. Irving S. Wright, Chairman, Dr. Samuel Bellett, Dr. J. Willis Hurst, Dr.
Paul Sanger, and Dr. Helen Taussig; staff, Dr. John D. Turner)

INTRODUCTION

Heart disease is the No. 1 cause of death in the United States. In 1963, over
993,000 Americans died of heart and blood vessel diseases; this toll represented
54 percent of all deaths in the United States. And yet, in fiscal year 1963, only
11 percent of all medical research expenditures (Government and private) were
used for research in cardiovascular diseases. In addition to those killed by
cardiovascular diseases in 1963, it is estimated that 14,600,000 survivors were
afflicted with definite heart disease and almost 13 million with suspected heart
disease. The deaths, illness, disability, and economic loss to family and to
Nation caused by diseases of the heart and blood vessels clearly place them as
the No. 1 health problem in America today.

Tremendous strides have been made during the last 15 years toward the
prevention or cure of some of these diseases. In large part, such gains have been
fostered by the wise and intelligent interest and awareness of the U.S. Con-
gressmen who have appropriated increasing amounts of moneys for medical re-
search since the end of World War II. These funds have made it possible for
investigators in the biomedical sciences to bring their talents and efforts to bear,
in a way never before possible in the history of mankind, on this most important
challenge to health.

Medical research has yielded a high return on the public investment. Analysis
of the health statistics over the last decade shows a definite decrease in the
deaths associated with a number of these diseases. For example, research in high
blood pressure has resulted in the development of drugs that effectively lower
elevated levels, Large numbers of Americans with high blood pressure have
been treated successfully with these drugs over the last decade. Over this same
interval, the number of deaths attributed to high blood pressure has decreased.
Though the drugs are not the sole reason for this fall, they are a most important
one. In addition these drugs have made it possible for a large percentage of
people with high blood pressure to return to work and a normal life. There is no
question that such salutary results are a product of medical research.

One form of blood vessel disease—atherosclerosis, especially of the coronary
arteries—has not shown the decline reported for other forms of cardiovascular
disease, according to the death rates. In spite of intense research efforts, coro-
nary heart disease remains the No. 1 cause of death in adult males and females
in the United States. This is not to say, however, that medical research has not
made great strides in this field.. As a matter of fact, the results of research
in atherosclerosis have been perhaps even more spectacular than in many other
fields.

Examples are numerous. Atherosclerosis of the major arteries of the body
has been attacked surgically with gratifying results. With the development of
artificial arteries, it is now possible to replace or bypass many diseased segments
of arteries and restore normal blood flow to vital organs. An increasing number
of Americans are now leading normal lives as a result of such advances in vas-
cular surgery. :

Electrical devices, cardiac pacemakers, have been developed that can restore
to normal a diseased heart’s abnormally slow rate. Some of these pacemakers

171

 

   
 

172 COMBATING HEART AND OTHER MAJOR DISEASES

can be implanted to maintain a normal heart rate for years. Indeed, more than
5,000 adults living with implanted pacemakers might be dead but for this advance
in technology.

The dreaded complications of an acute heart attack—thrombosis and embol-
ism—have been greatly reduced in frequency by the use of anticoagulant drugs.
Preliminary work with clot-dissolving drugs, or fibrinolytic agents, in treating
thrombotic episodes shows considerable potential; more work in this area could
result in significant contributions.

Research efforts are underway at the present time to develop an artificial heart
to replace a diseased heart. Experimental models have already been tried in
man.. These models are being modified ; and, with the aid of industry, it is hoped
a an effective model may become available for widespread use by 1970 or even
earlier.

Another development which has become possible due to increasing research into
the immune responses of men has been in the field of organ transplantation,
Kidneys, livers, lungs, and recently hearts have been transplanted into man
from primates or from man to replace diseased organs, Though the results leave
much to be desired, early work in this complicated field has shown sufficient
promise to justify intensification of such research.

The advances in cardiovascular disease over the last two decades were not
considered possible 50 years ago. Funds, in increasing amounts appropriated by
Congress for facilities, training, and research, together with funds from volun-
tary agencies and private sources, have made these advances possible. Thanks
to these historymaking developments, physicians today know more than ever
before about heart and blood vessel diseases and can do something about them.

Still there is a long way to go. It is imperative that these advances be capi-
talized upon and the research effort intensified and accelerated if these diseases
are to be brought under control.

In addition to the development of new knowledge through research, a pressing
need is the application of the fruits of research so that the American people can
receive the full benefit of what medical research has accomplished. At present,
they are denied much that medical knowledge has to offer. In part this is
because of shortages of professional health workers and medical facilities. It
is also partly related to the public’s lack of awareness of recent developments
and techniques of prevention and treatment. The patient with heart disease
should receive the best that modern medicine has to offer, not only to save his
life but also to restore him to his family as a productive and useful citizen,
Such treatment can only be accomplished by a coordinated national program to
overcome shortages where they exist, by stronger educational efforts directed
toward the professional and general public concerning the prevention and treat-
ment for cardiovascular diseases, and by the development of properly distributed
community resources sufficient to provide excellent medical care from the onset
of symptoms of heart disease to the patient’s return to community life.

In evaluating the research, training, and control needs in cardiovascular dis-
east, it is worthwhile reviewing the wise and thoughtful provisions of the Na-
tional Heart Act: :

“The purpose of this act is to improve the health of the people of the United
States through the conduct of researches, investigations, experiments, and
demonstrations relating to the cause, prevention, and methods of diagnosis and
treatment of diseases of the heart and circulation; assist and foster such re-
searches and other activities by public and private agencies and promote the co-
ordination of all such researches and activities and the useful application of
their results; provide training in matters relating to heart diseases, including
refresher courses for physcians; and develop and assist the States and other
agencies in the use of the most effective methods of prevention, diagnosis and
treatment of heart diseases.”

Unfortunately, many of these important provisions have not been carried
out to the extent possible. The Subcommittee on Heart Disease of the Presi-
dent’s Commission on Heart Disease, Cancer, and Stroke has developed a series
of recommendations to permit the fullest possible implementation of these provi-
sions and to meet the charge given to the Commission by President Johnson
“* * * to recommend steps to reduce the incidence of these diseases through new
knowledge and more complete utilization of the medical knowledge we already
have.”

Most of part 1 of this report emphasizes conclusions and recommendations.
With spme redundancy, part 2 deals mainly with the background for these
conclusions.
 

 
  
  
 
 
  
 
 
  
  
  
  
    
  
  
   
  
 
   
   
 
   
  
 
 
 
 
 
 
 
 
 
  
  
 
 
 
  
   
 
 
  
  
  
    
   
 
   
  
 
  
 

PP

COMBATING HEART AND OTHER MAJOR DISEASES 173

> than REGIONAL HEART DISEASE CENTERS FOR CLINICAL INVESTIGATION, TEACHING, AND
lvance PATIENT CARE
mbol- It is recommended that at least 25 heart disease centers be established on a
lrugs. regional basis in selected universities and medical research institutions through-
ating out the country.
could A heart disease center ig defined as an organizational unit, including indivduals
from various disciplines in medicine, the broad purpose of which is to conduct
heart research and traning aimed at the prevention, alleviation, and cure of heart and
ed in blood vessel disease. Such an organizational unit should be administratively
oped and physically part of a large medical complex which is already engaged in
even medical research and training.

The center must have space appropriate to the program to be mounted, per-
into mitting reasonable expansion, Nonmatching support dollars should be available
tion, for the construction of hew space or the renovation of existing space.
man The research program should include clinical investigatious, utilizing hospi-
Pave talized patients, outpatents in certain instances, and a variety of modern lab-
‘dent oratory facilities. Research support should include funding for all aspects of in-

patient and outpatient observation, construction, or renovation of space, salaries
not of all categories of personnel, purchase of equipment and supplies, including
i by laboratory animals, and so forth.
lun- It is mandatory that the personnel of each center be large enough in number
nkg and represent enough disciplines to facilitate investigation in depth, utilizing
ver a broad range of scientific methods. Such a center might include internists:

cardiopulmonary physiologists ; cardiologists oriented toward electrocardio-
Api- graphic interpretation and electrical termination of abnormal rhythms; pe-

ripheral vascular Specialists ; cardiac and vascular surgeons ; lipid, coagulation,
and general biochemists ; statisticians: epidemiologists : radiologists with appro-

Ing priate training; and, in some cases, geneticists. Computers may be employed for
an full exploitation of data developed in these centers,

Such centers would be strongly oriented toward ¢linical investigation but at
the same time would provide high-quality patient care, including rehabilitation,
It and would also be concerned with teaching and the training of persounel con-

its cerned with heart disease.
se The teaching function should include the training and support for physicians,
is

surgeons, radiologists, nurses, and professional personnel in other pertinent
t disciplines. Also included should be training programs for personnel staffing
oO

the heart stations. The center should also serve a teaching function for the
ad medical community of the region.
te Since the research and training activities demand patients, the centers will
d necessarily also be concerned with patient care. It is visualized that each center
at will require up to 30 hospital beds—medical, surgical, and rehabilitation, in
addition to the beds already available in that hospital facility—as well as an
j=

outpatient care facility.

It should be emphasizd that it will be necessary to develop regional centers
where none exist. During the first 3 to 5 years of the program, investments
I will have to be made in potential regional sites,

i A total of $166.2 million over a 5-year period should be provided to establish
1 and maintain these 25 centers. Authority should be given to provide up to 100
” percent for construction and renovation costs. The proposed 5-year budget for
; this program is as follows:

Projected outlay for 5 years

[Dollars in millions]

 

 

 

 

 

 

 

 

 

Year 1 2 3 4 5
Number of new centers_..--..--..-. 10 3 4 4 4
Construction and renovation.__._.__..___| $25 $7.5 $10.0 $10.0 $10. 0
Operating expenses_.___.22.0070777 777 17.0 22.1 28.9 35.7
Total... 25 24.5 32.1 38.9 45.7

 

43-669—65——12
 

—

174 COMBATING HEART AND OTHER MAJOR DISEASES

~The present program of matching grants for the construction of health re-
search facilities needs to be augmented with authority for the Public Health
Service to construct, on a nonmatching basis, research facilities for regional or
national purposes. The Public Health Service bas the responsibility for meeting
national research objectives. In pursuing these objectives, the Public Health
Service must have available a full range of mechanisms which are not dependent
on the availability of matching funds or the existence of institutional interest in
specific research programs. The additon of this nonmatching construction au-
thority would enable the Public Health Service to be more responsive to specific
research objectives established by the executive or legislative branches of the
Government. It is urgently recommended.

SPECIALIZED HEART DISEASE RESEARCH CENTERS

To permit the development of certain specific areas which require more con-
centrated effort in a particular field of research in cardiovascular disease, it is
recommended that at least 10 specialized heart disease research centers be es-
tablished in various health and medical research facilities throughout the coun-
try. These centers would be organizational units with personnel and in-depth
research and training objectives limited to a special facet of cardiovascular,
e.g., epidemiology, genetics, study of blood coagulation parameters and anti-
coagulant and fibrinolytic agents, pharmacology (especially of natural products)
or coronary prevention evaluation. These centers are to be distinguished from
the regional heart disease centers mentioned above in that they will not be
concerned with the total problem of cardiovascular disease. For example, there
is need for a minimum of three special epidemiological research centers in the
field of cardiovascular disease. Centers of this type require personnel from a
variety of disciplines, e.g., epidemiologists, biostatisticians, mathematical statis-
ticians, sociolcgists, nutritionists, pathologists, and others. Such a center would
develop and support epdemiological research projects in the broad field of cardi-
ovascular disease in suitable population groups in the United States and, where
unique research opportunities exits, in foreign countries. Specialized centers
in other specific research areas could be organized similarly in a manner appro-
priate to the nature of the task. There is definite need for this fiexible approach
to the establishment of specialized centers for in-depth research and training.

It is estimated that $300,000 per year is needed for each specialized center.
It is recommended that $600,000 be appropriated during the first year with annual
increments. of $600,000 up through the fifth year; a total of $9 million for the
first 5 years of this program.

DEVELOPMENT OF THE CENTERS

The planning, review, and early stages of the development of these centers
will be a major undertaking. The total effort will be of a magnitude for which
the present administrative structures at the National Institutes of Health are
not properly geared. It will be impractical to have the many detained ramifica-
tions of each plan subject to separate consideration by the several committees
which presently report to the Advisory Councils. For example, under the present
system, each one of these centers would involve disciplines requiring the action
of numerous study sections. The many committees concerned will not be able
to consider the material in parallel from the viewpoint of time. In the present
administrative structure, applications would have to be reviewed by committees
dealing with (@) construction and renovation, (b) program project, (¢) appro-
priate study section activity, and (d@) training grants.

In order to activate and develop this major program with essential flexibility,
it is recommended that an Advisory Committee on Regional Centers be estab-
lished by the Public Health Service. The function of this committee will be
the organization, development, coordination and review of all plans and projects
dealing with the development of heart disease centers and the presentation in
mature form of comprehensive proposals to the National Advisory Heart Council
for its consideration. This committee should also be concerned with positive
program planning as well as the development of a basic “core” of support which
would enable each center to become established, coordinate its essential func-
tion, and get underway.

During this period the center committee should utilize fully the talents of
the presently existing committees, especially those dealing with construction
a, ae

lth re-
Health
onal or
neeting
Health
endent
rest in
ion au-
specific
of the

e con-
. it is
be es-
coun-
depth
mar,
anti-
ucts)
from
ot be
there
1 the
om a
atis-
ould
irdi-
here
ters
pro-
ach

ter,
Aa]
the

 

COMBATING HEART AND OTHER MAJOR DISEASES 175

and renovation. One way to achieve this would be
each on the Advisory Committee on Regional Centers,

The experience gained during the ear]
opment of subsequent centers. This woul
After: the first 3 years, requests for additional Support from the

be submitted in each case through the usual channels and subj
tive review. :

to have representation from

erloading of the present
nt period. Furthermore,

will greatly enhance the
quality of the supporting data presented for consideration to the National Ad-

visory Heart Council. Such staff work will, in turu, lessen the burden of this
large program on the Council.

CARDIOVASCULAR RESEARCH FUNDS

although many other Government agencies are
In the private sector, the American Heart Ass
support for cardiovascular research; in additio
professional ang public education in this field.
and foundations, currently financing such resea
total of 37.

Expenditures for research in the cardiovascular diseases comprised only 11.8
percent of all medical research expenditures in the United States in fiscal
year 1962, as noted above. Although cardiovascular research expenditures, in
dollars, increased 8.7 percent in fiscal year 1963, the proportion to total medical
research expenditures decreased” ‘to-11 percent, indicating that research in
cardiovascular diseases is not keeping pace with the annual expansion in total
medical research. This neglect has occurred in Spite of the fact that over 50
percent of all deaths in the United States are due to diseases of the heart and
-blood vessels,

Closer examination shows that the total budget for the National Institutes
of Health (NIH) increased from fiscal year 1963 to fiscal ye.

ar 1964 by only 4
percent while the budget for the National Heart Institute decreased by almost
$15 million. Furthermore, although consetvative NIH estimates show that a

19-percent budget increase can be justified on current program needs, it is under-
stood that the bureau will be held down to a 4- to 8-percent increase for the
next Several years; barely sufficient to continue su j

not sufficient to allow development and support
proach is hardly realistic.
for a productive program of research on rigid a
percentage increase,

In order to facilitate intensified and expanded su
vascular disease, it is recommended that $40 milli
National Heart Institute in a 3-year period over a
tions for research project grants,

supporting some such research.
ociation is the major source of
0, it plays an important role in
The list of voluntary agencies
reh, is long and diversified—a

SPECIAL STUDIES

The National Heart Institute has given, and should contin
‘emphasis to epidemiological Studies and controlled clinical trials of drugs, diet,
use of tobacco, and surgical procedures, Broad clinical field trials of this nature

titutions. This should

meritorious projects of this type. In
order to facilitate the planning and implementation of special

the National Institutes of Health should be given authority t
whereby funds appropriated for these
-at the end of the fiscal] year,
Considerable work is being devoted by many inv
‘to the development of an artificial heart. To m
‘this problem, considerable research and dévelopme
institution members, but, more particularly, by in

ue to give, spectal

estigators at the present time
ount a large-scale attack on
nt by university and research
dustry will be required. The

‘same is true for other technical developments. The present Public Health

Service Act, as amended, does not provide direct authority to contract for

  
  
   
   
  
  
 
   
 
 
  
  
 
 
  
 
 
 
  
    
 
 
  
     
  
     
 
  
    
   
   
  
 
  
    
 
 
 
   
  
 
  
 
 
 
 
  
 
 
 
  
 
   
 
 
 
 
 
 
  
   
  
 
 
  
nee ee

176 COMBATING HEART AND OTHER MAJOR DISEASES

research and development purposes. The authority ‘being utilized for this pur-
pose is obtained by aelegation from the General Services Administration through
the Secretary of Health, Education, and Welfare: |: This delegated authority
‘is general in nature and does not contain certain features which appear essential
to contracting for research and development: purposes. In addition, any con-
‘tract let by the National Heart Institute, in excess of $25,000, must be approved
by the Secretary of Health, Education, and Welfare—a delaying and cumbersome
procedure. :

It is therefore recommended that the Public Health Service’s authority to
contract tor research be broadened to allow the Surgeon General or his delegated
agent—

(@) To make advance payments on contracts in order to assist contractors
in initiating new and compiex technical operations ;

(6) To pay for the cost of construction involved in and essential to
the successful accomplishment of the terms and purposes of a contract; and

(e) To commit contractural support for advance periods upwaid to 5
years to enable contractors to make substantial investment in facilities and
staff, as required for major contract operations, with confidence in substantial
recovery of costs and reasonably stable operations.

Further, it is recommended that the procedure of letting contracts be made
less cumbersome so that rapid strides can be made in the research and develop-
ment area without being impeded by unnecessary administrative and fiscal
restrictions.

It is also recommended that the National Heart Institute be appropriated
$10 million in the first year; $15 million in the second year; and $20 million in
the third year for research and development operations as a needed adjunct
to its current research program.

It is also recommenued that there be a greater expansion of the international
research program in order to capitalize on unique research opportunities abroad.

A need exists, both nationally and internationally, for the development, dis-
semination, adoption, and use of standardized nomenclature, criteria, and
methuds (clinical aud laboratory) utilized in cardiovascular (and other) re-
search so that the results and reports of investigators from different parts of
the world can be interpreted, reproduced and, when applicable, applied for the
benefit of the American people. The beginnings made in this direction have
proved most fruitful. An example is the Internationa] Committee on Blood
Clotting Factors which has been supported in large measure by funds from
the National Heart Institute. Efforts of this type are needed and should be en-
couraged und supported. .

An intensification and acceleration of the present research effort will require
staff with the numbers and competence to administer these programs. It is
recommended that there be a relaxation of the current limitations on positions
in order to support the development and implementation of new progranis,

TRAINING PROGRAMS

Research training can be supported and is supported by the National Insti-
tutes of Health and the National Heart Institute. Although a careful 1962
projection of manpower needs recommended a doubling of medical and scientific
manpower by 1970, there has been no substantial increase in training funds in
the NHI budget for the past 4 years except for minor increases to meet the needs
for increased stipends and educational allowances.

This is an unrealistic response to a vital need. A much larger corps of well-
trained research scientists and physicians is essential to an intensified and
accelerated program of research in cardiovascular diseases, This need must be
met,

The National Advisory Heart Council prepared a proposed budget for fiscal
year 1965. This budget was presented to the subcommittee of the Committee on
Appropriations of the House of Representatives in March 1964. The Council—
the senior advisory group to the National Heart Institute—in evaluating the pro-
gram needs for the institute recommended a 20-percent increase in fellowship
funds and an 11-percent increase in training grant funds. The appropriations
4to the NHI for fiscal year 1965 in the, fellowship and training grant areas do not
come near these recommended figures. There: was no increase at all.

It is recommended that the National Heart Insitute receive an annual increase
in appropriations up to 20 percent in training grant and fellowship funds over
the next 5 years so that a start can be made to meet, at least in part, the re-

ee
this pur-
1 through
authority
essential
any con-
approved
nbersome

hority to
lelegated

1tractors

ntial to
ict; and
id to 5
ties and
stantial

e made
levelop-
d fiscal

priated
Hion in
rdjunet

ational
abroad.
nt, dis-
a, and
or) re-
arts of
for the
1 have
Blood
3 from
be en-

equire
It is

sitions

ns.

Insti-

1962
ntific
ds in
needs

well-
and
st be

fiscal
-e on
cil—

pro-
ship
tions
) not

ease
over
 Te-

 

COMBATING HEART AND: OTHER MAJOR DISEASES 177

‘search manpower shortage. Further, it is recommended that undergraduate:
training grants be increased to $40,000 per eligible 4-year school and to $25,000.
per eligible 2-year school. pe

The Commission is aware of the efforts on the part of other official and volun-:
tary health agencies in the field-of cardiovascular diseases. For example, the
168 hospitals in the Veterans’ Administration, providing almost 125,000 beds,
many of which are physically near medical schools, constitute an excellent
total facility for bringing excellent medical care to a s‘zuble segment of the
population and, in addition, can provide an ever-expanding resource for clinical
and basic investigations. .

Much wider use should be made of the Veterans’ Administration facilities for
research and teaching in collaboration with other major research and teaching
facilities. The Veterans’ Administration has potential for large-scale and long-
term clinical studies. It is specifically recommended that the Veterans’ Admin-
istration be given the charge and the funds to carry out an expanded program of
research and teaching, in addition to patient care.

The valuable contributions to the research and community service effort made
by the American Heart Association and its affiliates are recognized.

ADVANCED CLINICAL TRAINING

The needs in manpower described above apply not only to research scientists
but also to practicing physicians in the heart disease field as well as in other
categories. These men and women are ultimately responsible for earrying the
fruits of research to the majority of the American people. And yet. under cur-
rent policy guidelines, the National Heart Institute can only support training that
is research oriented. .

Greater emphasis must be placed on the training of superior clinical plysicians.
There is a great need for a larger corps of clinicians who are capable of precise
diagnosis and providing appropriate treatment, clinicians with minds capable of
recognizing and applying new discoveries and clinical observations,

To meet this need. it is recommended that the authority be granted and the
funds appropriated for:

(a) The establishment of clinical fellowships in the cardiovascular field ;
and

(6) The establishment of full-time clinical investigators in the cardio
vaseular field.

In a medica! school, education and research go hand in hand. This should te
‘recognized by the Public Health Service, Administrative and policy attitudes
regarding research grants should be less. restrictive even when such education
involves clinical medicine and service. :

APPLICATION OF RESEARCH

The need for more effective and more widespread application of the products
of research is as great as the need for new knowledge through research. And yet,
financial support for this type of activity has lagged far behind research support;
in 1964, for example, the total budget for the heart disease control program was
one-tenth of the total budget for the National Heart Institute.

The Subcommittee on Heart Disease has explored in depth the current state of
knowledge in the field of cardiovascular diseases and has evaluated and outlined

‘the current and future research training and control needs (see pt. 2, below).

In almost every disease eategory in the cardiovascular diseases, the need exists.
in each State for a coordinated statewide program of heart disease control. In
rhenmatie fever control, for example, as in most other heart disease categories,
there is a variety of Federal, State, and voluntary programs. There is little
overall coordination of the ongoing programs and the agency responsible for a
given program varies from State to State. This situation is not helped by the
disagreement among health workers in the field as to whether rheumatic fever
prevention (and control efforts in heart disease in general) should be an official
or voluntary agency responsibility or both.

On the national level. greater efforts should be made to coordinate the activities
of the U.S. Public Health Service. the Office of Education. the Children’s Bureau,
the Vocational Rehabilitation Administration, the American Heart Association,

‘and other agencies involved in community services in cardiovascular disease.
“These agencies should pull together existing information so that an assessment
‘ean be-made of the heart disease control programs in each State, the extent of

  
 
 
  
 
  
   
 
  
   
  
 
 
  
  
 
 
   
  
 
  
  
 
 
  
   
   
  
 
 
  
 
 
 
  
    
  
 
 
 
 
 
  
 
  
 
 
   
  
 
  
  
   
  
 
  
   
 
  
 
  
  
  
 
 
  
  
 
  
 
  
 
  
  
  
  

 
 

178 COMBATING HEART AND OTHER MAJOR DISEASES

these programs, the responsible agencies within each State (at the State, county,.
and city levels), and the obstacles within each State which prevent implementa-
tion of a coordinated statewide program. This type of information is badly
needed.

A comprehensive coordinating effort should be made by the heart disease con-
trol program, in cooperation with the agencies referred to above. This could be
fucilatated by the appointment of a committee of scientists and health workers iu
this field to aavise the heart disease control program. Such a committee might
undertake the establishment of uniform criteria go that reports received from
each State could be pooled to give meaningful and accurate national data. It
might also recommend pilot projects-in heart disease control; successful projects
might ultimately serve as modeis for more large-scale operations.

Coordination within States

It is suggested that each State develop its own heart disease control program
(with operating sections for congenital heart disease, rheumatic fever and rheu-
matic heart disease, hypertension, coronary heart disease, cardiopulmonary dis-
ease, peripheral vascular disease, congestive heart failure) with tinaucial assist-
ance trom the heart aisease control program (with specially earmarked funds
for each of the operating sections).

It seems reasonable to recommend that each State choose the agency respon-
sible for the implementation and administration of a coordinated statewide pro-
gram since it appears that a single national recommendation might uot be suit-
able (or acceptavie) to all areas. The type of program adopted wouid aepend
on the local conditions.

Irrespective of which agency is ultimately .responsible for administering the
prograin in any given State, there should be representation from all other agen-
cies, public and private (voluntary), invoived in heart disease control activities on
a planning committee, or advisory council or other appropriate body. Critical
to the success of such a program would be an excellent relationship between the-
adiinistering agency and the practicing physicians within that State; this point
caniot be emphasized too strongly.

The role of the heart disease control program of the U.S. Public Health Service:
is to assist the States to develop and impiement heart disease control programs,

The Public Health Service has been seriously hampered from fulfilling its
mission in heart disease control by lack of sutticient authority and funds. The
refinement of techniques, pilot testing, and similar developmental work have been
all but negiected because of lack of project grant authority and funds to mount
such programs.

Some control techniques are available which cannot be demonstrated on &
widespread basis because they do not lend themselves to existing funding mecha-
nisms. The contract method of funding is difficult to use when projects provide
services and no clearcut product (such as a research result) for the Public
Health Service. A demonstration is most appropriately and feasibly funded by
a project grant which requires no extensive reports containing fresh data. The
contract mechanism, available to the heart disease control program through its
direct operations funds, is limited(ess-than- $700,000 in 1964) and is aptiropri-
ately used for those projects which pursue official goals. This does nut allow
support of many projects which, although they are not part of a section chief’s
immediate plan, are nonetheless well conceived and of real worth to the commu-
nity or to the future of heart disease control. In one year (1962) these unsolici-
ted but meritorious projects which had to be rejected represented a total need
of more than $2 million.

AUTHORITY REQUIRED

After full consideration of the need for developing sound and effective com-
munity service programs aimed at reducing the burden of cardiovascular diseases
in the United States, the following actions are specifically recommended :

The heart disease control program of the Public Health Service should be
given the authority to make project grants to public and other nonprofit organi-
zations for studies, experiments, feasibility trials, demonstrations, and training
in order to provide incentive and encouragement for the development and im-
provement of methods for application of the results of research to patients
in the community.

Specifically, it is recommended that a new subsection 314(n) be added to the
Public Health Service Act, which would provide that funds appropriated pur-
sSuant to subsection 314(e¢) would also be available for the Surgeon General to
    
  
  
  
 
  
 
 
 
  
  
 
 
 
 
  
 
   
   
  
  
 
  
 
  
  
  
 
  
 
 
 
 
   
  
  
 
 
   
   
   
   
  
  
 
 
  
  
 
  
 
 
 
 
 
 
   
        
   
  
 
 
  
   
  
 
  
  
  
 
 
  

ate, county,
mplementu-
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lisease con-
is could be
workers in
ittee might
eived from.
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ul projects

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COMBATING HEART AND OTHER MAJOR DISEASES 179

make project grants, on such terms and conditions as he finds neeessary, to
States and other public and nonprofit organizations for studies, demonstrations,
and the training of personnel.

It is also recommended that $1.5 million be appropriated to the heart disease

control program to initiate this project grant program with anuual increases
until $7.5 million is reached in 5 years.

HEART STATIONS

The Public Health Service should be given the authority and necessary funds
to award grants to establish and maintain a network of approximately 150 heart
stations in the United States, Approximately half of these stations should be
established in medical centers and in clinical facilities of the medical schools,
usually not those designated as regional centers; the other half should be in
community general hospitals, including Veterans’ Administration hospitals, not
necessarily connected with medical schools. This network would serve as a
pilot program for the demonstration of methods providing high-quality patient
care. The stations would have the following principal objectives:

1. Immediate and emergency care for patients with acute cardiovascular
emergencies.

2. Provision of cardiovascular diagnostie facilities for the screening of
patients to determine whether they will require the more highly technical
facilities available at the larger medical centers,

3. Stimulation of interest of medical students and practitioners.

4. Training of physicians in the community.

5. Education of the general public concerning prevention and treatment of
heart disease.

The stations will include intensive care units for the emergency care of
patients with heart disease. In addition, each station should be equipped to
diagnose and treat patients with peripheral vascular disease. They should be
established so that they may share certain facilities and personnel with stroke
stations. Therefore, it is desirable for the heart stations to be in the same area
of the hospital as the stroke stations and to work closely with them, avoiding
unnecessary duplication but supporting each other,

The stations will provide limited laboratory facilities, an outpatient clinie,
electrocardiographic and radiologic services. Patients requiring advanced treat-
ment would be referred to the regional center equipped to perform it.

In order to establish these stations, funds are necessary for the renovation of
existing facilities. It is estimated that renovation and equipment will cost an
average of $200,000 for each. An additional amount of $175,000 a year may be
required for the efficient operation of each station.

It is recommended that a total of $118.5 million be appropriated for a 5-year
period for the development of this program, according to the following table:

Costs of heart stations

[Dollars in millions]

 

 

 

 

 

Years 1 2 3 4 5
Number of new stations.__...-...._--...-.. 30 35 40 45 |-.----
Renovation costs._-.___...-_ 2-2 $6.0 $7.0 $8.0 $9.0 |i.
Operation expenses.._-.._-- 0 5. 25 11.375 18. 375 26. 25 $26. 25
Total... 11. 25 18. 375 26. 375 35. 25 26. 25

 

 

 

 

 

 

It should be pointed out that a recent (1961) survey of cardiac catheteriza-
tion, angiocardiography, and closed and open heart surgery facilities in the
United. States showed that 60 percent of hospitals equipped with cardiac
catheterization facilities performed fewer than 50 catheterizations per year: 79
percent of those with angiocardiographic facilities did fewer than 50 angio-
cardiograms per year; and, 77 percent of all hospitals equipped for open heart
surgery performed fewer than 50 open heart operations per year. Many such
hospitals did not use their facilities at all.

Preliminary data from another recent survey show that cardiopulmonary
laboratories and cardiac surgical facilities with the highest frequency of com-

 
LL

180 COMBATING HEART AND OTHER MAJOR DISEASES

plications are those with the least experience. These data add credence to
the belief that first-class teams must be kept reasonably busy, i.e., between
100 and 200 procedures per year or 2 to 4 cases per week. In addition to the
need for an adequate caseload, highly technical diagnostic procedures such as
angiography should be carried out at the institution where surgery, if indicated,
is to be performed, in order to avoid repetition of precedures.

Although many hospitals are anxious to be fully equipped and have cardiac
eatheterization and angiocardiographic apparatus for study of congenital and
acquired heart disease and to be able to perform open and closed heart surgery,
certainly the 800 which currently exist are not necessary, especially in view
of the fact that 270 of them reported no such operations at all in 1961. It
would seem far wiser to limit the number to 200 and 250 well-equipped centers
with well-trained teams and a sufficient caseload, and reserve the others for
emergency cardiac surgical work.

Consequently, it is recommended that highly technical cardiac diagnostic
procedures and cardiac operations should be performed only in institutions
where facilities for cardiac catheterization, angiocardiography (and aortog-
raphy), closed and open heart surgery are all available, and where the case-
load is sufficient. Patients found by heart stations, other health installations,
and practicing physicians to require such specialized diagnostic evaluation
should be referred to such institutions for definitive diagnosis and treatment.

STATEWIDE LABORATORY FACILITIES FOR HEART DISEASE CONTROL

There is need in every State for coordinated statewide laboratory facilities
to perform laboratory services related to heart disease control. These labora-
tories should form a part of a coordinated statewide program of heart disease
control, headed by a specific unit within the State health department. Such
a program to be successful, must coordinate the efforts of the numerouus public
and voluntary agencies whose work infringes on heart disease control and
must also collaborate closely with the private physicians of the State.

The objectives of this statewide laboratory network should be:

(1) The grouping of beta-hemolytic streptococci. Rheumatic fever is
potentially preventable through prompt identification and immediate treat-
ment with an appropriate antimicrobial agent of patients suffering from
beta-hemolytie streptococcal infections. Each State should have coordi-
nated laboratory facilities to identify the group A beta-hemolytic strepto-
ecoecus organism. Where such facilities exist. they have proved a_ tre-
mendous boon to practicing physicians and have facilitated rheumatic
fever control programs in that State.

(2) The provision of services for the laboratory control of patients
receiving anticoagulant agents. Over half a million patients in the T'nited
States are receiving anticoagulant drugs each year; it is probable that the
number will grow in the future. The dosage of these drugs must he tailored
to each patient individually and the dosage regulated by carrying out appro-
priate blood tests at frequent intervals. In many areas of the country. this
service is carried out by hospital and private laboratories. These labora-
tories need a central unit for standardization of their tests at frequent
intervals. In other areas, however, patients cannot receive this type of
medication because this service is not available. A statewide laboratory
network could help te provide this service in areas where it is needed.

(3) In conjunction with the heart disease control program (HDCP)
laboratory at the Communicable Disease Center (CDC), to provide the
service of standardization of other chemical lahnratory tests to hospital
and private laboratories in the country. The HDCP laboratory at CDC
is performing this service for laboratories all over the United States and
abroad at the present time. This statewide network of laboratories could
serve as local agents for this valuable program. As such. these local
lahoratories could also perform chemical determinations and participate
in large local and national enidemiologic studies in cardiovascular disease ;
in this sense, these laboratories would act as a valuable resource for certain
research programs of national interest.

It must he stressed that the development of such a laboratory network to per-
form the above services would make it possible to achieve an immediate, specific,
 

 

  
  
 
 
 
  
 
 
  
   
  
  
     
  
  
 
  
    
  
 
 
 
  
   
   
  
  
  
   
 
  
 
 
    
  
  
  
  
   
 

»

 

 

 

 

 

 

 

 
 
 
        
  
 
 

 

 

 

 

 

 

COMBATING HEART AND OTHER MAJOR DISEASES 181
1ce to and measurable impact in reducing death and disability. Each State should
tween assess its own needs. The heart disease control program of the Public Health
‘o the: Service should have the authority and specifically earmarked funds to assist the
ch as States in setting up and operating the needed facilities.
cated Therefore, it is recommended that the Public Health Service be given authority

; and funds to establish and maintain coordinated Statewide laboratory facilities
rdiae necessary for heart disease control programs. A total appropriation of $8.5
| and million over a 3-year period is recommended for this purpose—$2.5 million for
‘gery, each of the first 2 years and $83.5 million for the third.
view
. It COMMUNITY HOSPITAL PROGRAMS
nters In addition to the need for a coordinated national program of heart disease
3 for control, the need for a coordinated heart disease control program within each

. State, and the need for a network of heart stations throughout the United
ostic States, there is need for strengthening community facilities, Services, and pro-
tions grams in the field of cardiovascular diseases, A continuing program designed
rtog- to maintain a high standard of professional competence ot physicians, nurses
“ASe- and paramedical personnel and to educate the genera] public is needed to achieve
fons, the common objective of improving the care of the sick.
tion The community hospital should serve as the center of this pregram, in co-
ent, operation with government and private agencies,
In order to organize and keep such a program of continuing education in clin-
ical cardiology in operation, suitable personnel should be appointed to staff the
ties program in a given hospital. The staff should include a full-time director of
ira medical education with such help as he needs for the organization of meetings,
ase consultations, regularly scheduled staff and grandrounds, and clinical pathologi-
neh eal conferences, Members of the attending staff of the hospital should be en-
blie couraged to attend courses and take longer additional training whenever
possible, .
ind Though ideally all community hospitals with 300 or more beds should ulti-
mately mount such a program, it is recommended that such units be established
: and supported in 100 of these hospitals throughout the United States as a pilot
Is demonstration. It is estimated that about $75,000 per year would be needed to
at- carry out a program of this type in each hospital of this size. A total of $7.5.
dL million annually would be needed for expenses.
fo- CONCLUSIONS
tic An all-out national effort is needed now in research, development, and training,
and in the application of present knowledge in the field of cardiovascular dis-
its ease. Only in this way will it be possible to reduce the burden and incidence of
ed heart and blood vessel diseases, the No. 1 cause of death in this country.
he The following table summarizes the appropriations recominended to imple-
ad ment the national program outlined in this report. These figures are at the cur-
‘O- rent dollar value; should this value shift in the future, these figures should be
ig adjusted appropriately.
A~
. Year | 1 | 2 | 3 4 6
y Regional centers... nee 1 $25.0 $24.5 $82.1
) Specialized centers__. - .6 1.2 1.8
esearch grants—NHI_ - 8.0 12.0 20.0
e Contracts (R&D)—NH 10.0 15.0 20.0
1 Undergraduate training grants_—NH + 1.55 1.55 1.55
~ Graduate training grants and fellowship 4,3 5.2 6.3
7 Clinical fellowships and investigatorships 5.0 7.0 9.0
1 eart disease control project grants..-.____ 1.5 3.0 4.5
1 Heart stations. ___ See se sees ass, 11.25 18.375 26. 376
Laboratory facilities._-7 777777 2.5 2.5 3.5
1 Community hospital programs. ._-__-2 22 7.6 7.5 7.6
Total. ee 77.20 | 97. 825 | 182. 625

 

1 Figures in millions of dollars over and above current appropriations,

  
 

182 COMBATING HEART AND OTHER MAJOR DISEASES

REPORT OF THE CANCER PANEL

(Dr. Sidney Farber, Chairman, Dr. R. Lee Clark, Dr. Frank Horsfall, Dr. Charles
Mayo, General David Sarnoff, and Dr. Jane Wright. Staff: Dr. David Schot-
tenfeld, Dr.’ Maureen Henderson, Dr. Abraham Lilienfeld, Mr. Louis M.
Carrese ; consultant, Dr. Morton L. Levin)

Cancer is a term applied to a group if diseases having in common the trans-
formation of normal body cells into abnormally growing partsitic cells. Be-
eause of the fundamental nature of this biological change and the fact that it
ean occur in any organ of the body, cancer is one of the most complex and
difficult medical chailenges, both from the standpoint of treatment and research.
Although the group of diseases known as cancer have certain biologic features
in common, they differ widely with respect to clinical course, curability, known
etiology and diagnostic and treatment methods. The basis of the illness—
wancer—is the cancer cell. The known causes or agents which can transform
normal cells into cancer cells are numerous, but as yet no single agent or cause
has been. discovered which has been found to be common to all forms of cancer.
Also, the causes of nany forms of cancer are as yet unknown.

Research into the mechanism by which normal cells become cancer cells
and by which certain chemicals, viruses, and physical agents such as ionizing
radiation contribute to this change may involve any of the biological, chemical,
and physieal sciences. This is evident in the report of the Subcommittee on
Research which contains a review of the present status of knowledge on the
basie aspects of cancer. All of the presently known environmental factors in
cancer in man have been discovered primarily by the direct study of the disease
in humans. Hence, there is growing recognition of the need for epidemiological
study.of all forms of cancer in man, utilizing the most advanced methods and
adding objective biochemical and physical observations to the data obtained
by interview and history.

MAGNITUDE OF CANCER

The magnitude of a disease problem is usually measured by: incidence or
number of new cases per year; mortality or number of deaths per year; and
prevalence or number of cases under ‘treatment or care at one point in time
during a given year. With data on incidence and mortality from all causes, it is
possible also to estimate what proportion of the population may be expected to
develop the disease during life or at any specified age.

The number of new cases of cancer per year contineus to increase in part
as a result of increases in population and the increasing percentage of older
persons. Allowing for both these factors, the data from the cancer morbidity
reporting system in operation in upstate New York since 1940 indicates that
from the pericd 1941-43 to 1958-60 the number of new male patients per 100,000
population increased 31 percent. For females the rise was 5 percent. In
1941-43, the total cancer incidence rate was higher in females than in males.
In 1958-60, this situation was reversed; the male rate (261.3) exceeded the
female (244.7). This change was due almost wholly to the marked rise in lung
cancer, which has increased more rapidly among males. If we exclude lung
eancer from the 1958-60 figures, the female rate (239.9) continues to exceed
the male (232.7). Although lung cancer has increased in both sexes, the in-
erease among males has been more than twice that among females.

The most common forms of cancer in males are cancer of the skin, lung, pros-
tate, large intestine, stomach, rectum, and bladder. Among females, the most
common forms in the order of incidence are cancer of the breast, skin, cervix
uteri, large intestine, corpus uteri, ovary, rectum, and stomach.

Under present conditions, some form of cancer will affect 24 percent of men
and 27 percent of women now living. Cancer is the second most common cause
of death in the United States; in 1963 'it accounted for 285,362 deaths, or 15.7
percent of all deaths. At present rates, one in every four Americans now living
may be expected to develop cancer eventually, unless new preventive measures
can be developed and unless known causative factors can be more effectively
controlled.

It has been estimated that approximately 830,000 persons are under treatment
for cancer during the year, that the annual manpower loss from cancer morbidity
is 221,000 man-years and that the annual hospitalization cost is over $666 mil-
lion. More than 40 percent of deaths from cancer occur during the productive
Years of 25 to 64 years.

ae
ASES

fall, Dr, Charles
’r, David Schot-
Mr. Louis M.

mon the trang-
sitie cells, Be-
the fact that it
t complex and
t and research.
ologic features
‘ability, known
' the illness—
can transform
agent or cause
rms of cancer,

> cancer cells
h as ionizing
cal, chemical,
committee on
rledge on the
‘al factors in
of the disease
idemiologica]
Methods and
ata obtained

incidence or
tr year; and
int in time
causes, it ig
expected to

ase in part
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r morbidity
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ceeded the
ise in lung
clude lung
to exceed
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ow living
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ffectively

reatment
lorbidity
666 mil-
oductive

 
   
   
   
  
   
     
 
 
 
 
   
  
  
   
   
   
  
 
 
 
  
 
 
 
 
 
   
 
  
  
   
  
 
  
  
 
  
  
 
 
  
 
 
 
  
  
   
  
  
  
 
  
   
    
  
    
   
  
 
  
  
   
 
  

COMBATING HEART AND OTHER MAJOR DISEASES 183

The care of the cancer patient often requires major Surgery, prolonged hos-
Pitalization or nursing home care. and costly medication, Hence, cancer is often
economically catastrophic to the family of the patient. The total economic
-burden of cancer is about $11.2 billion per year in the United States.

PREVENTION OF CANCER

The prevention of cancer at present involves avoidance or renova] of known
environmental causes of cancer. This includes (1) avoidance of unnecessary
and avoidable exposure to ionizing radiation and excessive exposure to ultraviolet
radiation, (2) hygienic measures in occupation involving exposure to known
cancer-producing chemicals and dusts, and (3 ) avoidance of exposure to tobacco,
particularly cigarette smoke, which has been proven to play an important role
in the causation of cancer of the lip ,mouth, larynx, and lung. In addition, the
identification of the earliest detectable probable precursors of cancer—as in the
So-called carcinoma in situ of the uterine cervix—has now reached the stage of
practicability so that widespread utilization of uterine cytological tests to identify

these lesions could result in brevention of most of the 15,000 deaths from c¢ar-
cinoma of the uterine cervix each year,

The Subcommittee heard repeated testimon

services to provide the maximum application of exi
the prevention of eancer. O i

CURABILITY OF CANCER

The average cure rate for cancer, aS measured by the 5-year survival rate, is
estimated ag approximately 33 percent. The most recent relative 5-year sur-
vival rate, reported to the National Cancer Institute from a number of large
hospitals, indicates that in these hospitals the average cure rate is now 43 per-
eent. It is a reasonable assumption that improvement in early diagnosis and
more widespread utilization of existing knowledge Yegarding treatment would
result in an increased average cure rate of 50 percent or higher. To achieve this

will require increased Specialized facilities for cancer diagnosis and treatment
throughout the United States.

The Subcommittee heard testimony repeatedly indicating that there exists a

ain the new knowl-

RECOMMENDATIONS «

I. National network of facilities for patient care, research, and teaching in cancer

The Subcommittee envisions systematic patient care, research, and teaching
as the most effective means for providing multidisciplinary Services for the can-

cer patient and for developing a multidisciplinary research program. To accon.-
plish this, the Subcommitte

among all three levels,

Regional cancer centers would be the main nod
be tied to Selected medical School affiliated and

nore beds, with demonstrated interest in cancer, to be identified as clinical cancer
stations. The echelon in the network would consist of those smal] community
hospitals having approved cancer registers and/or tumor clinics which would
develop a relationship to a clinical cancer station in geographic proximity.

The planning, design, and review of this program should be oriented to the
Provision of a continuing flow of information and Services through all these facil-
ities. To insure the coordination of these multiple functions and to maintain
continued collaborative development of this program, the Subcommittee recom-
mends the establishment of a special committee to Teview plans and projects ;
the recommendations from this

Special committee are to be transmitted to the
National Advisory Cancer Council to aid the Council in making its recommenda-

tions regarding applications for the development of these facilities.

es of this network. These would
community hospitals of 200 or

 
   

 

 

 

 
   
 

184 COMBATING HEART AND OTHER MAJOR DISEASES

A. Regional cancer centers

Experience has shown that one of the most effective ways of providing the
necessary multidisciplinary and multifaceted approach to cancer is in a center
which brings together, in one location, all the clinical, scientific, and develop-
mental skills necessary. In such a center, investigators from a broad spectrum
of scientific disciplines focus on general and specific, basic, and clinical research
problems which relate to the prevention, diagnosis, and treatment of cancer.
Such centers can vary in size; in specific focus of interest; in representation of
disciplines; and in administrative affiliation and organization. Basic, medical,
behavioral, applied, and developmental scientists can all contribute to productive
research whether in a university, a hospital, or a community hospital-based.
center.

In a cancer research center, eradication of cancer is the accepted institutional’
goal. The translation of basic research findings, into successful clinical prac-
tice, makes clinical facilities and patient care an essential and integral part of a
research center. New methods of diagnosis and treatment, developed within
the cancer research centers, become prototypes of diagnostic and treatment pat-
terns for use in the general community.

Although they are mainly occupied with research, cancer research centers have
assumed major responsibilities in the training of research workers in many
disciplines as well as in the training and postgraduate education of physicians
in the care and management of patients with cancer.

At present, there are in this country only four fairly comprehensive cancer
research centers, which have broadly based and extensive clinical and basic
research programs, with representation from the many disciplines and specialties
necessary for a large-scale research effort. In addition, there are 10 other
eancer research centers which for lack of resources, have not been able to mount
more comprehensive programs. With appropriate support, many of these could
develop comprehensive programs.

The distribution of the existing cancer research centers is geographically
uneven. Most are located in the northeastern part of the country. A few
seattered centers are in the north-central section. There are scarcely any can-
cer research centers in the Southeast and only one west of Colorado. In 25.
States with a population of approximately 5.5 million, there is not 1 center.
California, with a population of about 16 million, has only 1 center and Texas
has 1 center for a population of about 9.5 million.

Recommendation.—In order to mount a national research program of the
necessary breadth and depth, the subcommittee recommends the eventual develop-
ment of a total of 20 comprehensive cancer research centers. This number is
based on a minimum of 1 center for each 10 million population.

Although there is an urgent need for new centers in the Midwestern, Western,
and Southern States, the subcommittee estimates that it will take 5 to 10 years
to plan, design, construct, and staff the new institutions. It is therefore recom-
memded that the order of development, of. this program be determined by the
rapidity with which centers can fulfill requirements. Priority should,be given to
those centers which already have plans for expansion into comprehensive institu-
tions. :

It is understood that three or four existing institutions are in a position to
apply immediately for developmental support over a 5-year period and that the
second 5-year period will see the progressive completion of four to six new centers
strategically located in relation to centers of population.

The estimated construction requirements will vary from the construction of’
a complete new physical plant to the renovation of existing space. Funds for
new construction and renovation should be made available by the Federal Gov-
ernment on a nonmatching basis.

There should be no restriction on the discipline eligible for staff appointments.
Scientific personnel needed include physicists, biclogists, chemists, surgeons,
gynecologists, physicians, genticists, statisticians, physologists, embryologists,
anthropologists, radiologists, epidemiologists, and sociologists.

Operating budgets must include all costs of: both inpatient and outpatient
care and observation ; convalescent rehabilitation and terminal care for patients
participating in investigative programs; round-the-clock consultation service to
all area physicians ; statistical and electronic processing services.

The regional cancer centers should set up an intercenter council to effect
liaison in programing, information exchange, joint research and clinical trials,
exchange in staff and students, coordination and evaluation of total program,
and advice to the National Cancer Institute concerning program requirements.
the
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COMBATING HEART AND OTHER MAJOR DISEASES 185

The estimated construction, equipment, and operating costs to initiate this
*program for a 5-year period are: :

 

 

 

 

Year
1 2 3 4 5
Number of new centers. 4 4 4 4 4
Funds required !__.._._.--------------~-+---------- sen e nee nn 50 90 150 150 160

 

 

 

 

 

 

1 Figures in millions of dollars.

It ig recommended that these funds be appropriated to the National Cancer
Institute to develop this program. oO

Administration for development of cancer research centers.—The National Insti-
tutes of Health does not have a mechanism for the rapid review and consideration
_of large-scale multidisciplinary undertakings. In the present system, plans for
_a multidisciplinary research center would require action by numerous study
sections. For example, an application for development of a cancer research
center would be reviewed by committees dealing with construction and renova-
tion, program project grants, training grants, and by appropriate study sections.

To expedite the development of these research centers and to avoid an undue
burden on present grant administration mechanisms, the subcommittee recom-
mends for the National Advisory Cancer Council the appointment of an Advisory

. Commitee on Cancer Research Centers. This Committee would be charged with:

The definition of criteria for comprehensive cancer research centers; the orga-
‘nization of a progressive program of center development; review of plans and
‘proposals submitted for developmental support. This Committee would also
be responsible for the coordination and evaluation of the total cancer research
program and for advice to the National Cancer Institute about further require-
ments when the present recommendations are fulfilled.

‘B. Cancer stations

To meet the urgent national need for a wider distribution of specialized facili-
-ties, techniques, and skills required to provide high-quality diagnostic and treat-
ment services to the patient with cancer, the subcommittee makes the following
recommendations :

Funds should be appropriated to te National Cancer Institute of the Public
Health Service to provide grants to 200 hospitals and medical centers for the
.development of cancer diagnostic, treatment, and consultation stations on a
demonstration basis. Of these units, 100 should be located in teaching hospitals
and 100 in community hospitals with 300 or more beds and accredited residency
training programs. Population and geographic needs should be taken into con-
sideration in the development of this program.

In the face of an outstanding community need, a smaller nonaccredited hos-
pital or a group of hospitais should be provided with the resources to develop
.comprehensive cancer services. In such an event, facilities for the treatment
of differing types of cancers can be located in different institutions.

These units will have the staff necessary to provide specialized care to the
patient with cancer. There will be specialists in radiotherapy, radiology, chemo-
therapy, and special diagnostic techniques. These specialists shou!d be in close
contact with the cancer research centers in order to obtain directly from these
‘research centers information and training in newer method sof diagnosis and
treatment. The diagnostic and treatment units will in turn convey informa-
tion to other community hospitals and physicians.

The units should also serve as a part of a network of facilities available for
collaborative clinical research programs carried out by the large cancer research
centers. Epidemiologists and biostatisticians within the research centers would
‘be responsible for the design and the analysis of clinical research carried out
within the network of research centers and diagnostic treatment units.

To fulfill its graduate educational function within its own community each
diagnostic and treatment unit must have resources o provide a 24-hour, 7-day-a-
week specialist consultation service without charge. This information service
would also have access to the information services provided by the research
. centers.

  
   
 
 
 
 
  
 
 
 
 
  
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
  
 
 
 
 
 
 
  
 
 
 
 
 
 
 
  
 
 
 
 
 
   
 

186 COMBATING HEART AND OTHER MAJOR DISEASES

Support for the initial construction, renovation, and provision of equipment and
development of laboratory facilities should be made avialable on a nonmatching
basis.

Laboratory facilities should include those necessary for chemotherapeutic
treatment.

Each center must have facilities to provide services for physical, social, and
vocational rehabilitation.

The operational budget for the diagnostic and treatment units should be
from several sources and should not include the cost of patient care,

It is assumed that these centers will gradually become self-supporting or will
require minimal subsidies within 10:to 15 years,

Emphasis should be placed on local resources for the provision of care for
medically indigent patients in a diagnostic and treatment unit. Patients other
than the indigent and medically indigent should pay for services,

Each diagnostic and treatment unit should be required to maintain a tumor
registry to insure proper patient followup and aftercare and should serve as
a tumor clinic center for other local hospitals and physicians.

The subcommittee reemphasizes the importance of the link between the cancer
research centers and the cancer stations and all other community medical facil-
ities. Only in this way will there be speedy, universal, and effective application
of new knowledge resulting from research,

Besides providing and demonstrating high-quality patient care the stations
will serve as a focal center for the training and continuing education of general
practitioners in the provision of high-quality care.

It is recommended that the following appropriations be made to the appro-
priate units in the Public Health Service to initiate this program for a 5-year
period.

[Dollars in millions]

 

 

 

 

 

   

 

 

Year
1 2 3 4 5
Number of new stations._.....-.......- -- 40 40 40 40 40
Costs of construction and renovation. _._ _ $8 $16 $24 $32 $40
Operational support_.._- 2 7 14 2t 28 35
Total... nen ee eee eee eee nee ee 15 30 45 60 75

 

 

 

 

 

CO. Other community hospitals

The Subcommittee on Cancer recommends that community hospitals with
approved cancer registries be brought into the national clinical cancer research
program. There are currently 1,000 hospitals with cancer registries approved
by the American College of Surgeons. Conceivably, if 200 of these were used
to serve as community stations, there still remains 800 hospitals as an immediate
resource complement for the program. Since, understandably, these community
hospitals would be general hospitals with an interest in cancer being one of many
interests, their contribution to the national program would be strictly through
clinical activities, teaching, maintenance of proper record registries, and
followup.

They would be physically adjacent to stations through which they would
“feed” clinical information and results and from which they would obtain direc-
tion. Thus, for example, comprehensive epidemiological studies, conducted at
the center level, could be carried out, reflecting information from all partici-
pating levels of the program.

The Subcommittee emphasizes the importance of the active linkage of the
centers, of the centers with the stations, and of the stations with community
hospitals and all other community medical facilities. Only in this way will there
be speedy, universal, and effective application of knowledge resulting from
research.

The Subcommittee further emphasizes that the principle of team care—
providing collaborative multidisciplinary knowledge and skills to the cancer:
patient—should be carried out throughout all echelon levels of the program,
pment and
imatching

lerapeutic
oeial, and
should be
ig or will

care for
nts other

a tumor
serve as

le cancer
cal facil-
plication

Stations
general

> appro-
1 5-year

 

 

 

 

s with
search
proved
e used
ediate
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many
rough
,» and

would
direc-
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unity
there
from

are—
ancer-
4

  
 
  
    
   
  
 
 
 
 
 
 
  
  
 
 
 
 
  
  
  
 
 
 
 
  
 
  
  
  
 
 
  
 
 
 
 
 
   
   
  
  
 
 
  
 
 
   
  
  
   
 
 
 
 
  
   
 
  
 
  
 
  
 
 
 
  
 
 
  
 

COMBATING HEART AND OTHER MAJOR DISEASES 187

IT, Additional support of cancer research

The national network will serve as a principal research resource. But the
existence of such a network does not preclude the development of additional
means of, stimulating research nor the expansion of mechanisms already in
existence. The research needs require a wide variety of organizational means.

A. Specialized cancer research centers and task forces

The Subcommittee heard a great deal of testimony in favor of the use of
special cancer research units and task forces to cencentrate research effort
in particular areas so as to hasten the solution of specific research problems.

It is recommended that support of this type be made available for 10 spe-
cialized cancer research centers during the next 5 years. These will be organi-
zational units with specialized personnel and with research and training objec-
tives in depth, limited to a particular facet of the cancer problem, with emphasis
on flexibility. They can be organized and established in various health and
medical research facilities. The Subcommittee recommends that at least one
research unit be established for each of the following areas:

1. An epidemiological unit for human population studies ;

2. A virology unit;

3, A carcinogenesis unit;

4. A cytopathology unit for the development of a cytopathology reference
and diagnostic laboratory;

5. A radiation and radiobiology unit;

6. An occupational and environmental carcinogenesis unit ;

7. A clinicopharmacology unit for study of teratological and carcinogenic
effects of drugs;

8. A clinical-pathology diagnostic research unit and reference laboratory ;

9. A surgical treatment research laboratory ;

10. A center for study of the incidence and epidemiology of cancer in
animals. .

A second type of task force approach would consist of the collaboration of in-
vestigators from several relevant disciplines concentrating on a particular form
of cancer ; for example, a hematologist, epidemiologist, cytogeneticist, and virolo-
gist could form a multidisciplinary team to develop a program of research in
leukemia. Or a surgeon, clinical endocrinologist, epidemiologist, and biochemist
could develop a research program in breast cancer.

Such multidisciplinary teams already exist in the major cancer research insti-
tutes. There are, however, other institutions with the necessary resources and
facilities which are interested in such programs. These institutions should be
encouraged to develop such specialized programs.

It is recommended that 10 such units be established.

It is estimated that for the two types of specialized units, $300,000 per year ig
needed for core support of each. It is recommended that the following appro-
priations be made available to the National Cancer Institute for progressive de-
velopment of this program over a 5-year period.

Appropriations for specialized cancer research units and teams

 

 

Year of program Number of Dollars in
new units millions
2 $0, 6
2 1.2
2 1.8
2 2.4
2 3.0

 

 

 

 

B. Research project grants

The Subcommittee endorses the existing system of review of research project
grants by study sections and advisory councils at the National Institutes of
Health and recommends expanded support of cancer research, Specifically it
recommends that an additional $40 million be appropriated in a 3-year period,

over and above the current appropriations, to the National Cancer Institute for
research project grants.

  
 

188 COMBATING HEART AND OTHER MAJOR DISEASES

&@. International research

Cancer does not recognize any national boundaries. It is a major cause of
eath in all parts of the world. People everywhere are interested in the conquest
.of this dread disease. It has been pointed out repeatedly that there are differences
in the frequency of cancer in different countries, Study of the reasons for these
differences undoubtedly will contribute to the final solution of the cancer prob-
lem. Therefore, the Subcommittee concurs with the recommendation of the Sub-
committee on Research on the need for an expanded support of international
medical research.

III. Application of medical knowledge in the community

It is estimated that one-third of all patients with cancer are cured or survive
at least 5 years after treatment at the present time. One-half of all cancer
patients could be cured if knowledge already accumulated through research
.conld be fully applied to all people in the Nation. Substantial reductions in dis-
ability resulting from cancer could also be made. Reduction of mortality could
result from preventive measures against some cancers, earlier diagnosis and
utilization of improved methods of treatment for others.

Financial support from Federal funds for national programs of this type has
‘lagged far behind the support of research. In 1964, for example, the total budget
for the cancer control program of the Public Health Service was 7.2 percent of
the total budget of the National Cancer Institute.

The Subcommittee has made a number of specific recommendations representing
-& beginning effort to extend the application of knowledge to the American people.
In doing so. the Subcommittee fully recognizes the limited nature of some of these
recommendations and the need for a more concentrated national and international
effort to use every present means available to reduce cancer mortality and limit
-eancer disability.

A. Prevention of cancer: Cigarette smoking and health

During the past decade, evidence has increasingly indicated a definite rela-
tionship between smoking and the occurrence of a variety of diseases. In
particular, the association of cigarette smoking with inereased liability to de-
velop Ivng cancer has been essentially demonstrated. The work in this area
of smoking and disease occurrence was summarized and evaluated in the Report
-on Smoking and Health, by the Advisory Committee of the Surgeon General
in 1964. In addition to confirming previous reviews, the report stated that
‘smoking was a serious hazard to health and indicated the need for more
aggressive programs of education and prevention.

The subject of smoking and health received attention from many witnesses
who appeared before the Subcommittee and a wide variety of recommendations
for action were suggested. It clearly appears that the reduction of cigarette
smoking offers large possibilities for the prevention of illness, disability, and
premature death in this country. :

Therefore, the Subcommittee makes the following recommendations:

1. The Subcommittee endorses the conclusions and recommendations of the
Surgeon General’s Report on Smoking and Health.

2. The Subcommittee recommends that steps be taken to decrease this health
hazard through educational programs, It recommends that $10 million be
appropriated to the cancer control program, Public Health Service, over a
8-year period for a comprehensive national program of education and public
information regarding the hazards of cigarette smoking.

The program should be aimed at the education of children, adults, physicians,
and educators with the assistance of State and local community agencies. A
network of smoking control clinics should be provided to assist those who desire
to give up smoking. New and more effective educational material should be
.developed.

B. The carly detection of cancer

More than 20 years ago, the Papanicolaou vaginal cytology test was shown
to be an effective screening procedure for the early detection of uterine cancer.
‘Data reported from the tumor registries of California and Connecticut have
-shown that current modes of therapy have increased survivorship of women
iuse of
ynquest
orences
r these
Yr prob-
he Sub-
ational

survive
eancer
scearch
in dis-
vy could
sis and

pe has
budget
cent of

senting
people.
\f these
ational
d limit

te rela-
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to de-
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Report
zeneral
od that
r more

ithesses
dations
garette
ty, and

“of the

| health
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sicians,
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> desire
ould be

_ shown
eancer,
it have
women

 

  
 
  
 
 
 
 
 
 
 
 
   
 
  
 
 
  
 
  
 
 
 
 
  
 
 
 
 
 
  
 
 
  
  
 
  
 
  
 
 
 
  
  
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
  
 
   

COMBATING HEART AND OTHER MAJOR DISEASES 189

with this disease and that over 90 percent of women treated when the disease
is at the earliest detectable stage are cured by the standard of the relative
5-year survival ratio.

Cytological examination for early diagnosis is becoming more frequent, but
studies have shown that its increased use is largely concentrated among women
of the higher socioeconomic groups, who have the lowest risk of cervical cancer.
For example, a recent report from California indicated that 63 percent of women
in the upper social classes had had a Papanicolaou test as compared to 36 per-
cent of women in the lowest social class.

The Subcommittee fully approves the Public Health Service supported projects
demonstrating the “14 step” control program for carcinoma of the cervix and
urges the cancer control program of the Public Health Service to increase the
number of projects and the number of communities in which such projects are
being conducted. However, the Subcommittee feels that there can be no valid
reason for delay in developing a national effort to prevent 14,000 unecessary
deaths from cancer of the cervix each year. Therefore, it recommends the de-
velopment of a national program for the early detection of cervical cancer,
consisting of two major components:

(a) A national educational program for the general public so that all women
are aware of the availability of this test. This should be eonducted by the cancer
control program, Public Health Service, in cooperation with State and local
health departments, the medical profession, and the voluntary health agencies
such as the American Cancer Society.

(b) A cervical cancer detection program directed at the approximately 8 mil-
lion women over 25 years of age who are admitted to hospitals in the United
States each year.

The Subcommittee feels that such a hospital-centered screening program will
be most economical, will reach the high-risk, low-socio-economic group, and offers
the greatest potential for rapid public and professional education.

In 1961 a New York State Department of Health program reported the detec-
tion among hospital admissions of 7 new cases of uterine cancer per 1,000 women
examined. Smears from 5,500 women were examined at a cost of $2 to $3 per
patient, Other studies have shown a higher frequency of new disease detection
when cells from both a cervical smear and vaginal aspiration, are examined.
With this type of examination 10 per 1,000 unsuspected new cases have been re-
ported in general populations and 18 to 30 per thousand in indigent populations.
Cells from both cervical and aspiration smears can be examined on a single
slide so that the most productive screening procedures can be implemented within
a ceiling of $3 per patient examined.

It is recommended that $5 million be appropriated to the cancer control pro-
gram in the first year and that this be increased by $2.5 million each year for a
period of 3 years, to provide grants to hospitals participating in this program.
At the end of 2 years a committee should be appointed to review progress and
plan for the future development of the program.

Total support for cytological examinations should be given to hospitals pro-
viding care for medically indigent patients, and partial support to hospitals
providing care to patients who do not have health insurance or other resources
to cover cytological examinations. All other hospitals should include this
examination as part of the routine physical examination, and the cost of cytology
should be included with the cost of other laboratory investigations.

In providing these grants, consideration should be given first to hospitals pro-
viding care for the indigent and the medically indigent.

C. Community cancer control programs

Community demonstration projects in the detection of carcinoma of the cervix,
of the oral cavity, and of the breast have been developed during the past 7 years.
Methods and instruments for the early detection of cancer of the eolon, rectum,
and breast are being developed.

The Subcommittee recommends an increase in community demonstration pro-
grams for the early detection of uterine, oral, and breast cancer and the organi-
zation of complementary and supplementary programs to demonstrate early de-
tection of cancer of all accessible body sites.

43-669—65——18
Reena ee ne

190 COMBATING HEART AND OTHER MAJOR DISEASES

It recommends that the folowing funds be appropriated to the cancer control
program of the Public Health Service for this purpose.

 

 

on

mp2 fa js

 

=
on

 

 

|
Dollars (millions)__---.. 2 nee 1.5 3 | 45 | 6

 

At the end of 4 years, the demonstration programs for which funds have been
Specifically allocated should be reviewed and evaluated and plans for future
programs developed.

IV. Education and training

Every witness who appeared before the Subcommittee testified to a shortage
of trained scientists, clinicians, teachers, and technicians in every aspect of can-
cer research and control. The Subcommittee is aware of the increase in trained
manpower necessary to implement the recommendations for expansion of the
cancer research effort and the application of knowledge. It fully endorses the
recommendations of the Subcommittee on Manpower and adds the following rec-
ommendations with regard to the specific requirements in cancer.

A. Undergraduate training

1. Medical schools—Each medical school now receives $25,000 from the Na-
tional Cancer Institute in support of undergraduate cancer education. The
Subcommittee recommends that these grants be continued.

However, there still exists a need for broadening the training of medical under-
graduates in the various aspects of the prevention, diagnosis, and treatment of
cancer, including the development of demonstration teaching programs in cancer
detection and in the care of the cancer patient.

There is also a need to provide organized cancer teaching and training op-
portunities for general interns and for residents now specifically concerned with
cancer diagnosis and treatment. Therefore, the Subcommittee recommends that
necessary funds as indicated below be appropriated to the National Cancer In-
stitute to provide additional grants of $25,000 to those medical schools which
develop specific educational programs in these aspects of cancer control.

Dollars
Year: (millions)
1-888 nnn 1.0
2 = 8 ne 1.5
B----~-- ~~ 8 2.0
4_---__- 8 25
B---~---- ~~ 2.5

 

This program should be reviewed at the end of 4
needs and development,

2. Dental schools.—iIn view of the important role played by the dentist in the
early detection of oral cancer and the need for the education of dental students
with regard to cancer control, the Subcommittee recommends an increase of
$10,000 in the annual undergraduate training grant presently awarded to dental
schools by the National Cancer Institute. This will require an additional annual
appropriation of $500,000 to the National Cancer Institute.

B. Clinical training

1. Residency training.—To recruit medical graduates into cancer specialties
in which there is a marked shortage of personnel, the Subcommittee recommends
that $500,000 per year be appropriated to the cancer control program in support
of residency training in a limited number of specialties, The designated spe-
cialties shall be those that are essential for progress in cancer control and which
have the greatest personnel shortage, for example, radiology, radiotherapy,
physical medicine, preventive medicine, and epidemiology, pathology, anes-
thesiology.

A supported resident should be required to spend at least 1 year of this training
period in work directly related to cancer, and the details of his training program
should be specified at the time the grant is requested. The program should be

| -
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COMBATING HEART AND OTHER MAJOR DISEASES 19]

developed on a trial basis for a 5-year period and be thoroughly reviewed after
4 years to determine future development,

2. Training of specialists.—Since 1968, cancer training for specialists in the
form of Senior-clinical traineeships has been available through the cancer con-
trol program of the Publie Health Service. Individual physicians who have
completed residency training leading to American Board certification in one of
the clinical specialties are eligible to receive an additional year of supervised
experience in their specialty with major emphasis on the management of cancer,
Every application for a traineeship must include a plan developed by the prospec-
tive trainee in collaboration with the clinician whom he has selected as training
director, and the Plan must be endorsed by an academic officia] of the training
institution.

Official announcement of the program and distribution of application materials
begun in late July 1963 resulted in 141 applications by the November 15 deadline.

Panels representing the five basic clinical specialties (surgery, gynecology,
pathologoy, radiology, and internal medicine) review the applications and assign
priorities according to scientific and educational merit. Final selection is by
staff. There were at first 108 awards, but after 9 withdrew, 99 actually began
the training program in July 1963. The total of grant funds obligated was
$868,000.

The Subcommittee recommends that $3.5 million be appropriated to the cancer
control program of the Public Health Service to increase the number of senior
clinical traineeships to 300. It is further recommended that priority should be
given to those specialties which have the greatest personnel needs: radiology,

radiotherapy, physical medicine, preventive medicine, and epidemiology, pa-
thology, and anesthesiology.

C. Training of technicians

In 1964, the eancer control program of the Public Health Service expended $1.5
illi i ici Enrolled in Supported programs
were 350 cytotechnologists, as well as radiographers and radiotherapy tech-
hicians. In view of the urgent needs for such personnel, the Subcommittee rec-
ommends that the appropriations be increased by the following amounts to the

cancer control program of the Public Health Service for expansion of this
program.

Year: Millions Year: Millions
Jee $1 4.2 4
gee 2 Doe ne 5
ar 3

dD, Continuing professional education

The Subcommittee emphasizes the importance of continuing education of
physicians and dentists as a basic responsibility of regional cancer centers and
cancer stations. It recommends that each center and station have a full-time
director of postgraduate education.

This position should be fully supported within the operating funds of all
regional cancer centers, When necessary, partial or total] Support for this pur-
bose should be ineluded within the Federal grants to the cancer stations.

FE. Training for research

In view of the pressing needs for research manpower in cancer, the Subcom-
mittee recommends that the program of research training grants and fellowships
administered by the National Cancer Institute be expanded. Specifically, it
recommends that the following annual appropriations, over and above the eur-
rent level, be made to the National Cancer Institute to support such an expanded
program.

[In millions of dollars]

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional funds

 

 

 
192 COMBATING HEART AND OTHER MAJOR DISEASES

F. Stabilization of academic positions

The Subcommittee repeatedly heard evidence of the critical need for stable
support for investigators and teachers in our research and educational institu-
tions. It wishes to record its regret that the research career award program has
been, discontinued by the National Institutes of Health.

In view of the pressing need for the development of stable academic positions.
the Subcommittee recommends that a broad program of academic career awards
be established by the National Institutes of Health to provide the needed stability
to academic careers. This program should be designed after review and consider-
ation of the best features of the career investigation awards of the American
Heart Association and the American Cancer Society and the Markle scholarships.
It should be developed on a more flexible basis than the research career award
program of the NIH so as to provide for a greater degree of participation of the
investigator or teacher in other institutional responsibilities at different phases
of his career. Provision should be made on a negotiated basis also for propor-
tional support of the awardee by his institution.

There should be two components of this program: (1) research career awards
and (2) teaching career awards. The Subcommittee recommends that, to pro-
vide career research and career training awards, $8 million be appropriated dur-
ing the first year of the program, $16 million the second year, $18 million the
third year, $20 million ‘the fourth year, and $24 million for the fifth year. The
Panel further recommends that no fixed ratio between career research and career
teaching awards be established.

G. Public education

The Subcommittee recommends that the present appropriation of the cancer
control program of approximately half a million dollars for general cancer educa-
tion of the public through health agencies and professional societies be increased
to $1 million and by increments of one-half million dollars to $2 million in 3 years.
At the end of 2 years, there should be a complete review of all supported programs
to determine future development.

V. Cancer morbidity reporting

For much of our knowledge of the occurrence of cancer and of time trends
we have been dependent on mortality records. These are often less accurate
than the information gathered during the patient’s life and available as cancer
reports or in physicians’ pathological laboratories and hospital records. Also,
differences in survival and case fatality of various forms of cancer make mor-
tality data of unequal and often unknown estimates of incidence.

Information on cancer incidence in the United States is based on the data
gathered by the continuous reporting systems of upstate New York, Connecticut,
and California and on single-year morbidity surveys made by the National Cancer
Institute in 10 selected cities for the years 1937 and 1947 and in Iowa for 1950.
The data gathered in this way have already provided valuable knowledge of the
occurrence of different forms and sites of cancer, time trends in incidence, case
fatality and survival rates, differences in cancer incidence in ethnic, socio-
economic, and other population groups, and have served as a basis for con-
ducting epidemiological and other population studies of the dimensions and scope
of cancer as a community health problem.

There is need for comparable, continuously gathered data for all sections of
the United States. Also, every State and community needs continuous morbidity
data on cancer to provide information regarding the magnitude of cancer as a
public health and medical care problem.

Therefore, the Commission recommends cancer be made a reportable disease
and that information on the incidence of cancer be gathered continuously
throughout the United States or in representative States and regions.

In selected States, cancer should be made reportable by law to avoid dif-
ficulties otherwise arising out of possible violation of the confidentiality of
medical records. Such a system of cancer reporting has been in operation suc-
cessfully in upstate New York since 1940. Reports should be required of phy-
sicians, pathologists, clinics and hospitals upon first making a diagnosis of cancer ;
and a copy of all death certificates should be sent routinely to the cancer report-
ing unit for recording and for comparison with previous reports.

The Commission recommends that the sum of $1 million per year be made
available to the National Cancer Institute to be used in assisting States in
  

able
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COMBATING HEART AND OTHER MAJOR DISEASES 193

initiating cancer reporting systems. Assistance should be provided in organizing
the reporting system, providing consultation service, purchasing equipment and
providing temporary clerical or other service, in an amount not to exceed $50,000
for any State during the first year and not to extend beyond 3 years.

Priority in establishing cancer reporting system should be given to States
representative of the various regions in the United States in which morbidity
data have not been gathered previously or gathered only periodically. States in
which there are established cancer research institutes should also be given
priority because of the opportunity for utilizing cancer morbidity records in
conducting or supplementing epidemiological studies undertaken by these in-
stitutes. The National Cancer Institute should consider the establishment of a
national cancer morbidity register, utilizing copies of State registry reports or
of abstracted data from such reports.

REPORT OF THE STROKE SUBCOMMITTEE

Dr. John §. Meyer, Chairman, and Dr. Howard Rusk; Staff, Dr. Nemat 0.
Borhani

BACKGROUND

The brain demands more than one-fifth of all the blood pumped from the heart.
The condition known as stroke is evidence that parts of the brain are not receiv-
ing their essential supply. In dramatic forms, stroke exhibits disastrous impair-
ment of intellectual and motor function, such as paralysis of the arm or loss of
speech, Although stroke is associated with various diseases of the blood vessels
of the brain, various types of arteriosclerosis are the most common contributory
factor.

In general, stroke may be divided into three main types:

(1) occlusion due to thrombosis or clotting of the cerebral vessel ;

(2) occlusion due to embolism, a fragment of a clot which becomes dis-
lodged from the heart or vessels of the neck and plugs the cerebral vessel;
and

(3) rupture of a cerebral vessel by high blood pressure or a flaw in the
vessel wall resulting in an aneurysm, a sac pressing on the brain and
threatening a brain hemorrhage.

Thrombosis and embolism account for the vast majority of strokes.

In contrast with their concern with many less common diseases, the public and
the professions have shown slight interest in the prevention, treatment, and
recognition of basic problems of the victims of stroke. One indication of this
apathy is that accurate information regarding the frequency of stroke is not
available, though estimates state that at least 2 million people living in the United
States show clinical evidence of this illness.

The human and financial cost of disability resulting from stroke weighs heavily
on the patient, as well as the family, the community, and the taxpayer. Even
after the initial episode of illness is past, the majority of stroke patients who
do not receive comprehensive treatment become dependent upon their families
and the community for the rest of their lives. In this condition, they may survive
for years.

Effective methods of prevention and treatment of various types of stroke,
including some recently developed, are available. For example, three of every
four patients with occlusive cerebral vascular diseases have symptoms that warn
of a disabling attack. About three of every four patients with symptoms of stroke
experience a discernible narrowing of the blood vessels supplying the brain, a
condition which is frequently amenable to surgical correction, although the
indications for surgical and medical treatment still need to be better defined.
Typical warning episodes of stroke are brief attacks of loss of speech, weakness
of the limbs, staggering, or loss of consciousness,

There are promising new areas for research in stroke prevention and treat-
ment, including epidemiological studies, alteration of blood-clotting mechanisms,
control of fat metabolism and hypertension, hyperbaric oxygenation (high pres-
sure oxygen chambers), blood vessel surgery, and new drugs to improve circula-
tion to the brain and to prevent arteriosclerosis (hardening) of cerebral arteries.

With modern medicine, many patients anticipating stroke can be treated effec-
tively to avert catastrophe; and, among those who have suffered severe stroke,
treatment can reduce or prevent chronic disability. To achieve such results, it
is necessary (a) for the stroke patient to have a high quality of medical care,

  
  
 
 
 
 
 
 
 
  
  
  
  
  
 
  
 
 
 
 
  
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 

194 COMBATING HEART AND OTHER MAJOR DISEASES

not only to save his life but also to restore him to his family as a productive
and useful citizen, and (b) to educate the professional and general public
concerning the prevention and treatment of stroke.

The problem of stroke must, therefore, be approached from two aspects:

(1) the development of a national and coordinated research program
aimed at determining the causes of the disease, developing techniques of
prevention, and improving methods of diagnosis and treatment; and

(2) the development of community resources to provide the best possible
medical care from the onset of warning symptoms of stroke to the patient’s
return to community life.

Many aspects of circulation of blood to the brain urgently need study. Many
fundamental problems of physiology, pathology, neurology, neuropathology,
circulatory dynamics, and blood clotting need to be studied with respect to
development of strokes.

One of the obstacles to successful research planning, in the past, has been
the assumption that stroke and coronary artery disease were the same, as shown
by the oft-quoted statement that cerebrovascular disease is a “later life edition
of coronary artery disease.” Evidence from pathological studies in man and
animal studies indicates that naturally occurring and experimentally produced
atherosclerosis does not occur in all arteries of the body at all locations in a
similar manner. This evidence suggests that studies oriented specifically to
the cerebral arterial system would contribute to understanding of the cause and
prevention of strokes. :

Recent epidemiologic studies also suggest differences between stroke and ar-
teriosclerotic heart disease. In a comparative review of mortality from stroke
and heart disease in Norway, Ustvedt noted that heart disease rates declined
in Norway and in Scotland during the war years and decreased thereafter,
whereas death rates from stroke remained rather stable during the war and
showed only a slight decrease after the war.

Ethnic differences in mortality from atherosclerotic heart disease and stroke
lend further support to the possibility that the two diseases may be different.

In addition, autopsy studies of diseased cerebral vessels in cases of stroke
have shown pathological changes of a nature different from those seen in coronary
vessels in arteriosclerotic heart disease. Furthermore, in physiology, anatomy,
and pharmacology, the cerebral collateral circulation differs from that of coronary
vessels.

Because (1) the suggested scientific evidence indicates that cerebral throm-
bosis and hemorrhage may represent a different disease process than atheroscle-
rosis and hypertension elsewhere in the body; (2) the care of the stroke patient
requires cooperation among such medical specialties as neurology, cardiology,
surgery, physical medicine, and rehabilitation; and (3) there have been great
advances in knowledge in this area which until recently was thought to be hope-
less, the Subcommittee therefore recommends that a national stroke program be
developed to deal with the two major aspects of the problem: (a@) Research and
training, and (0) patient care.

RESEARCH AND TRAINING

To develop the research needed, it is recommended that a national stroke
research training program be established within the Public Health Service.
The administrative facility for the development of the various research and train-
ing aspects of this program should be housed within the appropriate unit of the
Public Health Service. Henceforth, this administrative unit may be termed
the “National Stroke Program Unit.” This Unit should have a full-time perma-
nent staff, with responsibility for the development of this program. This pro-
gram should be developed with the advice of the Joint Council Subcommittee for
Cerebrovascular Diseases of the National Advisory Heart Council and the Na-
tional Advisory Neurological Diseases and Blindness Council.

The activities of this Unit would include support of a system of stroke centers,
separate research and training grants, and certain direct operations.

STROKE CENTERS
Regional stroke centers
It is recommended that at least 15 stroke centers be established on a regional
basis in selected medical schools and medical research institutions throughout the
country. Each would be an organizational unit, including individuals from vari-
tive
iblic

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nal

 

COMBATING HEART AND OTHER MAJOR DISEASES 195

ous disciplines, the broad purpose of which is to conduct research and training
aimed at the prevention, alleviation, and cure of the cerebrovascular diseases.
Such a unit should be administratively and physically part of a large medical
complex which is already engaged in medical research and training. The cere-
brovascular center must have space appropriate to the program to be mounted,
permitting reasonable expansion.

Nonmatching support dollars should be available for the construction of new
space or the renovation of existing space.

The broad design should include clinical investigations, utilizing hospitalized
patients, outpatients in certain instances, and a variety of modern laboratory
facilities.

Research support should include funding for all aspects of inpatient and out-
patient observation, construction or renovation of space, salaries of all categories
of personnel, purchase of equipment and supplies, including laboratory animals,
and so forth.

Since these organizational units will be expected to provide intellectual leader-
ship in cerebrovascular disease, it is essential that the personnel of each center
be large enough in number and represent enough disciplines to facilitate in-
vestigation in depth, utilizing a broad array of scientific methods. This means
that each center will have leadership provided by physicians or surgeons expert
in vascular disorders of the nervous system in the neurological or surgical or
cardiovascular areas.

The program must have research potential in several of the follow:
ing disciplines: neurology, therapeutics, angiography, rehabilitation, neuro-
ophthalmology, pathology and neuropathology, epidemiology, electrophysiologic
techniques, rheology, neurophysiology, psychology, methods of study of cerebal
blood flow, vascular physiology, psychiatry, lipid chemistry, mechanisms of
coagulation and lysis, and computer methodology.

Such a center would be strongly research-oriented but at the same time would
provide patients with care of high quality, including rehabilitation, and would
also be concerned with teaching and the training of personnel in the manage-
ment of stroke.

Examples of the type of research that should be conducted in these centers are
studies of:

(a) Collateral circulation of the vessels of the brain. /

(0) The neurological manifestation of strokes.

(c) Safe screening tests for cerebral vasomotor reactivity and cerebro-
vascular disease.

(d@) New methods of medical and surgical treatment and prevention of
strokes.

(e) Pathology of stroke.

(f) Rehabilitation methods.

The teaching function should include the training and support of physicians,
surgeons, radiologists, nurses, speech pathologists, physiatrists, and other pro-
fessional personnel in pertinent disciplines,

Since the research and training activities will serve patients, it is visualized
that each center will require up to 30 hospital beds—medical, surgical, and re-
habilitation—as well as an outpatient care facility.

It should be emphasized that, during the first 3 to 4 years of the program, it
will be necessary to make investments in institutions where the complete re-
Sources are not yet available but which have potential for development.

A total of $85.5 million over a 5-year period should be provided to establish and
maintain these 15 centers. Authority should be given to provide up to 100 per-
cent for construction and renovation costs. The proposed 5-year budget for this
program is as follows:

{In millions of dollars]

 

Number of years

 

1 2 3 4 5

 

Construction and renovation.......-...---.--------- 10.0 4 4 6 6
Operating expenses__

 

 

 

 

 

 

 

   
  
 
 
 
 
 
 
 
 
  
   
    
  
 
 
 
  
  
 
  
 
 
 
 
 
 
   
  
  
 
 
 
  
 
 
  
 
 
 
 
 
 
 
 
 
  
  
 
 
 
 
 
 
 
 
 

196 COMBATING HEART AND OTHER MAJOR DISEASES

Specialized stroke research centers

To allow flexibility for the development of a particular field of research, it
is recommended that at least 10 specialized stroke research centers be estab-
lished in various health and medical research facilities throughout the country.
These centers will be organizational units with personnel and in-depth research
and training objectives limited to a special facet of stroke, such as epidemiology,
instrumentation for cerebral blood flow and diagnostic tests, or experimental
cerebrovascular surgery in primates known to develop cerebral atherosclerosis.

These centers should be distinguished from the regional stroke centers, men-
tioned above, in that they will not be concerned with ail aspects for cerebro-
vascular disease. For example, an epidemiologist may desire to establish such
a specialized center to develop a program of study of the epidemiology of stroke
in certain population groups. Such a program will permit the development and
provide for the support of such a study in areas of the country that are par-
ticularly suitable for such research and which are not necessarily related to the
regional stroke centers described earlier.

It is estimated that a total $300,000 per year is needed for each one of these
specialized centers. It is recommended that $600,000 be appropriated during
the first year, $1.2 million during the second year, $1.8 million during the third,
$2.4 million during the fourth and $3 million during the fifth year.

Administrative mechanism for stroke centers

The planning and development of both types of centers will be a major under-
taking. The total effort will be of a magnitude which may require modifications
of procedures presently used my the Public Health Service for review of grant
applications. It would be impractical to have the many detailed ramfications
of each plan subject to separate considerations by the several committees which
presently report to the advisory councils. For example, under the present
system, each one of these centers would employ disciplines requiring the action
of numerous study sections. The several committees involved would not be
able to consider the material simultaneously; in the present administrative
structure, applications would have to be reviewed separately by committees
dealing with (@) construction and renovation, (6) program project, (c) ap-
propriate study section activity, and (d) training grants.

In order to activate and develop this major program with flexibility, it is
recommended that an Advisory Committee on Stroke Centers be established.
The function of this committee will be the organization, development, coordina-
tion and review of all plans and projects dealing with the development of stroke
centers and the presentation in mature form of the comprehensive proposal to
the appropriate advisory council for its consideration. This committee should
also be concerned with positive program planning as well as the development
of a basic “core” of support which would enable each center to become estab-
lished, coordinate its essential function, and, and get underway.

During this period, the center committee should utilize fully the talents of
the presently existing committees, especially those dealing with construction and
renovation. One way to achieve this would be to have representation from each
of these committees. The experience gained during the early period could be
applied in the development of subsequent centers. This would obviously have
great advantages.

After the first 3 years, requests for additional support for these centers should
be submitted through the usual channels and be subject to competitive review.

It is believed that this approach will prevent the overloading of the present
committees, sections, and staff during this development period. Furthermore,
it will coordinate this effort in a sound manner and will greatly enhance the
quality of the supporting data to be presented for consideration by the appro-
priate Advisory Council. This will in turn lessen the burden of this large pro-
gram on the Council.

RESEARCH PROJECT GRANT PROGRAM

During the fiscal year of 1963, the total expenditures, both Federal and non-
Federal, for grants directly earmarked for the support of research on stroke
amounted to $5.5 million, which represented 0.45 percent of expenditures for
medical research and 7.7 percent of total expenditures for research in cardio-
vascular diseases. Of this $5.5 million, $5 million represented Federal expendi-
tures. Clearly such a small allocation of funds for the support of research on
stroke does not reflect the importance of a disease that causes at least 12 per-
cent of all deaths in this country.

ts
 

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COMBATING HEART AND OTHER MAJOR DISEASES 197

Therefore, it is recommended that funds be appropriated to the National
Institute of Neurological Diseases and Blindness for increased support of re-
search projects in the field of stroke, so that the present level of Federal support
for research grants may be increased to at least $8 million a year for the next
3 years. This represents an increased appropriation of $10 million for a 3-year
period. These funds are to be used for grants or contracts in specific projects.
Special emphasis should be given to epidemiological studies of stroke, an area of
research that, up to now, has been almost totally neglected.

TRAINING PROGRAM
Research training

There is a need for developing a training grant program to prepare individuals
for a career of leadership in research in stroke. The complex nature of brain
function and the various cerebrovascular diseases suggest that optimum train-
ing for such a career would include extensive experience in neurology, cardio-
vascular medicine, angiography, neuroophthalmology, neuropathology, lipid
chemistry, electroneurophysiologic techniques, blood flow methods of various
types, clot lysis mechanisms, and epidemiology.

Education in depth for any one individual in all these fields is not practical.
The objective of the program will be training in depth in a laboratory area or
two and practical experience with additional laboratory methods as well as
basic understanding of the clinical nature of cerebrovascular disease. Emphasis
will be placed on the specific educational needs of the individual trainee, related
to his previous residency experience and his ultimate career goal, rather than
on the exact duration of the training.

Therefore, it is recommended that $1 million a year be provided through the
National Institute of Neurological Diseases and Blindness to develop a training
grant program in the field of stroke. Such grants would be given to educa-
tional institutions for the development and operation of training programs,
including support of faculty, facilities, and the provision of stipends for trainees,

Undergraduate training

One of the means for increasing professional interest in stroke and for re-
cruiting physicians into careers in stroke research is to provide a focal point
for the teaching of stroke in medical schools. The development of such a focus
of interest would serve as a stimulus to interdepartmental cooperation in other
research and teaching, including the development of joint projects, seminars,
and indoctrination in special problems of the patient with stroke.

One of the best mechanisms for providing for such a development is an under-
graduate training grant which will provide funds for hiring additional faculty
with a special interest in stroke, for fellowships for medical students, and asso-
ciated purposes. Therefore, it is recommended that $2 million be appropriated
annually to the National Institute of Neurological Diseases and Blindness so
that undergraduate training grants of $25,000 a year can be made available to
medical schools.

Clinical training

In addition to shortages in research manpower, there are also shortages of
practicing physicians in the stroke field. There is a great need for a greater
number of clinicians who are trained in precise methods of diagnosis and who are
capable of providing the best of treatment,

To meet this need, it is recommended that the authority be granted and the
funds appropriated to the National Institute of Neurological Diseases and Blind-
ness for the establishment of clinical fellowships and full-time clinical investi-
gatorships in the stroke field. More Specifically, an appropriation of $1 million
annually is estimated as necessary to develop this training program.

DIRECT OPERATIONS

In addition to developing the grant program discussed above, it is recom-
mended that a National Stroke Program Unit of the National Institute of Neuro-
logical Diseases and Blindness of the Public Health Service be responsible for
the following:

(a) development and maintenance of a National Center for Stroke Infor-
mation Exchange (including issuance of a cerebrovascular bibliography, an
index of current research activities, and statistics relating to stroke) ;

  
  
 
 
 
 
  
   
  
  
 
 
 
 
 
 
 
 
 
 
  
  
 
  
   
 
 
 
 
 
 
  
  
  
  
   
 
 
 
   
  
   
  
 
 
 
 
 
  
  
  
  
  
   
  
 
  
  
  
 
  
 
 
   
  
   
  
  
 
  
   
 
 
  
 
 
  
 
 
 
  
 

198 COMBATING HEART AND OTHER MAJOR DISEASES

(b) development and maintenance of a National Center for Collaborative
Field Studies including epidemiology, evaluation of therapy, etc.; and

(c) the provision of central laboratory and statistical facilities, including
computers and necessary electronic equipment for conduct of such studies.

The Commission is aware of the efforts on the part of other official and volun-
tary health agencies in the field of stroke. For example, the 168 hospitals in the
Veterans’ Administration, providing almost 125,000 beds, many of which are
physically near medical schools, constitute an excellent total facility for bringing
the best in medical care to a sizable segment of population and, in addition, can
provide an ever-expanding resource for clinical and basic investigation. Already
signficant contributions to our knowledge concerning stroke have come from
studies conducted in the Veterans’ Administration hospitals.

Every effort should be made to continue and amplify clinical studies of stroke.
The possibilities for research concerning the methods of rehabilitation currently
in use, as well as research concerning basic phenomena in recovery from damage
to the nervous system, are attractive and should be exploited. To this end, plans
should be directed toward maintaining a liaison between the National Stroke
Program Unit, Public Health Service, and the Veterans’ Administration, Voca-
tional Rehabilitation Administration, and voluntary health agencies such as
American Heart Association.

This unit should be provided with an outstanding professional and admin-
istrative staff. It is recommended that the sum of $7 million be appropriated for
a 5-year period to support its activities.

Patient care

The Neurological and Sensory Disease Service program, Division of Chronic
Diseases of the Public Health Service, should be given authority to make project
grants to public and other nonprofit organizations for studies, experiments, feasi-
bility trials, demonstrations, and training designed to provide incentive and en-
couragement for the development and improvement of methods for the applica-
tion of the results of research to patients in the community. Specifically, it is
recommended that a new subsection be added to the Public Health Service Act
which would adjust the ceiling and provide that funds appropriated pursuant to
subsection 316(a) would also be available for the Surgeon General to make proj-
ect grants in the neurological and sensory disease program area, on such terms
and conditions as he finds necessary, to States and other public and nonprofit
organizations for studies, demonstrations, and the training of personnel.

Stroke stations

An appropriate unit in the Public Health Service should be given the authority
and necessary funds to award grants to establish and maintain a network of
approximately 100 stroke stations in the United States. Approximately 50 of
these stations should be established either in medical centers or existing clinical
facilities of the medical schools, but not usually in those schools designated as
“regional stroke centers”; and the other 50 in community general hospitals, in-
cluding Veterans’ Administration hospitals and mental hospitals, mot necessarily
connected with medical schools. These stations would serve as a pilot program
for the demonstration of methods providing high quality patient care. They
would have the following principal objectives :

(1) Immediate and emergency care for patients with acute stroke.

(2) Stimulation of interest of medical students and practitioners.

(3) Training of physicians in the community in management of stroke.

(4) Identification of the stroke-prone individual and encouragement of
treatment to prevent catastrophic manifestations of stroke.

(5) Education of the public concerning prevention and treatment of stroke.

These stations will include intensive care units for the emergency care of
patients with stroke. They should be lecated that they may share certain
facilities and personnel with heart disease stations. Therefore, it is desirable
for the stroke stations to be in the same area of the hospital as the heart stations
and to work closely with them, avoiding unnecessary duplication but supporting
each other.

These stations will include laboratory facilities, physical medicine, and rela-
bilitation facilities, outpatient clinic and hosiptal beds, and provisions for elec-
troencephalographic, electrocardiographic, neurological, and emergency surgical
services.

In order to establish these stations, funds are necessary for the renovation of
existing facilities. It is estimated that renovation and equipment will cost an
SES

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COMBATING HEART AND OTHER MAJOR DISEASES 199

average of $200,000 for each station. An additional amount of $17
Will be required for the efficient operation of each station.
The Stroke Subcommittee Tecommends that a total of $77.75 million be appro-

priated for a 5-year period for the development of this program, according to
the following table:

5,000 a year

Cost of stroke stations

[Dollars in millions]

 

 

 

 

 

 

 

 

 

 

 

 

Year
ad
New stations_..---22. 00 30
Renovation costs____ $6.0
Operation expenses 12, 25
Total annual costs, 18, 25

  

 

 

 

 

 

 

Local community programs

Many of the victims of stroke require services at home, in hospital out-
patient departments, in clinics operated by public health departments, ete. In
order to expand and make more effective such services at a local community
level, it is recommended that the appropriate unit in the Public Health Service
be given the authority and funds for developing a program of project grants
to community agencies such as hospitals, public health departments, voluntary
health agencies for studies, experiment, feasibility trials, and demonstrations,
and training. Over a 5-year period, $22.5 million should be appropriated for
this purpose, with $1.5 million in the first year, with gradual increases until
$7.5 million is reached in the fifth year.

 

REPORT OF THE SUBCOMMITTEE ON REHABILITATION

INTRODUCTION

Rehabilitation has frequently been called the third phase of medicine
preventive medicine and curative medicine and Surgery. It is the period when
the fever is down and the stitches are out. In contrast to convalescence, in
which the patient is left alone to rest through the period whe
nature take their course, medical rehabilitation i i
the skills of a professional team are integrat

, following

, Social, and voca-
tional potentials,

The first objective of rehabilitation is to eliminate the physical disability,
if possible; second, to reduce or alleviate the disability to the greatest possible
extent; and, third, to retrain the person with a residual physical disability to

live and to work within the limits of his disability but to the hilt of his
capabilities,

skills of many disciplines : Physicians, physical therapists, occupational thera-
pists, speech therapists, rehabilitation nurses, psychologists, rehabilitation
counselors, orthotists, social workers, and therapeutic recreation specialists. It
is essential, therefore, that patients with heart disease, cancer, or Stroke in
need of rehabilitation services be referred at the earliest feasible time to
facilities where such Specialized personnel are available,

In the general or specialized hospital, the rehabilitation unit is a service
unit to the entire institution, as is the X-ray unit and pathology laboratory.
Medical responsiiblity during the period of definitive care rests with the initial
or admitting service, During this period, the rehabilitation unit serves in a
consulting role.

For example, if a patient with cancer of the larynx is to undergo lar
the speech pathologist from the rehabilitation unit may see the patien
tively to explain the principles of esophageal speech or the use of t

yugectomy,
t preopera-
he artificial

   
 

200 COMBATING HEART AND OTHER MAJOR DISEASES

larynx. He helps allay the fear of loss of speech and makes retraining following
surgery more effective.

When the patient with heart disease, cancer, or stroke has completed the de-
finitive phase of care and is in need of rehabilitation, he may be transferred to
the rehabilitation service where the total effort of the rehabilitation team
can be concentrated on his care and where he will be in a milieu conducive to
hope, tempered with realistic goals.

The Subcommittee on Rehabilitation heard testimony from individuals and
representatives of organizations who are experts in rehabilitation services for
persons with heart disease, cancer, and stroke to the effect that the complexities
of the physical, emotional, social, and vocational problems of patients with
heart disease, cancer, and stroke require a teamwork approach among many dis-
ciplines, e.g., physicians, physical therapists, occupational therapists, speech
pathologists, rehabilitation nurses, psychologists, rehabilitation counselors,
orthosists and prosthetists, social workers, rehabilitation administrators, and
others. It was repeatedly emphasized that because of its very nature, rehabili-
tation is a service program which is an essential and integral part of the total
medical care and medical and social responsibility for persons with heart disease,
cancer, or stroke.

Heart Disease-——The Subcommittee on Rehabilitation heard those testifying
repeatedly assert that the rehabilitation services we are providing for our fel-
low citizens with heart disease are far from optimal. Cardiovascular diseases
are not only the leading cause of death in our Nation but they also lead the causes
of disability. It is estimated that at least 20 million persons are handicapped
to some degree by heart disease. In the bringing of rehabilitation concepts and
methods to these persons, we should be concerned not only with the problems of
overt heart disease but the premorbid stages as well.

A major need is for continuing education of physicians, paramedical personnel
concerned with rehabilitation, and the public as to the potentials and methods
of rehabilitation. Despite efforts by public, professional, and voluntary agencies,
the potentials of rehabilitation, its concepts and its methods, are not well under-
stood. It was emphasized that the most important single contribution to the
more effective utilization of rehabilitation concepts and methods in services for
the patient with heart disease is continuing education for physicians.

The importance ef and the potential contribution of properly staffed work
classification units was repeatedly emphasized. Much needs to be learned about
energy costs and psychological problems of cardiac workers. There is need for
education of both labor and industry and the placement and compensation of
cardiac patient.

Cancer.—-It was repeatedly brought out that too often the surgeon feels only
the primary responsibility for the surgery, per se. Often, he does not have
the time or the interest to detail the possibilities of postsurgical rehabilitation.
The surgeon must realize that rehabilitation exists as a service program for him
and his patients. To help meet the responsibility of his disabled patients after
the surgery is completed, a program designed to meet the retraining needs of
the patient after the fever is down and the stitches are out must be set up. There
needs to be a new era of understanding as to the service role of rehabilitation.

This can only be accomplished by improving our total communications pro-
gram; eg., the American Cancer Society has provided certain literature but
organizations like the American College of Surgeons and other learned surgical
societies should be asked to sponsor training and demonstration programs in
rehabilitation for their membership. This could best be done by the inclusion of
papers presented at their regular meetings, films, film strips, teaching TV ma-
terial, and appropriate literature. Rehabilitation must be an integral part of
the total treatment of cancer patients.

Breast cancer—Surgeons who operate on patients with breast cancer must
be familiar not only with the philosophy and principles of rehabilitation but
with the practical means of incorporating this needed service into their thera-
peutic regimen. Lymphedema, for example, often a complicating factor follow-
ing mastectomy, can be materially reduced with proper physiotherapeutic and
rehabilitation procedures. There should be available, in a hospital treating pa-
tients with breast cancer, a rehabilitation team who can provide the needed
service to such patients. The service should be provided in the early stages and
continued as long as indicated. The problems of fitting a prosthetic brassiere,
the psychological problem in adjusting to a mutilating procedure, and many other
conditions created as a result of radical mastectomy, should be managed like any
other medical and psychological rehabilitation problems. Jt is the responsibility
——_

Va cae wee

ait

or

re

 

COMBATING HEART AND OTHER MAJOR DISEASES 201

of the surgeon to see to it that his patient receives not only a comprehensive and
good quality surgical care, but also is provided rehabilitation if indicated.

Cancer of the larynz.—A. specialized team to retrain patients with laryngeal
cancer physically and reorient them psychologically is an absolute necessity.

There are 3,000 to 6,000 new cases of cancer of larynx in the United States
annually ; there are an estimated 23,000 to 25,000 laryngectomized individuals in
this country. Speech therapy, using esophageal speech or electronic devices,
and rehabilitation of these patients is fundamental in their care.

A rehabilitation team can be invaluable to the cancer surgeon in meeting prob-
lems following maxillofacial and other types of radical surgery. In addition
to plastic surgery, much can be done physically by prosthetic devices, at which
time the orthotist and the dentist are invaluable members of the rehabilitation
team. Psychological support, also fundamental for these patients, is best provided
in a setting serving all types of disability.

Amputation.—Cancer is responsible for 5 percent of all amputations. A third
of the cancer amputees are children. The proper fitting with prosthetic devices
and training in their use is basic. Even though the life expectancy of these
patients may be limited, it is important for them to live the best lives possible.
This requires a total rehabilitation effort if the physical, emotional, psychological,
and vocational need of these patients are to be met.

Cancer of colon.—Colostomy offers another important opportunity for rehabil-
itation for cancer patients. Too often, the colostomized patient is left on his own
after surgery, not only to work out the technical details of managing the col-
ostomy but also to struggle through the depression that is usual after this type
of surgery. Here is real need for all types of patient support and education. The
American Cancer Society has provided certain literature and recently the Divi-
sion of Chronic Diseases in the Public Health Service has produced an instruc-
tional film for both professional personnel and patients. There is urgent need
for enlargement of such a program: unless it is developed, many patients will
be lost by default, even though their surgery is successful.

Stroke—In the past the patient with stroke has too often been considered a
hopleless candidate for the nursing home, the back bedroom, and the chronic wards
of the hospital. It was pointed out in the testimony that strokes occurred at all
ages and that, regardless of age, the patient was entitled to rehabilitation oppor-
tunities. It was further indicated that the individual with such severe brain
damage that he is unable to retain knowledge, the patient with cardiac failure
that made further energy demands impossible, and those with uncontrollable
malignant hypertension were obviously not suitable candidates for rehabilitation.
It was emphatically brought out that every stroke center or station must have
services of a comprehensive rehabilitation program, not only physical but
vocational.

There was special discussion on the most difficult problem in stroke: aphasia.
Actually this disabling condition should be considered a total problem of com-
munication rather than aphasia alone. There is a tremendous need not only
for more services in this field but for more research. This should not only be
done by the Vocational Rehabilitation Administration alone. Basic research
should be supported also by the National Institute of Neurological Diseases and
Blindness, the National Heart Institute, and any other agencies with either pri-
mary or tangential interest.

The person who has suffered residual disability following a stroke should not
be considered a specific clinical entity but, rather, an individual with a functional
deficit. The localization and extent of the anatomic and physiologic defect
produced by stroke results in variations in the hemiplegic pattern. No standard
program for the rehabilitation of the person with stroke is therefore possible.
Individual prescription and therapeutic measures‘must be based on analysis
and evaluation of the functional deficit.

The stroke patient in our society is at our mercy. He is not uncommonly aged ;
usually he is financially dependent ; he does not know what he needs or where to
find help; and he is certainly incapable of coordinating his own health services.
There is great need, therefore, to find methods of intra-agency and interagency

coordination within the purview of health, education, and welfare at local, State,
and National levels.

It is apparent that the U.S. Public Health Service through the State health
departments could serve an important function in continuing education in
rehabilitation of stroke victims as well as casefinding.

   
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
   
 

202 COMBATING HEART AND OTHER MAJOR DISEASES

Rehabilitation is not a subdivision of medicine but is actually in some resvects
broader than medicine, for it involves a wedding of the behavioral and social
sciences with biological sciences. This principle has not been adequately applied
in the case of stroke patients but should be encouraged.

Rehabilitation is an integral part of the medical care of patients with heart
disease, cancer, and stroke. It is essential, therefore, that any and all special-
ized facilities for the care of patients with heart disease, cancer, and stroke have
comprehensive rehabilitation service. The type of rehabilitation service and
the staffing patterns of such services will vary with the basic mission of such
specialized facilities. All persons testifying at the hearings of the Subcommittee
on Rehabilitation strongly recommended that persons needing rehabilitation serv-
ices because of heart disease, cancer, or stroke could best be served in a general
multidisability rehabilitation program.

Disability centers —Subcommittees on Heart Disease, Cancer, and Stroke have
recommended the establishment of diagnostic and treatment stations through-
out the country. These stations, which will be in community general hospitals
and medical centers affiliated with universities, will be responsible for providing
high-quality care for patients suffering from heart disease, cancer, or stroke.
Since it is recognized that each of these stations should be associated with a
rehabilitation unit capable of providing needed services, it is recommended,
therefore, that where none exist, a rehabilitation unit be established in each
and every one of the hospitals where heart disease, cancer, or stroke stations
are built.

Program services and staffing will vary in such units. However, a typical
rehabilitation unit will include at least a 20-bed ward for rehabilitation services.
The units should offer multidisability rehabilitation programs, but especially
oriented to meet the needs of heart disease, cancer, and stroke stations.

In order to establish such units, funds must be provided for the renovation
of existing facilities and for the construction of new ones. It is estimated basic
renovation will cost approximately at least $150,000 for each 20-bed unit. An
additional $150,000 a year will be required to meet half of the operating costs
of each unit. The remaining half can be met through fees for service and local
participation.

The Rehabilitation Subcommittee recommends that funds be appropriated
by Congress for a 5-year period for the development of this program. These
funds should be allocated by the Public Health Service so that this program
ean be administered in coordination with heart disease, cancer, and stroke sta-
tions. This program should be developed in collaboration with the Vocational
Rehabilitation Administration. The following table summarizes the annual
budget necessary for the development of this program on the basis of 100 re-
habilitation units. Total budget will vary, depending upon total number of

 

 

 

 

 

units.
Costs of rehabilitation stations
(Dollars in millions]
'
Year
1 2 3 4 5

Number of new units to be established._......-.------ 10 20 30 40 |--------..
Renovation or construction -...--...----------------- $1.5 $3.0 $6.0 $7.5 |_--...--__-
Operating expenses_..-.--.-------------------------- 15 4.5 10.5 12.0 $15

Total_.-_-.--..----------------+---------- eee 3.0 7.5 16.5 19.5 15

 

 

 

 

 

 

Demonstration projects—lIt is further recommended that all hospitals and
public health agencies serving persons with heart disease, cancer, and stroke
should be encouraged and assisted to make rehabilitation services an integral
part of their program. The Public Health Service should be given the authority
and necessary funds to make project grants to hospitals and public health agen-
cies for the development of demonstration projects in rehabilitation in the com-
munity. Such community rehabilitation programs should be integrated with
other services provided by hospitals and public health agencies to patients with
heart disease, cancer, or stroke. It is estimated that the sum needed to initiate
this program is $1.5 million the first year, to be increased in stages to $7.5 million
during the fifth year.
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COMBATING HEART AND OTHER MAJOR DISEASES 203

THE VOCATIONAL REHABILITATION PROGRAM

The major responsibility for rehabilitation services for the adult civilian
population of the United States is vested in the Vocational Rehabilitation
Administration, Department of Health, Education, and Welfare, and its counter-
part agencies in all 50 of the States, the District of Columbia, Puerto Rico, Guam,
and the Virgin Islands.

The principal programs conducted are (1) the basic program of vocational
rehabilitation services for disabled people, carried out cooperatively between the
States and the Federal Government, (2) research and demonstration, (3) train-
ing programs to produce more professional personnel, and (4) an international
rehabilitation research program.

State-Federal rehabilitation. services.—Disabled persons apply to, or are re-
ferred to, the State vocational rehabilitation agency to receive whatever com-
bination of services may be needed to achieve rehabilitation. The services avail-
able include medical, surgical, hospital, psychological, vocational, and other edu-
cation and training; job placement; followup in employment; and several other
related services. The key staff member in this program is the rehabilitation
counselor who works with the patient, the physician, the family, hospitals,
schools, employers, and others in laying out an individual plan of services and
in helping to carry it out. While some services (beyond counseling) may be pro-
vided directly by the State agency, most services are secured by purchase from
physicians, hospitals, rehabilitation centers, clinics, schools, sheltered workshops,
and other sources.

Some highlights.—In fiscal year 1964, almost 120,000 disabled clients were
rehabilitated by the Federal-State vocational program. This was the eighth
consecutive year that a new high was established in the number of persons
rehabilitated. Over the past 5 years, the number of rehabilitants has increased
36 percent.

A total of 400,000 disabled clients were served during the year by the State
vocational rehabilitation agencies, an increase of a little more than a third over
the last half decade.

During the same 5 years, the national rehabilitation rate increased from 49
per 100,000 population to 63 per 100,000.

More than a quarter of the rehabilitants were 45 years of age or over: 1 in 5
rehabilitants was less than 20 years old.

Of every 10 rehabilitants, 6 were male; 8 of every 10 rehabilitants for whom
race was reported were white.

Nearly half the rehabilitants had dependents.

The three largest sources of referral were private physicians (16 percent), and
hospitals and sanatoriums (13 percent), and educational institutions (13
percent).

Before receiving rehabilitation services, more than half the rehabilitants
were dependent on family and friends for their primary source of support.

At acceptance for service, to judge from past trends, about 21,000 rehabilitants
were being supported by public funds. Of these clients, some 16,000 were receiv-
ing public assistance payments at an aggregate annual amount of over $18
million. The other 5,000 were maintained by public institutions and other public
programs. At closure, about 6,300 clients were receiving public assistance of
less than $6 million annually, a net reduction of about 60 percent in the number
of public assistance recipients, and an estimated savings of nearly $13 million
in public support funds.

Nearly three-quarters of the rehabilitants were not working before rehabilita-
tion. The remaining clients were either employed, self-employed, unpaid family
workers, or homemakers. After rehabilitation, 83 percent of the clients were
earning wages. The average wage for the group was a little over $40 per week;
nearly 30 percent were earning over $60 per week. The aggregate annual earn-
ing of all rehabilitants was $250 million.

The number of clients rehabilitated who had been applicants for old-age and
survivors’ disability insurance benefits was about 9,600.

Of the rehabilitants closed into paid employment, more than 10 percent were
placed in professional and semiprofessional types of occupations and nearly 30
percent became skilled and semiskilled workers.

More than 90 percent of the rehabilitants required some type of purchased
service at cost to the agency. The services needed most frequently by all
rehabilitants were diagnostic procedures, 96 percent; training and materials, 36
percent ; and surgery and treatment, 35 percent.

  
 
 
 
  
 
  
  
  
 
  
  
 
  
 
 
  
   
 
  
   
 
   
  
  
 
 
  
  
 
  
  
 
 
   
 
 
 
 
 
  
 
 
  
 
 
 
 
  
 
 
 
 
  
 
 
 
  
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
  
   
 

204 COMBATING HEART AND OTHER MAJOR DISEASES

On the average, clients completed the rehabilitation process in approximately
13 months. The median time from referral to acceptance for service was about
2 months ; from acceptance to closure, 11 months.

Services for heart patients—From its inception, the State-Federal program
of vocational rehabilitation has served persons disabled by disease or disorders
of the heart. Since 1943, when legislation authorized the provision of services
to reduce or eliminate the handicapping residuals of disability, the program has
also provided medical restorative services for the cardiac with a potential for
work. State agencies have varied in the depth and scope of the services they
have made available to the cardiac case. Some have pioneered by arranging for
their clients to have surgery of the heart, including open-heart surgery, surgery
to insert “cardiac pacemakers,” to transplant arteries or veins, or to substitute
various synthetic materials for damaged arteries. In other States, arrange-
ments to provide these highly technical procedures have been made through other
public or private agencies, with the State rehabilitation agency coordinating
these other resources in order to develop the integrated pattern of services essen-
tial to the rehabilitation of the cardiac.

Emphasis has always been given to the following: comprehensive diagnostic
and evaluative services, physical restoration services, professional counseling,
prevocational and vocational training, and job placement and followup. All
clients of a State rehabilitation agency receive a general medical examination
at the time they apply for services. The family physician’s intimate knowledge
of the client and his circumstances is utilized fully, since he may direct
attention to secondary medical problems, or to emotional and social problems
which must also be resolved if the person handicapped by a cardiac condition
is to be successfully rehabilitated. Usually the agency will refer the client to a
eardiologist who thoroughly evaluates the cardiovascular and related systems.
In addition to providing such relatively routine tests as an EKG, X-ray, and
fluoroscopy of the chest, he may recommend further special studies which are
arranged for by the agency. The client may be referred to a work classification
fceenter, where a team of medical and vocational specialists determine his
physical capacity for work. Or he may be referred to the cardiac team of a
medical center where cardiac catheterization, angiocardiography, and blood
chemistries under standardized conditions of work are completed.

Once the evaluation of pertinent medical, psychosocial, and vocational factors
has been completed, the agency counselor, in consultation with his medical
consultant, will develop a rehabilitation plan cooperatively with the client and
his family. This plan may include provision for necessary surgical procedures.
Arrangments may be made for the client to go to a rehabilitation center where
tolerance for work may be developed under medical supervision, where train-
ing in “work simplification” can be received, as well as such additional services
as prevocational training, psychological testing, and personal adjustment coun-
seling. Sheltered workshops may be utilized to afford the client exposure to
work experience in order to develop confidence in his ability to return to the
labor market; or the plan may include his attendance at a vocational school
to develop job skills. ‘

The client and the counselor consider together all possibilities for remunera-
tive employment which are within the client’s residual physical capacity, his
particular aptitudes and interests and for which there are placement opportu-
nities available. These may include employment in the competitive labor market,
self-employment, a return to the job held prior to the onset of disability,
sheltered workshop activity, or homebound industry. Other community services,
such as homemaker services, may be incorporated in the work plan so that the
client may expend his energies at work more suited to his abilities.

In carrying out rehabilitation plans for cardiac patients, it is logical that
State agencies should uncover gaps in the services needed by their clients. In
cooperation with other community agencies, and with the support of the Voca-
tional Rehabilitation Administration, State agencies have stimulated the de-
velopment of many valuable resources for the rehabilitation of the cardiac.
Among these are cardiac evaluation centers at medical centers, work classifica-
tion units, homebound industries, rehabilitation centers, and sheltered work-
shops.

Equally important, State agencies have given essential support to these re-
sources by finding appropriate candidates for the services they provide and by
paying for the eare received by clients. The State agency may assign voca-
tional counselors to such facilities in order to increase their effectiveness, an
 

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205

activity frequently undertaken as an extension and improvement project with
the support of 75 percent funding through the Vocational Rehabilitation Ad-
ministration. Cooperative arrangements have been developed between Federal
and State agencies and the American Heart Association.

Rehabilitation for cancer patients—aAs is true with heart disease and stroke,
the practices of State agencies vary in their efforts to meet the rehabilitation
needs of cancer cases. Generally, the comprehensive evaluation and continuum
of services appropriate to the individual needs of the cancer client are similar
to those described earlier.

Because of the difference in State agency practices and the pressure of many
of these agencies to provide cancer surgery when the eligibility for vocational
rehabilitation services was uncertain, the Vocational Rehabilitation Admin-
istration has encouraged State rehabilitation agencies to include cancer pa-
tients in their caseloads where eligibility requirements are met and has issued
guidelines for provision of vocational rehabilitation services to indivduals with
eancer.

The agencies generally arrange for biopsies to be carried out when they are
required as part of the diagnostic workup and are approved by the agency’s
medical consultant. It is also general policy to provide necessary surgery when
the client is unable to pay for this service himself or when arrangements can-
not be made for surgery through other resources in the community. Sometimes
when an individual is accepted for service, a malignancy is discovered or sus-
pected, and the subsequent biopsy may indicate the necessity for surgery as a
lifesaving measure. In such cases, the State agency may provide for the neces-
sary surgery. If a client is known to have cancer at the time he is accepted
for rehabilitation service and the rehabilitation plan includes physical restora-
tion services to remove or alleviate the malignant condition, radiation therapy
and drugs may be provided as part of the physical restoration program.

Agencies have been cautioned against becoming involved in diagnostic surgery
in cancer cases with a grave prognosis. Thus, under current practices, a major
consideration for State agencies in accepting cancer cases for vocational
rehabilitation services is reasonable expectation that the individual will be able
to engage in a remunerative occupation.

The public program of vocational rehabilitation could expand its services to
meet the needs of a greater number of cancer cases through the following
measures:

State rehabilitation agencies should be encouraged to liberalize their policies
in accepting cancer cases for service, including cases where (1) the disease
process is considered arrested, and (2) where the cancerous progress may be
medically described as slow. This liberalization could be accompanied by a broad
program of interpretation of this new policy to physicians, community referral
sources, and the general public.

State agencies should broaden their service concepts for individuals with
cancer. In the case of laryngectomized individuals, physical restoration with
reconstructive surgery can often be beneficial. There is need, too, for the pro-
vision of training in esophageal speech and in cases where such speech cannot
be acquired to provide electronic devices to facilitate communication,

The Vocational Rehabilitation Administration should develop cooperative
agreements and programs with the medical profession and appropriate voluntary
agencies. For example, discussion should be initiated with representatives of
the American Cancer Society leading to cooperative programs in the rehabilita-
tion of cancer patients, as has been done with the American Heart Association
for cardiac cases. This should lead to improved coordination in providing
services at the State level.

Rehabilitation for stroke patients.—Often, for the patient, the return to a use-
ful and productive life following a stroke is a long and discouraging process,
but frequently much can be accomplished if vocational rehabilitation services can
be provided early and continued for the necessary time.

Patients with stroke are being served through State agency programs, although
unfortunately not in large numbers. The services provided are essentially the
Same as those for heart and cancer cases. In some cases physical restoration
services will include surgery for removal of clots, tendon transplants, tendon
lengthening, or release of spastic muscles.

Early referral is particularly important in stroke cases. Educating physicians
to early referral is a constant preoccupation of the Vocational Rehabilitation
Administration. It could be strengthened through coordinated action with State
and local medical associations as well as with State and local heart associations.

43-669—65—~—14

COMBATING HEART AND OTHER MAJOR DISEASES

  
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
  
   
 
 
 
 
 
 
 
 
 
 
  
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
  
  
  
 
 
 
  
 
   
  
  
  
 
    
   
  
  
 
 
 
  
  
 
 
  
 
 
 
 
 
 

  

  
 

206 COMBATING HEART AND OTHER MAJOR DISEASES

Provision should be made for State agencies to support stroke cases for
specified periods in nursing homes which have appropriate rehabilitation and
therapeutic services. Along this same line, needed therapy should be provided in
the home as a homemaker service.

In rural areas, State agencies should be enabled through special funding to
provide mobile diagnostic and therapy teams to evaluate stroke cases, determine
their degree of disability, and prescribe treatment. There is also a need for
the training of nurses and family members in order to provide needed therapy
under the direction of the patient’s physician and with the resources of the local
hospital.

States should be enabled to encourage by grants and other forms of support
the initiation of local programs of physical and speech therapy for stroke
patients, utilizing fully the community hospital and other relevant community-
based health programs.

Services for heart, cancer, and stroke patients——In the year ending June 30,
1964, nearly 120,000 disabled Americans were rehabilitated into public employ-
ment under the State-Federal vocational rehabilitation program. This was a 9-
percent increase over the preceding 12 months and the 11th consecutive year in
which a new high was established. Despite these advances, it is estimated that
there are 2 million Americans who are eligible for and who could benefit from
vocational rehabilitation services if facilities, personnel, and funds were avail-
able. The number newly disabled each year is 350,000.

Even present services under the State-Federal rehabilitation program are not
used to full effect for patients with heart disease, cancer, and stroke.

Of 110,186 persons rehabilitated into employment by State vocational re-
habilitation agencies in fiscal year 1963, only 5,188 (4.7 percent) had heart
disease, 539 persons (0.5 percent) had eancer, and 502 (0.5 percent) had strokes.
As the total number of persons rehabilitated annually into employment increased
steadily from 80,739 in 1959 to 110,186, the percentage of the total with heart
disease, cancer, and stroke remained constant.

By 1968 the Vocational Rehabilitation Administration projects a total of 161,900
persons rehabilitated into employment. If the percentage of the total with heart
disease, cancer, or stroke remains constant, vocational rehabilitation services
during fiscal year 1968 will be provided to only 7,500 persons with heart disease,
750 persons with cancer, and 800 persons with strokes.

Legistation.—Legislation currently pending before the Congress would allow
State vocational rehabilitation agencies to serve clients for a period of at least
18 months before all criteria of eligibility are met. If this legislation is adopted,
patients with heart disease, cancer, or stroke may receive intensive evaluation
services before it is definitely determined that there is a reasonable expectation
of ability to work for pay.

Further services could be provided for patients with heart disease, cancer, or
stroke if State legislatures appropriate more money for Federal matching, so
that State agencies may increase staff, expand services, and serve more clients.

State agencies can also be encouraged to develop more extension and improve-
ment projects (which are supported with 75 percent Federal funds) for persons
with heart disease, cancer, or stroke.

Services available for cardiac, cancer, and stroke patients through State re-
habilitation agencies could be considerably enhanced and expanded by clear-
cut authority to provide self-help devices such as mechanical stairs or other
structural alterations in the home. These facilities might be interpreted as
being in the nature of prostheses, but their primary function would be to serve
as aids to independent living rather than as devices designed to meet a voca-
tional need. Quite possibly, adidtional legislation would be necessary before
State agencies could have the authority to expend funds for the purchase of such
equipment, but this seems an area deserving careful analysis.

Vocational rehabilitation services should be extended to many more young
people with heart abnormalities in their early teens, since they require early
guidance by counselors for proper vocational planning. Young people with
organic heart disease, whatever their functional or therapeutic classification.
should be considered handicapped and eligible for vocational rehabilitation
services. Many of these young people with a history of rheumatic fever are
often classified 1—A and are, therefore, not acceptable to State vocational rehabili-
tation agencies. More education is needed in the eorrect use by physicians and
correct interpretation by counselors of the functional therapeutic classification.

The Vocational Rehabilitation Administration should be directed to launch a
 

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COMBATING HEART AND OTHER MAJOR DISEASES 207

special 2-year development program to provide a vastly expanded pattern of
operation in cooperative work with the States and communities in rehabilitating
the victims of heart disease, cancer, or stroke.

Specifically, the new programing should include:

1. New system of project grants, primarily to State vocational rehabilitation
agencies, financed entirely with Federal funds for a 2-year developmental period,
to provide complete and modern vocational rehabilitation services to persons with
disabilities resulting from heart disease, cancer, or stroke; $1.5 million a year is
recommended.

2. The construction of vocational rehabilitation centers and sheltered work-
shops with special emphasis on those which will be fully capable of providing
the most advanced evaluation and services for persons disabled by heart disease,
cancer, or stroke, as well as other disabilities including mental retardation.

To provide a strong incentive to cooperating agencies and groups, at least
three-fourths of the construction costs of these projects should be borne by the
Federal Government. This Federal support should also apply to necessary equip-
ment and the costs of staffing for the first few years.

Because many persons are so severely disabled they cannot reasonably be
expected ‘to even enter competitive jobs, yet are able to work productively in
sheltered workshops, the Federal Government, through the Vocational Rehabili-
tation Administration and the cooperating State agencies, should provide con-
tinuing Federal grants to help support sheltered workshops.

There are at present about 400 rehabilitation centers, varying in type, size,
service, and disability interest. Of these, probably about 75 are vocationally
oriented centers, including those with beds or dormitories and those functioning
on an outpatient basis. According to a recent estimate, at least 200 more voca-
tionally oriented centers are needed. Sheltered workshops currently number
about 650, with great variations. At least 1,000 more sheltered workshops should
be established.

For an aggressive and yet realistic approach, it is recommended that during
the next 5 years a minimum of 100 vocational rehabilitation centers and 500
sheltered workshops be established throughout ithe country.

The average cost per unit is estimated to be $700,000 for each center and
$120,000 for each sheltered workshop. The Federal Government’s share of this
amount should be at least 75 percent of such costs. The Vocational Rehabilita-
tion Administration should be given the authority and appropriation to undertake
this program. The following tables summarize the cost of initiating this
program for the first 2 years.

Annual cost of new vocational rehabilitation centers
[Dollars in millions]

 

Ist year 2d year

 

 

 

Number of new centers_.____-_._...--------u-------------------------------- 2 & 15
Total actual cost__-_-___ $3.5 $10. 5
Federal share..___.._-_-------------------------------- +--+ een eee eee 2.5 7.0

 

 

 

Annual cost of new sheltered workshops

 

 

 

 

 

[Dollars in millions}
1st year 2d year
Number of sheltered workshops. .__-------------------------- ene eee eee 50 50
Total actual cost __---.-_----...- 22-2 n-ne $6.0 $6.0
Federal share____-_-------------------------+------------ ae een 4.5 4.5

 

3. Legislative authority to permit the use of Federal funds by the Vocational
Rehabilitation Administration to match funds appropriated by city or county
governments which are used within the general framework of the presently
established State vocational rehabilitation program. This new authority will
encourage city and county governments to participate directly in the vocational
rehabilitation of their citizens suffering from heart disease, cancer, or stroke.

    
 
   
  
 
  
  
  
  
 
 
  
  
  
 
 
  
  
  
  
  
  
 
  
   
  
  
 
    
 
 
 
  
 
   
 
  
 
 
 
 
 
 
 
  
 
  
  
  
 
 
 
 
 
 
  
 
 
 
  
 
 
   
  
   
 

208 COMBATING HEART AND OTHER MAJOR DISEASES

It is estimated that $2.5 million is necessary for a 2-year period to initiate this

ram. : a
New legislative authority to enable the Vocational Rehabilitation Adminis-
tration to relax its present requirements in the acceptance of disabled persons
for services in the State-Federal program. .

Under present law, a disabled person must be found potentially employable
before rehabilitation services can be undertaken. In a large number of patients
recovering from heart disease, cancer, or stroke, employability cannot be prog-
nosticated until restorative measures have been administered for a variant period
of time. For the Federal-State program to play an aggressive role in reducing
needless disability, the agencies should be authorized and encouraged to provide
services for a preliminary period of time (which will vary but often runs from
a year to a year and a half) before deciding whether or not the individual
patient is likely to be employable. a

The extent of the additional outlay of funds will depend largely on the ability
of individual States to appropriate increased funds for matching purposes. It
is estimated that a sum of $1 million will be needed for the first year. Expendi-
tures for subsequent years will be incorporated in the growth of the vocation
rehabilitation program.

RESEARCH IN REHABILITATION

Since 1954, the Vocational Rehabilitation Administration has conducted a
program of research and demonstration grants and research fellowships and
since 1961, with the use of “counterpart” funds owed the United States, this
program has.been international. Some funds for research and demonstration
projects in rehabilitation are also available from the Public Health Service
through the National Institutes of Health and the Division of Chronic Diseases,
Bureau of State Services; the Children’s Bureau, Welfare Administration, De-
partment of Health, Education, and Welfare; and the Veterans’ Administration.
The research appropriation for VRA in the fiscal year 1965 was $22,685,000.

The public program of vocational rehabilitation today sights two goals: em-
ployment of disabled persons according to their abilities, their preference, and
their hopes for a secure future; and the reduction of dependency among disabled
Persons who cannot always undertake work for pay.

Some of the ways to achieve these goals have been clarified by Vocational
Rehabilitation Administration research and demonstration activities since 1955.

More than 850 projects supported by VRA were completed, in progress, or ap-
proved for initiation at the end of June 1964. In that year, more than $15 mil-
lion in Federal money was available for research projects, to support initiation
of new projects or continuance of prior awards. Research grants to State
rehabilitation agencies or private, nonprofit groups require a prospect of new
information or new techniques of benefit to the general program or certain areas
of rehabilitation endeavors.

‘The projects study virtually every field of rehabilitation: cardiovascular dis-
orders, mental retardation, mental illness, orthopedic disorders, speech and hear-
ing, visual disorders, aging and chronic illness, and other conditions that are
handicaps to employment and independent living. Not only is there research
per se, but demonstrations of the validity of new knowledge or ideas, adminis-
trative and program studies, and many projects on the periphery of the program
but valuable to its operation and progress. ’

The philosophic concepts of rehabilitation of the person with heart disease
have gained increasing recognition over the past two decades. This has resulted
from a sharper scientific delineation of rehabilitation as a concept coupled with
increased physiologic and biochemical knowledge of congestive heart failure
and better understanding of the meaning of cardiac functional classification in
terms of ergometry and ergonomics.

Projects in heart disease

With the aid of research and demonstration grants, the Vocational Rehabilita-
tion Administration has supported a number of cardiac work evaluation units
which have yielded valuable information on the capacity of heart patients to
engage in physical activity. The treatment and advice given to cardiovascular
patients as well as the vocational rehabilitation procedures have changed con-
siderably as a result of such findings. :

To restrict the patient to a level of activity far below his reasonable eapacity
defeats the purpose of rehabilitation. To neglect to protect the patient against
dangerous stresses at home, yet to overprotect the patient during employment,
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COMBATING HEART AND OTHER MAJOR DISEASES 209

is poor management, expensive both to the patient and the community. Reason-
able regulation of the patient’s activities so that he may resume an enjoyable and
productive life should be the goal.

The University of Minnesota, the University of Pittsburgh, and Columbia
University have each sponsored projects in work classification for heart patients.
The Minnesota unit studied the parameters of cardiac output and cardiac work
during vocational rehabilitation. The Pittsburgh unit conducted two projects:
One was to evaluate the effect of employment on cardiacs whose work tolerance
had been prescribed by the unit and the other was an effort to develop standards
for work recommendations by analyzing compliance with work prescriptions
and mortality. The Columbia University unit analyged and correlated data
on the vocational adjustment and personal characteristics of persons seen by
the unit.

The New York Medical College has studied the electrophysiological character-
istics of nerve and muscle to determine if changes occur in these characteristics
in the course of chronic occlusive arterial disease.

At Baylor University, the department of rehabilitation has installed an elec-
tronic data procesing system to study rehabilitation in severe neuromuscular
respiratory and circulatory disabilities. This is based on the idea of linear
programing used in industry to chart a complex flow of production. The reha-
bilitation process is examined through study of data recorded in a case history
over the period of hospitalization. This study should identify activity patterns
in specific categories of disability, including stroke and heart disease, during
hospitalization.

Northwestern University Medical School is studying the course of rehabilita-
tion of cardiac patients who have undergone corrective cardiac surgery in an
attempt to determine predictive indicators for recovery and long-term adjust-
ment. Psychological, psychiatric, neurological, social service, and cardiac diag-
nostic procedures are being employed in this 5-year study of patients who have
been operated on by means of closed- and open-type of cardiac operations. The
project will provide data basic to the understanding of the complexities of
rehabilitation of cardiac patients in a comprehensive manner.

A study of the effects of training and other factors on cardiac patients before,
during, and after a program of rehabilitation is being conducted at Montefiore
Hospital in New York. Baseline data on a cardiac patient group have been
developed. This group will be followed and studied according to criteria of
work physiology not usually applied to those with heart disease.

A home-care program for cardiac patients was carried out by the University
of Maryland Medical Center. An administrative unit was organized and home-
care services were provided for an experimental group of patients with serious
cardiac handicaps. Considerable differences in the rate of readmission to the
hospital were found between experimental and control groups. Not only was
the initial hospitalization much shorter for the experimental group, because
of the availability of the home-care program, but the rate of readmission was
much less for the experimental group. Differences in mortality rates of the
two groups were not significant.

A study of factors relating to unsuccessful vocational adjustment of cardiac
patients was made by the Heart Association of Southeastern Pennsylvania. It
showed that social and emotional factors were closely related to unsuccessful
adjustment rather than organic heart disease or vocational factors. Failure to
come to emotional terms with the illness, overconcern, anxiety, and bitterness
characterize this group. Failure to return to work is accompanied by family and
personal disorganization; family problems grow; problems are perceived
unrealistically.

The Human Resources Foundation on Long Island is conducting research with
far-reaching implications for heart disease and stroke victims. Through the
use of recently developed methods of telemetry, and in conjunction with new
psychometrics, the physical and psychosocial aspects of work are being studied
while the worker is on the job. It is expected that the project will develop
important knowledge bearing on the physical reaction of disabled persons to the
physical and emotional strains of the job and on the relation of such reactions
to the individual’s work adjustment.

Needs.—There is now available a considerable body of information regarding
the metabolic and cardiovascular requirements for short bouts of exercise by
hemiplegic patients. It is urged that studies be initiated on the effects of pro-
longed exercise on subjects with motor impairment, since information on this
question is sparse.

 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
  
 
   
 

210 COMBATING HEART AND OTHER MAJOR DISEASES

A project is needed to study means of early detection of cardiac cases as well
as the development of better evaluation procedures for the cardiac patient.

A study is needed of the work-potential indicators for cardiac patients, espe-
cially following cardiac surgery.

There is need for revision of physical standards for the cardiac in industry.
This revision should invite the participation of industrial medical directors.

A project to study psychosocial adjustment of the cardiac through the use of
group therapy and recreational facilities is indicated by recent findings. Also,
study of the premorbid and postmorbid personality of the cardiae will provide
guides to counselors and other rehabilitation personnel.

Further study is indieated for the causes of various vascular diseases; such
as arteriosclerosis and ‘atherosclerosis and peripheral vascular conditions. Also,
investigation of respiratory sequelae, as a rehabilitation problem in cardiac
disease, needs support.

In order to provide a continuity of service for youths disabled by heart disease,
a program to insure a progression from school to work is needed. This program
would establish demonstration projects which coordinate services between the
school’s secondary program and a work-adjustment program. There is consid-
erable experience with the mentally retarded which needs to be transferred and
modified to fit the needs of the youth disabled by heart disease. After testing
in 4 or 5 experimental projects, 10 selected demonstrations should be established
in various regions to promote the use of the procedures and methods developed
from the experimental studies. These activities should logically be integrated
with cardiac centers ‘and service units.

Projects in cancer

Victims of cancer, who are successfully treated, frequently are able to return
to their former occupations with little or no handicap. However, certain resid-
uals of cancer surgery require rehabilitation measures. For example, amputa-
tions are not uncommon and prosthetic appliances are fitted to replace the
amputated limb. Another result of cancer surgery, in some cases, is facial
disfigurement. Two projects studying the problems of facial disfigurement have
been completed under the auspices of the Vocational Rehabilitation Ad-
ministration.

Faciatly disfigured.—New York University Medical Center has completed a
study of the teamwork approach to rehabilitation. of ‘the facially disfigured. This
approach recognizes the extreme importance of the psychological and social fac-
tors in this kind of disability, along with medical factors. This project con-
centrated on patients requiring physical restoration by surgery. Of course,
facial disfigurement results from causes other than cancer but malignant growths
are a frequent cause for facial surgery with the consequent need for physical
restoration. The significance of the New York University study was in the con-
tribution of the psychosocial members of the team and in its analysis of the kinds
of patients who are more likely to be rehabilitated.

At Duke University, a related study concerned cosmetic prosthetic restora-
tion. Experiments were conducted to develop materials best suited for molds
and for the prosthesis itself. The study developed a satisfactory prosthetic nose
and established a cosmetic prostheses center.

Laryngectomy—Laryngectomized cancer patients, having lost their voices,
are taught a method of speaking called esophageal speech. They must learn to
impound air in the esophagus and to eructate at will. Articulation is carried on
as before.

Two studies of esophageal speech have been conducted at the University of
Kansas Medical Center. The first was to determine the relationships between
attitudes toward speech and the intelligibility of the esophageal speech of laryn-
gectomized persons. It was found that acceptance of esophageal speech was
closely related to intelligibility and the absence of swallowing noises, breathing
noises, low pitch, and so forth. The subjects whose speech measured as more
intelligible were making the healthiest adjustment to speaking situations and
usually they were verbal people in the preoperative pertod.

The second study by means of cinefluorography investigated physiological
movements in esophageal speech. Significant findings were obtained for teach-
ing esophageal speech. It was also suggested that the variables of personality.
motivation, drive, family environment, and aspiration level, which were not
evaluated in this study, are prohably more important for the speech learning
process than are the physical variables.

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COMBATING HEART AND OTHER MAJOR DISEASES 211

A project sponsored by the Junior League Speech & Hearing Center of Colum-
bia, 8.C., studied the social and vocational acceptability of esophageal speakers.
In a carefully designed study, comparison of normal and laryngectomized speak-
ers indicated that the laryngectomees were significantly less acceptable than the
normals regardless of whether acceptability is based upon closeness of social con-
tact permissible, the prestige levels of the jobs for which the speakers are con-
sidered adequate, the number of jobs for which the speakers are considered ade-
quate, or the degree of public contact entailed in jobs for which the speakers
are considered adequate. Moreover, the laryngectomees were judged to be sig-
nificantly less acceptable than the normals whether the comparisons were based
only on speech, only on appearance, or on the simultaneous speech and appear-
ance of the speakers, regardless of the presence or absence of information.

The primary purpose of a University of Pittsburgh project was to study
factors which might be related to the learning of speech in laryngectomized
patients. Specifically a number of biographical, medical, personality, social,
communication, and speech training factors were studied as correlates to speech
profiicency. Descriptions of specific speech training procedures were also ob-
tained and correlated to measures of speech proficiency. In addition, a popula-
tion of esophageal speakers was compared with a population of artificial ap-
pliance users on several measures of speech proficiency, as well as on factors
associated with speech proficiency.

In general, the results obtained favored esophageal speech over the use of
artificial appliances. Also, certain factors such as age and the nature of residual
musculature were important in prognosis, while early training, personality, and
social variables were shown to be closely related to proficiency in speech.

At Washington University, St. Louis, a project is being conducted to study
the neurophysiologic factors necessary in the reestablishment of normal swal-
lowing and voice in laryngectomized animals with mechanical prostheses and
patients with partial laryngectomies.

Needs.—Among the needs for research in rehabilitation of cancer victims are:

Further development of prostheses to replace deformities caused by cancer,
including lost appendages, at various stages of the disease, especially newer
techniques in prosthetics following disarticulation, and evaluation of various
materials in the manufacture of prosthetic devices.

A study of the rehabilitation needs of individuals with cancer of the bones
and joints.

Further studies of rehabilitation procedures in breast cancer. These should
include methods of minimizing disability, reducing edema, and improving pros-
thetic devices.

A study of the psychosocial relationships of the cancer patient and his family
during rehabilitation is indicated by recent findings, especially with respect to
breast and gastrointestinal cancer.

Separate but closely related studies of rehabilitation of individuals with
cancer of the lungs, genitourinary system, gastrointestinal system, or the larynx.

A study of the rehabilitation needs of patients with cancer or tumors of the
brain and neurological system.

Establisments of more centers for research and training, as well as services,
in the field of cosmetic prosthesis and surgical repair of facial disfigurement.

Studies of the effectiveness of preoperative and postoperative exercises and
other procedures of physical medicine in alleviating or reducing deformities due
to mastectomy.

Studies of preoperative and postoperative counseling in cases such as mas-
tectomy to achieve the best possible adjustment to the disability and to improve
vocational rehabilitation potential.

Experimental work in using identifiable signs to differentiate satisfied and
unsatisfied patients in the courses of undergoing repair for facial disfigure-
ment, and using these signs to measure need for psychotherapy prior to surgery.

In order to provide intensified research and treatment for laryngectomized
patients who require training in esophageal speech, it is recommended that a
university medical center already well equipped in this area be encouraged to
step up its program by a grant for 3 to 5 years of intensive study of the coor-
dination of surgical, psychiatric, psychosocial, and speech therapy facilities in
improving esophageal speech. From this experience, selected demonstrations
can be developed.

A study should be made of the attitudes of the professional personnel working
with individuals who are disabled by cancer and are in the process of rehabilita-
tion.

  
  
 
 
 
 
 
 
 
  
 
 
 
 
 
  
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 

212 COMBATING HEART AND OTHER MAJOR DISEASES

Stroke projects

There is no disability affecting larger numbers of Americans in which reha-
bilitation can play a more important role than stroke.

Energy expenditure—It is generally conceded that easy fatigability is a major
factor hampering the rehabilitation of patients with hemiplegia due to cerebral
vascular accidents. The Vocational Rehabilitation Administration has supported
studies at the University of California and New York University directed toward
analyzing this problem.

The California studies involved the measurement of energy expenditure in
normal persons and in hemiplegics. The investigators found higher energy ex-
penditures among hemiplegics than in normals doing equivalent exercise. How-
ever, it was demonstrated that hemiplegics with assistive devices could be
brought within the normal range at reasonable levels of speed of exercise. A
new method of measuring energy expenditure was described and its effectiveness
demonstrated. These studies indicated a need for further studies of energy
expenditures in common activities of everyday life.

A second project at California had two primary objectives: (1) to obtain
quantitative data on the physiclogical demands of certain types of activity, and
(2) to assess, wherever possible, the therapeutic results of certain exercise regi-
mens. On the basis of data obtained in these studies, there appears to be no
reason why hemiplegic patients, under adequate medical supervision, should
not be able to play a useful and productive role in society. However, if the hemi-
plegic patient is to engage in physical activity, care must be taken that in-
ordinate demands are not made on the afflicted regions of the body.

New York University Medical Center is conducting a study of the significance
of respiratory impairments in hemiplegics, scheduled for termination in February
1966.

Aphasia.—There has been rather wide-ranging study of speech and language
rehabilitation for aphasics, not all of which was directed at stroke victims,
but much of it applicable to this group. The diagnosis, treatment, or therapy
of aphasia, the prognosis for recovery, and the vocational rehabilitation potential
are tightly interwoven subjects for research. It should be noted, alsc, that
aphasia can be viewed as a closely related group of disabilities with a variety
of causes and manifestations. Thus, patients present varying degrees and com-
binations of expressive and receptive language impairment.

Improving differential diagnosis of aphasics is a basic step toward the improve-
ment of the selection of treatment methods and rehabilitation planning. Toward
this end, a project was carried out to_develop a test for aphasia. The result is
the language modalities test. It is an instrument to assess the impaired lan-
guage of the adult aphasic which permits a ready classification of the patient’s
communication problem and, at the same time, leads to the design of the thera-
peutic process,

A study of the stimulus-response relationships in the retained language of
aphasic adults revealed six factors: (1) Visual to oral transmission, (2) aural
to oral transmission, (3) visual to graphic transmission, (4} aural to graphic
transmission, (5) the ability to comprehend language symbols, and (6) the
ability to perform simple arithmetic operations. The test analyzes the patient’s
impairment according to these factors. Then the patient can be approached
directly with the type of language he needs along the pathway most evidently
available. The test also gives a scoring value based upon the patient’s recogni-
tion of his own errors and his tendency to correct them. This test may be one
of the most critical sources of information concerning the aphasic and his
amenability to therapy.

The purpose of an investigation at the Jewish Chronic Disease Hospital was
to study the value of psychotropic drugs as an adjunct to speech therapy for
aphasic patients. Only right hemiplegics were studied. Statistical analysis
indicated that the drugs had no significant effect on speech therapy or percep-
tion. However, analysis of the qualitative data from daily clinical records
indicated improvement in the patient’s emotional tone and alleviation of the
usual depressive reaction. It is not determined whether this improvement was
due to speech therapy, group therapy, the effects of the medication, or a combi-
nation of factors.

Improvement in speech therapy and in performance on tests of perceptual
organization occurred in patients who had sustained their cerebral vascular acci-
dents less than 6 months prior to evaluation and treatment. This improvement
was significantly greater than in those who were evaluated and treated after
the first 6-month period following their cerebral vascular accident.
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COMBATING HEART AND OTHER MAJOR DISEASES 213

Two currently active projects are using automated and programed presenta-
tion of language and berceptual learning tasks with immediate feedback as to
adequacy of response. These studies are seeking to develop the kinds of stimu-
lus inputs effective in increasing learning in hemiplegics. Results should help
lead to clarification of teaching techniques with specific forms of intellectual
deficit, as these relate to patient learning in rehabilitation. One of these projects
is coordinated with a similar project in Milan, Italy, to enable cross-cultural
comparison of the effectiveness of training procedures in different languages.

A project recently initiated is studying paired-associate learning, verbal con-
ditioning, aging, and brain damage. Comparisons will be made between subjects
more than 60 years old, and subjects 25 to 45 years old. They will be studied
with respect to their ability to perform paired-associate learning tasks and the
effect of verbal conditioning procedures. Questions of learning ability and
general adaptability to new conditions are crucial for a variety of professional
disciplines working in psychiatry, physical medicine and rehabilitation, and
related fields with brain-damaged patients. An investigation of verbal behavior
in relation to aging and brain damage will add significant information concern-
ing the strengths and deficits encountered in these groups.

A study of the visual-space perception of the hemiplegic is being conducted at
Baylor University in order to elucidate a relatively unexplored impairment
which may affect the patient's potential for rehabilitation. Particular emphasis
is being placed upon changes in perceptual capacities in the course of rehabilita-
tion and the relationship of these capacities to functional motor performance,
neurological status and intellectual functioning.

The task of determining the ability of brain-damaged individuals to profit

and ability.

Other medical studies.—A. basic study at Kenny Rehabilitation Institute found
a significant relation between atherosclerosis in the peripheral blood vessels of
the extremities and in the cerebral blood vessels. A related project in California
(the Rancho Los Amigos Hospital, Inc.) seeks (1) to determine the frequency,
severity, and the types of cardiovascular problems present in hemiplegic patients
undergoing rehabilitation, (2) to develop practical physiological methods and
to obtain objective data for evaluation of these cardiovascular problems, and (3)
to correlate objective data, so obtained, with the ability of patients to undergo
rehabilitation.

Investigators at the Kenny Rehabilitation Institute in Minneapolis have
sought to evolve a practical tool or technique that would have significane in
predicting functional ability of the hemiplegic patient and the likelihood of his
eventual employment. A feasible technique would make it possible to direct pa-
tient treatment according to residual capacities and establish realistic rehabilita-
tion goals. To thig end, data were compiled from detailed physical examinations,
aphasia tests, and EEG readings of a series of hemiplegic patients. The data
will be analyzed statistically to establish the interrelationships of perceptual,
verbal, sensory, and motor function with the location of the lesion and the degree
of rehabilitation achieved,

A study is being conducted at Baylor University to develop quantitative
methods for evaluating spasticity.

An important means of overcoming physical limitations of hemiplegics is pro-
vided by orthotic and prosthetic devices developed mainly through research since
World War II. These devices provide synthetic muscles consisting of gas-op-
erated or hydraulically operated braces and other types of devices to overcome
weakness, paralysis, or absence of extremities. As has been demonstrated in
other research projects, orthotic and prosthetic devices reduce the energy ex-

acute stage and the influence of rehabilitation. The study also includes a
preliminary investigation of the problems of the patient and his family in the first
year after discharge from the hospital. One purpose was to determine which
patients with cerebrovascular accidents do better with rehabilitation training
than they would be expected to do merely as a result of encouragement to

  
a

 

214 COMBATING HEART AND OTHER MAJOR DISEASES

activity and prevention of stiffness and pain in joints. Patients were assigned
at random to treatment and control groups and their performance was assessed
before and after treatment. Improvement was observed in both groups. There
was no statistically significant difference between the gains of the two groups
in any of the tests of strength, performance, or aphasia. Interim reports in-
dicate that improvement after discharge was dependent upon the strength of
family relationships and the individual’s perception of himself as a functioning
or as an immobilized person.

The University of Minnesota investigators are seeking to determine the effect
of intensive rehabilitation upon maintenance of the capacity of self-care and
independence by patients with hemiplegia resulting from cerebrovascular acci-
dents. They will determine the general health needs, the physical capabilities,
the extent to which social, vocational, and economic needs have been met, and
what community resources have provided assistance or guidance to the patient
and his family. Attitudes of the patient and family toward rehabilitative status
will be investigated as well as the extent to which the public health nurse has
contributed to continuing the care plan instituted in the hospital.

A demonstration project at Long Beach, Calif... completed in 1960, was directed
at the vocational rehabilitation of the physically rehabilitated hemiplegic in a
workshop setting. The subjects were considered “nonserviceable” by the State
vocational rehabilitation agency and therefore presented little prospect of voca-
tional adjustment. The purpose was to determine to what extent this “non-
feasible after evaluation” group could become acceptable for competitive em-
ployment with the help of assistive devices, mechanical modifications, situa-
tional work adjustment techniques, and training in a transitional workshop.
The cooperation of the State rehabilitation agency and community industries was
active and contributed considerably to the success of the project. Factors that
worked against successful rehabilitation were ( 1) the presence of concomitant
disorders, particularly seizures, cardiac conditions, visual disorders. diabetes,
and other liabilities, and (2) emotional or personality disorders. The project
demonstrated (1) that workshop evaluation and training can have a marked
effect on the employability of hemiplegics, (2) that intensive placement activities
are necessary to educate employers and sell the hemiplegic’s abilities, (3) other
neople’s attitudes, including rehabilitation personnel, must be changed regarding
the potentials of hemiplegics, (4) all possible techniques of rehabilitation. includ-
ing adaptive devices, selective tests and measures, job survey. and further re-
search must be utilized to the fullest extent to provide successful rehabilitation
for hemiplegics.

Needs.—Research in rehabilitation of persons with stroke is particularly diffi-
cult due to many practical considerations in the clinical situation which handi-
can research. Some of these are:

1. Tnaccurate determination of extent of pathology.

2. Loss of research population due to deterioration or death of patient or
his strong motivation to return to his community and family upon improving.

As a result, research populations are too small for meaningful statistical
evaluation or include too wide a range of ages, e.g., 20 ta 70.

Tf one attempted to adhere to the ideal of experimental design, probably no
clinical research would be conducted other than case studies.

To facilitate clinical research, an organized and standardized approach to
data collecting must be instituted. Major neurological and rehabilitation centers
should coordinate their activities. With electronic data processing, reports from
any investigators can be centralized. Uniformity is the prime need in ter-
minology and in recording autopsy, neurologic, psychologic, speech, and social
backeround data. Data built up in a central pool can then be analyzed with
statistical confidence bevond the reach of an individual clinical research study.
Unless some centralization and organization of data is achieved, clinical research
in rehahilitation will continue to be loose and inconclusive, if not productive of
contradictory results.

Further research to determine the bases of selection, types of training. and
placement opportunities should be instituted in representative areas of the
country, since some sections are more likely than others to offer job opportunities
to hemiplegics. As the general conclusion that the work habits, reliability, work-
life prognosis. and amenability to training are more important than the exact
job skills in this research may not hold up in all circumstances, workshop train-
ing must be adjusted accordingly. In some instances, it might well be implied
that specific mockups of particular industrial jobs would be the only way to
determine the competence or potential of hemiplegics to fill such jobs.
 

COMBATING HEART AND OTHER MAJOR DISEASES 215

Ten selected demonstrations, based on the prototype established in Long
Beach, Calif., should be established in conjunction with good multidisability
facilities in different regions.

There is a need for further study of spasticity to determine causes and methods
of treatment, including special devices and drugs.

A study of the rehabilitation of hemiplegics who are victims of disease as
compared with victims of trauma, should include special attention to brain
damage as it relates to problems of the dominant lesion versus the nondominant.

A study of the use of assistive devices and their efficacy in the rehabilitation of
hemiplegics should give special attention to ambulation activities.

Further studies in the psychosocial and emotional problems of the hemiplegic
warrant special attention to the family unit.

A study of maximum hospitalization necessary for hemiplegics is needed
to pay special attention to effects on vocational rehabilitation.

A recent study shows that the use of a mobile rehabilitation team to evaluate
patients in rural areas is practical. This technique should be applied to deter-
mine effectiveness of early and complete diagnosis and treatment of hemiplegic
stroke patients in rural areas.

International research

Foreign countries which are conducting most of the research financed with
counterpart funds are India, Pakistan, Israel, Egypt, Yugoslavia, and Poland.
The projects range from the field of orthopedics and prosthetics to the area of
social problems. The handicaps range in scope from cerebral palsy to blindness
and include cancer, heart disease, and stroke.

A study at the Hadassah University Hospital in Jerusalem consists of a survey
of hemiplegics in Israel and their rehabilitation. The objectives are: to appraise
incidence and prevalence of hemiplegics in Israel; to provide data concerning
the psychological and psychosocial response to hemiplegia on behalf of the
patient himself and his surroundings, with special attention to the sociologic
and ethnologic structure of the patient’s community; to investigate special in-
volvements and resulting mental and emotional conditions; and to evaluate spe-
cial therapy and total assessment and planning of rehabilitation for the future
based on the assembled data.

Another project in Israel concerning the hemiplegic is a study by the Ministry
of Health of the causes and costs of the nonrehabilitation of patients hospital-
ized because of cerebrovascular accidents or valvular disease of the heart. This
study will inquire into the professional and administrative factors, during hos-
pitalization and after discharge, which may be responsible for the failure to
restore patients to employment or self-care, and to estimate the costs which
such failure imposes on the economy.

Cancer patients have not received great attention in the international research
program primarily because of a lack of personnel and facilities. The Tata
‘department of plastic surgery of the J. J. group of hospitals in Bombay is
studying the use and acceptability of facial and facio-maxillary prostheses for
persons with facial defects caused by congenital lesions, trauma, cancer, burns,
and other causes. ‘The investigators are fabricating prostheses and developing
new fabricating and fitting methods which may be suitable to local conditions
while they study the psychological reaction of the patient to such prosthetic
restorations. They also plan to develop a facial prosthetic center for the
purpose of training other personnel.

There is an increasing interest in many countries in research in the field
of cardiac disease. Counterpart funds are supporting a project at the cardiology
unit of Memorial Hospital in Bombay to study methods for the rehabilitation of
cardiac patients, including studies of their medical, social, psychological, and
vocational needs. The hospital will establish a cardiac work evaluation unit
to determine the psychological and socioeconomic factors affecting a patient’s
recovery and set up guides for the establishment of cardiac rehabilitation units
in other institutions in India.

In Israel, one of the projects being supported is at the Government hospital,
Donolo, in Jaffa. This project will investigate the influence of body activity
on the physical and vocational rehabilitation of coronary patients. They will
carry out both a retrospective and a prospective study. In the latter, they will
set up gradual physical training programs for 100 coronary patients, and bio-
chemical and electrophoretic methods will be used to investigate the connection

 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
  
 
 
 
  
 
 
  
 
 
 
 
  
 
 
   
 

iii i ——

216 COMBATING HEART AND OTHER MAJOR DISEASES

of cholesterol and other lipids to the incidence of myocardial infarction in
middle-aged patients.

Another project at the Heart Institute of the Tel-Hashomer Hospital in Israel
deals with a research and demonstration project for training of the handicapped,
mainly cardiac patients, in agriculture, specifically nursery vegetable growing,
bulb and flower cultivation, and beekeeping.

In Pakistan, a project at the Jinnah Central Hospital in Karachi is carrying
out an epidemiologic study of cardiovascular disease. As a consequence, a Na-
tional Heart Institute of Pakistan is being developed.

Still another project in heart disease is at the Cairo Rehabilitation Center in
Egypt, which is investigating methods for the rehabilitation of youth disabled
by heart impairment by providing comprehensive rehabilitation services to
selected heart patients.

Research needs abroad for rehabilitation are similar to those in this country.
However, since the service needs are so great in these countries, and the per-
sonnel available is limited, it is felt that most of the emphasis should be in the
field of applied research in which the provision of needed services is an essential
part. It is important that certain basic research programs be carried on in these
countries, but the greater emphasis should be on applied research and provision of
services, including rehabilitation services. As these service needs are met to a
greater degree, efforts may be made to establish centers in these countries where
basic research can be pursued.

There should be a coordinated effort in promoting research within these coun-
tries in view of the shortage of qualified personnel and funds. It is also important
that the benefits derived from research elsewhere should be applied in those
countries receiving American support. The research supported through this inter-
national program has benefited greatly those countries and this country as well.
The program has created a growing cooperation and reciprocity among these
nations. Most are incorporating the results of research into their rehabilitation
activities by enlarging their resources and facilities and by sharing their experi-
ences and knowledge with other countries. They continue the work of these
projects even after the support is terminated. The United States benefits from
the projects, since a number of them have been carried out in circumstances
unavailable in the United States, in peculiar ethnic and cultural situations and
dealing with victims of Hansen’s disease, a rarity in the United States.

A cooperative project in “Advanced Epidemiology of Cardiovascular Disease”
to be conducted by New York University, now under consideration, would use
counterpart funds in India, Pakistan, Egypt, Israel, and Poland and Yugoslavia
to study various selected population groups in an effort to determine the uni-
versality of genetic factors in coronary heart disease and stroke. The proposal
is based upon the thesis that genetic influences play a major role in the inci-
dence of arterial degenerative disease. The influence of diet, tension, work,
cigarettes, alcohol, and other environmental factors may operate through a mal-
functioning or inadequate genetic makeup. Collaborators in the foreign coun-
tries would provide U.S. investigators with samples of venous blood of persons
who had experienced myocardial infarction or cerebrovascular accident and
simular samples from the patient’s parents, siblings, uncles, aunts, and grand-
parents. Blood serum would be frozen and transported by air to New York for
lipid and enzyme studies.

Ways should be sought to increase the number of such cooperative research
internationally with the hope of obtaining knowledge which cannot come from
domestic projects but which would be of value in the rehabilitation of persons
in the United States with heart disease, cancer, or stroke.

Efforts should also be made to broaden the number of nations in which the
Vocational Rehabilitation Administration can conduct research in rehabilitation
under Public Law 480, which authorizes the use of counterpart funds.

General research needs

There is a need. growing in intensity, for means of collecting, cataloging, in-
dexing, storing, and retrieving the proliferating published and unpublished studies
in each of these disease groups. At the same time, there is a need to apply nu-
merous specific findings in a combined pattern of service to victims of these dis-
eases. And, finally, there is the need to foster the dissemination and use of the
new knowledge, techniques, and patterns of service.

There are a number of means to be considered or tried experimentally. One
might be establishment of specialized medical, psychosocial, and rehabilitation

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COMBATING HEART AND OTHER MAJOR DISEASES 217

teams with special research units attached in various parts of the country. An-
other would be to establish major rehabilitation research and training centers
for each of these disease groups, modeled after the Vocational Rehabilitation
Administration's currently successful regional research and training centers.
An alternate method is to divide these needs into smaller components to be
conducted under individual grants.

It appears that the need to provide some cohesiveness and comprehensiveness
to the research and demonstrations in each of these disease groups requires
some device, some organizational approach, which will perform these functions.
In addition, for reasons of economy, in order to buy the most research mileage
with limited resources, organization of these programs becomes vitally important.

It would also seem appropriate to take advantage of the existing research
groups already advanced in certain lines of investigation regarding rehabilita-
tion in heart disease, cancer, and stroke, and to utilize the experience of these
groups, the already developed facilities, and the established reputation which
knowledgeable professional persons throughout the country recognize.

The recommendations which follow are intended to indicate specific types of
support that could be given to recognized research groups in these disease en-
tities. No attempt is made to identify “recognized research groups” at this
point.

A series of research seminars should be conducted in several regions of the
country. Their purpose would be to encourage the dissemination of new research
information and encourage the exchange of ideas among those working in the
field of vocational rehabilitation with intensive interest in heart disease, cancer,
or stroke. These seminars should be staffed with good editing and writing per-
sonnel in order that reports will be well written and thorough.

There are strong movements afoot in several fields to improve the dissemina-
tion of knowledge by intensive efforts to catalog and index published and
unpublished studies and reports. The use of computers has. speeded up search
procedures, but the laborious job of finding, cataloging, and indexing is not much
improved. The National Library of Medicine has demonstrated the use of a
computer and tapes to produce an index and bibliographies, but the recapture and
selection and evaluation of information is not yet automated.

It is important to the field of vocational rehabilitation that a cataloging and
indexing program be initiated in the areas of heart disease, cancer, and stroke.
It is recommended that three closely related research projects be developed to
perform this function and establish its continuation as a part of a larger overall
plan for cataloging and indexing all vocational rehabilitation studies and reports.

It is expected that each of the five research and training centers would receive
$200,000 a year for the purpose of expanding research activities in these disease
groups.

Also, in the first year, $500,000 would be allocated to a collaborative epidemio-
logical study in which one center would act as the data collection and analysis
eenter. This amount would gradually increase to the rate of $1 million by 1970.

Recent studies have indicated the extreme importance of the psychosocial
aspects of the disabled person’s life in the success or failure of vocational rehabil-
itation. In the next 5 years much emphasis will be placed on studies of (1)
pre- and post-morbid personality; (2) the effects of counseling and psycho-
therapy at crucial points in the rehabilitation; (3) the influence of the family
on success of rehabilitation; and (4) family counseling. In heart disease, can-
cer, and stroke studies there is need to push research further along these lines
and to disseminate the findings through demonstrations.

Another area that needs development is the use of real work situations in
industry to increase job readiness and placement prospects of the disabled
person. Projects should be established to work with stroke, heart disease, and
cancer patients in close cooperation with specific industries found suitable
and willing to cooperate. Graduated work levels need to be defined in relation
to the specific disability and procedures experimentally tested to determine the
most effective use of the work situation. Five experimental projects should be
launched as soon as good planning procedures allow. When experience has
been gained in this area, selected demonstrations should be established in 15
to 20 different settings in order to promote the widespread use of these proce-
dures in vocational rehabilitation.

The subcommittee heard testimony as to the need for continuing research in
methodology, instrumentation, development of self-helf devices and the evalua-
tion of rehabilitation techniques in the eare of patients with heart disease,
cancer, or stroke. It is recommended, therefore, that the National Heart In.

   
 
 
 
  
 
 
 
 
 
  
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
   
   
 
 
 
 
  
   
 
 
 
 
  
 
  
 
  
 
  
 
 
 
 
 
 
 
 
 
 
   
  
   
  
  
 
 
 
 
 
 
 
  
 
 
  
 
 
 
  
 
  
 
  
  
 
 
  
  
  
 
 
 
  
  
 
  
 

218 COMBATING HEART AND OTHER MAJOR DISEASES

stitute, National Institute of Neurological Diseases and Blindness, and Division
of Chronic Diseases of the Public Health Service increase their support of re-
search programs in the rehabilitation of heart disease, cancer, and stroke
patients.

In addition, it is recommended that a sum of $10 million be appropriated for
the Vocational Rehabilitation Administration for the first year, with annual
increases, until $15 million is reached in the fifth year for research in the re-
habilitation of persons with heart disease, cancer, and stroke; and that this
amount be in addition to the regular budget for research and demonstration
projects. These funds would be utilized by the Vocational Rehabilitation
Administration for support of research in rehabilitation, for the development of
possible collaborative research among the existing centers, and for community
research and demonstration programs.

Research and training centers

Under authority from the Congress, the Vocational Rehabilitation Adminis-
tration provides grants to a limited number of universities to support re-
habilitation research and training centers. Such centers must be distinct
organizational and physical entities providing a continuing framework for
clinical research and training in rehabilitation, with the medical and other
services considered essential in carrying out a comprehensive program of
patient care and rehabilitation, including the provision of specific beds assigned
to rehabilitation.

The research conducted by these centers may encompass any aspect of the
rehabiitation process, from onset to retraining and placement of the disabled.
It may be broadly directed to a wide range of medical or other fields of re-
habilitation, or specifically concerned with rehabilitation as it applies to
specific diseases or a group of related diseases.

The training program of these centers may provide training of all types, long
term as well as short term, professional, technical, and for any or all cate-
gories of students, graduate or undergraduate, working in any of the medical
or medically allied and other professions engaged in rehabilitation. Programs
also provide training in such areas as the principles of rehabilitation, special
problems of rehabilitation, as related to specific disabilities or groups of dis-
abilities, and the interrelationship of medical and other disciplines in the
practice of rehabilitation. In all instances, trainiag must be based upon a
defined, organized program of instruction designed for undergraduate medical
students, interns, residents, and undergraduates and graduates in the allied
professions working in the field of rehabilitation.

In June 1968, there were four special research and training centers in opera-
tion, all of a type designated as medical centers, at New York University,
University of Minnesota, University of Washington, and Baylor University in
Texas. An additional medical center, Western Reserve University-Highland
View Hospital, Ohio, opened in 1964 and one prospective center is to be given a
developmental grant. The amount of $2,600,000 appropriated for 1964 will
be used to continue the present five regular medical centers, and providé funds
for developing the prospective center. The 1965 cost of continuing these six
centers is estimated to be $3 million. The $3,385,000 requested for 1965 will .
permit financing of two more centers specializing in mental retardation, at an
initial cost of $385,000 in 1965. The programs in the centers and the need for
them are discussed below.

The program of the rehabilitation research and training centers is enter-
ing its third year. The New York University Medical Center and the Univer-
sity of Minnesota Center have been in operation since November of 1961.
They are doing research on many basic problems intimately related to the cor-
rection of disability, the preparation of the individual for a place in his com-
munity, for self-maintenance and vocational attainment in keeping with
potential ability. Hach of these programs has been successful in attracting
skilled researchers and effective training personnel on a full-time basis. Med- 1
ical and nonmedical students at the undergraduate and graduate levels at the
centers have been recipients of extended intensive training in rehabilitation
and have had increased opportunity to participate in research on certain disease
processes and the rehabilitation of persons handicapped by them, on impair- :
ment of physiological furiction resulting from disabilities, and on the clinical
management of patients with long-term illness and impairment. ‘

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COMBATING HEART AND OTHER MAJOR DISEASES 219

There bas been a gradual growth of research and training activities in these
centers since their inception. The training activities have been strengthened
through the introduction of new courses such as “Speech Rehabilitation of the
Brain Injured” ; the development of teaching aids and manuals, e.g., in the field
of orthotics; expansion of electro-physiology research; biochemical studies in
cardiovascular disease; and use of new approaches to pulmonary studies.
Such expanded programs will lead ultimately to solutions of some of the more
trying problems of the seriously disabled, chronically ill patient. Furthermore,
up to 40 percent of the increased funds will be utilized for bringing in addi-
tional patients for research who will at the same time be the recipients of
the most modern comprehensive care.

The two more recently established projects at the University of Washington
and Baylor College of Medicine are moving along steadily and with evidence
of significant progress though they have been in operation but a year and a half.
The University of Washington has added to its staff in rehabilitation medicine
an orthopedic surgeon, a psychiatrist, and rheumatologist. It has added a psy-
chometrist to assist in prevocational evaluattive procedures ; a mechanical and
an electrical engineer each of whom serve not only as teachers of the engineer-
ing aspects of rehabilitation medicine but also carry medical orientation to stu-
dent engineers who are seeking a career in this new and relatively pioneer area
of service. Also, there has been the development of a new brace and phos-
thetic shop to serve the training, research, and patient care needs of the
program.

Included in the new research are studies on: hemiplegia and its effects on
learning, being carried out to determine in particular what happens when the
right or left side of the brain has been damaged; the rehabilitation potential
of the patient undergoing treatment and convalescence in the home; evalua-
tive investigations on upper extremity bracing; and reconstructive surgery in
quadriplegic hands—to cite but a few of the more recent developed studies.

At Baylor Medical Center, research is moving at a steadily increasing pace.
A research committee, consisting of 11 full-time faculty members with consul-
tants, reviews, evaluates, and approves research projects carried out under the
existing center grant. It provides periodic reevaluation of research progress,
consultation in preparation and execution of research, and a forum for exchange
of ideas and techniques among clinical programs, physiology, biochemistry, and
pharmacology.

A major recent effort has been undertaken to define research problems in
rehabilitation medicine. This effort is based on a detailed analysis of the patient
population (Texas Institute of Rehabilitation and Research), their character-
istics by age, sex, and color; diagnostic groups; and specific patient problems
encountered and presently coded. These facts were then analyzed to form the
pasis for justifying research priorities. Studies in the human capacity for
physical work, cardiovascular responses to exercise, studies on the urinary
bladder in spinal cord injury, electromyographic differential diagnostic tests
in muscle fiber lesions, and many others are currently moving ahead.

Similarly, the training program has provided a teaching staff and an exemplary
care program to develop medical student elective courses; student nurse rota-
tion (eight senior students every 8 weeks) in comprehensive nursing and post-
graduate courses in collaboration with the Texas Woman’s University ; medical
social service rotation with the University of Texas at Austin; and the extensive
enlarging of clinical psychology training programs with the University of
Houston.

As a result of its expanded activities in research and training resulting from
this program, New York University recently decided to build a new nine-story
research building adjacent to its institute of physical medicine and rehabilita-
tion. It has added more than 20 full-time research workers at the M.D. or P.H.
D. level as a result of the grant and a number of these experienced investiga-
tors are working in the fields of heart disease and stroke. Emphasis is given to
the problems of heart disease, cancer, and stroke not only in undergraduate
medical training but also in postgraduate residency training which serves 55
to 60 physicians each year.

The Western Reserve University-Highland View Hospital project, recently
activated, enjoys an excellent research and training environment and offers
great promise for the future. Excellent treatment facilities are available.

The prospective center in the South Atlantic region is at a stage of development

that will not warrant funding on a full scale. Rather, it is intended to select

  
 
   
 
  
 
 
  
  
  
 
 
 
 
 
 
 
 
  
   
 
 
 
 
  
 
 
 
 
  
  
 
 
 
  
  
   
 
 
 
 
  
 
 
 
 
 
   
  
 
  
    
  
  
 
 
 
   
  
 
 
 
 
  
   
  
 
 
    
 

220 COMBATING HEART AND OTHER MAJOR DISEASES

an institution which justifies the judgment that a year or two of support will
aid it in developing a program of research, training, and patient care com-
parable to centers now operating at the high level described above. This type
of grant is looked upon as developmental in nature but is to be made only
to universities with medical schools of the highest caliber in the region to
be served, with a record of growth, academic standards, breadth of program,
and commitment to research and training that gives assurance that the award-
ing of a developmental grant will result in attainment of complete status as
a successful rehabilitation research and training center in 1 to 8 years.

A few of the research projects in the cardiovascular field being conducted at
these centers are as follows:

1. In the Rehabilitation Research and Training Center at Baylor University
several projects are directed at measuring cardiac response to work tests and
the circulatory fitness of atherosclerotic patients during the performance of
physical activities.

2. In the Rehabilitation Research and Training Center at the University
of Minnesota studies are continuing on (1) evaluation of cardiac output,
cardiac work, and metabolic rate during hydrotherapy and exercise, (2)
cardiac output determinations by the measurement of the electrical impedance
of the thorax, and (3) on peripheral circulation.

3. The New York University Research and Rehabilitation Center is conducting
a group of studies of congestive heart failure and cardiac arrhythmias based
on the techniques of producing congestive heart failure in guinea pigs and
surgical procedures on dogs for the atrial fibrillation study. It is hoped
that this approach to the study of congestive heart failure will yield basic
understanding along the lines of enzyme deficiencies. As a consequence, per-
haps a better rationale of treatment may result which may improve the
longevity of patients who are experiencing congestive heart failure. It is
hoped that clearer and basic understanding of atrial arrhythmias, and perhaps
ventricular arrhythmias will then lead to a more fundamental appreach to
treatment. In addition, epidemiological studies on coronary heart disease
will be undertaken in two areas: the human or clinical area, and the basic
science or biochemical area. Also studies on heart transplant are being
carried out.

Further research regarding the relation between myocardial energy require-
ments and common activities should be supported. It is suggested that regional
centers—

(a) Continue the studies of the requirements for cardiac work in rela-
tion to muscular work throughout the range of vocational activities;

(b) Extend the studies of cardiac work to situations requiring ambula-
tion;

(ce) Extend the studies of cardiac work to situations producing emotional
stress;

(@) Extend the studies of cardiac work to vocational activities carried
on under adverse environmental conditions ; and

(e) Support the development of methods to measure cardiac ‘output and
cardiac work more precisely and over shorter intervals of time so that
phasic changes of cardiac performance can be studied.

Such studies can be pursued in a regional research and training center with
previous work in the field. Regional centers can be encouraged to step up
programs which have been started in these research areas.

In order to increase the research and training activities of these centers in
heart disease, cancer, and stroke, it is recommended that—

(a) The number of such centers be increased to 10 during the next 5
years; and

(6) The funding of such centers be increased per center per year as the
need and program justifies.

TRAINING IN REHABILITATION

A shortage of trained personnel has remained the greatest single deterrent
to the more rapid increase in rehabilitation service since the inception of
modern rehabilitation services for civilians after World War II. In its report
of January 25, 1952, to the Chairman, Manpower Policy Committee, Office of
Defense Mobilization, the Task Force on the Handicapped stated: “The field
of rehabilitation, as a growing force in our national life, faces certain serious
 

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COMBATING HEART AND OTHER MAJOR DISEASES 221

personnel difficulties which place limitations on the present ability of our
country to bring more disabled persons into activity and productivity.”

In a report issued February 10, 1956, the Health Resources Advisory Com-
mittee, Office of Defense Mobilization stated: “A nationwide shortage of
trained workers is preventing the benefits of modern rehabilitation reaching
vast numbers of the Nation’s disabled.” It further stated: “Although the
number of such personnel has increased substantially in recent years, the
number today is still not sufficient to meet present national needs or expected
future needs.” Despite the substantial national increase in rehabilitation
personnel as a result of ‘the training program of the Vocational Rehabilitation
Administration which was started in 1955, the statement of the Health Re-
sources Advisory Committee, Office of Defense Mobilization, is as valid today
as it was when made in February 1956.

A training program to increase the number of qualified persons for the
disciplines allied with rehabilitation also was initiated by the Vocational
Rehabilitation Administration in 1955. The pattern of rehabilitation services
was becoming infinitely more complex, and there were critical personnel
shortages existing or expected for the expanded program in prospect.

The early training program began with an appropriation of $900,000, for
the 1955 support of 77 teaching programs in various subjects in several colleges
and universities, 201 traineeships for students selected by schools to reeeive
stipends, and 16 short-term courses for various objectives.

In 1963, training grants totaled slightly more than $13 million. This amount
was used to support 489 long-term grants for 2,812 traineeships and for scores
of short-term courses, Many of the grants were for rehabilitation medicine.
In fiscal year 1965, there were 68 medical schools conducting courses with the
aid of VRA funds, reaching 250 undergraduates, 250 residents in training,
and 8 academic careerists.

Another field of great emphasis is rehabilitation counseling for State agencies
and rehabilitation facilities. There are close to 40 educational institutions
receiving support for curriculums in this subject, reaching somewhere around
900 trainees. In 1955 there were only 53 such traineeships.

Almost every field touching upon rehabilitation is helped by the training
program. In addition to the fields named above, there is training support
for physical therapy, occupational therapy, speech and hearing, social work,
psychology, prosthetics and orthotics, and nursing.

There are also short-term courses in an increasing number. In 1963-64, 148
such courses were supported to refresh and reeducate rehabilitation personnel,

to keep them abreast of current developments and techniques. These courses
served 6,086 trainees.

Long-term training

Physicians.—Physicians required for diagnosis, treatment, and rehabilitation
of individuals with cancer or cardiovascular disease may belong to almost any
branch of medicine. Of greatest relevance, however, are physicians in internal
medicine, surgery, cardiology, and physical medicine and rehabilitation who
function in rehabilitation centers, hospital rehabilitation units, cardiac work
classification units, or other facilities primarily concerned with restorative
services for patients with heart disease, stroke, or cancer. While no quantita-
tive estimates are available for the number needed to enter the field each
year, it is estimated that special, intensive refresher courses in rehabilitation
of patients with cancer or cardiovascular diseases should reach about 500
physicians each year. Of this number, about one-third should be those in
residency training so that they may practice their specialty with up-to-day
knowledge of contemporary rehabilitation methods and techniques.

Of major importance in rehabilitating stroke and cancer patients are the
physicians who specialize in physical medicine and rehabilitation. There are
an estimated 550 physiatrists in the United States. This figure includes 418
physicians certified by the American Board of Physical Medicine and Rehabili-
tation, according to the 1963 directory of medical Specialists. An additional

tation centers; the total estimated need may be as much as 3,000. As in any
field of medicine, the supply falls short of meeting the needs.

About 385 residents have been approved by the American Board of Physical
Medicine and Rehabilitation. The percentage of residencies that are unfilled
is much higher than in the older and better established medical specialities—
436696515,

  
 
 
 
 
   
  
  
 
   
  
 
 
 
 
 
 
   
 
 
 
 
 
 
 
  
 
 
 
  
 
  
  
 
 
 
  
  
 
 
  
  
  
 
  
  
 
  
   
   
 
 
   
   
  
  
  
 
 
  
 
 
  
  
 
 
 
 
  
  
 
  
 
 
   
 
   
   
 
 
 
 
  
  
  
 
   
  
  
 
 
 
 
  
 
  
 

222 COMBATING HEART AND OTHER MAJOR DISEASES

about 50 percent. About 90 percent of the residents in training in this specialty
are receiving VRA traineeships. On June 30, 1964, 149 residents were enrolled
for full-time training in physical medicine and rehabilitation. About 130
annually complete the board requirements for admission to examination and
about 50 take the examination each year.

An experimental teaching program is also in effect in one university hospital
which provides for the rotation of the intern staff through the rehabilitation
service. This experiment will be closely watched for possible establishment of
similar teaching programs in other centers.

Two pilot programs, initiated in 1962 for the purpose of providing fully
trained residents in physical medicine and rehabilitaton wth advanced prepara-
tion for an academic career, were continued in 1963. In 1964, 20 academic career
trainees were expected.

Other than the 149 physicians enrolled in postgraduate training in rehabilita-
tion medicine under VRA fellowships, there are enrolled in such training 15
to 20 physicians who are permanent residents of the United States and about
40 foreign physicians who will leave the United States at the conclusion of their
training but who make a contribution to the clinical care of patients. Although
the Veterans’ Administration provides residency training in physical medicine
and rehabilitation, the majority of their residents are career men who join the
Veterans’ Administration.

Nurses.—-Grants have been made to 10 of the 33 graduate schools of nursing
with the objective of producing instructors of rehabilitation nursing. In the
United States, there are 636 approved schools of nursing. Of this number, 521
are hospital schools, 35 are junior college associate degree programs, and 80
are university programs offering a baccalaureate degree. Faculty who are
qualified to incorporate teaching of rehabilitation are needed in nearly all of
these schools.

Currently, the national supply of rehabilitation nurses with training under
the Vocational Rehabilitation Adminstration or equvalent formal training or
experience ig around 500. Approximately 6,000 others have limited preparation
through short-term training.

Currently there is a national need for at least 1,400 nurses with graduate
training in rehabilitation, Of these, 176 are needed to provide at least 1
faculty member for each baccalaureate degree program and 48 to provide 1
faculty member for each graduate school of nursing. In public health, 50 are
needed to provide 1 consultant for each State health department division of
nursing and 860 to serve as consultants in public health and home nursing care
programs. Another 250 are needed as rehabilitation specialists in rehabilitation
eenters and hospitals with comprehensive rehabilitation services.

Psychologists —Psychological services are essential in the rehabilitation of
persons with heart disease, cancer, or stroke.

The National Education Association has estimated a demand for 7,500 new
college and university faculty members in the field of psychology in the 1960’s.
In addition, a need during the current decade for 8,000 to 10,000 psychologists in
nonacademic positions has been predicted. Expanded programs of research and
services in the areas of mental iliness and mental retardation further underscore
the need for many more psychologists.

Since it take a minimum of 4 postbaccalaureate years to train psychologists
in rehabilitation, and since rehabilitation centers, private and public, are utilizing
psychologists to a greater degree each year, the need for psychologists in reha-
bilitation has increased significantly. Many positions remain unfilled because
of the shortage of trained persons.

At present, 80 students who are recipients of VRA traineeships are enrolied
in doctoral training programs that emphasize the psychological rehabilitation of
the disabled.. Though there is an annual recurring need for at least 400 doctoral
graduates, only about 40 students complete their doctoral training each year
in rehabilitation psychology.

Occupational therapists—Since 1955, about 1,400 students have received
financial assistance in completing training in occupational therapy. The number
of traineeships has increased from 52 in 1955 to 274 in 1963 and an estimated
350 in 1964.

A most significant development has been the marked interest on the part of
experienced occupational therapists in graduate study to prepare for teaching or
research positions. Since 1960, traineeships have been awarded to 65 individuals
for advanced study, and graduates are now filling key posts in training and
research programs.
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COMBATING HEART AND OTHER MAJOR DISEASES 223

About half of the 31 schools of occupational therapy have received teaching
grants to help them expand their faculty, increase the rehabilitation content in
the curriculum, and strengthen the integration of theoretica] and clinical course
work.

Our national supply of qualitied occupational therapists is approximately 7,500
but unfortunately less than half, $200 are professionally active. National needs
are estimated at 12,000, with 4,000 new graduates needed annually. Currently
2,450 students are enrolled in basic professional education and 59 in graduate
education. The annual number of graduates in occupational therapy programs
is around 400.

Physical therapists—With the withdrawal in 1962 of National Foundation
support in the field of physical therapy, the VRA has been the major source of
support for teaching grants and traineeships for this critical field of rehabilita-
tion. In 1964, traineeship grants were made to 41 of the 42 approved schools of
physical therapy: In addition, teaching grants were given 32 schools to ‘assist
them te employ additional faculty and to strengthen and coordinate their clinical
programs. In 1962, 134 students were recipients of VRA undergraduate trainee-
ships and the next year 305 students received assistance. This number in 1964 is
350 students, which represents approximately one-third of the enrollment of
schools of physical therapy.

Since 1958, VRA graduate traineeships have prepared 78 physical therapists
for teaching, research, and administration positions in universities, hospitals,
and clinical settings.

Currently the national supply of qualified physical therapists is around 9,000.
There are known vacancies of more than 1,000 but in many instances new posi-
tions are not created despite known need because experience shows such positions
will not be filled. A nationwide manpower survey conducted by the American
Phystéal Therapy Association may provide firm data but experience would indi
cate there is a national need for 14,000 physical therapists. Fortunately, there
has been a marked increase in enrollments in the past few years. It is estimated
that 1,000 students, including declared inajors, primarily at the junior and senior
levels, were enrolled during the 1968-64 academic year and the actual enroll-
ments may be much larger.

Recreation personnel.Social and personality factors exert a powerful infiu-
ence in the success or failure of an individual’s rehabilitation program. Severe
disability, such as is encountered so frequently among persons who have suffered
heart disease, cancer, or stroke, often produces a “withdrawal” pattern in which
the patient’s unwillingness to present himself and his disability to others in a
normal social relationship presents a major obstaele to successful rehabilitation.

In coping with this problem, therapeutic recreation plays an important and
sometimes decisive role. Functioning as part of the total rehabilitation effort,
recreation offers an attractive and acceptable way for the patient to begin
reestablishing social contacts and healthy relationships with other people, and
in the process to build the confidence in himself which is so essential to complete
recovery and successful living. Often these recreational outlets are the bevin-
ning of new attitudes, improved personal appearance, and other factors which
are prerequisites to getting and keeping a job.

At present the Vocational Rehabilitation Administration provides grant sup-
port to seven universities which offer graduate programs in recreation for the
fll and handicapped, including clinical affiliations with hospitals, However, the
need for well-trained recreation personnel to serve the ill and handicapped far
outstrips the present supply coming from this limited number of training
resources.

The present limitation here is almost solely a matter of funds. The Voca-
tional Rehabilitation Administration should he provided the additional Federa}

funds necessary to furnish teaching and traineeship grant support to the addi-
tional schools which now have acceptable graduate teaching programs in recrea-
tion for the ill and handicapped. This will not only show prompt results in
greater number of students being trained but also will encourage several other
universities which presently are considering the strengthening of their curricula
to offer a full graduate program in this important field.

Counselors.—Since 1954, grants to support the training of rehabilitation coun-
Selors for eraployment in State vocational rehabilitation agencies and other com-

munity rehabilitation programs have been given 246 different colleges and
universities.

  
 
 
 
   
   
   
 
 
 
 
 
 
 
 
  
 
 
 
 
  
   
  
   
  
    
  
 
 
  
  
    
 
 
   
   
 
 
  
   
 
  
  
  
   
 
 
  
  
   
  
 
 
   
 
   
    
    
 
   
 
 
 
 
  
 
 
   
   
  
 
 
 
  
  
  
 
 

Di SS

224 COMBATING HEART AND OTHER MAJOR DISEASES

In fiscal year 1963, 35 institutions were conducting rehabilitation counsel or
training programs. In addition, one other university was engaged, with the help
of a VRA grant, in recruiting faculty and students. Enrollment statistics for
1963 indicated that the 35 programs had 651 full-time students. An additional
414 students in related fields were enrolled part time in rehabilitation counseling
courses.

Of the 651 students enrolled for full-time study in 1963, 545 (83 percent)
received a VRA traineeship for all or part of the year. There has been a steady
increase in the number attracted to the field, along with some decrease in the
proportion of full-time students receiving a VRA traineeship, a significant indi-
eation of the acceptance of a relatively new professional concentration.

Periodic followup studies of the employment status of graduates have indicated
that about two-thirds are working in a rehabilitation program and that an addi-
tional 10 percent are continuing graduate study directed toward a doctoral
degree.

Of about 5,000 active rehabilitation counselors in the Nation 3,500 are employed
in the public programs and 1,500 in others. To fill existing vacancies and newly
established positions, 1,200 new rehabilitation counselors are needed annually.
Currently there are from 900 to 950 enrolled in graduate training programs and
around 300 graduated annually.

Social workers.—In 1963, teaching grants were given 39 of the 56 graduate
schools of social work, primarily to enable them to employ field instructors for
students in supervised field work units in rehabilitation settings. Grants were
awarded also for traineeships for 255 students of social work in 1968,

Between 1955 and 1963, 1,236 traineeships were awarded to students in schools
of social work for part or all of their 2-vear course. A followup study of the
employment status of 589 VRA trainees on April 1, 1962, indicated that of 451
whose status was reported, 86 percent were in the labor market. Of those em-
ployed, 71 percent were working in agencies providing rehabilitation services to
disabled people. The major achievement, however, has been the changes in
curriculum content relating to rehabilitation, so that all graduates of schools of
social work bring to their future jobs a better understanding of the potentialities
of disabled people and methods of rehabilitating them.

Currently there are around 105,500 persons in the United States employed in
what are usually described as social work positions, but only about 20 percent
hold master’s degrees from a school of social work. ‘To fill existing vacancies,
around 15,000 more social workers are needed. Of these 15,000, about 2.250
are needed for the health field. Currently some 6,600 students are enrolled in
56 graduate schools of social work and 2,700 graduate annually.

Speech therapists—Despite progress in the effort to increase the numbers of
personnel qualified to diagnose and treat individuals with communicative dis-
orders, the shortages are still acute. Since the beginning of support of training
in ‘these fields in 1958, the number of universities with teaching grants has grown
from 7 to 60 in 1964 and the number of traineeships from 28 to 475 in 1964.

As a result of teaching grants, universities have been able to strengthen their
graduate courses and clinical practice so that graduates are better prepared to
treat adults with speech and hearing handicaps. In 1962 a study of 228 students
who had completed training as speech and hearing specialists with the help of
VRA traineeships showed that about 85 percent were making a direct contribu-
tion in these fields.

In 1964 our national supply of persous engaged in speech pathology and audi-
ology was around 14,000. Our national need is 20,000, with only 1,500 new per-
sons entering the field annually. Currently 1,100 students are enrolled in train-
jing and 750 graduate annually.

Within the field of speech pathology there are two highly specialized areas in
the field of heart. disease, cancer, and stroke—post laryngectomy speech and
aphasia.

There is a relatively small number qualified to work with laryngectomees.
At the present time it is estimated that fewer than 400 trained persons are pro-
viding services in postlaryngectomy or esophageal speech to laryngectomees.
More are being trained in short-term programs.

A conservative estimate of the number of trained. persons providing language
and speech training to the aphasic on a full-time basis would be 250. In addi-
tion, there are a number of speech clinicians, some with limited training, pro-
viding minimal services. Some of these clinicians may provide services to one
or two aphasic patients each year.

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COMBATING HEART AND OTHER MAJOR DISEASES D5

It is important that every speech clinician receive specialized training in work
ing with both the laryngectomee and the aphasiec, Competence in this work is
important to every clinician in a large rehabilitation center, in small community
hospitals, private practice, and other environments.

Every rehabilitation environment should have at least one speech clinician
who possesses special competence in working wtih the aphasic. This would
mean that some 400 to 500 speech clinicians with special competence in working
with the aphasic should complete training each year. In addition, training
should be provided to the clinician presently in practice through a series of
intensive, short-term courses,

Prosthetists and orthotists.—Since 1953, 83 major medical centers have con-
ducted more than 500 short-term courses with a total enrollment of about 8,000
trainees. In 1963 more than 1,400 rehabilitation personnel attended 87 courses
which were a part of the extensive courses in upper and lower extremity pros-
thetics and orthotics, management of the juvenile amputee, and orientation.

VRA support was first extended in 1957 when responsibility for support of train-
ing programs in this field was transferred from the Veterans’ Administration.
VRA teaching grants enabled the three universities to employ a year-round teach-
ing staff.

To facilitate coordination and communication, the University Council on
Orthotic-Prosthetice Education ( UCOPE) was established in 1962. Composed of
the medical and educational directors of the major programs, the Council has
been able to achieve a more uniform approach in curriculum offerings, teaching
materials and methods, and evaluation procedures.

Supported jointly by the Vocational Rehabilitation Administration and the
Veterans’ Administration, the National Academy of Sciences’ Committee on Pros-
thetics Education and Information has continued to develop and expand an
extensive informational program for these fields, has assisted in the development
of new amputee clinies, and has Prepared brochures, films, and slides for use in
medical training programs and in schools of physical and occupational therapy.

thetics-orthotics was developed at New York University in 1961, Five students
were enrolled in this curriculum in 1964, In June 1965, the first class of
students will receive academic degrees for professional training in prosthetics.
orthoties,

Training programs at three universities have provided short-term courses in
prosthetics and orthotics to prosthetists, orthotists, physicians, surgeons occu-
pational therapists, physical therapists, rehabilitation counselors, and related
personnel. In addition, specialized training programs have been developed for
prosthetists and orthotist-trainees, at the undergraduate and technicians level
so that they may function more effectively as recognized members of amputee
clinic teams in rehabilitation centers, medical schools, and hospitals throughout
the country.

In its initial stage, this program was limited to prosthetics which, of course,
may be employed for amputations due to cancer. There has been increasing
emphasis recently on orthotics with implications for services to stroke victims,

Currently, there is a national supply of 1,100 certified orthotists and pros-
thetists, and an estimated need for an additional 40 certified orthotists and 20
certified prosthetists each year. In addition, approximately 180 new prosthetic-
orthotic technicians are needed annually to back up the certified personnel in
these fields. By selecting, fitting, and teaching the use of artificial limbs, braces,
and other orthopedic appliances these services may contribute materially to the
function and comfort of cancer and stroke patients.

Short-term training

An indispensable part of the training grants program has been support of
workshops, seminars, institutes, and other training courses of brief duration.
These are conducted to keep professional personnel in various fields abreast of
new developments.

The VRA utilizes its nine advisory panels on training to identify major needs
and priorities for continuing professional education as well as the ad hoc advisory
committees and regional committees on inservice training of State vocational
rehabilitation agency personnel,

A VRA Committee on Short-Term Training, composed of three Assistant Com-
missioners and the Chief of the Division of Training, reviews the annual plans
for short-term training submitted by the regional offices and various units in the
Washington office and determines the distribution of available funds for the year.

   
 
 
  
  
 
   
  
 
 
    
  
  
  
  
 
  
 
 
 
  
  
  
    
   
   
 
 
  
  
  
 
   
 
 
  
  
   
   
 
 
 
 
 
 
 
  
  
  
  
 
  
  
 
 
 
   
 
 
  
  
   
 
 
 
 
 
   
   
 
  
  
 
 
 
  
   
  
  
 
 
  
  
 
  
 

226 COMBATING HEART AND OTHER MAJOR DISEASES

In 1965, trainees in short-term courses number 873; in 1963, about 6,000 at-
tended courses with VRA financial assistance.

VRA-supported short-term training courses in fiscal year 1962 were distributed
as follows:

 

Number of trainees

 

Number
Subject of course of State Non-
courses vocational vocational
rehabili- rehabili-
tion tation

 

—
oe
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Executive development____---------~--------------------~----
Supervision__...---..----
Orientation of new counselors__-..-_-------

Medical aspects of vocational rehabilitation __
Prosthetics and orthotics_..-.--------------

Mental retardation. .-.__
Mental illness--..-------
Rehabilitation of the blind.
Rehabilitation of the deaf.
Rehabilitation facilities. _
Prevocational evaluation _
Curriculum improvement. --
Other courses_.-__-..----------------- +220 22 een een nen eee

 
 
 
  
 
 
  
 

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In 1968, there was an important endeavor to raise the standards of professional
competence of speech pathologists and audiologists in providirg diagnostic and
treatment services to adults with communicative disorders. WRA-supported 18
short-term courses for a total of 570 trainees. These courses focused on (a)
teaching of esophageal speech to laryngectomized patients, (0) diagnosis and
treatment of stutterers, (c) auditory rehabilitation, (@) evaluation and re-
habilitation of the aphasic patient, (e) neurological aspects of diagnosis of
speech and hearing disorders, (f) oral linguistie deficiencies in handicapped
adults, and (g) speech therapy of cerebral palsied persons.

Courses in prosthetics and orthotics supported from 1963 funds are noted above.
More than half of those enrolled in short-term courses were on VRA traineeships.
Continued emphasis is placed on provision of training in orthopedics or physical
medicine and rehabilitiation to physicians still in residence or serving in prosthetic
teams in the community.

Short-term training courses on improvement of methods of training rehabilita-
tion personnel and on curriculum development have been supported for the field
of medicine, physical therapy, rehabilitation counselling, psychology, and social
work in 1963. /

Employment placement.—Specialized courses on placement of handicapped per-
sons in employment and in the development of employment opportunities for
disabied persons are planned for 1965. It is expected that about 10 courses will
be held for about 250 counselors and other personnel in State agencies.

Improvement of training—Seminars and other short-term training courses
will be held in 1965 to assure continued improvement in university and other
rehabilitation training programs. About 3 such courses, attended by about 225
VRA trainees, are planned.

Rehabilitation facilities.—Short-term training courses for directors of sheltered
workshops and floor supervisors will be increased in 1965; about 5 training
courses will be conducted for 75 VRA trainees.

Prosthetics-orthotics—Pilot courses were conducted in 1962, 1963, and 1964
in spinal orthotics, in lower extremity orthotics. and in prosthetic techniques
related to the total contact socket. These lead naturally to programing of
additional courses in these relatively new subjects. Not only will these advanced
eourses bring new members of clinic teams to the training centers, but also
former trainees who have had the basic courses in prosthetics of the lower and
upper extremities will be expected to return for training that incorporates the
latest developments.

The American Board of Certification in Prosthetics and Orthotics requires
attendance at these courses for certification and the Veterans’ Administration
requires such attendance in its contracts with prosthetic-orthotic firms.

ae
 

8,000 at-
tributed

 

iinees

 

Non-
cational
habili-
ation

 

 

sional
> and
ed 18
1 (a)
; and
1 re
is of
pped

ove,
hips.
sical
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will

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225

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64.
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of
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COMBATING HEART AND OTHER MAJOR DISEASES 227

About 1,100 individuals will attend these courses in 1965, of whom 350 will
be VRA trainees,

Continuing education

One of the greatest deterrents to more effective rehabilitation services is the
failure of practicing physicians to utilize rehabilitation concepts and methods in
the early care of patients with heart disease, cancer, and stroke and their failure
to make early referral of severe cases to specialized institutions with an effective
staff. One study showed that many physicians were not familiar with services
available from the State-Federal vocational rehabilitation program; 92 percent
did not know the source of funds used to pay for such services; 80 percent did
not know a State vocational rehabilitation agency representative ; and 80 percent
had never referred a case to the State vocational rehabilitation agency,

It is encouraging, however, that there is increasing awareness of the value of
rehabilitation among physicians and that the percentage of clients of State
rehabilitation agencies referred by physicians and hospitals is gaining. In 1963,
the two largest sources of referral to State rehabilitation agencies were private
physicians (16 percent) and hospitals and sanatoriums (18 percent).

In February 1958, the American Medical Association reported that 25 of 53
State medical societies had committees on rehabilitation. In January 1964, the
number had risen to 44 of 54 State medical societies.

Despite the efforts of the American Medical Association, American Heart
Association, American Cancer Society, the heart disease control program of the
Public Health Service, the Vocational Rehabilitation Administration, and other
groups, the concentrated efforts on continuing education have not been as pro-
ductive as desirable.

In relationship to need, there is also a paucity of audiovisual and other teaching
materials on rehabilitation for use in the continuing education or enlightenment
not only of physicians but of paramedical personnel and others. The valne of
such material has been shown by the excellent reception of the publication,
“Strike Back at Stroke,” films produced by the Division of Chronic Diseases,
Bureau of State Services, Public Health Service, and the series of audiotapes
on rehabilitation produced by New York University with the aid of a grant from
the Vocational Rehabilitation Administration.

It is apparent from the statistics on national needs for personnel in some of
the professions discussed earlier that there is no possibility of our national supply
meeting national needs in the foreseeable future. Professional aids have been
successfully utilized in some of these professions. Nursing, for example, hag
made use of practical nurses, attendants, ward clerks, and other ancillary nursing
service personnel for many years. The American Occupational Therapy Associa-
tion with the aid of grants from the Vocational Rehabilitation Administration
has launched programs for the training of occupational therapy assistants par-
ticularly in the care of the chronically ill and the aged. These programs have
been successful and are being expanded for training of such assistants for
neuropsychiatric services. Some use is made of case aids in social work and
rehabilitation counseling.

This Subcommitee believes that a national conference on the development
of professional aids in rehabilitation would be of value.

The function of such a conference would be—

(a) To gather selective representatives of the therapeutic professions,

(6) To exchange information about present methods of care.

(c) To discuss ways and means of implementing present recruitment
activities.

(d) To review alternative solutions for meeting personnel needs.

(e) To discuss the selection of screening of aids.

(f) To develop safe care principles to avoid poor practice.

(7g) To discuss methods of training.

(h) To review problems of legality and certification.

This Subcommittee also recommends that funds be made available to the
Vocational Rehabilitation Administration for the following activities:

(@) Medical undergraduate training: One of the means for increasing pro-
fessional interest in rehabilitation and for recruiting physicians into careers
in rehabilitation medicine is to develop and expand the teaching programs in
rehablitation in all medical schools. One of the best mechanisms for providing
for such a development is an undergraduate training grant which will provide
funds for additional faculty in this specialty, for fellowships for medical stu-
dents, and allied purposes. Currently, the Vocational Rehabilitation Admin-

   
  
  
  
  
  
  
 
 
 
  
 
   
 
  
 
 
 
 
  
  
 
 
 
  
 
 
 
 
   
 
 
 
  
 
 
 
 
 
 
   
   
   
  
  
 
 
 
 
  
 
   
  
 
 
 
  
  
 
   
  
 
  
 
 
  
 
 
 
 
   
  
  
  
 
  
  
  
 
 
 
 
  
  
 
  
 
  
 
 
 
 
 
  
 

228 COMBATING HEART AND OTHER MAJOR DISEASES

istration is making annual grants of up to $25,000 to 70 medical schools to en-
rich their teaching of rehabilitation medicine, It is recommended that an addi-
tional $2 million be appropriated annually to the Vocational Rehabilitation
Administration to provide grants of $100,000 a year to 20 medical schools for
increased emphasis on the teaching of rehabilitation medicine with priority being
given to medical schools which have stations for persons with heart disease,
cancer, or stroke.

(6) Clinical fellowships in rehabilitation: The Vocational Rehabilitation
Administration has a program for the support of comprehensive and integrated
programs designed to provide training in the fundamental principles of reha-
bilitation during the residency of physicians receiving specialized training in
internal medicine, neurology, cardiology, etc. It is recommended that this pro-
gram be expanded and that an additional sum of $500,000 be appropriated an-
nually to the Vocational Rehabilitation Administration for this purpose.

(¢) Training grants in rehabilitation: The Vocational Rehabilitation Admin-
istration presently provides grants to selected medical schools for the support
of programs designed to train specialists in rehabilitation. It is recommended
that this training grant program be expanded with an additional sum of $500,000
a year.

(¢@) Postgraduate education: Additional funds should be appropriated to the
Vocational Rehabilitation Administration to provide grants to key medical and
public health institutions and agencies throughout the country fer support of
short-term training courses, seminars, conferences, and workshops in rehabilita-
tion services for heart disease, cancer, and stroke patients.

BIOMEDICAL ENGINEERING

At the hearing of the Subcommittee on Rehabilitation, experts in bioengineer-
ing testified that the full potential benefits of the application of bioengineering
in the rehabilitation of persons with heart disease, cancer, and stroke had not
been fully recognized or exploited. The challenge, they said, was to maximize
the positive benefits which the field of rehabilitation can possible derive from
bioengineering.

Such contributions thus far have been limited. Engineers who work on medi-
cal and rehabilitation projects currently work with small, inefficient, and inade-
quate facilities. Lacking a broad base of staff, equipment, and facilities
capable of being directed toward broad problems and problem areas, such
activities tend to be limited to gadgets and the development of a specific device
to meet the needs of a specific patient.

Even under these conditions, when a device has been developed which has
shown its merits, there are seldom means of making the value known to potential
users or producing the necessary numbers. As a result, the cost per unit is
extremely high and results of such service are not generally available except in the
most sophisticated rehabilitation centers. Even in the most advanced rehabili-
tation centers, the utilization of engineering talent, skills, and experience is
limited.

Private industry should be encouraged to devote its resources to developing
new bioengineering equipment useful in the rehabilitation of persons with heart
disease, cancer, or stroke.

More clear-cut authority should be given the National Institutes of Health
to support bioengineering activities on a broad basis as well as the more re-
stricted basis of rehabilitation services to persons with heart disease, cancer,
or stroke. Under present regulations, research project directors are unable to
subcontract with industry for engineering consultation or services. If this
roadblock could be eliminated, money would be saved and services greatly
enhanced by the facilities, experience, and knowledge of private entrepreneurs.

The Department of Health, Edueation, and Welfare should have an advisory
committee of experts in engineering, electronics, clinical medicine, research medi-
cine, rehabilitation, and other appropriate disciplines to guide its policy for sup-
port of research and training grants in bioengineering. Such a body, could also
serve in an advisory capacity to other Federal agencies, such as the Interstate
Commerce Commission, in the efficacy and safety of equipment.

There is a need for specialized centers in which highly experienced engineers
can work in research and development in a clinical environment as a part of
the rehabilitation team where they can learn about bioengineering problems
which they may help to solve.
 

 

    
    
  
 
  
 
  
  
  
  
  
 
 
 
 
  
  
 
 
 
 
  
 
 
  
 
  
   
   
  
 
  
   
  
  
 
  
  
  
 
 
   
  
  
  
   
   
   
    
   
 
  
  
 
  
  
   
 
  
    
 
 
   
  
  
   
 

———

COMBATING HEART AND OTHER MAJOR DISEASES 229
1001s to en- : . :
- It is, therefore, recommended that funds be made available to the Vocational
at an addi Fey ee ws : 7 . wo
elite ae Rehabilitation Administration to provide grants to medical and research insti-
habilitation . : ara . : :
schools for tutions with outstanding rehabilitation services to establish three regional re-
ority being habilitation-biomedical engineering research centers, The following table gives
| ae ; the annual cost of this program in millions of dollars.
rt disease,
abilitation [Dollars in millions]
orn Years Ist
raining in
t this pro- New centers established
riated an-

 

Construction costs

 

rpose, Operating expenses.220000° 0770p
on nin-

Admin Tota
le Support

mmended eee ee ee
f $500,000

Howanzp A, RuSK, M.D., Chairman.

 

ed to the
dical and
upport of REPORT OF THE SUBCOMMITTEE on Manpower
ehabilita-
(Dr. Edward Dempsey, Chairman, Dr. Marion Fay, Mr. Marion Folsom, Gen.

Alfred Gruenther, and Dr. Hugh Hussey, Staff; Stephen J, Ackerman, and

Dr. William L, Kissick) :

. PREFACE
engineer-
gineering The President’s charge to the Commission on Heart Disease, Cancer, and
had not Stroke was in very broad terms. It asked for recommendations concerning a
naximize total program of attack. Recommendations for needed research were requested,
ive from and programs for applying already existing knowledge were also desired.

The Commission, in responding to this charge, concluded that to expedite its
on medi- work, it should form several subcommittees of which this, on manpower, is one.
d inade- The Subcommittee, in turn, decided that it should concern itself with health
‘acilities care as a whole, since heart disease, cancer, and stroke represent 71 percent
Is, such of all deaths currently, and these diseases constitute, as it were, the majority
ec device stockholders in the health field. As such, the interests of the other health fields

must be considered and safeguarded, else serious imbalances result.
ich has The Manpower Subcommittee, therefore, took as its purview the needs for
otential personnel in the entire health establishment. This is a formidable task, Be-
unit is tween $35 and $40 billion are expended annually for health; between 3 and 4
it in the million persons work in health-related activities. The subcommittee found it
ehabili- necessary to concern itself with the supply and training of doctors and nurses
ence is aids, scientists and X-ray technicians, nurses, and animal caretakers, specialists,

and general practitioners. There are approximately 40 health occupations ;
eloping moreover, indications are that the occupations loosely grouped as auxiliary and
t heart Supportive are rapidly increasing both in numbers and variety,

To carry out its task, the subcommittee sought information about present
Health and prospective sources of manpower. It examined the extent and adequacy
ore re- of the present devices and facilities for training men and women in the requisite
rancer, numbers and skills. Because it discovered very early in its deliberations that
ible to the presently available manpower is woefully inadequate and that training fa-
f this cilities are seriously deficient, the subcommittee undertook to inquire about ap-
reatly proaches for better and more efficient use of existing personnel and of increased
neurs. utilization of current resources, facilities, and authorities for training: and
visory finally, because even with the greatest attainable efficiency, our current re-

medi- sources appear still to be inadequate, the subcommittee gave thought to programs
r sup- whereby the necessary manpower may be ultimately provided. The following
d also chapters and sections contain the considerations upon which these conclusions
rstate are based. There is, ultimately, a concise list of our specific recommendations.

The Subcommittee on Manpower, in submitting this report, would like to
neers record that it has found its task challenging, arduous, and rewarding. The
irt of “continuing education” it has obtained has come at an almost excessive rate.
blems It has reviewed countless publications, hag heard testimony from 35 experts in

8 full days of hearings during a 4-month period and has received numerous
depositions from other individuals unable to appear personally. It has had

  
 

i

  
 

230 COMBATING HEART AND OTHER MAJOR DISEASES

access to the deliberations of the other subcommittees, especially those dealing
with research, facilities, and communications. It has had the dedicated services
of staff members who are most knowledgeable and energetic, and for whom no
limits can be set to mark their contributions. Nevertheless, despite its debts to
others, acknowledged or unacknowledged, the subcommittee herewith submits
this report as a consensus of the considered judgments and opinions of its own
members. We owe to others most that is good; we cheerfully accept responsi-
bility for what is not.

MARION Fay,

Marion B. FoLtsom.

ALFRED M. GRUENTHER.

Epwarp W. DEmMpsey, Chairman.

SUMMARY

The manpower needed for attacking the three great killers—heart disease,
cancer, and stroke—requires expansion of the work force of the entire health
establishment. The principal reason for our failure today to maintain the health
of millions of people who are dying or incapacitated by these killers is the
paucity of health manpower available to do the necessary work.

The necessary work force, professional and nonprofessional, cannot be diverted
from other fields. There are critical shortages in alli fields of medicine already;
diversion would simply compound the difficulties. Developing shortages of
physicians were forecast by the Bane Committee in 1959 and by the Jones Com-
mittee in 1960; we are experiencing today the results of our past failure to
enlarge our programs of medical education.

Medical education has a long leadtime. No matter what we do today, the
number of graduating physicians is fixed through 1969 by the number already
enrolled. The leadtime for training specialists is also 4 or more years. Special-
ists trained in heart disease, cancer, or stroke cannot be produced in sufficiently
increasing numbers until the end of the decade.

Faced with these unhappy facts, the subcommittee has concluded that the
manpower needs for physicians and other highly skilled health personnel, caused
by our expanding economy, our enlarging population, and our increased oppor-
tunities, are so great as to be unattainable during the next decade. We believe,
therefore, that we must make the most efficient use of our present institutions and
personnel in order to spread their effects as widely as posssible.

We must immediately undertake programs designed to provide semiskilled
assistants, since these can be trained more rapidly than can specialists, and they
can be used to augment the effectiveness of specialists. We must undertake
recruiting and training programs for the myriad kinds of supporting personnel
needed in the health industry.

We must encourage extensive planning by community agencies leading to the
formation of medical complexes, whereby health care can be delivered more
effectively and in which programs of continuing education will decrease the rate
at which a physician’s knowledge becomes obsolescent. :

We must take all possible steps to assure that the potentials of existing facil-
ities and institutions are used effectively for training manpower. In particular,
we believe the Federal institutions such as the Veterans’ Administration hospitals
and those of the Department of Defense and the Public Health Service should be
developed to realize their full training potentials, as should also municipal and
community hospitals.

All of these programs, listed above, are desirable in their own right as they are
directed toward producing the best possible medical care with the most effective
use of manpower resources and at the least possible cost. They should, therefore,
be implemented immediately. They are not adequate in the long term, as they
make no provision for the increased research needed to discover still more funda-
mental causes for and therefore better ways of preventing or treating human
diseases. They are designed to relieve the emergency caused by our past failure
to develop effective manpower resources.

We therefore wish to endorse the present research and training programs and
to urge that they be continued and expanded, especially with research in better
ways of delivering patient care and better devices for graduate and continuing
education.

We favor the recommendation of the Research Subcommittee that regional
biomedical laboratories and animal resources be established.
ling
vices
n no
ts to
mits
own
onsi-

2a8e,
alth
alth

the

rted
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ased
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and

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and

are
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hey
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and
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mal

 

COMBATING HEART AND OTHER MAJOR DISEASES 231

We also endorse the concept that renewed efforts be made to establish a larger
number of “centers of excellence” than we now have.

But, especially, we urge that an immediate and massive program be under-
taken, leading to new construction and enlarged operation of medical and
dental schools, nursing schools, and institutions for training of auxiliary per-
sonnel so that shortages in the health professions will be eliminated, so that
manpower will be available in numbers sufficient to meet the present and forth-
coming challenges of new and exciting opportunities for better health, and so
that the United States, in the future, can vontribute manpower to improve the
health of the world rather than be dependent upon imported physicians.

The Subcommitee has noted with great interest the progress in vocational
training and in practical nursing reported by agencies such as the Office of
Education and the Labor Department under the Area Redevelopment Act and
the Manpower Development and Training Act. It is also aware of the rapidly
expanding vocational programs being undertaken in community colleges, as
regular studies and as evening and correspondence courses.

The Subcommittee wishes to endorse these programs and to indicate its belief
that these are the devices of choice for training subprofessional personnel.

We believe, however, that the Department of Health, Education, and Welfare
should establish an office for the coordination of these vocational and other train-
ing programs, since too often there is little contact between the secondary school
system and medical education. There should be the greatest cooperation between
the educational and the health service professions. The Subcommittee believes
this recommendation to the especially important, as it applies also to the proposals
made by the Surgeon General’s Consultant Group in their report entitled “Toward
Quality in Nursing.” The Subcommittee believes that the closest coordination
should exist among all the groups carrying out programs of nursing, technical
and vocational education and that the practical training of health personnel
should be carried out in hospitals, and medical and dental school facilities.

Except for mental health, authority to give grants for training applies to
training in research. We believe a strong case can be made for the support of
clinical training in all fields, because demonstrable shortages exist, the stipends
of interns and residents are insufficient, and the long and unremunerative period
of training in a medical specialty is discouraging to students of moderate means.
We believe, therefore, that legislative authority should be sought whereby
the Public Health Service could offer training grants to clinical as well as
research trainees. We make this recommendation in the expectation that the
fewer the restrictions placed on the activities of the trainee, the more efficiently
he will be able to undertake his mission.

The Subcommittee recognizes that these programs will be expensive and that,
judged by present appropriations, substantial additional sums will be required.
Nevertheless, it believes strongly that its recommendations are justified. Ex-
penditures for health, and for health manpower, contribute remarkably to the
economy. Salaries paid to health personnel return by one channel or another
to the gross national product. They enhance the GNP by restoring to effective
production those persons ineapacitated by disease. The 365,000 Americans
between the ages of 25 and 64 who died of heart disease, cancer, and strokes in
1962 would have earned wages totaling more than $1.5 billion and paid close to
$200 million in Federal income taxes had they lived one more healthy working
year. Besides being justified on humanitarian grounds, health pays remarkable
dividends. The Subcommittee is confident, therefore, that its recommendations
are sound, judged either by humanitarian or by economic standards.

CONCEPTS AND DIMENSIONS

Scope

Health services, one of the largest social enterprises in the United States,
represented total expenditures of $35.4 billion (5.9 percent of the gross national
product) and employment of upward of 3 million individuals (4 to 5 percent
of the total labor force) during 1964. Health manpower needs are diverse and
requires many special skills. Any review of the encyclopedic resources con-
cerning manpower reveals that the range of skills, aptitudes, and general in-
terests required of health manpower is as great as in virtually any other societal
institution. There are careers in the health disciplines for individuals with
highly disparate backgrounds, diverse levels and duration of preparation, and
significantly divergent interests and capabilities.

 
  
 
  
  
  
  
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
  
  
 
 
 
 
 
 
 
 
  
 
 
  
 
   
 

232 COMBATING HEART AND OTHER MAJOR DISEASES

A successful program to combat heart disease, cancer, and stroke will re-
quire a diversity of manpower and a broad spectrum of services. These diseases
are responsible for a substantial portion of the morbidity and disability expe-
rienced by our society. The application of a wide range of skills is necessary
in assisting the individual patient to achieve optimum restoration in order to
perform a useful role in society.

The most recent Health Manpower Source Book (1) characterizes the scope
of health manpower as follows:

“In broad terms, 3 to 4 million persons can be considered as being involved in
the many aspects of health services. The health services industry in 1960
employed about 2.6 million persons in hospitals, clinics, health organizations,
private offices, laboratories, and remaining places where medical and other
health services are provided. This count does not include military personnel in
hospitals and other settings who also contribute to the health of the Nation. An
additional half million persons in occupations usually considered in the health
field are employed in other than the health services industry. For example, only
3 percent of the veterinarians and 7 percent of the pharmacists are classified as
in health services. Another half million or more persons are in industries directly
or indirectly related to health services. For example, large numbers of persons
are engaged in the manufacture of drugs and medicines and the wholesale and
retail trade connected therewith.”

The Bureau of Census counted 2.6 million members of the health services indus-
try in 1960. More than two-thirds of those workers, 1.7 million, are employed
in hospitals. Health services, ranking third following agriculture and
construction, represented 4 percent of the 64.6 million people counted in 71 indus-
tries. About half of the total health workers have college degrees or are highly
trained. It may be surprising to learn that 8 percent of all librarians are em-
ployed in the “health services industry,” as are 30 percent of all biologists, 4 per-
cent of personnel workers, 4 percent of recreational workers, 30 percent of psy-
chologists, 7 percent of secretaries, 4 percent of telephone operators, 8 percent of
laundry workers, 6 percent of stationary firemen, 8 percent of cooks, and a be-
wildering variety of other occupations. including electricians. carpenters.
chauffeurs, barbers, seamstresses, meatcutters, and bakers. “Only the candle-
stick maker is no longer employed in the health services industry.”

The Public Health Service estimates manpower supply for approximately 40
health occupations. In 1960, the manpower in these fields totaled in excess of
2.1 million. In addition to physicians, dentists, nurses, and optometrists, the
number includes health physicists, biostatisticians, medical care administrators,
and certain less well known therapists and technologists. Furthermore, esti-
mates of manpower supply are not available for personnel in food and drug
protective services, health information and communications. medical engineering
and electronics, and orthopedic and prosthetic appliance work.

Trends

Health manpower has increased rapidly during every decade of this century.
Although the proportion (50 percent) with a college education has persisted, a
smaller share of these employees are physicians or dentists. Despite increased
demands for health services by an aging and prospering population, the ratio
of physicians to population has remained static. Specialization and increasing use
of diverse health personnel are the most prominent characteristics of health
manpower. The trends seem to be related to population increases. to higher
levels of education, and to increased availability of procedures benefiting health,
as well as to an expanding economy which has generated more disposable per-
sonal income.

The vigor of the health establishment can be measured by its rate of growth
in comparison with that of the whole population, or with the growth of other
social institutions. Since 1900, the population of the United States has increased
2% times, but the college-educated or professionally trained moiety of health
workers has increased sixfold, from fewer than 0.2 million to exceed 1.1
million in 1960. In the same period, the number of physicians has doubled.
dentists have tripled, and other personnel have increased hy a factor of 18.

With these changes in growth rate and numbers, there have also been profound
changes in medical practice. At the turn of the century, the changes in medical
education stimulated by the Flexner report were still in the future. Few physi-
cians had benefitted from foreign study. the system of residency training begun
by Halstead and Osler was unknown. and the practice of medicine was. numeri-

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COMBATING HEART AND OTHER MAJOR DISEASES 233

cally, confined largely to general practice. Thirty years ago, one doctor in six
was a specialist; at the beginning of World War II only one in five had special-
ized. Today, however, 4 out of 5 of our graduating physicians are undertaking
Specialized training. With the greatly enhanced interest in advanced training,
the number of specialists rose to 36 percent of all M.D.’s in private practice in
1950, 44 percent in 1955, 56 percent in 1960, and 61 percent in 1963. Correspond-
ingly, the proportion of physicians having ‘first contact” with patients (personal
or family physicians) has fallen sharply.

Qualitative changes are largely the result of an increasing range of service,
educational, and research opportunities. The development and growth of spe-
cialization has resulted from efforts to achieve the depth of knowledge neces-
sary for effective performancce in specific areas. The exponential growth of
Scientific knowledge has contributed to the inexorable trend of specialization as
well as to the potential for improved health services. Whereas in the early
part of this century, a single health professional could provide a wide range of
services, now these services are provided more effectively with greater skill and
competence and in more depth by several specialists, no one of whom conven-
tionally provides the range of services formerly demanded of practitioners.

It is hardly a coincidence that Specialization and increased employment of
various assistants have gone hand in hand. The solo practice characterized by
the doctor of the old school required only casual assistance. Laboratory pro-
cedures did not exist, nor, if they had, would they have been useful since drugs
with specific actions and tolerances were hardly known. Social workers were
little needed when family practice and home care were the watchwords. With
the advent of anesthesia and asepsis, surgical procedures previously only
dreamed of became commonplace; hospital care supplanted home care when
adequate nursing and superior knowledge exorcised the fear of cross-infection ;
the gathering together of physicians and trained assistants set the stage for still
further specialization. Finally, in World War IT, the superior results obtainable
by specialists became widely evident. Physicians returning from military serv-
ice demanded specialty training in unprecedented numbers, and the tide thus
gathered was never slackened. In 1941, there were 7,553 interns and 4,100 res-
idents in U.S. hospitals. Almost all of the internships (92 percent) offered were
filled. By contrast, in 19638, 12,229 internships were available of which 9,636 were
filled, and 37,357 residencies were offered to 29,485 takers. With the continuous
surge of new technology, one can anticipate additional careers as new specialists
emerge in an effort to cope successfully with the potential offered by scientific
and technological advances, Specialization and diversification will no doubt
continue as major characteristics of health manpower in future decades.

Manpower for heart disease, cancer, and stroke

The Subcommittee early concerned itself with the question of manpower needs
for heart disease, cancer, and stroke as separate from the requirements for those
of the rest of medicine. Although specifically charged to make recommendations
in these categorical areas, the Subcommittee believes it impossible to plan pro-
grams for training manpower only for heart disease, eancer, and stroke. We
believe the problem facing this Commission to be immense. The diseases that
fall within our purview cause over 70 percent of all deaths; consequently, we
believe we cannot separate their requirements from those of the rest of medicine
without inadvertently creating the most serious imbalances. Peter cannot be
robbed to pay Paul that much. We believe, therefore, that we must concern
ourselves with the manpower needs of the entire social institution we call health.

RESOURCES

Neglected sources of talent for health services are to be found at every hand:
among youth, the retired, women, the underprivileged, minorities, the unem-
ployed and in the health professions themselves.

Youth

The Nation’s foremost manpower resource for the health establishment is that
sector of the population that reaches age 18 each year. The number has in-
creased from 2.8 million in 1963-64 to 3.7 million in 1964-65, reflecting an upsurge
in births at the end of World War IT, Approximately 3.5 million will celebrate
their 18th birthday each year during the remainder of the decade, with 4 mil-
lion reached by 1975.

  
 
 
 
 
 
   
   
 
 
   
  
 
 
  
 
   
    
  
  
 
 
 
 
 
   
 
 
  
 
 
 
  
  
  
 
 
 
 
 
  
  
  
 
 
 
 
 
  
 
 
 
 
  
 
 
   
  
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
  
 
 
 
 
 
 
 
 
  
 
 
 
 
  
 
  
 
 
 
  
 
  
 

234 COMBATING HEART AND OTHER MAJOR DISEASES

As noted previously, the range of talents and skills required of health man-
power is broad. Accordingly, efforts to acquire talent and energy for the attack
on heart disease, cancer, and stroke require approaches to various abilities
and capacities. A concern with graduate education must be complemented by
programs aimed at appropriately preparing and utilizing individuals whose edu-
eations have progressed only to the secondary schools. Manpower for both the
complex, sophisticated, and highly analytic functions as well as the more limited
tasks requiring a modest intellectual capacity is abundantly available in our
Nation’s youth.

Approximately two-thirds of our students attain high school graduation.
Much of the remainder, other than the mentally retarded or chronically il] who
either drop out or fail to complete their studies, represents a critical waste of
human resources and a deficiency in our social system. Imaginative new ap-
proaches to vocational, technical, and academic programs are needed to convert
this waste into an asset. Some have been proposed; more are needed.

Among the 64 percent of the age group graduating from high school, only half
enroll in institutions of higher education. Not all who have the intellectual
capacity and aptitude for collegiate and graduate study continue formal educa-
tion. Both the person and the public benefit when a youth with talent pursues
education in a junior college, professional, or vocational school, or university.

The variety of skills required for the Nation’s health services mandates the
participation of all educators dealing with the health disciplines in attempts to
approach these problems in the broadest societal context. Imaginative inno-
vations in the training of individuals for health careers can assist a substantial
number of young people to find employment in an economy which has a dininish-
ing need for unskilled, untrained individuals.

Women

Although 51 percent of high school graduates are girls, only 42 percent of the
entering classes in institutions of higher learning are females. Moreover, the
attrition among women in institutions of higher education is greater. Without
going into a more detailed analysis, it may be noted that the tendency for women
to neglect their intellectual potential represents a serious social waste and
personal loss. Women are approximately one-third of the Nation’s labor ferce.
The report of the President’s Commission on the Status of Women revealed that
an increasing portion of women are returning to the labor force us they are
relieved of the raising and care of their children. These women, wany in the
fourth, fifth, or sixth decade of life, compose an expanding resource, particularly
in the health disciplines where patient care and other services put a premium on
maturity and effective personality. The waste represented by the loss of talented
women need not be tolerated.

Socially and economically disadvantaged

Another neglected source of manpower is found among the many who suffer
social or economic handicaps. Our educational institutions have been responsible
for truly extraordinary accomplishments in providing oportunities for talented
and motivated youngsters to acquire a variety of skills. They have been singu-
larly unsuccessful, with few exceptions, in approaching the stucent with unreal-
ized potential who is unmotivated or disenchanted. Often these neglected
individuals have the necessary innate ability, but they are frustrated because
technical or professional work represents an alien culture. Such waste of
human resources is especially notable among Negroes and other minority groups
as well as among the 11 million children and youth who live in relative poverty.

Technologically displaced

The large number of unemployed persons in a period of great prosperity is
a paradox of our time. Our economic growth results, in part at least. from the
rising productivity achieved by automation; yet, this very triumph dislocates
employment opportunities. Many who because of automation are unemployed
renain unemployable unless retrained. Meanwhile, the increasing complexity
of our industrial procedures requires an ever more highly trained work force.
The unemployed have a double meaning for the Commission. That poverty
and disease share the same bed is well known; that the technologically dis-
placed are a manpower resource which can be retrained for employment in the
health industry should be equally evident.

For the technologically displaced, automation represents more of a threat than
a benefit. In many respects, they are another facet of the challenge to our edu-
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COMBATING HEART AND OTHER MAJOR DISEASES 235

cational system represented by the high school dropouts. As our technology
advances and becomes more sophisticated, technological displacement moves up
the ladder of skills. Thus we find a diminishing market for many white-collar
Positions as the cybernetic revolution takes over the jobs of office workers.
Health services, confronted with enormous manpower needs, must explore re-

cruitment and retraining efforts that attempt to use the talents of those dis-
placed or deprived of work by automation.

Handicapped persons

The physically and mentally handicapped, all too frequently, are considered
as a burden to society rather than as a human resource, even if only marginal.
During a period of full employment such as World War II, many individuals
who previously were classified as handicapped or incapable rehabilitation found
places in the economy and recouped their social value. The unique challenges
and needs related ty heart disease, cancer, and stroke can be approached in
imaginative Ways so that in ministering to the needs of one individual, the op-
portunity can be presented to another—himself handicapped—to assume a so-
cially useful role and thus enhance his own dignity.

Retired persons

In our society, retired or aged persons unquestionably are the most frequent
victims of heart disease, cancer, and stroke. Many of these individuals are
frustrated as they seek a role and function in society. But many constitute a
resource which is seldom perceived. Usually they are regarded only as consum-
ers of health services, which they are for the most part. However, striking
examples of their potential aS 4 manpower resource are seen in their services in
the home care, friendly visitor, and meals-on-wheels programs that have been
developed in some communities for chronically ill individuals, including a high
nuinber of victims of heart disease, cancer, or stroke,

Effective use—A potential resource

The final manpower resource may seem paradoxical for it comprises the in-
dividuals currently engaged in health Services. <A far greater impact and effec-
tiveness can be realized for them through organization and modification of their
roles. Many of the services provided currently by individual callings have ac-
crued more by force of tradition and custom than by lIegic or economy. There
have been only a few scattered attempts to define appropriate roles for various
professions through job analysis. Shortages of manpower require that trained
professionals spend the maximum portion of tine with those responsibilities
that best employ their knowledge and experience. Less demanding tasks must
be allocated to other categories of personnel if skilled manpower is to be used
effectively.

In a society where there is great concern for insuring the availability of health
Services of high quality, there is always the danger of the underutilization of
human resources because many receive training which extends beyond the re-
quirements of the tasks they are called upon to perform. This is a difficult con-
cept to grasp, especially in the face of widespread concern for quality per-
formance in all research, educational, and service activities in the health pro-
fessions.

Prof. Eli Ginzberg hag noted underutilization of highly trained personnel in
“capital-poor institutions” such as universities, hospitals, and other agencies in
the service sector of our economy (2). It igs not unusual for a scholar or scientist
of substantial accomplishments to waste his time trying to type a letter or re-
pair a piece of scientific apparatus, a task that could be completed by an

i i ici i i The exploration of
these issues as they influence the health professions and their effectiveness in
combating heart disease, cancer, and stroke require careful formulation of con-
cepts, investigations, and demonstrations. We have made advances, but the
application of principles learned must be much more widespread. The patholo-
gist does not read all of the slides prepared from cervical smears but rather suner-
vises a corps of cytotechnologists. On the other hand, a specialist fully trained
in the diagnosis of ocular changes in hypertensive disease can waste hours of
valuable time, energy, and talent in performing refractions, a task that ean be
performed with ample skill by a person with much less training.

Increasing Specialization in the provision of health Services has led to the
suggestion of the team approach for the provision of services that were pre.
viously provided by one individual. This is not to imply that a team will pro-

  
 
   
  
  
  
 
 
   
  
  
 
 
   
   
 
 
 
   
    
   
 
  
  
 
  
  
  
   
  
 
 
 
 
  
   
 
   
  
 
 
 
 
  
  
 
  
 
 
 
  
  
 
 
 
  
 
  
 
   
  
   
    
    
 
   
   
   
   
 
 
 
 
 
  
 
 
 
   
  
 
  
 
 
  
 
 

236 COMBATING HEART AND OTHER MAJOR DISEASES

vide the same services; but the team can furnish much more highly skilled,
extensive, and competent versions of the same category of services. In addi-
tion, research is needed to test the validity of having services that were once
provided by one professional category transferred to one or more individuals
with a lesser level of preparation. This redefinition of role and the appropriate
modification of specific tasks in order to have them carried out effectively by a
person with lesser skills can result in vastly increased effectiveness in the use
of health manpower. The increasing need and demand for health services to
combat heart disease, cancer, and stroke, as well as increasing educational needs
and expanding research opportunities require enlightened use of supportive per-
sonnel working in concert with the more highly trained specialists.

Changing the dimensions of health manpower and restructuring tasks are
closely related. Each requires new techniques for the provision of health serv-
ices. The purpose of both is to increase the efficiency and effectiveness of the
single professional; to expand the quantity and enhance the quality of all health
services, research endeavors, and educational activities: and to achieve the
fullest range and the highest quality of these for the entire Nation.

SUPPLY AND GOALS: 1965-75

Each achievement in the treatment of heart disease, cancer, and stroke presages
new challenges. As our scientific capacity grows, the greater is our need for
effective application of this knowledge to benefit individual patients. Moreover,
the greater our success in coping with the organic aspects of these diseases, the
more we are challenged to maintain the individual’s level of function and to en-
hance his capabilities and potential for rehabilitation after illness strikes. These
medical advances also affect the needs and demands for health manpower.

Changing health needs

Sir Geoffrey Vickers has characterized the history of public health as “* * * a
record of successive redefinings of the unacceptable” (3). Even a few cases of
polio in a community with a population of several million are unacceptable. By
contrast, 400 deaths each year from cancer of the cervix—usually susceptible to
detection and cure—are accepted, albeit reluctantly, in New York City alone.
This permissiveness need not and must not persist. This waste of human life
need. not be tolerated.

The advances being made with respect to acute leukemia in children suggest
that deaths from this disease need not be accepted a few decades hence. Man’s
persistent optimism and continuous search for new fields to conquer ean find sus-
tained stimulation and challenge in the investigation of the causes of heart
disease, cancer, and stroke and in the provision of the most complete and respon-
sive care for patients for whom these diseases represent an awesome burden
and all too frequently a death warrant. Each gain in health service or knowledge
is antecedent to new and more complicated health needs that require expanded
health services and manpower capable of adopting to new requirements.

A Presidential Commission addressing itself to the challenges of heart disease,
eancer, and stroke is one result of significant success in combating infant mortal-
ity, a host of communicable diseases, nutritional deficiencies. and environmental
stresses. This commission is a vivid illustration of the truism that the health
achievements of one generation are instrumental in determining the health
challenges of the next.

Substantial changes in our economy have occurred in the past decade and a
half affecting future health needs. The population of the United States has in-
creased sharply, from 152 million in 1950 to over 198 million in 1964, and is
projected to be between 209 and 214 million in 1970. At the same time, the
economy of the country has expanded greatly; the gross national product (GNP)
has increased from $285 billion to over $600 billion in 1964, An increasing pro-
portion of this GNP is spent on edueation and health. In 1950. 26 percent
of the 18- to 21-year-olds were enrolled in institutions of higher education: this
figure increased to over 40 percent in 1963. Our institutions of higher education
spent $2.7 billion in 1950 (less than 1 percent of GNP): by 1963. the figure
had more than tripled to $8.9 billion (1.5 percent of GNP). Health care ex-
penditures in 1950 were $12.2 billion (4.6 percent of GNP): in 1963, the figure
was $32.9 billion (5.8 percent of GNP}. Estimates place the expenditures in
1964 at $35.4 billion. There seems to be every indication that we have the capa-
city to respond to the challenge of our expectations.

We stand at a point in time when great achievements are possible. To cite
three pertinent examples, realistic estimates indicate that application of current
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COMBATING HEART AND OTHER MAJOR DISEASES 237

knowledge could save the lives of one-third of all those now dying of cancer ; the
ravages and deaths caused by rheumatic heart disease could be effectively pre-
vented; strokes could be prevented in large numbers of individuals destined
to suffer from them, or the resulting disability could be alleviated by rehabilita-
tion. These benefits are not now widely available because of deficits in trained
manpower. We cannot treat many cases of surgically curable cervical cancer
because we do not have enough cytological technicians to staff screening pro-
i i personnel, nurses, and
other workers to detect and treat the streptococcal infections which, if ignored,
lead to valvular damage to the heart. We have shocking deficits in personnel
needed to detect, prevent, treat, or cure the cardiovascular diseases to which
man is heir. Judged against these needs, nothing less than q maximum effort
is justifiable.
Requirements

Manpower requirements may be estimated in various ways depending on the

selection of premises. Several groups, comprised of experts in their fields, have
reported the specific manpower needs following detailed analyses based on an-
ticipated demand, increased utilization of existing resources, and expansion of re-
Sources to meet realistic goals. Only a few studies are mentioned here.

The Bane report in 1959 stated that, to graduate 11,000 physicians a year
by 1975, it would be necessary to have an increase of 3,600 graduates over the
current number. ‘Three approaches were recommended: (a) expansion of
enrolment in existing schools; (b) establishment of new programs of basic
medical science ; and (c) establishment of new 4-year schools,

A report on manpower for biomedical research, prepared by the National
Institutes of Health in 1962, projected net additional requirements of “45,000
professional workers, fully qualified to engage in medical research as in-
dependent investigators by 1970” based on an estimate of $8 billion for total
national expenditures for medical research in 1970. It was further determined
that, of these new research workers, 56 percent will be Ph. D.’s, 25 percent
M.D.’s, and 19 percent less than doctoral level. The report assumes that 15
percent of the physicians graduated in 1965 will enter research within 15 years
following graduation.

Although increases among professional
population growth, the supply falls far short of recognized needs. The report of
the Surgeon General’s consultant sroup on nursing has set 680,000 nurses by
1970 as a feasible goal, while calculating 850,000 to be the ideal goal. The
feasible goal represents almost a 25-percent increase over the 1963 estimate of
550,000 professional nurses in practice.

Judgments of experts as to specific requirements for health manpower are
urgently needed, particularly judgments i

to professional workers. Such a professional judgment has
field of nursing. Comparable decisions for other health sery
tribute significantly to the formulation of patterns of medical care that would
assure the most effective use of health manpower.

or has reexamined Some of the alternative
methods of formulating manpower requirements and goals. Two such approaches
studied are:

1. Projections based on maintenance of exi
to population in future years’ and

2. Projections based on existing manpow
tion’s educational facilities, and the potential

Projection of existing ratios

Our manpower resources will be taxed to capacity to meet the foreseeable
demand for health services, The most conservative estimate of the need for
physicians—that we merely hold the present ratio of physicians to population—
projects a need for 346,000 physicians by 1975. The Nation’s 87 medical and 5
osteopathic schools had a total enrollment of 33.595 during the 1963-64 aca-
demic year; 7,694 physicians were graduated. Assun

ning current expansion
of existing schools and Opening the 12 to 15 new schools now in vari-

ous stages of development will probably yield approximately 9.000 erad-
uates per year by 1975. This will not maintain the present ratio of 149
physicians per 100,000 persons. That ratio can be maintained only by the
substantial importation of foreign-trained physicians,

nurses more than keep up with

sting ratios of health personnel

er resources, capacity of the Na-
expansion of such facilities,

43-669 6516

  
 

238 COMBATING HEART AND OTHER MAJOR DISEASES

A stable, or even rising, ratio of total physicians to population can disguise
a declining ratio of physicians in private practice. As of December 31,
1968, 18 States and the District of Columbia had at least 1 physician in pri-
vate practice for every 1,000 in the civilian population. Assuming that
this rafio is a reasonable measure of need for the remaining 37 States, it is
estimated that there is a shortage of 20,000 physicians for private practice at
the present time. Were we able to expand the output of the Nation’s medical
and osteopathic schools by 25 percent immediately, it would require 10 years
to make up this deficit alone. Moreover, this goal does not consider the addi-
tional requirements for physicians in teaching, research, and administrative
positions or the fact that about 20,000 of the physicians now in private practice
are 65 years of age or older and are reaching the age of professional obsolescence.

Dentists, like physicians, are not being prepared in sufficient numbers to main-
tain ratios to population. There has been a decline in the ratio of active non-
Federal dentists per 100,000 civilian population from 49.9 in 1950 to 44.9 in
1963. Even with current planned growth of U.S. dental schools, a continued
decline in the dentist-to-population ratio is forecast.

Effective development of manpower resources

What are our manpower resources? Are we effectively planning the de-
velopment of these resources for the health professions? Determination of the
potential members of certain health disciplines can be projected from the per-
centages of college graduates who enter these callings. By applying current
ratios to estimates of future bachelor’s degrees, we can project the number
available to enter health professions.

More than 365,000 bachelor’s degrees were awarded in 1861. In the
fall of that year, approximately 8,900 medical and osteopathic and 3.600
dental students commenced their professional education, following the attain-
ment of the bachelor’s degree. Roughly 742,000 bachelor degrecs are predicted
for 1975. If the above ratios hold—40 to 1 for physicians and 100 to 1 for
dentists—we have the manpower potential fer more than 18,000 new medical
students and 7,000 new dental students for the fall of 1975. Since the existing
and anticipated facilities will accommodate only two-thirds of these potentials,
our manpower resources far exceed the existing and anticipated cupacity of
our educational institutions. Moreover, future college graduates will face re-
stricted opportunities to prepare for these professions. It is not the scarcity of
manpower resources that requires us to depend on the contribution of approxi-
mately 1,600 physicians from foreign medical schools per year, to meet our
demands for health services, but rather the limited capacity of our own educa-
tional institutions to accommodate the available potential manpower. The
ironic situation, in which the wealthiest nation in the world depends on the
less affluent for health manpower, can be corrected. We should become a
creditor and not a debtor society.

Health manpower goals

Our goals are the minimization of human suffering and the ‘maximization
of social usefulness of the individual which yields dignity in life. With standards
such as these, the health manpower needs for research, service, and educational
programs directed toward the mitigation of heart disease, cancer, and stroke
are enormous. Accordingly, the subcommitee can see no alternative but to ex-
pand to the maximum the Nation’s educational capabilities for training health
manpower.

‘the Bane report stated that the average physician sees twice as many patients
in a given period of time compared to a generation ago. Professor Seymour
Harris has noted the increase in the number of patients handled by physicians
is related to the increase in the hours worked and to rising productivity resulting
from greater use of other personnel, equipment, drugs, and improved medical
education and training (4). There is no doubt that 1 hour of a doctor’s time
today is more productive than a generation ago. It is also a fact that his
greatest productivity level has not been attained.

Efforts to achieve increased productivity of health manpower through organi-
zation, coordination, and planning are essential.

The expansion of existing schools and the development of new schools for
educating physicians, dentists, nurses, scientists, and other allied health per-
sonnel requires extensive planning and the investment of large sums of capital.
Consequently, the rate of growth of these schools (the number of graduating
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COMBATING HEART AND OTHER MAJOR DISEASES 239

physicians has increased only 2.4 percent in the past 5 years) has been and,
unaided, will continue to be slow. ;

Because the needs for trained health manpower are so great as to be un-
attainable during the next decade, we believe that a double-edged program should
be undertaken immediately. On the one hand, the greatest efforts must be made
to utilize our present manpower resources,in the most effective manner ‘possible.
This will not be easy. Nevertheless, we must make every possible effort to
achieve the most effective use of scarce professionals to obtain the ultimate
level of productivity.

On the other hand, we must also immediately begin a massive program for
the training of additional physicians, dentists, nurses, and other health personnel
as rapidly as possible. The leadtime in medical, dental, and scientific education
is long. Nothing we can do toady can increase the number of physicians before
1969. We must plan so that our deficits will ultimately be made up, our de-
pendence upon foreign graduates will be abolished, and our ability will be
restored to provide medical care of the highest quality for our Nation and to
assist other parts of the world to improve its medical care.

PLANNING THE EFFECTIVE USE OF HEALTH MANPOWER

A factor of controlling importance in our time is the spectacular advance of
medical science during the past 50 years. It has brought with it great scientific
and technical advances but it has also created great problems in applying
the technology for the benefit of all people. Specialization, fragmentation, in-
creasing costs and the split of the cultures between scientist and practitioner
have confused us all. Dr. Vannevar Bush has indicated that before this cen-
tury goes much further, there must be bold social and economic innovation to
match the giant strides being made by the scientists.

he rapid growth of health activities has created problems now becoming
troublesome indeed. Small institutions, necessary for. health care a generation
ago when transportation was slow and medical procedures were simple, are now
inefficient when access is easy‘and duplication is expensive. The rate at which
new knowledge found its way into practice was inconsequential when research
was an amateur’s avocation, but it is critical today when medical science is
making rapid and spectacular advances. The organizations whereby health
research is translated into medical practice are no longer adequate. Rapid
progress, transportation, and communication both demand and permit new
dimensions to health institutions. |

Medical complexes, in which medical schools are coupled with teaching hos-
pitals and in turn both are affiliated with community health institutions, furnish
an organizational structure whereby research can quickly be applied to patient
eare, whereby specialty training ‘can be related to health needs, whereby con-
tinuing education can prevent medical obsolescence, and whereby the public’s
interests can be best served.

The Subcommittee’s principal recommendations, therefore, will relate to the
development of such medical complexes as the prime instrument for bringing
about the community planning necessary if health care is to achieve these new
dimensions and if manpower is to attain new effectiveness.

Community health planning

The institutions responsive to health needs have compounded, rather than
simplified, the problem of effective manpower use. Historically, hospitals, clinics,
medical schools, and other health care institutions have been located where they
are because of parochial or political considerations. Communitywide planning
has played very little part. The topsylike growth of these institutions was costly
and inefficient but was bearable so long as the procedures carried out in them
were relatively simple, since no great strain was placed on the manpower in short-
est supply nor was the economic burden caused by duplication unduly heavy. Re-
cently, however, specialization has greatly changed this situation. The more
complex procedures, now common, require expensive equipment, sophisticated
laboratory determinations, and teams of highly skilled people. When such
people and procedures are active only part of the time, the inefficiency is very
great. Thus specialization, created in order to improve the quality of medicine,
has, as an adverse side effect, made medical care so expensive as to limit its
availablity.

Comparable needs for optimum utilization exist with health programs and
the use of health facilities. In many situations improvements can be more readily

  
  
   
  
  
 
  
   
  
  
  
  
  
  
 
 
 
 
 
 
  
 
 
 
  
  
   
 
 
  
 
 
  
  
  
  
 
 
  
 
 
  
 
 
  
  
  
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
  
 
 
 
    
 

240 COMBATING HEART AND OTHER MAJOR DISEASES

accomplished with facilities than with people. It is unfortunate that our society
has been able to afford the waste represented by two competing hospitals, each
operating at substantially less than full capacity, existing to serve some of a
community’s health needs, when a single community hospital with a bed capacity
larger than either one but less than the combined total of the two could operate
with far more economy. The inappropriateness of this lack of community plan-
ning is emphasized when it is realized that such a community, with its excess of
beds for acute hospitalization, usually has unmet needs for long-term care beds.
ambulatory services, a home care program, and other health services.

Unnecessary duplication, and the waste of material and human resources that
it represents, is also found in two situations of particular relevance to this Com-
mission. The newer technologies and instrumentations found in medicine are
often glamorous and prestigious. Thus, the two competing community hospitals
mentioned above, in addition to being overbedded struggle to match each others
new acquisitions. Each wants to offer its clientele the finest scientific medicine
available, so there will be two pump oxygenators or two cobalt bombs or two
high voltage X-ray devices in a community where even one would not be utilized
to capacity. Since each of these instruments must be maintained by a competent
staff of professionals and technicians, the waste of the equipment for a substantial
portion of its useful life is compounded by the useless dissipation of scarce
manpower.

A beginning response to these problems can be seen in a few of the Nation’s
more progressive and active communities. The concept of areawide planning is
being implemented through councils of social agencies, utilization committees,
and community health or patient care councils. These voluntary organizations
attempt to achieve coordinated efforts on the part of various independent agencies
and individuals concerned with the health and medical needs of the community’s
citizens. Unfortunately, in most situations, these activities can function only in
an advisory capacity for lack of the statutory responsibilities comparable to
those existing in the State of New York. Such endeavors are of the utmost
importance if we are to realize our aspirations for programs that will have
maximum impact on heart disease, cancer, and stroke. Independent and often
competing activities of hospitals, health departments, and medical practitioners
—each working in isolation and often at cross purposes—are not in the best
interests of the consumers of health services, the health profession, or the Nation.

Moreover, the total scheme of health services available in a community must
be considered or the highly specific and carefully focused efforts can come to
naught. Thus, a failure to provide for needed ambulatory services, long-term
care facilities, home care programs and the like, can result in a siphoning off
of high-cost acute hospital beds by patients whose needs are for other than the
highly compiex skills and resources represented by the general hospital. In such
a Situation, failure to perceive the specialized need within the context of more
general patient requirements generates a self-defeating fragmentation. Just as
the availability of cardiologists in a community has major implications for the
professional activities of the general practitioner, so does the addition of a spe-
cialized activity such as a “stroke center’ affect and evolve with the redction of
the societal matrix in which it is placed.

When specialization breeds fragmentation in health services as the cost of
enhanced quality the apparent gain is in reality temporary and is more than off-
set by the long-term losses. Such a policy is patently folly in medicine as well
asin the market. Therefore, a program of incentive grants is needed to encour-
age community inventories, utilization committees, and other coordinating
activities.

Within individual communities, only rarely are there effective mechanisms for
preventing duplication, or for efficient use of manpower or for reporting and con-
trolling costs. Even within single institutions, methods for allocating costs are
originarily rudimentary as judged by business standards. As a result, no effec-
tive way exists for measuring the relative merits of two different procedures lead-
ing to the same objective. Laboratory procedures, for example, often can be done
either by manual determination, using a technician’s time, or by automated
methods with an initial high capital cost but with negligible costs for labor.
Accounting, billing, and data handling systems represent other cases in point:
relatively few institutions have adequately evaluated the cheapest and most
efficient way of getting the job done.

The interest of the Subcommittee on Manpower in the matter of cost analysis
stems from the fact that objective data concerning the efficient utilization of
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COMBATING HEART AND OTHER MAJOR DISEASES 24]

manpower simply do not exist at present. Many examples of glaring inefficiency
come easily to mind. Doctors whose patients are in two or more hospitals lose
worktime in traveling between them. The standby use of highly trained per-
sonnel in emergency rooms duplicated in nearby institutions is clearly wasteful.
Such examples Suggest gross inefficiency, but without cost analysis the real mag-
nitude of the problem is unknown, Without cost procedures, one service cannot
be compared with another ; the efficiency of one institution cannot be proved as
contrasted with another, and the benefits provided to the community by its in-
vestment of money and men cannot eyen be estimated.

The development and application of standardized cost procedures would go far
toward eliminating another cause of inefficiency—that resulting from the dis-
agreement, acrimony, and opposition caused by misunderstandings, There is a
seneral suspicion that the high per diem costs of teaching hospitals are caused,
somehow, by loading patient care with the costs of teaching and research—in
other words, that the Sick are being victimized. On the other side of the penny,
proponents for academic medicine point out that the care provided in teaching
hospitals is superior, that the medical schools contribute knowledge and man-
power over and above that needed for minimum standards, and that teaching
cases, by their very selection as such are the more difficult and time-consuming
ones, Without the knowledge gained from agreed-upon accounting procedures,
such disagreements foster Suspicion between hospital and medical school, between
Clinician and academician, and between trustee and faculty members, The re-
sulting bickering is destructive to morale and constitutes an important drain upon
efficiency,

Out of considerations such as those touched on above, come some suggestions
for improvement of health care administration and the most effective use of
our manpower resources, With the adoption of standardized cost finding pro-
cedures, planning on a wider scale becomes possible, With community planning
for health facilities, cooperation, and coordination rather than competition, will
result. With the organization of health care complexes, each consisting of a
medical school—teaching hospital as q center, and with community hospital as-
sociated with it, an organization ig created whereby medical care of the high

i i i insti available to entire communities,
personnel and equipment is mini-

mized, and whereby the dangerously scarce skilled manpower can be deployed

in the most effective way.

The Subcommittee has been impressed with testimony it has heard indicating
that preventive medicine can be made vastly more effective and can, therefore,
complement the therapeutic management of acute disease. Concepts of compre-
hensive medical care are now so far advanced that it should be possible in 10
years to assure any community that large numbers of its people would not have
their medica] problems neglected, We wish to state this objective here, as our
manpower projections should be compatible with the evolution of medical prac-
tice now occurring. We believe medical complexes such as those Suggested

here to be the organizations of choice for developing programs of comprehensive
care.

The Subcommittee wishes to suggest as one of its m
that expanded medical complexes be encouraged and established in those com-
munities where the necessary patient Populations, medic
highly skilled health personnel and leadership in community pla
the concept feasible, We. therefore, have included the
medical complexes ag an extended guide to the concept.

The medical complex

Institutions devoted to health education and health care, are, today, v:
different from their antecedents.

nning render
following account of

astly
Medical education was originally an ap-

subjects.

The transformation of medical schools into medical school-teaching hospital
hospital associations—prototypes of the current medical centers—came about
through a fortunate combination of circumstances. A cadre of well-trained
young physicians brought to the United States ideas they had received in Ger-
many; Flexner pointed out that most institutions of medical education fell
abysmally short of what could be done; the Rockefeller and Carnegie Founda-
tions used their funds to establish demonstration projects in selected schools;
the American Medical Association established an effective accreditation mech-

  
  
 
  
 
 
  
 
  
   
  
   
 
 
  
  
  
  
 
 
  
   
   
 
   
 
  
 
 
  
  
    
   
   
  
  
  
  
  
 
 
 
 
 
 
   
  
   
  
 
 
  
 
 
 
 
 
  
  
  
 
  
   
 
  
 
 
  
  
 
  
  
  
 
  
 
 
  
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242 COMBATING HEART AND OTHER MAJOR DISEASES

anism; and an aroused public, made aware of health benefits then available,
used its disposable income to create institutions destined to change the face
of the medical world. But the process took 30 years to accomplish—roughly
from 1910 to 1940.

With the close of World War II, two new phenomena made their appearance.
The first was that young physicians returning from military service had noticed
the demonstrably more successful care provided by specialists as contrasted with
that by those lacking specialty training. These returning veterans besieged
medical schools and teaching hospitals, demanding the specialty training the
value of which they so keenly appreciated. As first believed to be a passing
fad, encouraged by the GI Bill which made it economically possible to
acquire this training, medical educators paid relatively little attention to the
phenomenon. However, it continued, having caught on; the current graduates
also demanded specialty training; the tide. of residents rose and rose until:
today, more than 10 percent of all physicians are in house-staff positions, and
about 80 percent of current graduates plan to become specialists.

The second postwar phenomenon consisted of massive funding of medical
research through Federal and private agencies. During the war, the Office of
Scientific Research and Development had played an important role in the war
effort; after the war intensive efforts were made to find permanent devices to
continue this fortunate coupling of public funds with private science, both
being used in the national interest. Out of these efforts grew institutions such
as the National Institutes of Health, the ‘National Science Foundation, and a
host of programs also concerned with some aspects of health such as those of
the Armed Forces, the Veterans’ Administration, and the Atomic Energy Com-
mission. With the support forthcoming from these agencies and programs, the
research potential of the country was greatly enhanced. With the manpower
derived from the enlarged specialty training programs mentioned above, 2
source of academically oriented, scientifically minded physicians was assured.
With the greatly expanded activity in each specialty area, an extensive building
program got underway, one result of which was that specialty departments
in general hospitals affiliated with medical schools were transformed into entire
hospitals, eache in its own right. Medical schools, therefore, became the unifying
center of a cluster of specialty hospitals in which teaching, service, and research
all are carried out. In such medical centers today, there are maternity, psy-
chiatric, children’s, orthopedic, eye, ear, nose, and throat and other specialties.
to name only some. Institutes of radiology, of neurology, of cancer, and of
yarious other supporting or disease-oriénted categories are also common.

That speciality training is desired—-indeed’ demanded—is indicated by the
fact that four out of five graduating physicians seek it. That the medical school-
teaching hospitals association is a highly desirable place to undertake this
training is shown by the fact that two-thirds of al house staff are now located
in such affiliated hospitals, despite the fact that nonaffilinted hospitals pay
larger salaries and often spend relatively large sums to support directors of
medical education and other full-time staff members in an attempt to provide
attractive teaching programs. That the medical care provided ‘in the teaching
hospitals is superior, is ordinarily accepted without question. As a model upon
which to build still larger and more perfect medical institutions, the medical
center has much to recommend it. It is an instrument which permits harmon-
jous blending of public and private philanthropic funds. The expansion of
present centers to include peripheral community hospitals, health departments,
and other community health facilities within their organizational framework
would provide the final part of the center concept, namely, the mechanism by
means of which teaching, research and patient care can best be delivered to
the entire community.

Medical schools have as a primary responsibility the education of students to
the stage at which the M.D. degree is awarded, The faculties of medical schools
also often teach students in the health professions other than medicine, they pre-
pare scientists, guide postdoctoral interns and residents through their graduate,
specialty training, and they supervise the clinical conferences, symposia, semi-
nars, and other exercises which, for the voluntary staff, represent continuing
education. The expansian into complexes including other community health
resources provides a mechanism whereby graduate and continuing education
can be greatly enhanced, as each such peripheral facility becomes a focus for the
continuing education of its staff, under the guidance and supervision of appro-
priate faculty members. A mechanism is therein provided whereby education
becomes a continuum and not an interlude in the physiciai’s life.
 

COMBATING HEART AND OTHER MAJOR DISEASES 243

Besides teaching, research is the other pervading theme providing counter-
point in institutions delivering excellent medical care. It is the process whereby
the system constantly renews itself; it prevents dogmatism; its fosters a ques-
tioning, self-critical attitude; and it constantly generates new information to
stimulate the inquiring mind. Laboratory research is perhaps best done in a
clositer, but clinical research begins at every bedside and at every clinic ex-
amination. Clinical research, especially on rare diseases, requires large initial
patient populations from which suitable cases can be selected. Clinical re-
search requires an organizational system whereby cases occurring in different
places may be treated identically. Clinical research to achieve greatest useful-
ness, should be carried out under the scrutiny of the entire medical staff in
order that the patient may best be protected and the results most quickly dis-
seminated. The expansion of present medical centers to include community
hospitals provides the mechanism whereby greatly improved clinical research
becomes possible.

The support of medical enterprises comes, today, from a bewildering variety
of sources, both public and private. Unrestricted endowment and tuition income,
restricted endowment and gifts, research, and training grants, income from
patient care and from ancillary sources related to patients, all play a part. Gifts
and grants come both from public and private sources and are provided by sepa-
rate agencies too numerous to count and with separate restrictions too disparate
to summarize. Confronted by this confusion of sources it seems unlikely. that
an orderly system of support can quickly be created and, therefore, that planning
on an extensive scale can be accomplished by donor agencies. The grantee in-
stitution can, however, engage in comprehensive planning, can fit each piece of
support into its proper niche, and can create the orderly mechanism whereby
enormously varied kinds of support may be coordinated into a single continuous
system of medical education, research, and patient care. The advantages of such
coordination are obvious; the expansion of medical centers by the inclusion of
community hospitals provides the enlarged scope whereby the economie ad-
vantages of comprehensive planning can be increased.

Expanded medical complexes of the type envisioned here cannot be created
overnight, nor rapidly in large numbers. A start can be made, however, in
individual instances, where feasible. For example, in Kentucky, a satellite
institution has been adopted at Moorehead, 80 miles away, and at Washington
University, the Ellis Fischel Cancer Hospital at Columbia, Mo., has a full-time
staff provided by the medical school at St. Louis. In other instances, a single
service within a hospital might be incorporated into the complex, this to furnish
the stimulus for the remaining services to bring themselves up to the standard
necessary for incorporation. In other instances, stroke, heart, or cancer stations,
as recommended by other subcommittees of this Commission, might be formed
within community hospitals by the medical complex, again to furnish not only
patient care but also the example and stimulus necessary for the other services
to bring themselves up to higher standards. The expansion of medical complexes
by the inclusion of community hospitals, or of individual services within com-
munity hospitals, is thus feasible immediately.

To encourage development of such expanded complexes, as a basic device for
best providing training, research, and patient care, the Subcommittee recom-
mends a program of institutional grants, these to be flexible in nature in order
to provide whatever the individual institution may most need to bring about the
organization of the enlarged complex. The Subcommittee understands that in
some instances buildings may be most urgently needed, in others laboratory
equipment and renovation to foster a research program in the community loca-
tion, in still other places, a nucleus of full-time staff may be essential and in
most instances support for an administrative mechanism will be required.
These complexes are justifiable, largely by their regional nature, by their service
and patient care aspects, and by their utility in the continuing education of
puysicians. Because these functions go far beyond the classical missions of
medical schools and other local institutions, there should be full funding of
the necessary expenditures, both for construction and for operation.

A PROGRAM FOR THE FUTURE

The foregoing chapters have presented evidence that the needs for health
manpower are virtually insatiable. The present rate of training is not main-
taining our present capabilities in the health field. Increasing population, in-
creasing demand for medical services and procedures conferring benefits un-

 
   
  
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
  
 
  
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
   
   
  
   
 

244 COMBATING HEART AND OTHER MAJOR DISEASES

dreamed of a few years ago, all have combined to create a crisis in health man-
power. Because the numbers of physicians, dentists, and other highly trained
specialists are woefully inadequate, and because our training facilities are
seriously deficient, we propose that maximum efforts be made to increase
professional health manpower, and that intensive efforts be made to improve
efficiency of the use of our present scarce professionals.

Increased health manpower

That we need greatly increased numbers of physicians is, today, unarguable.
We are presently not even graduating enough new doctors each year to keep
up with population growth. We can hardly count on, nor can we morally de
fend, the importation of physicians trained by countries less fortunate than ours.
Such current imports are at the rate of about 1,600 per year. Our best efforts
since 1959—-the year of the Bane report—have resulted in planning for 12
to 15 new schools. Clearly, without more massive support of medical education
than we have as yet been able to generate, we face a grim future, medically.
In the face of the rising demand for physicians in every field of service, it is
futile to think of diverting physicians into heart disease, cancer, and stroke
programs; to do so would be catastrophic in a nation in which faulty distribu-
tion of physicians and increasing abandonment of general practice is already
posing serious, if not critical problems for the provision of medical care. It is
inescapable that we need more doctors, that the opportunities now apparent
in heart disease, cancer, and stroke cannot be realized until we have more
doctors, and that the support of medical education is the only way we can get
more doctors.

We can no more separate national from international aspects of heart disease,
cancer, and stroke than we can distinguish the manpower needs for these diseases
from those of medicine at large. Medicine in the United States owes an im-
measurable debt to other countries; Vesalius, Pasteur, and Virchow lived and
taught in Italy, France, and Germany. The modern medical world is no less
international; Fleming’s discovery of penicillin in England made possible the
prevention of rheumatic hearts, and the cytological test for detecting cervical
cancer was developed here by Papanicolaou, who came from Greece.

Heart disease, cancer, and stroke observe no national boundaries, yet their
incidence and severity vary in different countries and so provide fascinating clues
for research to explain these differences. Discoveries, once made in medicine, are
freely available everywhere; we have benefited from Lister’s principles of anti-
sepsis as Europe has profited from the Salk and Sabin polio vaccines.

Foreign laboratories are an important training resource for young American
Scientists. Foreign scientists collaborate extensively with Americans in conjoint
research projects. Foreign experience with variant forms of disease is valuable
in devising measures to deal with our own medical problems.

For years, we have been importing physicians from other countries. Indeed.
the Bane report in 1959 anticipated that we would continue to do so at a rate
of 750 per year, although the consultants questioned then whether or not this
should be done when physicians were needed so badly in other parts of the world.
Despite these qualms, we are parasitizing other countries at an increased rate
(1,651 in 1963). Approximately one-third of the medical graduates in Canada
each year migrate to the United States—296 in 1961 (5). This drain upon other
nations is neither to their best interest or ours; the “brain drain” is resented by
the countries suffering from it; the inability of the United States to provide for
its own needs ill fits our posture as a world leader; offers by the U.S.S.R. to
provide medical personnel for the emerging African nations and for international
efforts against disease have counted heavily on the propaganda front; in short,
our national interest requires us to provide the manpower necessary for our
obligations as a world leader in medicine.

The Subcommittee believes that the solutions to the physician shortage must
be found in Federal programs. We are well aware that the diversity of medical
education in the United States is one of its greatest strengths, and we know
further that this diversity is maintained by the admixture of private, municipal,
State, and Federal funds which support medical education. Nevertheless, we
believe the present shortages to be so critical, and their further neglect so disas-
trous, that Federal programs must be undertaken as the only solution which
can be found in time. Moreover, physicians are, in fact, a national resource
in that the welfare of the Nation depends upon their ministrations. The
schools that produce them are alsu national resources—their graduates migrate
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COMBATING HEART AND OTHER MAJOR DISEASES 2A5

freely throughout the country, their demonstration projects modify medicine
widely, and the knowledge gained in them is immediately available everywhere.
While in no way wishing to discourage local philanthropy—indeed elsewhere we
recommend community planning—we nonetheless believe the local communities
are presently unable to shoulder all the load; we believe that benefits of better
medicine to observe no boundaries; in short, we believe the support of medical
education to be a national necessity. We, therefore, recommend that the nettle
be grasped firmly by the introduction of an entire system of programs support-
ing medical education; for institutional grants, for student scholarships, for
traineeship stipends during the graduate years of specialty training, for the
support of senior faculty of medical schools and complexes, and for construc-
tion and renovation of facilities to permit enlargement of our medical educa-
tional system. We do not fear the encroachment of the Federal Government
upon local management if this recommendation is carried out; indeed, past
experience has been that the infusion of Federal support into medical institu-
tions has actually stimulated the availability of local funds.

Two other points should be made in support of this position. Graduate
training, toward the Ph. D. degree, has been accepted for years as suitable for
scholarship aid, justifiable because scientists are in short supply and their train-
ing is in the public interest. However, the attrition rate in graduate training
is substantial. A majority of all beginning graduate students fail to reach the
goal of the Ph. D.’s degree. Against this alarming attrition rate for Ph. D.’s
only about 10 percent of medical students drop out. Considering that each year
increased numbers of medical doctors are joining the research and teaching
ranks, one can argue successfully that health research manpower would be in-
creased as much by scholarship support for M.D.’s as for Ph. D.’s. There thus
seems to be no real justification for withholding scholarship support from med-
ical students, even if only research needs are considered. Moreover, since
critical shortages of physicians now exist, and since those in private practice
are declining at an alarming rate, we believe medical scholarships are necessary
to prevent diversion of excellent candidates into other fields. Recent studies
have shown a preponderance of medical students to come from relatively high-
income families. Although only 5 percent of American families have more
than $15,000 annual income (before taxes in 1962), these families supply
almost 30 percent of the medical students. One-half of all medical students
come from families with annual incomes of $10,000 or more. It can hardly
benefit the Nation to permit its physicians to be recruited predominantly from
among the wealthy. Whichever way we turn, the Subcommittee is forced to
conclude the substantial support for health education is needed. The Subcom-
mittee believes that scholarship assistance for medical students and stipends
for graduate clinical training especially for physicians aspiring to careers as
teachers should be made available to assist the recruitment into medicine of
highly qualified individuals now unable to enter medicine for financial reasons.

The second point concerns the effect of our federally supported research
programs upon medical schools. It is certainly true that, in balance, medical
schools are greatly improved as a result of the intellectual ferment engendered
by the enlarged research activity and by the additional people supported by re-
search and training grants. Nevertheless, a price has been paid: single-minded
attention to teaching has been disturbed; funds have been diverted within the
schools because of less than adequate reimbursement for indirect costs; the regu-
lations which inhibit investigators paid exclusively by research grants from en-
gaging in teaching and patient care fly in the face of the philosophy universally
held that a combination of teaching, research, and service is desirable, and the
fragmentation of interest thus created has been divisive and not in the schools or
the Nation’s best interests. At the same time, the poorer medical schools have
been unable to benefit from enlarged research activities to the degree possible in
richer institutions, since they do not have the free funds necessary to prevent
imbalances. It is certainly in the national interest, in view of the shortage of
physicians, to assist these impoverished schools so that they can continue to
provide medical education of adequate quality. .

We believe, therefore, that teaching and patient care should be recognized as
part and parcel of research efforts. We know that many individuals in our
medical centers and complexes work more nearly an 80-hour week than the 40-
hour norm on which accounting principles have been based. We can find no
impropriety in permitting an investigator paid from research grant funds to
teach and to see patients as do his colleagues paid from institutional funds.
We recommend, therefore, that scientists wholly paid by research grants be

  
 
 
  
 
  
 
 
  
  
 
 
 
  
 
  
 
 
  
  
 
 
 
  
   
  
  
 
  
 
 
 
 
   
 
   
 
 
  
  
  
 
 
  
  
   
 
 
  
   
  
  
   
 
   
 
  
 
  
 
  
 
 
  
  
 
  
 
   
 
 
   
246 COMBATING HEART AND OTHER MAJOR DISEASES

allowed to teach and care for patients as do other faculty members. We also
recommend that institutional grants be made for the support of costs, including
faculty salaries, of medical schools, and finally, in order to support additional
numbers of full-time faculty and as awards of great prestige and special recog-
nition, we recommend the continuation and expansion of the Research Career
Award and the Research Career Development Award programs as Faculty
Career Awards and Faculty Career Development Awards.

Lest the foregoing paragraph seem to downgrade the need for research scien-
tists and technicians in favor of physicians and allied health workers in the
service areas of medicine, we wish to affirm emphatically our understanding
that health research, in the end, will provide better methods for the prevention,
detection, and cure of heart disease, cancer, and stroke than those we have now.
Fascinating new vistas are now opening up in our understanding of these disease
processes. The relationships between viruses and cancer, the factors influencing
inherited susceptibility to cancer, the associations among factors relating to
diet, obesity, and cardiovascular disease, the degree to which damage to the
elastic tissues are involved in aneurysms and atheromatosis; these and many
other problems illustrate the degree to which research may soon alter profound-
ly our understanding of disease processes. In considering health manpower
needs, therefore, continued, determined, and imaginative programs for training
research scientists, technicians, biomedical engineers, and other health allied
personnel should be strongly emphasized. Indeed, in reviewing the history of
some of the present research training programs, we have been struck by the
facts that support has sometimes been grudging and capricious; that programs
once started have been restricted or have retrogressed; and that total needs,
for example, the training of technicians, have had little ecousideration. We
recommend, therefore, that the research training programs be carried forward
vigorously and completely.

When considering ways in which medical schools can best be belped to increase
the number and quality of the Nation’s physicians, it is apparent that different
schools have very different problems. Some of the newer and some of the im-
proverished schools badly need full-time faculty in larger numbers. They need
research programs of greater vigor and size, and they need to develop the local
prestige which permits the full-time faculty to assume the leadership necessary
jn order to set standards of practice. At the other end of the spectrum, the
traditionally prestigious and well-supported institutions have faculties and
facilities the envy of their less well-endowed competitors, but have jacked any
stimulus to relate themselves more widely to the total health problems of their
communities. Between these extremes a large number of medical schools need
long-term financial assistance in order to enlarge and stabilize their full-time
faculties. The leading schools, with suitable encouragement, can expand imme-
diately into medical complexes, as discussed in chapter 4. The middle group can
grow into institutions which later will have the strength to form complexes
and the more impoverished schools need emergency assistance to prevent their
actual disappearance from the scene. It seems nonsensical to plan for rapid
formation of new schools without at the same time stabilizing those already
operative. We believe, therefore, that institutional grants should be provided
whereby all medical schools could strengthen their faculties in order to assume
greater community responsibilities. One component of these grants should be
weighted to favor the schools with small full-time staffs. Conversely, grants
for the formation of complexes together with career and career development
awards would enable the leading schools to continue development of their in-
tellectual resources and encouragement deployment of their faculties in ways
most advantageous for the health of their communities.

We come at last to examine whether or not additional doctcrs can be re-
eruited to meet the needs discussed here. Not too many years ago, Cassandras
cried that a falling number of applicants to medical schools portended failure
for any attempt to expand the medical education system. However, the tide
has turned and is now running in strongly. The ratio of pacealaureate graduates
to first-year medical students has been approximately 40 to 1 for many years;
projections of college graduates forecast that 742,000 degrees will be awarded in
1975; and, if so, we could accommodate about 18,000 medical students without
any decrease in quality from present standards. In addition, recent trends have
shown that national merit scholarship winners are turning in increasing numbers
toward the health sciences as careers. Women also represent a vast and nearly
untapped resource for the health professions. The Soviet Union has long had a
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COMBATING HEART AND OTHER MAJOR DISEASES 247

preponderance of women in medicine (approximately two-thirds) and in Eng-
jand, about one-quarter of all medical students are female. All of these indica-
tors lead to the conclusion that adequate numbers of qualified applicants will be
forthcoming. In view of the presently enormous need for additional physicians,
and considering that highly qualified applicants will be available in large num-
bers, we have no real choice except to expand our institutions for medical educa-
tion as rapidly as possible. We believe this to be a problem of national
dimensions, partly because one can hardly expect local resources to provide
fully for the needs of other regions, and partly because the provision of medical
education for those young men and women who are highly qualified is necessary
as a matter of public policy.

The President’s charge to the Commission requires us to determine where
impediments now hamper successful programs. We have determined that in-
adequate facilities and resources, particularly in the preclinical years of medi-
cine, are the primary obstacle inhibiting the training of adequate numbers of
physicians. We suggest, therefore, that the construction and other features of
the Health Research Facilities Act and the Health Professions Educational As-
sistance Act should be implemented fully. We believe further that the statutory
limitations in these acts, both in dollars and in time, should be increased and
‘extended.

The foregoing discussion has focused almost exclusively on the education and
training of physicians. The subcommittee does not wish to imply that shortages
and the problems of supply are limited to this category of health manpower.
It is fully recognized that many of these same problems exist in dentistry, nurs-
ing, and other health professions. Moreover, the close relationships and inter-
dependency of the educational and training programs of several health
professions in university medical centers indicates that there is a sharing of
common problems and a mutual interest that mandates planning and a compre-
hensive approach to the development and expansion of the Nation’s resources
for the preparation of increased personnel for the health professions. Con-
struction grants; institutional support; scholarships, traineeships, and fellow-
ships; and faculty career and development awards are needed, not just in
medicine, but in the several health professions that are so critical to the vi-
ability and effectiveness of the health establishment. The Health Professions
Educational Assistance Act ,the Nurse Training Act, the Graduate Public Health
Training Amendments of 1964, and other training programs of the Public Health
Service represent enlightened first steps toward even more imaginative and
responsive programs in the future.

All too frequently the importance of allied, auxiliary, or supportive health per-
sonnel is ignored in consideration of the Nation’s requirements for health
manpower.

Since physicians and nurses are not available in sufficient quantity, we must
make better use of trained assistants at the same time we expand our medical
and other health professional schools. ‘Not too long ago, nurses could not give
medications, nor use a hypodermic syringe. Today, these and much more com-
plex procedures are routinely performed by nurses. In the last generation, what
laboratory work there was, was done by the physician; today, the much-enlarged
battery of laboratory determinations are performed by corps of technicians
working under the direction of a clinical pathologist. Yet, the degree to which
medical procedures have been separated into component, and simpler, maneuvers
is much less than that done as a matter of course in industry. Similarly, auto-
mation has hardly been developed at all in the medical field, yet it is obvious
that cell counts, chemical tests, analysis of bioelectrical records, and many other
procedures are suitable for mechanization. We believe, in consequence, that
there should be strong support for research in methods leading to job analysis
and to the mechanization of medical procedures, so that they can be performed
by other than the scarce, highly trained categories of manpower.

This recommendation leads directly to the question of whether adequate man-
power exists to supply the needs for these new, partly skilled jobs. Here, the in-
formation is heartening. The rising tide of war babies, the large numbers of
employable women, the technologically displaced, and the other categories dis-
cussed in chapter 2, all point to a presently sufficient supply of untrained
men and women power. What is needed is increased capacity for training.
Given the necessary funds, the facilities now available in high schools, commun-
ity colleges, hospitals, aud medical centers are probably adequate to train such
auxiliary and supportive persons; however, adequate teachers are not available

  
 
    
   
  
  
  
  
  
   
  
 
 
 
 
 
 
   
  
   
 
   
  
 
  
   
  
  
   
 
 
 
  
  
   
  
 
  
  
  
  
  
 
 
 
  
 
  
   
   
   
  
  
   
  
  
 
 
   
  
  
  
  
  
  
 
  
   
 
 
  
 

248 COMBATING HEART AND OTHER MAJOR DISEASES

in anything approaching sufficient numbers nor are adequate teaching programs
available. We recommend, therefore, strong support of the vocational education
programs of the Office of Education as they relate to the health fields and to the
similar programs supported through the Department of Labor’s Area Redevelop-
ment Act, the Manpower Development and Training Act, and the Economic Op-
portunity Act. We believe that the Department of Heaith, Education, and
Welfare should assume leadership in assessing needs and in encouraging and
promoting the development of new and expanded programs of vocational training
in the health fields.

We believe that shortages of teachers will continue to plague health programs
for some time to come, and we strongly urge teacher-training programs in these
activities. Also, since the Office of Education customarily works with and through
the school systems of the States, whereas medical education and many of the
health profession schools, even in State institutions, have little contact with the
secondary school system, we recommend that a coordinating function be estab-
lished within the Department of Health, Education, and Welfare. Ideally, it
would seem that support through the Office of Education might well go to the
schools and community colleges providing vocational education courses, and that
assistance for the practical training or on-the-job experience might come through
grants made by the Division of Community Health Services to the health institu-
tions. The Subcommittee believes that adequate authority for such programs
now exists, but that the Division lacks sufficient funds to implement these in-
centive grants adequately. In this instance, the investment of relatively small
sums of money for planning and coordinating activities in health institutions
eould greatly enhance the effectiveness and impact of the funds available for the
training of health manpower under the Vocational Education Act.

Promoting effective use of health manpower

Whichever way we turn, the Subcommittee is forced to conclude that rapid and
substantial Federal support of education is needed in all the health fields. That
this is not the whole answer is clearly recognized by the Subcommittee. In-
creased efficiency must be achieved in the health establishment. The importance
of community planning and the creation of medical complexes as steps toward
increased effectiveness in the use of health manpower has been stressed in
chapter 4.

Areawide or community planning of health facilities is widely discussed, fre-
quently advocated, but ail too seldom practiced. Few planning activities have
gone beyond facilities to attempt to plan in terms of health manpower and serv-
ices. The Hospital and Medical Facilities Amendments of 1964 authorized grants
for ‘“* * * developing and supervising and assisting in the carrying out of com-
prehensive regional, metropolitan area, or other local area plans for coordination
of existing and planned heaith facilities, and facilities related thereto, and
services provided by such facilities.” The Subcommittee wishes to go on record
as supporting this legislation; furthermore, we recommend the fullest imple-
mentation of this program and its expansion as soon as is feasible.

Throughout any discussion of the mechanisms for achieving the most effective
use of skilled manpower there is recognition of the need for research and in-
vestigations concerning patterns of organization, communications, and inter-
personal relations. Such research is of singular importance to the health
establishment if we hope to achieve new methods of patient care, and more
adequate approaches for the delivery of high-quality health services that in-
corporate the very latest biomedical achievements. Such research must be
directed toward a range of topics including training techniques, job analysis.
multidisciplinary health services, continuation education, patient response to
health needs and the like. Research in health services can enable us to achieve
the maximum yield in both quantitative and qualitative terms from our existing
health manpower.

The next logical step following the acquisition of new knowledge is to imple-
ment these findings through demonstration projects. In areas other than health.
development is recognized as the companion of research. Such a relationship
and its merits are often overlooked in the health establishment. The principles
of coordination of health services or of comprehensive care that are formulated
through research must be tested and improved through repeated attempts at
implementation in different settings. The health establishment can profit from
the extraordinary achievements in industry where basic research, applied re-
search, and development are carried out sequentially in pursuing an objective.
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COMBATING HEART AND OTHER MAJOR DISEASES 249

An extensive program of demonstration grants can stimulate the necessary
developmental activities that are so desperately lacking in health programs
today.

We should like to close this section with some remarks on the seale of future
planning. Many of the manpower problems are the result of inadequate prepara-
tion in the past. The health industry has grown rapidly, from $13.5 billion in
1955 to $35.4 billion in 1964, and some projections predict health expenditures
of $84.4 billion by 1975. This trend is in line with the commonly expressed
opinion that rising productivity should be coupled with increased expenditures
in the public sector of our economy. As these changes have occurred, the ex-
panded health research programs of the postwar years have generated a multi-
tude of new procedures, some of which are simple and readily applicable and
some of which are complex, expensive, and esoteric. High energy radiotherapy,
open-heart surgery, hypothermia, hyperbaric oxygenation and many others are
examples of procedures requiring expensive equipment and well-trained teams.
Others are even now visible on the horizon; it is certain that transplantation
of organs and correction of inheritable defects will soon receive extensive trials.
In research, similar developments are commonplace; the light microscope has
given way to the electron microscope and the X-ray microscope is in prospect.
Each is more expensive, each requires more space and each involves larger
numbers of more highly trained manpower than did its predecessor. The fore-
sight needed to plan today’s institution which can meet tomorrow’s needs is
surely not beyond our capabilities. We have in the United States several medical
schools planned 50 years ago which accommodate today twice the original num-
ber of students and immeasurably enlarged research programs. We can, and
should, plan today’s facilities and organizations large enough and flexible
enough to expand for tomorrow’s needs, Yesterday’s small and parochial in-
stitutions are being transformed into today’s larger and more comprehensive
units; these in turn must inevitably coalesce into communitywide complexes,
each part of which has room to breathe and grow. Our plans and dreams must
be on a scale to fit tomorrow’s reality. Niggardly and haphazard contrivances
today will ill subserve and long constrain tomorrow’s progress. To build health
complexes, to provide centers of excellence, to produce enough dedicated people.
to improve the Nation’s health, and the world’s—these are challenges to test
our souls. We have already begun ; let us continue.

RECOMMENDATIONS

Throughout this report of the Subcommittee on Manpower there runs a theme
of urgency. Our expanding population, particularly that component especially
susceptible to heart disease, cancer, and stroke, is creating demands for health
manpower never before realized.

The recommendations of this Commission, if needed, will employ many addi-
tional people, both professional and subprofessional in health services. The
public demand for the medical care now possible or soon to be realized has
created needs for health personnel which are, for the time being, insatiable.

manpower effectively and to enlarge rapidly our resources for increasing the prep-
aration of health personnel needed so urgently. Toward these needs we be-
lieve the following actions to be necessary :

We must expand the basic Tresources and facilities for educating and training
health personnel. The Subcommittee on Manpower recommends that:

1. The Health Professions Educational Assistance Act of 1963 be amended to
eliminate the ceiling on appropriations ; that a severalfold increase in appropria-
tions be provided so that no school with capacity to expand its student body

> and that boldness be exerted to stimulate the de-
velopment of new schools.

2. Legislation be sought to permit forthright support of medical education,
this to include formula grants to health profession schools,

We must develop increased opportunities for education and training leading
to ieee the health occupations. The Subcommittee on Manpower recom-
mends that:

3. Programs designed to attract young people into the health professions and
related disciplines,

  
 
 
  
  
  
  
     
   
  
  
 
   
   
  
 
    
   
  
  
 
 
  
 
   
 
   
   
 
   
  
   
  
 
 
 
  
   
  
 
 
  
  
  
 
  
   
   
  
 
 
  
 
 
  
 
   
  
 
 
   
 
 
  
  
  
 
  
 
 

250 COMBATING HEART AND OTHER MAJOR DISEASES

4. A coordinating office be established within the Department of Health, Edu-
cation, and Welfare to provide liaison among the agencies and programs con-
cerned with health manpower.

5, A program of grants be made available to stimulate the training of health
personnel in community and junior colleges, in cooperation with medical centers.

8. The Health Professions Educational Assistance Act of 1963 be amended to
provide for a program of Federal scholarships for talented medical and dental
students in need of financial assistance and that matching grants for the cost
of education accompany each scholarship.

We must increase the efficiency and. effectiveness of the highly skilled health
manpower now available. The Subcommittee on Manpower recommends that—

7. There be established a health manpower unit to carry out continuous assess-
ment of national manpower requirements for health services. The Subcommittee
further recommends that the Surgeon-General appoint a consultant group. to be
staffed by the Manpower Unit,. to, advise.on problems of health technician per-
sonnel.

8. Greatly increased emphasis and support be given to programs of research
and research training in community health with special emphasis on the problems
of more effective use of health manpower and improvement in the coordination
and delivery of health services.

9. There be increased support of demonstration projects under the Community
Health Facilities and Services Act of 1961 with special emphasis on new patterns
for the delivery of health services that achieve more effective use of health man-
power.

We must shorten. the time between scientific discovery and widespread applica-
tion. The Subcommittee on Manpower recommends that—

10. A broad and flexible program of grant support be undertaken to stimulate
the formation of medical complexes whereby university medical schools, hospitals,
and other health care and research agencies and institutions will work in con-
cert.

11. The establishment of full-time career awards in universities and other in-
stitutions, not only for research personnel but also for clinical investigators and
clinical professors.

REPORT OF THE COMMUNICATIONS SUBCOMMITTEE

(Mr. Emerson Foote, Chairman, Mr. Barry Bingham, Mr. John Carter, and Dr.
R. Lee Clark. Staff: Dr. Bayard H. Morrison, Mr. Marcus Rosenblum. and
Dr. Abraham M. Lilienfeld. Consultant : Mr. Mike Gorman)

The prevention and control of heart. disease, cancer, and stroke—the saving
of a human life—begins not with the doctor, the hospital, or the medical center.
It begins with the individual himself.

He decides to go for a checkup—either before symptoms appear or at the
earliest sign of trouble. Or he decides not to. The decision, often made casually
or even subconsciously, may add or subtract a decade from his life.

Many factors influence his decision. One is his financiul condition. Another
is the convenience and accessibility of medica! attention. The most important
factor is the state of his knowledge about health matters.

Once he enters the medical orbit, his fate is again subject to many whims
of chance. If he is wise enough to make his appointment soon enough, and if
the physician he chooses is trained and equipped to detect an incipiently dan-
gerous condition and make the prover referral. and if his community is blessed
with the special skills and facilities his condition requires and if he is able
and willing to follow through the preseribed course of treatment—in this happy
conjunction of circumstances—his life will be prolonged, his function unimpaired
or restored.

Breakage of any link in this chain can nullify the strength of the others.
Nearly every link depends upon the right knowledge in the right place at the
right time. Conversely, many thousands of heart disease, cancer, and stroke
deaths occur because of failures in the communication of lifesaving knowledge
to the potential victim or to the physician who treats him.

It is to these costly failures that the Subcommittee on Communications has
directed its principal attention. We recognize the vital importance of research
communication—between scientist and scientist. We wholeheartedly endorse the
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COMBATING HEART AND OTHER MAJOR DISEASES 251

recommendations of other Subcommittees concerning the need for strengthening
the medical library system and adding to the electronic capability for handling
research information, But we feel that the greatest impact on death and dis-
ability from heart disease, cancer, and stroke, now and in the years immediately
ahead, can be made through intensive nationwide effort to bring to the physician
and the public the information they need about these diseases. It has been said
that knowledge is power. In health, it is the power of life and death.

A Federal mandate

The Federal Government, as described elsewhere in this report, has been given
a clear mandate and substantial resources to support the generation of health
knowledge through biomedical research. The results of this policy have been
the great scientific advances that characterize our time.

But knowledge unused is knowledge wasted. And strangely, the Federal Gov-
ernment has not been given a similar mandate and similar resources to support
the transmission of medical knowledge to its point of application.

One point of application is the meeting place of physician and patient. Knowl-
edge or the lack of it on the part of the patient brings them together in time or
keeps them apart too lung. Knowledge or the lack of it on the part of the doctor
determines the success of their encounter. Clearly, this is the ultimate target
of biomedicai research. These are the prime audiences. Equipping both patient
and physician for their encounter is a communications task: a process of educa-
tion and information.

There are longstanding and largely unspoken obstacles to vigorous Federal
participation in this process. Federal support of education in any form has been
viewed darkly because of fears of Federal control in a political sense. Strong
Federal programs of public information have been treated with suspicion
through fear of self-aggrandizement via press agentry.

Without seeking to judge broader policy matters, we submit that in the com-
munication of health kuowledge these fears are illusory and irrelevant. They are
worse: they contribute to unnecessary death and disability.

In the generation of health knowledge, the Federal Government has abundantly
demonstrated its aiblity to stimulate and support productive effort without stifling
control. It has doue su by developing a partnership of Federal and non-Federal
scientific resources in a system which promotes individual freedom and initiative.
Similarly in the communication of health knowledge, it can and must develop
a partnership whereby scientific and communications skills and resources, both
Federal and non-Federal, work together to transmit the urgent messages upon
which health depends.

The Subcommittee on Communications therefore recommends, as a funda-
mental policy underlying its subsequent specific recommendations, that the com-
munications functions of the Public Health Service, and especially those related
to public information and the continuing education of the health professions, be
recognized and supported on a scale commensurate with their importance as a
major weapon in the prevention and control of disease.

Publie information

The public has an almost insatiable thirst for health information. News-
paper readership studies have shown that health articles rank high both in
number of readers and in retention of information. Every major daily news-
paper has at least one column devoted to health. News which suggests a
scientific breakthrough is given front-page prominence. The general interest
magazines rarely go to press without a substantial quota of health information.

Yet the public remains remarkably uninformed, or remarkably slow to act,
on many matters which are quite literally “of life and death.” Part of the prob-
lem may stem from the sheer profusion of available information, sometimes
contradictory and frequently half-true or halfhearted.

In all three disease fields falling within our purview we were told by medical
experts that the average American family today is not aware of the simple,
fundamental measures necessary to protect its members from these diseases.
This is a failure of communications.. The coronary-prone middle-aged male, the
young mother with one of the seven danger signals of cancer, the corporation
executive who is suffering from one or more precursors of stroke—why don’t they
act while there is still time? Because they either lack the information, or the
information has been presented in such a fashion that they lack the motivation
to act upon it.

  
 
 
 
  
  
  
 
  
 
 
 
 
  
 
 
  
  
  
 
  
  
  
  
  
  
   
   
 
 
  
  
 
   
   
  
  
 
   
 
 
 
 
 
 
 
 
  
  
 
  
 
  
 
  
  
 
  
  
   
  
   
  
  
   
 

252 COMBATING HEART AND OTHER MAJOR DISEASES

We must therefore make much greater and more imaginative use of existing
communications media, and we must create bold new channels of information
to close the alarming gap between the acquisition of research knowledge in our
medical centers and laboratories and its dissemination to the family physician
and to the general public.

We have a magnificent and exciting story to tell. Every American is deeply
concerned with the preservation of his own health and that of his loved ones, yet
we have not capitalized upon that concern. We must take the plunge into the
mainstream of modern communications. We must use the advertising and
promotional techniques which have been so successful in creating a demand for
consumer goods to create a similar demand for the knowledge which will save
thousands of precious lives.

We therefore recommend the following steps be taken :

STRENGTHENING PHS INFORMATION SERVICES

We believe the Public Heaith Service has a duty and a responsibility to use
every possible resource to bring the latest health information to the American
people. In a matter so urgent as the prolongation of life and the prevention of
needless disability and death, we must insist upon the highest priority for
these communications activities.

For this reason we recommend that the funds appropriated for the Office of
Information and Publications in the Office of the Surgeon General should appear
as a budgetary line item. They should be increased by $750,000 per year to
finance such additional activities as—

(a) Recruitment and inservice training of information specialists, selected
from among young college graduates, to improve dissemination of health
information to the public;

(bv) Creation of materials for free public service announcements on
health for use by radio, TV, and magazines ;

(c) Development of fact books on specific health topies, summarizing
present scientific knowledge for the use of reporters and community leaders;

(d@) Development and production of a health yearbook, similar in scope
and quality to the agriculture yearbook, to create a series of authoritative
and understandable reference volumes in specific health topics;

(e) Assignment of writer-editors to accompany foreign PHS missions
and to report promptly on the findings and experiences of such missions;

(f) Assignment of writers to produce prompt summary reports of scien-
tific conferences in forms suitable for the health professions.

TRAINING IN HEALTH COMMUNICATIONS

Because the transmission of medical information has been given such a low
priority in our total national health effort, we have given little attention to the
recruitment and training of communications specialists in the health field.
There is a desperate shortage of these skilled specialists, both in the Public
Health Service and in medical centers and universities throughout the country.

We therefore recommend that the Office of Information and Publications in
the Office of the Surgeon General be allocated a specific annual sum of $1 million
solely for these training purposes:

(a) A grant program to educational institutions for the development of
pilot training programs in the field of medical communications. Such grants
should support the development of a core curriculum, the payments of faculty,
and provision of stipends for trainees. A university which has both a medical
center and a school of journalism would probably serve as an excellent setting
for these pilot training programs in communications.

(6) Provision of fellowships for the on-the-job training of a variety of per-
sonnel in the gathering and writing of science information materials. Many
of these fellows would be trained in the various agencies of the Public Health
Service; many would be trained in our medical centers and large research
institutions throughout the country.

In addition, we recommend that the Public Health Service conduct and sup-
port seminars and other methods designed to give professional science writers
aa aad they need to write accurately, responsibly, and clearly on health
subjects.

Science writing is a highly developed skill. The popularization of such
scientific fields as nuclear physies and space has been brilliantly successful.
 

  
 
  
  
 
 
   
  
  
 
 
  
 
  
 
  
 
  
 
  
 
 
 
 
   
 
 
  
 
 
 
 
 
   
  
 
 
 
 
 
 
  
   
 
 
  
 
  
  
  
 
 
 
 
  
 
 
  
  
 
  
 
  
  
  
  
  
 
 
 
  
  
  
   
   
   
 
 
 
  
  
 

COMBATING HEART AND OTHER MAJOR DISEASES 253

f existing In the medical field, both within and outside Government, there has been a
formation persistent reluctance on the part of scientists and physicians to take professional
ge in our writers behind the scenes on a basis of mutual confidence and open doors to
physician genuine understanding on matters of profound interest to the public. As a

result, medical writing in the popular media—again with some outstanding
is deeply exceptions has tended to be fragmentary and often ntisleading. The Public
ones, yet Health Service should take the lead in remedying this condition, and its public
-into the information offices should be authorized and encouraged to do so.
sing and
mand for RESEARCH CENTER ON HEALTH MOTIVATION
will save

In mounting preventive attacks upon heart disease, cancer, and stroke, we
face the difficult challenge of changing the life patterns and habits of millions
of people. For example, it is fairly easy to put out a pamphlet listing the
various factors which predispose an individual to a heart attack, but it is
extraordinarily difficult to get that individual to reduce his calorie intake,

y to use to give up cigarette smoking, or to limit the stress factors in his daily life.
-merican Little research has been done on the effectiveness of the various approaches
ntion of which have attempted to change the ingrained habits of people. Unless this
rity for important research is conducted by behavioral scientists, sociologists, and other
specialists, we will lack a solid scientific base from which we can tailor our
Office of educational efforts toward motivating change in people.
| appear We, therefore, recommend that the Public Health Service be provided with
year to funds to initiate the development of a center for research in health motivation.
In addition to specific behavioral studies directed at the individual decision-
selected making process in changing patterns of living, the center would analyze the
' health contents of public campaign materials with reference to their effectiveness and
influence upon behavior, and it would hopefully concentrate particular atten-
ents on tion upon hard-to-reach population groups which reject existing educational
campaigns emphasizing individual initiative and changes in living patterns.
larizing It is estimated that $500,000 a year for 5 years would be necessary to initiate
eaders ; the development of such a motivational research center.
nitathes Continuing education of the health professions
The forward sweep of medical science has brought about a kind of instant
lissions obsolescence in medical knowledge. Most physicians practicing today received
ssions; their medical education in the 1930’s and 1940's. The fact that they are prac-
' scien- ticing two or three decades later poses @ critical obstacle to the delivery of

up-to-date health care.

For many years, lipservice hag been paid in the medical profession, as in
most other professions, to the concept of continuing education. But the facts
of daily life are hard to overcome.

a low Most doctors work a 60-hour week. Even their free time is never truly free.
to the They are deluged with paper, ranging from professional journals to flyers
field. advertising the latest medical gimmick, Among the papers are invitations
Publie to attend lectures, seminars, clinical conferences. But only the supermotivated
untry. or the semileisured are able to respond often enough to keep pace with their
ons in changing profession.
nillion Thus the greatest single obstacle to a cohesive program of continuing educa-
tion for the medical profession is time. The second is diversity of interests
nt of and needs. The third is the fact that continuing education, although it is
srants recognized as a critical problem in medicine today, is not the primary respon-
culty, sibility of any significant segment of our national health resource.
edical Medical schools, the logical locus for the major effort, are correctly pre-
etting occupied with undergraduate education first and research second. Continuing
education, if it receives any attention at all, must settle for what is left of
f per- already inadequate resources. Similarly, community hospitals could contribute
Many greatly to the continuing education of community physicians, but their first
ealth job is to care for the patients. Professional societies have many other
earch responsibilities,
Yet continuing education is a categorical imperative of contemporary medi-
Sup- cine. Without a large-scale, effective organized effort, the worlds of science
‘iters and practice will spiral still farther apart. The gap between what is known
ealth and what is received by patients will be harder and harder to bridge.
The Public Health Service clearly has a leadership role to play in helping
such to forge a national continuing education effort, by assisting all the available
sful. resources in giving due attention to this problem.

43—669—65——_17

  
 

254 COMBATING HEART AND OTHER MAJOR DISEASES

STRENGTHENING CONTINUING EDUCATION PROGRAMS

The Subcommittee recommends that appropriate units of the Public Health
Service be provided with funds and authority to:

(a) Stimulate and support through grants, contracts, or in other appro-
priate ways, demonstration projects and experiments directed by medical
schools, community hospitals, professional organizations, or any other appro-
priate agency, designed to make important scientific knowledge systematically
and conveniently available to practicing physicians.

(b) Stimulate and support research projects designed to develop new and
improved methods of conducting continuing education programs, including
experimentation with various media (ie., closed or open circuit television, etc.),
various instruction methods (ie., programed instruction, seminars, etc.),
and various means of evaluating such programs in terms of their actual
impact in upgrading medical practice.

(ce) Disseminate as widely as possible the results of experiments, demonstra-
tions, and other projects in the continuing education field, whether sponsored
by the Public Health Service or by others, so that all interested organizations
may benefit from the experience of others.

(d) Conduct studies and demonstrations in communications technology and
educational methodology.

For these purposes the Subcommittee recommends appropriations of $2. mil-
lion for the first year, $4 million for the second, and $6 million for the third.

A NATIONAL MEDICAL AUDIOVISUAL FACILITY

The imaginative use of new communications media offers the best hope for
necessary breakthroughs in continuing education. The Subcommittee believes
that in addition to its broad program of support for continuing education
outlined above, the Public Health Service should also take leadership in
producing, disseminating, and promoting the use of audiovisual materials for
continuing education of the health professions.

The Public Health Service Audiovisual Facility, located at the communicable
disease center in Atlanta, Ga., on a small scale, has already demonstrated high
competence in the production of training and educational materials, and in the
collection and dissemination of such materials produced elsewhere.

We, therefore, recommend that the Public Health Service Audiovisual Facility
be enlarged in scope and strengthened so that it may become a national medical
audiovisual center. To this end we recommend the following specific steps:

(a) The appropriation of $1.5 million for necessary renovation and expansion
of facilities.

(b) Appropriation of $1.5 million for the first year, sealed upward to $4 million
for the fifth year, to develop an intramural program which would include produc-
tion, experimental use, and evaluation of educational materials in such areas as
radio, television, motion pictures, programed instruction, etc.; research and
training programs in audiovisual fields; international exchange of medical mo-
tion pictures ; and other purposes. :

(c) Authorization of an extramural program of grants and fellowships and
appropriations to support such a program, beginning at the level of $1.5 million
per year and rising to $8 million at the end of a 5-year period; such a program
would enable the Center to support selectively promising projects in audiovisual
communication at medical schools, community hospitals, and other institutions
and to assist, through training grants and fellowships, in the development of a
national cadre of medical communications specialists.

In addition to the program outlined above, the Subcommittee feels that the
National Medical Audiovisual Facility should exert immediate and strong lead-
ership in two communications media of particularly high promise for continuing
education of the health professions. These are, first, the field of closed circuit
television which is already being used sporadically, to a limited extent, by medi-
cal schools, hospitals, and other health agencies; and, second, the use of portable
projectors for cartridge-type films which are especially adaptable to private use
by physicians in their own offices, at times of their own choosing.

We therefore recommend: (a) That an appropriation of $2 million per year,
initially, be made to the National Medical Audiovisual Center for the specific
purpose of developing, disseminating, and evaluating closed circuit television
programs on subjects of vital interest to the health professions.
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COMBATING HEART AND OTHER MAJOR DISEASES 255

(b) That an initia) appropriation of $1 million per year be made to the Na-
tional Medical Audiovisual Center to produce short films for use in cartridge-
type projectors, and to Promote the widespread use of this promising new edu-
cational device by the medical profession.

TELEVISION

The health world has been slow to focus the awesome power of television on
Specific health problems requiring specific public understanding and response.

The medium is ideally suited for delivering clear visual information in dra-
matic and forceful terms. The art of the documentary film, true to science
and at the same time challenging to the interest, is highly developed. Com-
mercial television is capable of reaching an overwhelming mnajority of the Ameri-
can people, and educational television is growing rapidly.

Yet health documentaries have been few in number, uneven in quality, and
Senerally drab in presentation. It has been their quality, rather than their
Subject matter that has relegated them to unattractive scheduling and doomed
them to small audiences. Television producers are as aware as newspaper and
magazine editors of the tremendous public interest in health, The products,
with a few shining exceptions, have simply been inferior in the highly competi-
tive world of commercial television.

The Subcommittee recognizes the problems faced by a Government agency
like the Public Health Service in recruiting and employing scarce topflight
creative talent in motion pictures and television. It recognizes the scientific
knowledge necessary to give complete accuracy and authenticity to health

audiovisual center.

We therefore recommend that the Public Health Service be authorized, and
that funds be appropriated, to contract with professional television producers
for the production of twelve 30-minute documentary films each Year of the
highest quality, on subjects related to heart disease, cancer, and stroke, and
any other subjects as may later be deemed desirable. Each film should be
budgeted at or about the level of $150,000 to assure writing and production that
will make the films competitive with the best of commercial television. This
price should include a sufficient number of prints to assure widespread use on
local commercial television outlets across the Nation. The contract should
also provide for the full participation of the producer and his organization in
the marketing of the films. The Public Health Service, in conjunction with
non-Federal scientists and physicians designated by the Service, should have
full control of the content of each film. The. films should be available for com-
mercial sponsorship within q predetermined range of appropriate product classi-
fications, excluding such obviously inappropriate Sponsors as tobacco companies,
pharmaceutical firms, and the like.

In the Subcommittee’s view, the potential of television as a disseminator of
health information to the public can be realized only through quality production
of authoritative material, made available in such a way that it can be viewed
in prime television time by the widest possible audience. The method proposed,
which consists essentially of a Federal investment in communication talent, would
cost about $1.8 million per year. Alternative methods, such ag the governmental
purchase of prime time, would cost as much and result in the showing of inferior
products, with inevitably inferior results. The impact of 12 first-class docu-
mentary films, each carrying a message of urgent importance for the protection
of American families, would be immediate and overwhelming.

The Subcommittee further recommends that the Public Health Service be:
authorized, and that funds be appropriated to the National Medical Audio-
visual Center to support through appropriate mechanisms, such as grants or
contracts, the development of effective television programing in the health.
field on the Nation’s educational television stations. The sum of $1 million per:
year is recommended as a beginning figure,

TV programs reach school audiences at all levels from primary school through
college. In many communities, the ETV program is viewed widely by the adult:
intellectual and civic leadership as well. It represents an excellent medium for

attracting young people to health careers, for establishing and maintaining
desirable health habits, and for stimulating desirable communitywide health
activities. In many areas, ETV facilities can also be used for continuing educa-

  
   
  
 
  
  
 
 
 
 
  
 
 
 
 
    
   
 
  
  
 
 
 
 
 
 
  
 
   
 
 
  
 
  
  
 
  
  
  
  
 
  
   
   
  
 
 
 
   
 
 
 
 
  
  
 
 
 
 
  
 
 
 
 
 
 
  
  
  
  
  
 
 
 
 
 
 
  
  
 
 
  
 
 
 
 
 
  
  
  
 
  
 
 
  
 

256 COMBATING HEART AND OTHER MAJOR DISEASES

tion of health professionals. The health potential of this growing educational
force has scarcely been touched.

A CLEARINGHOUSE FOR DRUG INFORMATION

The Subcommittee recognizes the fact that improper use of drugs is today an
important cause of avoidable disease. Because the gaps and wasteful duplica-
tion associated with present independent efforts to handle drug information are
repsousible for much important information failing to recah those who need it
most, and in view of the progressive increase in the consumption of medications
and other chemical products, the Communications Subcommittee endorses current
proposals for the establishment in association with the National Library of Med-
icine, a national drug information clearinghouse, serving and supporting govern-
mental and nongovernmental drug information units.

We believe that the clearinghouse should be given authority and eventually
additional funds for providing grants to promote compatibility and cooperation
among drug information units.

The clearinghouse should include full information on the chemical structures
and biological properties of all known compounds and the derivatives of such
chemicals, with regard for their cellular, environmental, and social effects. It
should gather information from all reliable sources, including the published
literature, conference proceedings, Government reports and other records. Fur-
ther, that the clearinghouse should produce, both for general and specific users,
annotated bibliographies, systematic files of information on drugs in forms suit-
able for replication, critical reviews, compilations of evaluated data, judgmental
responses to individual inquiries, and other appropriate information.

The promotion of health

The Subcommittee on Communications is well aware of the fact that its
recommendations range beyond the problems of heart disease cancer, and
stroke, if these problems are considered narrowly. We feel strongly that more
effective transmission of health information to the public and the professions—
whatever the specific subject may be—is essential to the saving of human lives.

We believe further that strengthening our health communications resources
must inevitably advance the crusade against heart disease, cancer, and stroke.
As a member of the Commission stated early in its deliberations:

“We have a majority interest in personal disaster in the United States—and
conversely a majority opportunity to help improve the health and prolong the
life of the U.S. population.

“That is beeause 71 percent of all U.S. deaths are caused by heart disease,
eancer, or stroke.

“Seventy-one percent is a majority interest in anything.”

People want information about heart disease, cancer, and stroke. If reliable
information is presented to them, they will act upon it. And their action will
set in motion a chain of events that will sharply reduce the toll of these diseases.

In this sense, communication is as fundamental to health as research itself.
We of the Communications Subcommittee urge that the worlds of medical science
and medical practice accept this added challenge. And we strongly recommend
that the Federal Government fulfill its responsibility to promote the health of
the Nation through strong and effective communications programs.

REPORT OF THE SUBCOMMITTEE ON FACILITIES

(Mr. Arthur Hanisch, Chairman; Mrs. Florence Mahoney, and Dr. E. M. Papper;
Staff, Dr. Bayard H. Morrison, and Dr. Abraham M. Lilienfeld)

INTRODUCTION

Research, patient care, education, and training of health personnel require
appropriate, well-equipped facilities. The burgeoning population and simul-
taneous obsolescence of existing facilities have severely strained State and com-
munity abilities to provide new facilities and renovate old. Federal assistance
through the Health Research Construction Act and the Hospital Survey and
Construction Act, has been a vital force in alleviating a critical, nationwide need
for care and research construction. The recently enacted and funded Health
 

COMBATING HEART AND OTHER MAJOR DISEASES 257

Professions Educational Assistance Act holds out a similar promise for educa-

tional and training facilities.

Yet, the mounting of an expanded national effort to reduce the burden and
incidence of heart disease, cancer, and stroke will clearly require the establish-
ment of additional facilities for research, education, and the care of patients

with these diseases. Other Subcommittees of
need for and recommended the development of

the Commission have cited the
additional categorical facilities.

However, since a large part of medical research, patient care, and health
education in all health institutions is necessarily concerned with heart disease,

cancer, and stroke, the Facilities Subcommittee
mine the entire national need for patient care,

considered it desirable to deter-
research, and educational facili-

ties. As no estimate of national need was available, the Subcommittee undertook
a survey of medical, dental, osteopathic, public health, and veterinary schools;

of research centers; and of community hospitals.

The aim was to obtain informa-

tion regarding their needs, plans, and problems in respect to coustruction of new

facilities and reconstruction of old.
Each institution was asked to estimate not

only their needs but also how

much could be met through present Federal programs, including Federal money

awarded without requiring matching funds.

Questionnaires were sent to 978 institutions : 99 medical schools (88 established,
1 to open in the fall of 1964, and 10 in various stages of planning—medical schools

were asked to provide information on their affilia

ted hospitals) ; 49 dental schools;

5 colleges of osteopathy; 12 schools of public health; 18 schools of veterinary

medicine; 24 research institutes; 53 communit
with medical schools, with a bed eapacity of
8.5-percent sample of the national complement

y hospitals (largely unaffiliated
less than 300, representing an
of hospitals of this size) : and

118 largely unaffiliated community hospitals (with a bed eapacity of 300 or
more, representing a 28.8-percent sample of such hospitals).
In addition to requests for information on needed facilities, the deans and

administrators received the following questions :

“What obstacles are presently impeding or may later serve to impede imple-

mentation of your plans for construction and ren

ovation?”

“What is your view of eategorical research eenters, i.e., cancer, cardiovascular
or stroke centers, embodying clinical and nonclinical disciplines? If desirable,
how should they be constructed and administered, e.g., within the university

framework, university-affiliated, federally sponsored, independent, etc.

On the whole, there was better than a 75-
Nearly 60 percent of the tastitutions provided

Qe
percent response to the survey.
detailed categorical estimates of

their needs. The results of this survey are presented separately, as a source
paper, although specific items are cited throughout this report of the Sub-

committee.

This report discusses facilities recommended by Subcominittees on Heart

Disease, Cancer, Stroke, and Rehabilitation ;
educational facilities; patient care facilities ;
animal care facilities.

research facilities in general;
medical library facilities; and

This Nation has numerous other resources which could be developed, strength-

ened, or modified in ways that would expand

research, education, and health

care. It would have been manifestly impossible for the Subcommittee to con-
sider them all. Therefore, this report will deal with the following few: general
research support grants; the Veterans’ Administration; Public Health Service

Hospitals; grants for developing new resourc

es; and statistical resources.

FACILITIES RECOMMENDED BY OTHER SUBCOMMITTEES

The Facilities Subcommittee has reviewed t

he facilities recommendations of

the Commission’s Subcommittees on Heart Disease, Cancer, Stroke, Rehabilita-

tion, and Research and concurs wholeheartedly.

It appears, moreover, that there is widespread support for the concept of
categorical research and care units as endorsed by these subcommittees. In
the survey conducted by the Facilities Subcommittee, 63 percent of responding

institutions, particularly research institutions

and health professional schools,

favored the establishment of categorical research centers. Furthermore, most
suggested that such centers should be developed within the nniversity-medical

school framework or be university affiliated.

Regarding construction and renovation of research centers, and facilities for

patient care and professional education, almost 75 percent of the responding

  
 
  
 
 
  
  
  
 
 
  
 
 
 
 
 
  
 
  
 
  
   
  
 
 
  
   
 
 
 
 
  
 
 
  
 
  
  
 
 
  
  
 
 
 
   
 
 
 
  
 
  
 
  
 
 
 
  
 
 
 
     
 

258 COMBATING HEART AND OTHER MAJOR DISEASES

institutions asserted that the primary obstacle to growth was a lack of sufficient
funds. Among those who commented on the proper role of the Federal Govern-
ment in construction and renovation of health facilities, a great majority
indicated that such assistance was not only necessary but should be expanded
and made more flexible through the use of low ratio or nonmatching funds.

RESEARCH FACILITIES

Of the institutions surveyed, 218 submitted categorical estimates which, in
total, presented a need for research and research training facilities that would
cost $1.1 billion in 10 years for these institutions alone. It was felt that only
46 percent of this need could be met with existing requirements for obtaining
Federal support. Nearly 90 percent could be met, it was estimated if Federal
grants were available on a nonmatching basis.

Approximately 85 percent of the total need for research facilities was ex-
pressed by 124 responding schools. The remaining 15 percent reprexents the
stated needs of 77 hospitals and 17 research institutions.

If the 10-year needs of these 77 hospitals are used as a basis for estimating
the requirements of 1,034 hospitals with similar characteristics, a 10-year pro-
gram of building and renovating research facilities would amount to about $1.5
billion. By the same method of calculation, the total 10-year program for
1,217 institutions—hospitals and health professional schools—would be $2.8
billion.

EDUCATION AL FACILITIES

The Facilities Subcommitee fully concurs with the Manpower Subcommittee’s
recommendations concerning educational facilities. The Facilities Subconinittee
found in its survey a striking confirmation of the national need for strengthen-
ing biomedical facilities.

The 218 institutions submitting categorical information estimated a 10-year
educational facilities need of $868 million, more than 90 percent of which rep-
resents the requirements of 124 schools. These schools feel able to satisfy only
53.6 percent of these needs with present sources of support. Present support
is said to be sufficient to finance only 31 percent of a much smaller need presented
by 77 hospitals and for only 20 percent of the estimated needs of 17 research
institutions. If nonmatching Federal money were made available, the institu-
tions indicated that all their 10-year needs could be met.

A projection of 10-year needs—based on the information submitted by the
relatively small number of responding institutions—was made for 1,034 hospitals
and for 1,217 institutions of all types, using the method explained in the separate
survey report. Based on the response of 77 hospitals, the estimated 10-year
need for educational facilities for 1,084 hospitals would cost more than $950
million. Based on estimates provided by 201 institutions (excluding research
institutions), the 10-year need for educational facilities for 1,217 institutions,

. excluding those predominantly in research, is approximately $2 billion.

PATIENT CARE FACILITIES

Hiil-Burton program.—tThe program for the construction of hospital and medi-
cal facilities under the Hospital Survey and Construction Act (the Hill-Burton
Act), as amended, has been one of the most remarkable achievements in the his-
tory of health services. It has contributed to the health of this Nation in the
unique American way, capitalizing on freedom and private initiative but summon-
ing the resources of Government to catalyze, raise funds, and provide legal sup-
port where private resources are inadequate, and to do this through the Federal-
State partnership exemplified by the grant-in-aid technique. Since inception of
the program (August 13, 1946), more than 7,000 projects have been approved,
investing $6.64 billion of which $2.11 billion were grants by the Federal Govern-
ment. These funds have provided more than 300,000 hospital beds and more than
2,000 rehabilitation facilities, public health centers, diagnostic and treatment
centers, and State health laboratories. The general hospital beds of the Nation
are now sufficient to meet 83 percent of current needs, in contrast to 59 percent
in 1948. However, State agencies report that 183,000 additional new beds must be
provided to meet the Nation’s prospective requirements.

The Hill-Burton program has also stimulated improvements in hospital design
and construction ; it has raised State licensing standards for hospital maintenance
and operation and for construction and equipment ; and it has assured efficient and
 

COMBATING HEART AND OTHER MAJOR DISEASES 259

economical use of these resources through surveys which guided planning for
hospitals and other health facilities. The program has also helped to attract
physicians and other health personnel to the modern working facilities in rural
areas formerly deprived of elementary health services.

These gains are indeed impressive. But many unfinished tasks remain. The
population continues to expand and to move to new neighborhoods. There are
serious shortages of hospital beds in many new suburbs. Sparsely settled areas
are still insufficiently supplied. Metropolitan areas with well-established old
institutions are seriously lacking modern facilities. Older hospitals in the major
cities are deteriorating at a disturbing rate, and plans to prevent this decline in
quality are impossible to execute with available funds.

Also new methods of treatment and new demands for patient care require new
facilities, especially those needed for an aging population and for treating cancer,
heart disease, and stroke. A 1960 study conducted by the Public Health Service
with the collaboration of the American Hospital Association concluded that the
need for modernization and replacement of obsolete hospitals would total $3.6
pillion. In addition to the need for modernization, it is estimated that the
critical need for new beds to serve patients with chronic diseases is on the order
of 500,000. Testimony before the Subcommittee on Facilities suggested also that
such beds should be provided not only in chronic disease hospitals and nursing
homes, but in medical centers where the best medical care would be applied both
as a service and as an example to students, residents, and house officers.

These needs have been recognized. The 1964 Amendments to the Hill-Burton
Act embody forward-looking principles appropriate to their solution.

Modernization of hospitals —Despite the outstanding success of the Hill-Burton
program, it is yet to cope with the increasing rate of obsolescence and inefficiency
of the bed capacity of the large metropolitan hospitals. This hospital situation
is not only a local handicap to health services, but ultimately it will have a
retrogressive effect on standards of medical care. The reason for special attention
to these centers is that most of them are affiliated with universities where they
earry on research and train and educate specialists in the various health sciences.
The metropolitan hospitals, in fact, are the bedrocks of basic medical and clinical
knowledge.

In 1960, $3.6 billion was estimated by the Public Health Service as the amount
required to modernize metropolitan hospital beds. Undoubtedly, the cost would
be greater today.

Until this year, the allotment formula and priority principles of the Hill-Burton
program have favored rural areas on the basis of relatively greater need for
additional beds. Because of the urgent needs of urban hospitals for moderniza-
tion on contrast to the need for new beds, it is desirable that a fund for moderniza-
tion be specifically established in the Hill-Burton program and that annual
appropriation be sufficient to respond to the urgent need for modernization.

The Subcommittee notes with satisfaction that the legislation of 1964 gives
special consideration to obsolescence of health facilities in the more densely
populated areas of the States.

The Subcommittee views the $160 million appropriation authorized for a 4-year
period as a sound but less than optimal level of support for the urban moderniza-
tion program.

Planning of hospital facilities—The complexities of hospital facilities and
health care are such that no single or simple solution to their developent is war-
ranted. Time-proven methods of providing hospital service to patients with
chronic disease, of course, must be continued and expanded. However, it is also

essential that health facilities in a given area be so planned and directed by local
and State agencies, in collaboration with appropriate voluntary groups, that
they may be effectively and economically coordinated. Because the planning of
health facilities has been so successfully demonstrated, it is desirable to extend
this program of planning to larger areas on a formal basis. The Public Health
Service should be charged with the development of the coordination of health
facility planning by local and State agencies. Therefore, the Subcommittee
applauds the adoption in the amended Hill-Burton Act of a multimillion dollar
program whereby the Surgeon General of the Public Health Service is empowered
to make grants to State agencies to meet up to 50 percent of the costs of projects
relating to the development of areawide plans for coordination of health and
related facilities and services.

Long-term-care facilities —The shortage of facilities for the care of chronically
ill patients is serious. This dislocation should be corrected if only to minimize
the use of acute general hospital beds for chronic disease purposes. However,

  
  
 
 
  
  
 
 
 
 
  
 
  
 
  
  
  
  
 
 
  
  
 
 
  
 
  
 
 
  
 
 
  
 
 
 
 
 
  
 
  
  
 
  
 
 
 
 
 
 
 
 
  
 
  
 
 
   
  
 
 
 
 
   
 
 
 
    
   
 

260 COMBATING HEART AND OTHER MAJOR DISEASES

the chronic disease patients in many instances should be in specialized institu-
tions professionally associated with general medical centers. It is reported by
the State agencies that more than 530,000 additional beds for long-term patients
are required. This figure represents a current shortage only. It does not take
into account the fact that the population over age 65 is rapidly expanding: by
1980, the aged population will probably exceed 24 million.

It is necessary, therefore, not only to correct the present deficiencies but to
anticipate the needs of an aging population which will inevitably be afflicted with
cardiocirculatory and malignant diseases to a significant degree. Testimony and
written reports suggest to the Subcommittee on Facilities that the coordination
of chronic disease hospitals and nursing homes in the present legislation should
be combined into facilities for long-term care. The previous annual appropriation
called for a ceiling of $20 million for each of these two categories. The Hill-
Burton program has already built more than 40,000 beds for long-term care.
‘An annual appropriation of $40 million should produce 8,000 beds each year, an
increase insufficient to keep up with the aging population.

Therefore, the Subcommittee warmly endorses the 1964 provision whereby (1)
chronic disease hospitals and nursing homes are combined into a single category
of long-term care facilities and (2) the appropriation ceiling for long-term fa-
cilities is increased from $40 million to $70 million annually.

This $70 million appropriation will produce about 15,000 beds on an ‘annual
basis. When one adds this 15,000 to the estimated 30,000 beds for long-term care
which are constructed outside of the Hill-Burton program annually, a total of
45,000 beds annually will be produced. This number will match the population
increase plus the obsolescence rate and also reduce the deficit by more than
26,000 beds annually. Even though this rate of growth is not ideal, the approach
is sensible and practical.

Administration of State plans—Success of the Hill-Burton program depends
in large measure on planning and operations by each State. Accordingly, the
Facilities Subcommittee warmly endorses the 1964 provision whereby each State
is authorized to use 2 percent of their yearly allotment (up to $50,000 a year)
to pay as much as 50 percent of the cost of administering the State plan, on the
condition that the State funds in support of administration are expended in an
amount at least equal to the amount so expended in the fiscal year 1964.

Survey results-——-The need for facilities for patient care which was esti-
mated by 218 institutions that submitted categorical data amounted to more
than $1.6 billion in 10 years. Again, the greatest part of this $1.1 billion—
represented the needs of health professional schools, primarily the schools of
medicine. As a group, the schools estimated that only 46 percent of this
amount could be paid with the aid of existing programs; €.g., the Hill-Burton
program. The schools of osteopathy, whose needs are relatively modest, in-
dicated that they could meet less than 0.1 percent of their needs for patient
care facilities with existing sources of support; schools of dentistry, on the other
hand, indicated an ability to satisfy 63 percent of their wants with the help
of these programs. The combined group of hospitals felt capable of meeting
only 44.7 percent of their needs; the combined group of research institutions only
53.5 percent.

The consensus of responding institutions was that nearly 85 percent of the
needs for care facilities could be met if Federal grants were available on a
nonmatching basis. Each institutional group indicated that prospects for im-
proving facilities would be substantially improved if nonmatching grants were
available.

Based on the information submitted by 201 institutions of all types, the
projected needs of 1,217 institutions for construction, renovation, and equipping
of facilities for patient care would cost more than $7 billion in 10 years. Of
this estimate, nearly $2 billion is for schools and more than $5 billion is for
hospitals.

MEDICAL LIBRARIES FACILITIES

A detailed analysis of the need for medical library facilities appears as a
source paper for this Subcommittee. Rather than repeat substantial portions
of this report, it is sufficient to note here only the main argument, the Sub-
committee’s conclusions, and recommendations.

The disrepair of the medical library system, so essential to the transmis-
sion of medical knowledge across time and space, constitutes a major weakness in
both Federal and private health and medical programs.
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COMBATING HEART AND OTHER MAJOR DISEASES 261

The medical library function.—The concept of ready access to a compre-
hensive store of recorded knowledge has for centuries tantalized the scholar
and investigator. To achieve fingertip control of the literature, of all that is
known about the causes, treatment, and prevention of heart disease, cancer,
and stroke, and to make this knowledge available to researchers, educators,
and practitioners, is an objective to which this Subcommitte wholeheartedly
subscribes. Traditionally, the medical library plays the central role in the
interchange of published biomedical information.

imbalance of support.—While most medical institutions have made spectacular
advances in recent decades, the medical library has failed to keep pace. The
Department of Health, Education, and Welfare appropriations for 1964 totaled
over $5.5 billion. Of this, $36.1 million ( approximately 0.65 percent) were de-
voted to scientific and technical information activities, but less than $1
million accrued directly or indirectly to the support of non-I’ederal medical
libraries.

The adverse effects of neglected libraries have been protested by librarians
themselves for many years. Physicians and scientists today reinforce their
argument. The National Advisory Health Council on April 3, 1964, passed
a strong resolution urging prompt and effective remedial action.

The medical library community.—The number of specialized health-related
libraries in the United States estimated at 6,503, is growing. Of these, 995
are associated with educational institutions, 3,178 with hospitals, 1,180 with
agencies of State and Federal Government, 1,100 with industry, and 50 with
State and local medical societies. The estimated total number of medical
libraries which the Subcommittee identifies as the legitimate objects of its
concern is 4,223.

The community of medical libraries with its common dedication to the im-
provement of health may be thought of in terms of a more or less integrated net-
work. The medical libraries lend and borrow from each other to supplement
their resources to a far greater extent than any other library group.

In relation to this community, the National Library of Medicine (NLM)
has developed unique functions. It has provided leadership in dissemination
of information, accepting responsibility for the provision of the indexing tvols
used by these libraries, and, by lending otherwise unobtainable books and
journals, accepting responsibility to act as a central depository. The NLM
may, therefore, be considered the heart of the national medical library network.
Through its development of the world’s largest collection of the published medi-
cal literature and through its sponsorship and operation of the medlars system,
the largest computer-based information storage and retrieval system yet to be
devised for a published literature, the NLM has demonstrated its leadership,
capacity, and responsibility. In the Subcommittee’s judgment the proper base
for the development and implementation of plans to strengthen the Nation’s
medical libraries is the National Library of Medicine.

Conclusions and recommendations.—Conclusions and recommendations in the
following pages have been reached after careful consideration of this complex
issue and with a full understanding of the magnitude of effort called for.

CONCLUSIONS

The deficiencies in medical communications, particularly in the Nation’s
medical libraries, affect the activities of 3 million medical and paramedical per-
sonnel. The effect of the weaknesses of the medical library system on medical
tesearch, teaching, and practice should be recognized as threatening.

To a large extent, the medical library deficiency has been compounded by health
activities funded by the Federal Government. Increases in users, service de-
mands, or needs for materials and the volume of documents are a direct con-
sequence of Federal stimulation. A third factor is that the Federal Government

alone is capable of supplying the support in the volume and within the time
limits indicated.

RECOMMENDATIONS FOR FEDERAL ACTION

Programs to be conducted by the National Library of M edicine.—The NLM re-
quires both legislative authorities and funds for the purpose of strengthening and
enlarging its intramural activities and for the purpose of conducting the type of
support program described below. The Subcommittee recommendations, there-

   
  
 
  
 
 
 
 
  
   
  
 
 
  
   
  
 
  
 
  
 
 
   
 
  
  
 
 
  
 
 
 
 
 
  
 
 
 
  
  
 
 
 
 
 
  
  
  
 
 
 
  
 
  
  
 
 
   
 
  
 
  
 
 
 
 
 
  
   
   
  
  
   
 
  
——— rr ——————— tt

262 COMBATING HEART AND OTHER MAJOR DISEASES

fore, aim at strengthening of NLM in order to bolster the other components of
the Nation’s medical library network.

National Library of Medicine —¥or 2 number of years the NLM, serving as 2
packstop for all medical libraries, has faced operating problems developed by the
same forces affecting others jn its community. These include the massive in-
creases in volume of medical and paramedical literature, the increasing de-
pendence of the bealth professions on jnterdisciplinary literature not previously
associated with health research, and the urgent need to develop new and noncon-
ventional systems for the pibliographic management of these literatures.

In order to meet these challenges, the NLM must be strengthened. It is essen-
tinl to provide adequate resources not only to keep abreast with the volume of
health publications, put also to acquire books and journals in closely related
scientific fields. The computer-based medlars program is undermanned in rela-
tion to both the volume of the literature and the power of the machine system.
At present. the human component required for machine searching equates to only
10 percent. of the potential machine capability. The machine search potential of
the medlars system should be shared at the earliest possible date with universi-
ties having adequate computer and medical library facilities. The Subcommittee
thus endorses the NLM’s plan for decentralization of medlars output while recog-
nizing the need for continued centralized control of input. of paramount im-
portance is the conduct of an intramural research and development program for
the purpose of exploring and exploiting new technologies for more efficient man-
agement of the world’s biomedical literature.

The Subcommittee therefore recommends that $2 million per year for a S-year
period be made available to the National Library of Medicine ‘cor research and
development of basic knowledge in the handling of biomedical information.

Medical library assistance program.—The NLM should be made responsible
for the development of a program designed to rehabilitate the medical library
network. Such a program would have the dual objectives of strengthening
the depressed elements of the existing network, and simultaneously of develop-
ing new technologies and service patterns applicable to medical library prac-
tice of the future.

Included in such a program should be provision for matching grants to
support construction of new medical libraries and the renovation of existing
facilities, training grants expressly designed to attract and develop professional
medical librarians and other information specialists, jn order to remedy critical
existing manpower deficits, and grants to enable medical libraries to strengthen
their collections until they approximate the minimal standards established by
professional organizations.

The library should also conduct a progranl for the support of Mbrary-related
secondary scientific publications such as translations, abstracts, pibliographies,
and critical reviews.

Concurrently with the above programs, the library should sponsor research
and development in medical library science and related mechanisms through
grants and contracts. It should actively pursue the development. of new tech-
niques, systems, and equipment for processing, storing, and distributing informa-
tion in the medical and related sciences. The importance of developing 4 CO-
ordinated national system of cooperating medical libraries should be the concept
underlying support of these technical projects.

It is recommended, therefore, that the NLM should support and assist the
development of improved medical library services in the United States through @
program of grants and contracts in areas of medical library facilities, resources,
personnel, and secondary publications. The library should also conduct forward-
looking research and development for the purpose of increasing the effectiveness
of medical library service throughout the Nation. It is recommended that $30
million per year for 5 years should be appropriated to the National Library
of Medicine for this support program.

Legislative authoritie ——At present, the NLM lacks clear and comprehensive
authorities to undertake such a proad-seale program. Through delegation by
the Surgeon General, the library has authority “for research fellowships,
traineeships, and grants-in-aid related to library-based programs and health
communications” and by ruling of the Comptroller General of the United States
authority to make grants for such research-related functions has been confirmed.

Nonetheless, these authorities are distinctly limited and do not constitute
a clear expression of full authority for the library’s pursuits jn behalf of our
national needs. For lack of a clear-cut legal pase, the NLM cannot develop pro-
 

  
  
 
 
 
 
 
 
 
 
 
  
 
 
  
 
 
 
 
 
 
   
 
 
 
 
 
 
 
  
 
 
 
  
 
 
 
 
 
  
 
 
 
 
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

COMBATING HEART AND OTHER MAJOR DISEASES 263
S of grams in such areas as the rehabilitation or construction of library facilities
and resources.
as a New legislative authority is necessary if the NLM is to upgrade the national
the medical library network. Such a legislative move should have sufficient scope
; d- to encompass the broad aspects of this proposed program, and should authorize
de- adequate funding over an extended period of time; i.e., a 5-year period.
usly Therefore, it is recommended that the Department of Health, Education, and
20n- Welfare should initiate broadly conceived legislation clearly authorizing the
National Library of Medicine to assist the medical libraries of the Nation as
ot proposed in this report.
2 0
ied ANIMAL RESOURCES FOR BIOMEDICAL RESEARCH
ala-
om. It has been estimated that 50 million animals were used for biomedical research
nly in 1968. The Pharmaceutical Manufacturers Association estimated that its
of member concerns used 9 million in 1961. The Cancer Chemotherapy National
rgi- Service Center of the National Cancer Institute uses approximately 3 million
tee animals yearly, while 1 million are used yearly by NIH in its Bethesda facilities.
og- Almost 50 percent of current NIH-supported research grants are dependent on
m- animals.
for Many striking advances in disease control could not have been achieved with-
in- out the use of laboratory animals. As research vistas widen, the dependence on
animal test systems becomes greater. The need is not only for increased numbers
ar but also for improved quality, both in respect to freedom from disease and to
nd specificity of genetic makeup. The sophisticated research of today demands
sensitive instruments which can reproducibly record subtle changes.
le If the research animal, which represents such a sensitive system, by virtue of
ry disease or variable genetic constitution, reacts inconstantly or unpredictably to
ng experimental situations, time, money, and the experiment are lost. Such oc-
p- currences are, in fact, not uncommon. Inadequate animal housing facilities,
c- often by promoting a high incidence of infection, have frequently accounted for
such experimental failure.
LO To provide a controlled environment for animals is not merely humane: it is
ie essential to a successful experiment. The need for increasing and improving
ul animal resources has been voiced on a number of occasions by concerned parties
il including the Surgeon General of the Public Health Service, a congressional
n advisory committee, and the Institute for Laboratory Animal Research.
y Major problem areas and program recommendations are listed below:
institutional animal resources—There are approximately 650 nonprofit and
d nongovernmental biomedical research institutions. Although the principles
, expressed in “Guide for Laboratory Animal Facilities and Care” are generally
accepted, it is widely acknowledged by members of the scientific community that
1 most institutions are unable to implement fully the guidelines expressed. A
1 recently completed survey of 561 institutions conducted by the National Academy

of Sciences Institute of Laboratory Animal Resources (ILAR) revealed that

only 50 percent of the surveyed institutions could meet the standards for adequate

. care. (Of the 561, 58 institutions, including medical, dental, and veterinary

. schools, hospitals, and private laboratories were visited. An additional 508 were
sent questionnaires. }

The following table of existing characteristics of animal care facilities may
help in understanding the expressed needs of the institutions surveyed.

 

 

Needs expressed & Percent
Centralized animal care facilities....__.___..------------ 60.9
Thermostatically controlled heating system______.-.-______-_-__ 66.0
Air conditioning of animal quarters:

Complete____________---- ee
Partial__-_.. 2-5 wee.
Recirculation of air
Postoperative recovery rooms for animals____..-___________-_ 41.0
Cage-washing machines____________ --- — a--- ~. 32.0
Autoclaves for bedding and equipment_ --- 50. 0

 

Fifty percent of the institutions visited cited a need for new construction.
In addition, there were many other expressed needs for renovation, additional
space, and equipment. As a further example of the space needs, 411 of the 563
institutions reported an immediate unfunded need for more than 1 million square

  
 

264 COMBATING HEART AND OTHER MAJOR DISEASES

feet of space. This need did not take into account presently funded construction
or future 10-year needs.

Therefore, the Subcommittee recognizes that the most urgent need in respect
to laboratory research animals is that of strengthening institutional laboratory
animal resources.

It recommends that the Public Health Service be given incrersed appropria-
tions to implement a national program of construction and improvement of in-
tegrated institutional animal resources.

Establishment of regional research centers.—Research progress. in the judg-
ment of the Subcommittee, will be expedited by regional centers with special
animal facilities.

LABORATORY ANIMAL GENETIC CENTERS

Although the demand for a variety of animals of specific genetic makeup ha<
exceeded the supply and although a number of techniques for producing such
animals are known, there are neither sufficient funds nor facilities to utilize
these techniques in a program designed to meet existing needs.

To meet the needs of increasingly diverse and sophisticated research, where
reproducible accuracy is mandatory, there is a critical demand not only for
greater numbers of known strains but also for development and provision of new
strains. For example, the extensive program of the National Cancer Institute
meets only the needs of its contractors and of some grantees. Supplies of animals
suitable for research in immunology and tissue transplantation are inadequate:
exchange of such animals is often on the basis of friendship rather than on need.

In addition, species not ordinarily considered as laboratory animals may well
prove ideal for certain research purposes. At present, facilities for evaluation,
breeding, and supply of such animals do not exist.

Furthermore, there are no means for preserving and supplying animals which
represent a unique genetic composition or exhibit the unique heritable defects
which appear fortuitously in breeding colonies and which lend themselves so
peculiarly to research purposes.

Therefore, suitable regional facilities are needed to provide the following
gervices:

Productions of highly inbred standard strains of rodents in numbers sufficient
to meet the needs of the biomedical community.

Preservation of animal strains manifesting unique genetic characteristics or
heritable defects, such traits having occurred fortuitously in breeding colonies.

Research, development. and production of new strains of animals with unique
characteristics of value in specific research areas.

Research and development, for research purposes, of animal types not generally
considered as laboratory animals.

A monitoring service whereby the genetic purity of commercial lines can be
periodically evaluated and insured.

Provision of either colony seed stock or larger numbers of animals to investi-
gators or commercial breeders on the basis of competence and need.

Establishment, maintenance, and propagation of a nuclear colony of each
strain.

LABORATORY ANIMAL MEDICINE

As mentioned above, the laboratory animal is as critical to the success of an
experiment as is any other sensitive instrument. To insure reproducible and
accurate results, research animals must be not only of known and consistent
genetic makeup, but also free from disease. Unfortunately, the characteristics
of the normal animal are not an open book. Little is known of the normal
hematology. biochemistry, anatomy. and physiology of the laboratory animal.
Furthermore, the nature, diagnosis, and control of animal diseases are not well
understood. It is known, however, that animals obtained in the wild or from the
pound are typically invested with parasites or evidence other signs of illness.

The ILAR survey of animal facilities revealed that nearly 50 percent of the
dags used by the various institutions are obtained from ponds.

Primates other than rhesus monkeys are usually collected from nature.
Nearly 40 percent of the cats used were obtained from pounds or from nature.
Further, few institutions placed great emphasis on disease control in their animal
stock, by provision of quarantine or isolation facilities, routine necropsies for
colony deaths, studies of diseases of laboratory animals, or provision for or
utilization of facilities for such investigations or procedures.
 
 

 

COMBATING HEART AND OTHER MAJOR DISEASES 265

For such purposes, regional centers, patterned after the successful primate cen-
ters, should be established for the study of animal medicine. These cen-
ter should be established within the university framework, should maintain
close ties with veterinary schools, and should undertake the following projects :

Determine the normal state of jJaboratory animals, by defining normal hema-
tologie and biochemical values as well as by filling in the gaps in existing knowl-
edge of anatomical and physiologic characteristics.

Undertake studies of animal diseases and environmental health problems as
well as methods for diagnosis, control, and prevention.

Provide diagnostic and consultative services to nonprofit health research
eenters and, when consistent with program interests, to commercial breeders.

Hence, acknowledging the critical part that laboratory animals play in bio-
medical research and realizing the problems that exist in providing these animals,
the subcommittee submits the following recommendation :

The Public Health Service should be given appropriations to construct and
operate two Or three regional laboratory animal genetic centers (other than
primate) and two or three regional centers for research in laboratory animal
medicine (other than primate).

Research project grants in laboratory animal medicine.—In addition to de-
veloping several new centers for research in laboratory animal medicine, existing
capabilities should be utilized and strengthened. A project grant and contract
program should be initiated to provide funds for the support of studies designed
to determine the characteristics of the normal and diseased laboratory animal
and by doing so improve the health of the major laboratory animals needed fot
biomedical research. Therefore, realizing the importance of advancing knowl-
edge in laboratory animal medicine on a broad front. The subcommittee submits
the following recommendation ‘

The capabilities of existing animal research institutions should be fully
utilized through a program of project grants and contracts.

Animal farms.—The subcommittee favors the development of animal farms and
their integration into a national network of animal resource facilities. The
animal farm, which logically should be established in relation to health profes-
sional schools, provides an ideal environment for the breeding and care of certain
animals to be used in biomedical research. In addition, such farms, rather than

ban facilities, could provide logical centers for the temporary

more confined ur
quarantine of newly procured animals and for the jsolation, care, and study of

sick animals.
Under suitable circumstances, larger farms could be used profitably not only

by affiliated schools but also by nearby research institutions and community
hospitals.

Training. —There is a critical need for personnel at all levels in the laboratory
animal field. The JLAR survey revealed that only 30.8 percent of the animal
care activities of 143 medical, veterinary, and dental schools and private labora-
tories are under professional supervision.

It appears reasonable to assume that responsibility for these activities within
hospitals lies even less frequently in the hands of those versed in laboratory
animal medicine. There is aiso a need for additional animal technicians. In-
ereased availability of training programs will be instrumental in enhancing
eareer possibilities for all those involved in the specialized field of laboratory
animal medicine and care.

The Subcommittee realizes that the development of manpower js a critical
feature of improved programs in laboratory animal medicine. ‘Therefore, it
offers the following recommendation :

The Public Health Service should be given the specific legislative authority
and appropriations necessary to support training programs for veterinarians,
husbandrymen, and other animal disease specialists.

Appropriations.—A ppropriation levels recommended for these activities are
$10 million for the first year increasing to $20 million by the fifth year, for the
facilities and $0.5 million for the first year of the training program, increasing
anually until $1.5 miilion is reached in the fifth year.

GENERAL RESEARCH SUPPORT GRANTS

Authority for the general research support program of instiutional grants was
provided by the Congress in 1960 and funds for its implementation were first

made available on January i, 1962.

 
  
 
  
   
   
 
  
 
  
  
  
 
   
 
 
  
 
 
 
 
 
  
 
 
 
  
 
   
 
  
  
  
 
 
  
 
  
  
 
 
   
  
 
  
 
  
  
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
    
 
 
  
 
  
 
   
 
 
  
 
 
 
  
  
 
  
 
 
 
  
  
i iii ii

266 COMBATING HEART AND OTHER MAJOR DISEASES

The enabling legislation states that funds up to 15 percent of the yearly
amounts provided the Public Health Service for research grants or research
training grants may be set aside and awarded to institutions in general support
of their research and research training programs.

Prior to passage of this legislation, the desirablility of finding ways to permit
institutions to shape more actively the character of local research and training
activities had been widely acknowledged. The recognition of this need has arisen
as the Federal Government assumed an increasing role in research support,
generally through specific project and training grants which tended to unbalance
instiutional research programs.

‘he formulas and criteria determining insetitutional eligibility for general
research support grants were carefully formulated and serve to select competent
centers heavily engaged in research but demonstrating a potential for significant
further growth. Priority has been given schools for the health professions.

In awarding such grants, prior scientific and budgetary appraisals by study
sections or advisory councils are not required. The grantee institutions deter-
mine fully how the awards are used. Fundamental decisions in respect to eligi-
bility, entitlement, and review of end-of-year progress reports are the responsi-
bility of the Public Health Service and advisers.

The program is constituted, therefore, in a manner that will permit grantee
institutions to exercise greater coutrol over the content and direction of their
research efforts and thereby cultivate and strengthen an atmosphere of broad-
based scientific excellence.

The experience and reports of recipient institutions indicate that the program
is accomplishing this goal in an exemplary manner. As intended, the funds
have been used in a variety of ways to foster research objectives. For example,
new faculty and scientists have been recruited and supported; new areas of
yesearch have been supported ; central research resources, €.8., animal facilities
and statistical services, have been strengthened; trainee programs have been
aided ; and risk capital has been provided.

During the life of the institutional grants program, yearly appropriations have
ranged from an initial $20 million to an anticipated $40 to $45 million for the
current fiscal year. At no time has program funding reached the authorized
limit of 15 percent of total Public Health Service research grants.

In 1964 the funding level was approximately 7.9 percent of the grants total.
The authorized limit will not be reached in 1965.

The Subcommittee, recognizing that a stable, well-balanced, and progressive
research environment is generally one that is responsive to the needs of the
institution, and recognizing that the institutional or general research support
grant program serves as a powerful but incompletely utilized force in the devel-
opment of such an atmosphere, strongly believes that the total authorized re-
sources of this program should be made available to eligible institutions. There-
fore, it. submits the following recommendations :

Henceforth, the general research support grants program of the Public Health
Service should be funded at the authorized yearly limit of 15 percent of the total
research and training grant appropriation.

Graduate schools engaged in biomedical research supported by Public Health
Service grants should be entitled to receive grants under the general research
support program.

General research support grants should be awarded. in two categories: Unre-
stricted funds to be devoted to research as at present, and awarded on a formula
basis; negotiated awards to facilitate the conduct of research, pased on docu-
mented applications, to defray the direct and indirect costs of the supporting
organization and services which are not ordinarily chargeable as indirect costs.

VA RESEARCH AND EDUCATIONAL ACTIVITIES

With its 168 hospitals, 89 affiliated with medical schools, and 91 outpatient
clinics and regional offices, the Veterans’ Administration (VA) has the largest
system of health care facilities in the world. In the past year, 610,000 patients
were admitted to VA hospitals ; 3,695,000 were followed as outpatients. Of the
patients admitted, 107,000 had cardiovascular disease and 40,000 had cancer.
newly diagnosed in about 30,000. A professional staff of more than 9,000 physi-
cians, psychologists, social workers, and Ph. D. scientists provide a high level of
care and participate extensively in research, educational, and training activities.
A complete and sophisticated record system is maintained and lends itself readily

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COMBATING HEART AND OTHER MAJOR DISEASES 267

to rapid analysis. Thus, through its comprehensive pool of reseources, the Vet-
erans’ Administration offers a unique potential for care, research, and education
programs in heart disease, cancer, and stroke.

The VA is carrying on a vigorous and comprehensive program in fundamental
and clinical research. Utilizing an appropriation of $32.4 million in fiscal year
1964, approximately 25 percent of the VA’s professional staff participated in
more than 6,500 research projects and 40 cooperative studies and published nearly
2,500 scientific papers. Of the research projects, over 1,200 concerned cardio-
vascular problems, 450 were in neurological disease, and over 400 dealt with
cancer and allied diseases,

Clearly these research efforts, enriched by a close contact with major universi-
ties and other Federal agencies, benefit not only the veteran population but also
the general population.

The Subcommittee takes cognizance of and commends the Veterans’ Adminis-
tration for the impressive strides they have made in utilizing a vast research
potential. Realizing, however, that this potential has not been fully developed,
the Subcommittee offers the following recommendation:

The Veterans’ Administration should be given increased appropriations to
carry out research in aging and chronic disease, including heart disease, cancer,
and stroke.

Research grant program.—Much of the VA research effort is carried on in
close collaboration with 78 affiliated medical schools. Therefore, to utilize and
coordinate VA and university resources in a way that will serve to transmit the
benefits of research to the greatest number, the Subcommittee makes the follow-
ing recommendation:

The Veterans’ Administration should be given specific authority and funds to
make research project grants to the affiliated medical schools for collaborative
research projects in chronic diseases, including heart disease, cancer, and stroke.

Education and training program.—tin the area of education and training, the
VA uses its extensive physical and human resources, including 89 hospitals with
medical school affiliations, in all phases of medical education, During fiscal year
1968, nearly 38,000 students and employees participated in a variety of educa-
tional activities sponsored by the Veterans’ Administration.

Under the auspices of affiliated medical schools or universities, 17,790 under-
graduate and graduate students in medicine or allied fields received some part of
their education and training in VA facilities during fiscal year 1963. Among this
number were included 10 percent of the Nation’s medical residents, 21 percent of
the dental residents, 19 percent of the Nation’s dental interns, 27 percent of
medical undergraduates, and 10 percent of the Nation’s student nurses.

A recent survey conducted by the Association of American Medical Colleges
revealed that if VA hospitals were not available, affiliated medical schools would
be required to expend approximately $8 million for staff and $90 million for
facilities.

It appears clear, therefore, that the VA represents a significant force in the
education and training of manpower in the medical and paramedicati fields. The
Subcommittee commends the VA for the industry and initiative shown in assum-
ing a leadership role in these activities which are so vitally related to the
provision of superior medical care for the veteran and general populations of
the Nation.

Here, too, however, a vast resource is being incompletely utilized.

Therefore, the Subcommittee recommends that the Veterans’ Administration
be given the support and increased appropriations necessary to develop its
scientific manpower training program to its full potential.

PUBLIC HEALTH SERVICE HOSPITALS

The Hospital Division of the Public Health Service Bureau of Medical Services
operates 12 general hospitals, 2 neuropsychiatric hospitals, a leprosarium, and
numerous outpatient clinics for the purpose of meeting the health needs of
approximately 400,000 legal beneficiaries, not including the American Indians
and Alaskan natives. To illustrate the Hospital Division’s involvement with
the diseases of concern to the Commission, it should be noted that during fiscal
year 1963, its units treated approximately 5,000 patients with a primary diagnosis
of heart disease and 1,700 with cancer. In addition to providing medical care,
the majority of PHS hospitals are engaged to some extent in research and train-
ing. In general, these activities are carried out in close collaboration with nearby
medical schools.

  
 
 
  
 
 
  
  
   
 
  
 
 
  
    
  
  
 
  
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
  
   
 
 
  
  
  
  
   
 
 
 
   
 
  
 
 
 
   
   
 
  
 

268 COMBATING HEART AND OTHER MAJOR DISEASES

PHS hospitals are currently training 100 interns and 135 residents in 11t
specialties. Training in cardiovascular research is offered at two hospitals ;
clinical cancer research fellowships exist at two hospitals; and a cooperative
program with the National Institute of Neurological Diseases and Blindness
supports the training of medical neurologists. In addition, there are training
programs for dentists, pharmacists, nurses, and physical and occupational
therapists.

The clinical facilities of affiliated medical schools are frequently used in
PHS training programs; furthermore, PHS hospitals are used in the education
of medical students.

In fiscal year 1964, 118 professional staff engaged in cardiovascular and can-
cer research projects funded at a level of approximately $1.1 million, an amount
which reflects a progressively increasing interest and commitment to the con-
quest of heart disease, cancer, and stroke. A variety of funding mechanisms,
including direct appropriations, grants, and trausfers of funds, are required to
support these projects. It is apparent, however, that persent research efforts.
employ but a small part of the Division’s exceptional human and physical re-
sources.

An increase of these programs would clearly benefit not only the merchant
seamen, Coast Guard, and other legal beneficiaries of PHS hospitals, but also
the American people.

An important obstacle to realizing these goals is the critical need for research.
space in PHS hospitals, either through renovation of present quarters or con-
struction. Steps to fulfill space requirements must necessarily precede signifi-
cant continuing expansion of research efforts.

In summary, the Subcommittee acknowledges and commends the PHS Hospital
Division for its role in meeting the health needs of an important segment of the
population; in training health professional an paramedical personnel; and in
carrying out research in the areas of concern to the Commission. The Sub
committee also believes that the Division must use its resources more thoroughly
if it is to realize its potential for research and training. It offers this recom-
mendation:

The Public Health Service should receive an appropriation of funds needed
to permit renovation and development of additional research space within its
existing hospitals and to support increased research and training activities
in chronie diseases, including heart disease, cancer, and stroke.

DEVELOPMENTAL GRANTS

Several Subcommittees of the Commission have made specifie recommenda-
tions for construction of centers in which talented scientists representing many
disciplines will utilize modern techniques and equipment to mount attacks
on heart disease, cancer, and stroke. It appears likely that initially such
units will be established within institutions that have strong and comprehensive
research and clinical capabilities in terms of interest and ideas as well as
human and physical resources. ‘

Employment of existing centers of excellence for this purpose must, of
necessity, be only one aspect of a broad-based assault on these diseases. The
other must, of course, be the development of new centers of scientific and
clinical excellence, either by building them from the ground up or by increasing
the competence of existing institutions.

The importance and necessity for such developmental programs have been
stressed by responsible members of the biomedical community. This Sub-
committee, through its survey of yearly 400 health institutions across the
country, has been impressed by the widespread interest of schools and hospitals
in creating research environments or expanding their existing research efforts.

The need for additional space and equipment was expressed by almost all
institutions; the inability to meet fully these needs through existing programs
was voiced by most. Institutions with little or no investment in research
activities for the most part saw little hope of siginficant program changes in
view of the overriding demands of their service and educational activities.

Many institutions significantly engaged in medical research and positively
interested in expansion of these activities into heart disease, cancer, and
stroke found their efforts hampered by similar handicaps. In addition, they
cited the tasks-of capitalizing the research space and equipment needed and
manning and operating the facilities, if provided.
 

COMBATING HEART AND OTHER MAJOR DISEASES 269

It appears clear to the Subcommittee that many of this Nation’s developing
and underfinanced professional schools, community hospitals, and research
institutions represent fertile ground from which the research programs neces-
sary for a concerted attack on heart disease, cancer, and stroke could spring.

Yet, today Federal agencies generally recognize only a limited mandate for
such resource development. The National Science Foundation has mounted
a limited national program of developmental grants for science programs in
liberal arts colleges and universities. The National Heart Institute has been
tavorably impressed by the results of its experimental developmental grant
program wherein a limited number of community hospitals have been supported
in their efforts to create and strengthen cardiovascular research programs.

The Subcommittee believes that this concept should be broadened to include
support for research activities in heart disease, cancer, and stroke. A develop-
mental grants program for medical schools should be nurtured and administered
by the Public Health Service. The following aims and criteria should char-
acterize this program :

Creation of an atmosphere conducive to the formulation of programs wherein
skilled scientists, through a multidisciplinary approach, could bring to bear on
the three diseases their most advanced equipment and techniques.

Initial awards should be made to institutions with demonstrated research
interest, capability, and leadership. Subsequent awards should be made to insti-
tutions with comparable levels of interest and potential, but less evidence of
achievement and capability.

Efforts should be made to disburse these funds in a manner that will create
focuses for the development of medical complexes, with prime emphasis being
directed to those regions evidencing greatest need.

The funds awarded should not be designated for support of usual patient care
activities, nor should they include the costs of specific research projects, nor
should they support general research training programs. Funds for the support
of these activities should be obtained from other sources.

Funds should be granted by the Federal Government on a nonmatching basis.
Recipient institutions should plan and indicate in their applications how the
funds would be expended in relation to program objectives. Grant applications
should be reviewed by a peer group of medical educators and other distinguished
citizens.

Moreover, the Subcommittee feels strongly that the Publie Health Service
should collaborate closely with the National Science Foundation (NSF) in con-
ducting its developmental grants program. Care should be taken that the activ-
ities of the NSF in stimulating all of the sciences should integrate with, rather
than overlap or conflict with the activities of PHS, whose responsibilities lie
directly in health and health-related sciences. It is through such coordination
of efforts that the Federal Government can best stimulate the development of
research to meet the health needs of the Nation.

Therefore, realizing the importance of conducting research programs in heart
disease, cancer, and stroke from a broad base and realizing that a great unde-
veloped potential for such work lies within existing health institutions, the Sub-
committee submits the folowing recommendation :

The Public Health Service should be given appropriations of $40 million over
the next 5 years to initiate a program of nonmatching developmental grants in
aecordance with the aims and criteria specified above. During the first year, $3
million should be anpropriated.

STATISTICAL RESOURCES

The Commission, in reviewing existing statistical data on heart disease, cancer,
and stroke, recognized certain areas of health statistics that are in need of de-
velopment. In our expanded national effort to reduce the toll of heart disease,
cancer, and stroke, strong statistical programs are necessary to describe the
nature of the problems to be dealt with and to provide indications of progress
toward the goals. Therefore, the Commission offers a series of recommendations
on mortality statistics, morbidity data, training of statisticians and physicians,
and community service statistics.

Mortality statistics—Registration of deaths, as a guide to administration and
epidemiology, calls for professional quality of performance and standard methods,
applied throughout the system with regard for several contributing factors in
death. .

43-669— 65—-——18

 
   
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
 
  
 
 
 
 
 
 
 
 
   
 

270 COMBATING HEART AND OTHER MAJOR DISEASES

THE VITAL STATISTICS SYSTEM

The administration of public health measures for the control of widespread
diseases, such as heart disease, cancer, and stroke, is directed by local officials.
In order to plan for applying control measures, detailed information is needed
for each local jurisdiction about the specific groups exposed to the greatest risk
or most susceptible to the disease to be controlled. Furthermore the information
must be available year in and year out in order to measure the effectiveness of
the programs.

The only comprehensive source for such statistical information is the data
obtained from the registration of deaths. It covers the entire population: State
by State, county by county, and city by city. All States and local areas have
mortality data available to them but only a few are able to employ this resource
effectively. The frequent failure to employ such data is, in part, attributable to
lack of money and lack of competent personnel.

For the first half of this century, mortality studies were in the mainstream
of research and health practice. Mortality statistics furnished an essential tool
for epidemiological studies of our principal disease problems; such as, smallpox,
tuberculosis, diphtheria, malaria, typhoid fever, searlet fever, whooping cough,
diarrhea and enteritis in children, and maternal complications due to child-
birth.

The problems presented by the effective use of mortality data for heart disease,
cancer, and stroke are much more subtle and difficult than those encountered
in infectious diseases. As a result, higher skills in the use of statistics as well
as greater resources are needed. Against these needs, we face the fact that the
States and local areas have necessarily had to apply the resources for vital sta-
tistics largely to furnishing the public with legal records on demand. In con-
sequence, State and local governments have tended to neglect the development
and exploitation of statistics for the study and control of disease.

The States have sole authority for collecting records of births and deaths in
the United States. The Federal Government develops national vital statistics
from copies of the records supplied by the States. The only compensation to
the States is for actual copying costs and this may not exceed 4 cents per record.
Thus, the major share of the cost of the Federal-State system has been a State
burden; yet, the major scientific applications of the system have been made by
the Federal Government. The Federal Government is also almost entirely de-
pendent upon the State efforts for maintaining the quality of information on the
records. Aside from technical assistance provided to the States by the Federal
Government, there is no present means by which the latter can give support
adequate to the national requirements for data.

These facts point to the need for and propriety of Federal aid to the States
in strengthening the system.

¥inancial aid to the States for vital-and health statistics should be provided
through a categorical grant program administered by the Public Health Service:
the agency charged with the responsibility for collecting, analyzing, and publish-
ing these national data. Such aid should finance the salary of competent'statis-
ticians and necessary supporting services. The aid should be dedicated to the
following objectives:

Improving the quality and timeliness of data collected through death
registration ;

Carrying out regular epidemiological studies using the death record as a
starting point ; and

Intensive tabulation and analysis of the mortality data with special
reference to describing the problems in detail and measuring progress and
change.

The subcommittee recommends that a sum of $750,000 should be appropriated
to the National Center for Health Statistics to initiate this grant program. This
amount should be increased to $1,500,000 during the second year and increased
gradually thereafter until it reaches $3,500,000 during the fifth year, representing
roughly about 50 cents per vital record. filed.

MULTIPLE-CAUSE CODING

The traditional practice in the compilation of official mortality statistics has
been to attribute to each death a single disease entity as the underlying cause of
death. This practice served the purposes of public health well, while infectious
diseases constituted the major public health concern. With the decline in in-

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COMBATING HEART AND OTHER MAJOR DISEASES 271

fectious disease mortality, and with the growing importance of the chronic
diseases, official mortality statistics have become less satisfactory for the study
of chronic conditions; such as, the cardiovascular diseases where more than one
disease is usually present at the death. For example, a cardiac patient frequently
dies of stroke but it is not possible to characterize this event suitably by the
present method of compiling mortality statistics. The selection of a single disease
for tabulation, in such events, inevitably results in the loss of information.

For the chronic diseases, the single or the underlying cause concept is out-
moded. Cardiovascular disease often occurs not as a single process but as a
disease complex. The underlying cause concept requires that the disease which
started the sequency of events that led to death be identified. For the clinician,
this task is frequently impossible. In the nature of events, mortality statistics
on chronic disease give an incomplete and often inaccurate view.

It is recommended that data of this kind be prepared by coding all diagnoses
reported on death certificates and tabulating statistics on disease complexes
as well as the reported associations between various diseases. This procedure
will require additional coding, punching, and tabulation after the development
of coding principles and necessary guidelines. It is estimated this can be done
by the National Center for Health Statistics for about $125,000 per annum.

Statistics of morbidity and disability —Much progress has been made in meas-
uring morbidity and disability as a result of the passage of the National Health
Survey Act in 1956. The surveys authorized by this law are carried out by the
National Center for Health Statistics with the help of the Bureau of the Census.

Measures of disability and other types of impact on the family from recognized
ilIness are available from the health interview survey. The survey has recently
completed a study which included a carefully standardized cardiovascular
examination of a representative sample of adults, aged 18 to 79 years. This
study adds previously unavailable data on untreated morbidity.

Nevertheless, knowledge of the complete spectrum of morbidity remains far
from incomplete. Most needed at the present time is detailed diagnostic informa-
tion regarding treated cases of a kind that can be obtained from records of
physicians, hospitals, and other medical and nursing institutions. The mecha-
nisms, to be discussed below, for producing statistics on hospital, medical, and
nursing care will aiso provide the diagnostic detail in statistics of morbidity,

«A special word needs to be said about cancer statistics. The most comprehen-
sive and useful surveys of cancer in the United States have been those made by
the National Cancer Institute in 1937-39 and 1947-48. These surveys, covering
10 large cities in the country, were conducted by canvassing completely all po-
tential sources of information about treated cancer in the cities surveyed. Non-
resident cases were eliminated and census population statistics were used to
provide the population-at-risk. Consideration should be given to repeating this
survey on a wider scale at the time of the 1970 census.

Much has been said about the lag in time between the discovery of new medical
scientific facts and the application of this knowledge. There is undoubtedly a
considerable gap between, on the one hand, existing knowledge of the means of
preventing or alleviating chronic diseases; i.e., the advanced methods of preven-
tion, treatment, and rehabilitation and, on the other hand, the application of
these methods in everyday medical care. We know good measure of the mag-
nitude of this gap, however, because there is little or no systematic statistical
information about methods of treatment in day-to-day use in the practice of
medicine.

Evaluation of progress, or lack of progress, in closing the gap requires com-
prehensive statistics on patient care and treatment. Such statistics must be
compiled from surveys of records at all levels of care, in the offices of physicians,
in hospitals, and in long-term care institutions of all types.

Unlike other medically advanced nations of the world, the United States
has never had detailed national statistics on hospital inpatients. However, a
promising start has been made in the National Center for Health Statistics.
Working with the American Hospital Association and the Blue Cross Associa-
tion, the Center is developing a continuing sample survey of hospital discharge
records which will not only produce an accurate cross section of the cases
treated in short-term hospitals but will do so with a minimum of burden on
the hospitals.

The initiation of this survey will be a contribution of great importance to
our knowledge of methods of treatment, and, as has been pointed out earlier,
such data will also help to fill in a missing piece in the coverage of the entire

 

  
  
 
 
 
 
 
 
 
 
 
 
  
 
 
 
  
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
  
 
  
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
   
 

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272 COMBATING HEART AND OTHER MAJOR DISEASES

spectrum of morbidity. The Public Health Service has requested S8700,UU0 in
additional funds for the first full year of operation of this survey. From the
standpoint of the interests of the Commission, this request deserves full support.

While this project represents an excellent start in collecting needed statistics
on patient care and treatment, it does not, of course, cover the full range of
care. Records of inpatient care in most hospitals are reasonably complete and
uniform. Records of outpatient care in clinics and doctors’ offices, and records
of care in long-term institutions, such as nursing homes, are a different matter.
Much methodological work needs to be done in order to make reliable studies
of care in such places.

In resident-type institutions, for example, records must be designed that can
be filed out in a uniform fashion by all such establishments. Many of the
most seriously ill people are found in these reservoirs of chronic disease, but
the problems in studying them are formidable. However, here, too, a start has
been made in the National Center for Health Statistics, with a series of surveys
of patients in places providing nursing and personal care. Such surveys should
be contined and extended.

We still need to know a great deal more about the everyday care being given
patients with heart disease, cancer, or stroke. What prescriptions are given?
What regimens prescribed? What operations called for? When are specialists.
called upon? What rehabilitation efforts are made’ The great majority of
these decisions are made in the offices of the attending physicians. But as yet
there have been few surveys in the United States to provide such descriptive
information.

It is time to begin to interest the medical profession in participating in such
studies. It is possible, by the use of sampling, to design studies in such a way
that the burden on any one physician is minimal. The chief obstacle, perhaps
is to overcome the natural reluctance of the physician to report intimate details
of his practice. The organization carrying on the work must have a foolproof
mechanism to insure confidentiality and a reputation for complete impartiality.
The Commission strongly urges that the Public Health Service stimulate studies
of general and specialty practices on a sampling basis to determine methods of
treatment in everyday use.

Professional training and physician education.—There is an urgent need to
improve the professional qualifications of statisticians and the statistical sophisti-
cation of physicians.

TRAINING IN HEALTH DEMOGRAPHY

As pointed out in the previous section, it is necessary to increase the resources
available to vital statistics activities of the States in order to assure produc-
tion of reliable and useful mortality statistics. The Commission’s recommenda-
tion that a grant program be instituted for assistance to States in this area
would provide minimum funds for payment of salaries, computer services, etc.,
but it would not solve the other problem that has been mentioned: the severe
shortage of trained statisticians.

The changing character of public health practice coupled with the demo-
graphic, social, and economie changes in the United States has placed strong
demands on health departments for skilled statistical services. Health depart-
ments are becoming involved in various kinds of research, most of which require
a combination of high order statistical sophistication and a practical, operating
statistical organization. There is need to develop practical skills for various
levels of statistical work in data collection, data processing, data analysis, and
data presentation. Among other things, this includes registration methods,
coding practices, tabulating techniques, questionnaire eonstruction, forms de-
sign, records management, computer programing, and statistical administration.

To insure a satisfactory supply of trained personnel for these programs, the
Subcommittee offers the following recommendation :

A grant program should be established to be administered by the National
Center for Health Statistics for training in health demography. Such a program
would provide both academic training at the graduate level at universities and
applied training at the National Center for Health Statistics. It is anticipated
that approximately 50 individuals would participate in the former type of train-
ing and about 20 in the latter each year. Annual cost is estimated at approxi-
mately $500,000.

MEDICAL CERTIFICATION

As has been implied, the death certificate has long been the chief source of in-
formation for guiding plans for the study and control of cardiovascular diseases

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COMBATING HEART AND OTHER MAJOR DISEASES 273

aud cancer. Mortality statistics depend on the accuracy and completeness of the
medical certification entered on the death record.

A pilot study of the clinical evidence available in completing medical certifi-
cations demonstrated serious problems in reporting the conditions causing death.
These problems reflect variations in understanding of the requirements for certi-
fication, in diagnostic information available regarding the decedent, and in State
laws concerning the certification of deaths falling under the jurisdiction of the
medicolegal system.

A program should be initiated to improve the quality and accuracy of cause-of-
death statistics and to maintain a continuous measure of its quality. Its first
goal should be to educate medical students, interns, and practicing physicians in
a uniform understanding of what information should be reported on the death
certificate. Second, a regular mechanism to measure the completeness and quality

-of the reported information, particularly for the cardiovascular diseases, should

be established. Third, since a large number of sudden deaths from the cardio-
vasctiar diseases fall under the jurisdiction of coroners and medical examiners,

efforts to improve the quality of reporting must extend to these officials, by

strengthening and supporting the medicolegal responsibilities in each State.

COMMUNITY NEALTH PROGRAM

The Subcommittee attempted to obtain a national picture of the present status
of community health programs concerned with heart disease, cancer, and stroke
at a State and local level. Meaningful information and data describing services
currently being provided at the State and local level to patients afflicted with
these diseases was absent. The various programs within the Division of Chronic
Diseases of the Public Health Service have also indicated that the absence of
such data represents a serious deficiency in their program planning.

In order to carry out effective program planning, a national inventory of com-
munity health program activities is necessary. There is a need for benchmarks
to describe the current level of program activity and from which progress in the
future can be measured. Yo develop such a national inventory, the Subcommittee
offers the following recommendation:

A Center of Program Statistics should be established in the Division of Chronic
Diseases of the Public Health Service. This Center would coordinate the plans
developed by each operating program to assemble pertinent program statistics to
meet their needs. Each program should establish a statistical capability to
formulate data collection methods and procedures. review the data assembled,
analyze the information for completeness and accuracy, and identify program
implications.

Periodic and recurring surveys should be initiated, using sampling methods
wherever applicable, to provide data relative to each program. Whenever possi-

‘ble, data should be collected to permit a qualitative classification of each activity

on the basis of its relative effectiveness in reducing morbidity, mortality, or
disability.

It is estimated that during the initial year of the proposed program that an
additional personnel ceiling of 32 persons will be required by the Division.
An annual budget of $500.000 is reeommended to cover salaries, administrative

-Support, service contracts, and methodological research.

REPORT OF THE SUBCOMMITTEE ON RESEARCH

‘(Dr. Philip Handler,” Chairman, Dr. Frank Horsfall,’ Mr. James Oates, Gen.
David Sarnoff,* Dr. Edward Tatum, Dr. Efraim Racker.) Consultants to the
Subcommittee on Research: Dr. Edward Dempsey,’ Dr. Renato Dulbecco, Dr.
Philip P. Cohen, Dr. Irvine Page, Dr. Charles Dunlap, Dr. Harry Eagle, Dr.
Irving London, Dr. J. F. A. McManus. Dr. Alexander Hollaender, Dr. Herman
Rahn. Dr. Eugene Stead. Dr. Lewis Thomas, Dr. Maurice Visscher. Staff: Dr.
John 1D. Turner

INTRODUCTION

Research related to heart disease, cancer, and stroke was, at all times, in the
forefront of the minds of the members of this Commission. Each of the several
Subcommittees of the Conumission devoted much of its attention to current means
for the acquisition of new knowledge concerning these disorders, their alleviation

1 Member of the Commission.

  
  
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
 
 
 
 
 
 
 
 
 
 
 
  
 
  
 
 
 
 
 
   
 
 
 
   
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O74 COMBATING HEART AND OTHER MAJOR DISEASES

and prevention, and proposed plans for enhancing and extending the national effort
in this regard. Nniquely among the Subcommittee of the Commission however,
the Subcommittee on Research, which was composed of several members of the
Commission augmented by Dr. Efraim Racker, of the Public Health Research In-
stitute of the City of New York, and Dr. Edward L. Tatum, of the Rockefeller
Institute, devoted itself to means of acquiring greater insight into fundamental
aspects of the normal biology of man himself as well as those physiological
phenomena which lead to the development of heart disease, cancer, and stroke.

The Subcommittee engaged in two major activities :

1. The Subcommittee met with a group of invited consultants for several days
in Washington to discuss specific means whereby our national capability for the
conduct of biomedical research might be enhanced and extended.

The consultants present on that occasion were:

Dr. Philip P. Cohen, University of Wisconsin.

Dr. Renato Dulbecco, Salk Institute for Biological Studies.

Dr. Charles E. Dunlap, Tulane University.

Dr. Harry Eagle, Albert Binstein College of Medicine.

Dr. Alexander Hollaender, Oak Ridge National Laboratory.

Dr. Norvin Kiefer, Equitable Life Assurance Society.

Dr. Irvin London, Albert Einstein College of Medicine.

Dr. J. F. A. McManus, University of Indiana.

Dr. Irvine Page, Cleveland Clinic Foundation.

Dr. Herman Rahn, University of Buffalo.

Dr. Eugene Stead, Duke University.

The major recommendations and philosophy espoused in the report which
follows reflect. the discussions of this group. The Commission is much indebted
to these consultants for their imagination and wisdom.

2. The Subcommittee solicited, from the individual viewpoints of each of a
series of knowledgeable experts, substantive summaries of the present state of
diverse facets of the biological espects of heart disease, cancer, and stroke.
Most generously, our respondents contributed summaries which were invaluable
to the Subcommittee. Unfortunately, considerations of space alone preclude
publication of these summaries in their entirety. Accordingly, it appeared desir-
able to present with the report of the Subcommittee a single capsular summary
of current knowledge and research into the biology of heart disease, cancer, and
stroke, as gleaned from the essays so generously contributed. For the effort
involved in preparation of these summaries, the Subcommittee is particularly
indebted to Mrs. Norma Golumbic, of the National Cancer Institute, and Dr.
John D. Turner, of the National Heart Institute, and of the staff of this Com-
mission. Although the Subcommittee is pleased indeed to present these sum-
maries, for which it must acecept responsibility jointly with the immediate
authors thereof, it is pleased also to acknowledge its indebtedness and express
its gratitude to the scientists who so carefully presented thoughtful essays
which reflect both their knowledge and their scientific philosophy while express-
ing its deepest regrets that this volume cannot include these essays in their
entirety. Here, we can only list these worthy contributors to this common
effort.

Dr. Edward H. Abrens, the Rockefeller Institute, “PWardening of the Arteries:
Can It Be Prevented by Appropriate Choice of Diet?”

Dr. Albert J. Dalton, National Cancer Institute, “The Role of Electron Micros-
copy in Cancer Research.”

Dr. Harry Eagle, Albert Einstein College of Medicine, “Significant Features of
the Growth of Mammalian Cells in Tissue Culture.”

Dr. W. U. Gardner, Yale University, “Endocrine Factors in the Etiology and
Pathogenesis of Cancer.”

Dr. Alfred Gelhorn, Columbia University, “Endocrine Factors and Neoplastic
Growth.”

Dr. Leonard D. Hamilton, Sjoan-Kettering Institute for Cancer Research.
“Tonizing Radiation in the Genesis of Cancerous Change in. Cells.”

Dr. W. Stanley Hartroft, University of Toronto, “Btiology and Pathogenesis or
Arteriosclerosis.”

Dr. Charles Heidelberger, University of Wisconsin, “Chemical Inhibition of
the Growth of Normal and Malignant Cells.”

Dr. Sibley W. Hoobler, University of Michigan, “Hypertension.”

Dr. Kurt J. Isselbacher, Harvard University, “Tipoproteins of Serum and
Tissues.”

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COMBATING HEART AND OTHER MAJOR DISEASES 275
fort Dr. John A. Jacquez, University of Michigan, “Permeability and Transport:
ver, With Particular Reference to Cancer.”

the Dr. Hilary Koprowski, the Wistar Institute, “Progress and Prospects of Viral
| In- Tumorigenesis.”
aller Dr. Leopold G. Koss, Sloan-Kettering Institute for Cancer Research, ‘Cancer
ntal Cells in Light Microscopy.”
sical Dr. Paul Kotin, National Cancer Institute, “Chemical Agents in the Genesis of
oke. Cancer.”
Dr. Lloyd W. Law, National Cancer Institute, “The Role of the Thymus in the

lays Reaction of the Host to Cancerous Cells.”

the Dr. William D. McHlroy, the Johns Hopkins University, “Current Understand-

ing of the Mechanisms of Cellular Differentiation.”

Dr. Daniel G. Miller, Sloan-Kettering Institute for Cancer Research, “Immuno-
logical Defects in the Individual Afflicted With Cancer.”

Dr. Lioyd J. Old and Edward A. Boyse, Sloan-Kettering Institute for Cancer
Research, “The Antigenicity of Malignant Tumors.”

Dr. Clarence P. Oliver, University of Texas, “Inheritance of the Tendency
to Cancer.”

Dr. Irvine H. Page, Cleveland Clinic Foundation, “The Kidney in Hyper-
tension.”

Dr. O. H. Pearson, Western Reserve University, “Endocrine Factors in the
Etiology and Pathogenesis of Cancer.”

Dr. Van R. Potter, University of Wisconsin, “Metabolic Abnormalities in
the Host: Tumor Relationship.”

ich Dr. J. H. Quastel, McGill University, “Transport Processes in Tumors.”
ted Dr. Philippe Shubik, the Chicago Medical School Institute of Medical Research,
“Summary of Chemical Carcinogenesis.”

fa Dr. Chester M. Southam, Sloan-Kettering Institute for Cancer Research,
of “Reaction of the Host to Transplantation of Cancer Cells.”

ke. Dr. P. R. Srinivasan and Ernest Borek, Columbia University, “A Biochemical

ple Basis for the Genesis of Cancer.”

de Dr. Eugene A. Stead, Jr., Duke University, “Physiology of the Failing Heart.”

ir- Dr. Daniel Steinberg, National Heart Institute, “Metabolism of Adipose

ry Tissue.”

nd Dr. C. Chester Stock, Sloan-Kettering Institute for Cancer Research, “Chemical
ort Inhibition of the Growth of Normal and Cancerous Celis.”

ily Dr. James F. Toole, Bowman Gray School of Medicine, ““A New Cause for
or. Stroke—The ‘Steal Syndromes.’ ”

m- Dr. Arthur C. Upton, Oak Ridge National Laboratory, “Inhibition by Ionizing
mn- Radiation of the Growth of Normal and Cancerous Cells, and Ionizing Radiation
ite in the Genesis of Cancerous Change in Cells.”

SS Dr. F. Stephen Vogel, Duke University, “Contributions of Electron Micro-
ys scopy to the Understanding of Brain Tumors.”

‘Se Dr. Sidney Weinhouse, Temple University, “Metabolism of Neoplastic Tissues.”
‘ir Dr. Jack P. Whisnant, Mayo Clinic, “Experimental Cerebral Infraction,
om Embolism and Hemorrhage, and Other Observations.”

Dr. Abraham White, Albert Einstein College of Medicine, “Endocrine Factors
in the Etiology and Pathogenesis of Cancer.”
Dr. Irving 8. Wright, Cornell University, “Etiology and Pathogenesis of
S- Myocardial Infarction.”
Dr. Donald B. Zilversmit, University of Tennessee, “The Metabolism of the
of Arterial Wall.”
Dr. C. Gordon Zubrod, National Cancer Institute, “Physiology of the Individ-

we

da ual Afflicted With Cancer (Anemia, Infection, and General Debility).”
The Subcommittee is also pleased to express special thanks to Dr. E. Cowles
ie Andrus, Conference Director, and to the many scientists who prepared papers for
the Second National Conference on Cardiovascular Diseases for making these
1, papers available to the Subcommittee and the Commission to aid them in their

deliberations and in the preparation of the source papers contained in this
r report.
THE SUBCOMMITTEE ON RESEARCH,
f Dr. PHILIP HANDLER, Chairman.
Dr. Frank L. Horsrat., Jr.
Mr. JAMES F, OATES.
1 Gen. Davip SARNOFF.
Dr. Epwarp L. Tatum.
Dr. ErraAIM RACKER.

  
 

276 COMBATING HEART AND OTHER MAJOR DISEASES

ON TIIE CURRENT STATE OF BIOLOGY

The prime reason for hope that man may learn to control these dread diseases
is the remarkable rate at which insight has been gained into the nature of life.
the structure and function of living forms. One hundred years ago, no more
was known of man than could be determined with the naked eye or a primitive
microscope. Chemical examination of living tissue had only begun and the con-
cept that all living forms are built of relatively similar “cells” had only recently
gained acceptance. Since then, the pace of investigation has accelerated progres-
sively so that, seen in retrospect, the total body of knowledge has doubled ap-
proximately every 10 years. The fund of knowledge descriptive of human biology
today ig about 1,000 times as great as it was in 1864.

It is almost 150 years since it was recognized that living organisms are con-
structed of aggregations of cells, each of which, in mouse, man, whale, or, for
that matter, spinach, is usually about the same microscopic size and exhibits
generally similar, grossly observable characteristics. Accordingly, it has been
apparent that, if one is to understand “life,” one must first understand the nature
of its basic unit, the cell. Much remains to be learned ; nevertheless, acceptable
albeit only partial answers are currently available to most of the major ques-
tions which have been raised concerning the living cell:

Is there a functionally meaningful arrangement of subcellular structures?
Of what chemicals are these constructed? How do cells manufacture the organic
compounds of which they are composed from the materials available in their
environments? How do cells maintain the constancy of their internal composi-
tion when bathed by a fluid of dramatically different composition? Why do cells
need energy? How is useful energy made available to the cell by the chemical
transformations undergone by carbohydrates and fats? If the cell is a minia-
ture chemical plant in which hundreds of individual chemical reactions are
constantly in progress, what factors are operative to assure that the totality
functions as a harmonious, integrated whole? What are enzymes and how
do they work? Where in the cell does the genetic information reside? "What
chemical structures serve as the repository of that information? How is the
information encoded and how is it read out so as to control the structure and
function of the cell? And how is this information duplicated perfectly during
cell division?

Woefully incomplete but nevertheless rather satisfying answers are presently
available to each of these, the cardinal questions of cell biology. Remarkably, to
the extent to which these matters are presently understood, such understanding
has virtually all been gained since World War II. It is precisely this glimmer
of understanding, a preliminary description of the living cell in the language of
chemistry, which constitutes the frequently cited “revolution in biology.” And
it is no exaggeration to state that our hopes that understanding and. hence.
control of cancer as well as of most forms of genetic, metabolic, and infectious
disease must derive from the answers to these questions if these hopes are to
be realized.

Animals, including man, are highly organized structures, built of vast. num-
bers of cells of many kinds. Most of these cells are quite remote from the ex-
terior of the body and are dependent upon the circulatory system to provide a
continuing supply of nutrients and oxygen while removing metabolic end prod-
ucts including carbon dioxide. Failure of the circulation, therefore, is incom-
patible with life.

The major single cause of such failure is atherosclerosis, the deposition of in-
soluble matter in the cells lining the inner surface of arteries, be they the coro-
nary vessels which nourish the heart itself, the vessels leading to or within the
brain, the aorta, trunk supplier of most of the body, or the vessels which nourish
legs or arms.

The past 10 years have witnessed an ever more sophisticated attack upon
atherosclerosis, an attack which includes such facets as: detailed examination of
the manner whereby such fatty deposit in the arterial wall takes place; study of
the factors which influence this process, particularly the amount and nature of
the blood lipids; study of the relation of these factors to diet, age, sex, or endo-
crine factors; or examination of the physiology of the individual so afflicted,
particularly the relation to blood pressure, kidney function, brain function. or
eardiae function.

In parallel has come a diversity of therapeutic trials based on the limited
understanding already at hand with respect to dietary control, drugs. and vas-
eular surgery.
 

COMBATING HEART AND OTHER MAJOR DISEASES 277

Neither the current level of understanding nor the available therapeutic pro-
cedures are adequate, at present, and endeavors in both directions must be
prosecuted with great vigor if future generations are, hopefully, to be spared the
pain of watching men and women destroyed during what should be their middle
years. The success of this venture can, by no means, be guaranteed. That the
goal is even conceivable in the minds of some reflects the confidence engenered
by the ever greater understanding afforded by biomedical research in our time.

How has this come about? It is a truism of science that “one cannot do the
right experiment until the right time.” Two interpretations, both correct, may
be placed upon this aphorism. In one sense, it implies that a given observation
may defy interpretation or remain, seemingly, without significance until there
has been gathered, by design or otherwise, enough related information to permit
building the original observation into a logical conceptual structure. Indeed
such an observation may be the very keystone of that structure but, unless there
be some vision of the total structure, that keystone is devoid of meaning.

Consider, for example, the fact that the viral origin of a malignant tumor of
chickens has been known for more than 50 years. In the minds of all but a few
investigators, this failed to engender a general hypothesis concerning the viral
origin of tumors until the following had occurred: (@) Neoplasia was found to
be associated with viruses in a considerable number of additional instances.
(b) Viruses were found to be built, in part, of nucleic acids, the chemical carriers
of genetic information. (c) Studies of the relationship between the chromosomal
material of bacteria and some of the specific viruses which infect them revealed
the manner in which viral nucleic acids can enter a bacterium, become physically
associated with the latter’s own genetic material, be duplicated each time the bac-
terium undergoes division, and yet find no obvious “expression” until some un-
toward alteration occurs in the cell’s environment, such as a change in tempera-
ture. Only then does the cell machinery normally responsible for duplication of
its own genetic material embark upon the synthesis of many copies of the original
invading virus. As these leave one cell, they invade other cells about them.
These studies provided a model for the manner in which a virus, capable of subtly
modifying the life of an animal cell so that it grows abnormally ignoring normal
constraints, might persist in that cell undetected for a prolonged period, and,
later, be found in all the cells of a growing tumor. (d@) Other viruses were
found to invade animal cells in tissue culture and to affect them much as could
be predicted from the bacterial model. Only when all of this information was in
hand was the stage set for a general theory of the viral origin of cancer—and,
hence, its current testing—although the prime observations had actually been
made two generations earlier.

The second sense in which the aphorism concerning the timing of experiments
is correct relates to the availability of tools and techniques as well as the state of
science and its own technology. In a general way, the further one departs from
the immediate experience of man’s own senses, the larger, more complex and more
expensive is the equipment required for observation. This has long been appar-
ent in our examination of the physical world. The more detailed the study of
the remote vastness of the universe has become, the larger and more complex have
become the telescopes and their spectroscopie cameras. Perhaps the ultimate in
this art are orbiting telescopes controlled from the ground, the television cameras
mounted in Ranger VII, and the huge earthblasted radiotelescopes of our time.

Again, as physicists have turned their attention penetratingly inward to the
planetary electrons about the atomic nucleus and then to the subparticles of the
nucleus itself, the finer and more detailed their examination, the larger and more
costly have their instruments become, from simple electroscopes and X-ray tubes
to eyclotrons, bevatrons, and synchrocyclotrons.

This process has been no less characteristic of the progress of biology. Within
our lifetimes, the equipment of a typical biology laboratory has gone from crude
light microscopes, test tubes, staining jars, and a museum to electron micro-
scopes, ultracentrifuges, chemostatic growth chambers, hyperbaric operating
rooms, recording spectrophotometers, and their like. In biology, as in physics,
chemistry, geology, and astronomy, the more remote from common experience is
the bit of information sought by an investigator and the more detailed and
sophisticated the understanding which is hoped for, the more powerful and costly
are the tools required to secure it. Until such tools are designed, produced and
made available, it may well be impossible for even the most gifted investigator to
attack, meaningfully, the problem to which he has addressed himself.

  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
  
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
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278 COMBATING HEART AND OTHER MAJOR DISEASES

The accelerated growth of knowledge and understanding of living forms in our
time, then, expresses both senses of the aphorism. Chemistry and physics have
now developed to the point where they are applicable to biology. The bits and
pieces of yesterday’s piological understanding, which was largely descriptive, have
slowly been welded into a more consistent, coherent and rational pattern which
permits far greater understanding as well as prediction, and offers a guide to fur-
ther investigation. Such investigation has become possible as the tools to do the
job have been developed.

At this writing, there is reason to believe that this pace can continue to quicken
if the American people will choose to support exploration of biology as they have
supported exploration of the atom and of the universe. Then can we hope to
attain the more detailed understanding of the living cell which may reveal the
nature of the delicate change in the balance of cellular activities which is mani-
fest as neoplasia.

Hopefully, also, there may be an unraveling of the next layer of understanding,
the manner in which highly specialized cells such as those of the brain, kidney,
or heart perform the specific functions which, uniquely, they contribute to the
total living organism. In parallel we can hope to witness revelation of the
manner whereby the nervous and endocrine systems coordinate and integrate
the entire organism.

With such information in hand, incisive understanding of disease, ie., dis-
turbances of this orderly functioning, may be expected whereas without such
information, sufficient understanding is inherently impossible. In such com-
prehensive biological understanding lies most of our hope for control of the wide
yariety of disease to which man is heir.

Withal a serious caveat, in two parts, must pe placed before the American
people. First, it must be understood that biomedical research is not simple:
it is extremely difficult and treacherous. Even when dealing with minimally
complex organisms such as bacteria, one must contemplate systems immeasur-
ably more complex than those usually considered by the physicist, chemist. or
astronomer. How much simpler is the nuclear chemistry of a remote star than
the myriad aspects of a single cell composed. of thousands of representatives of
each of perhaps 2,000 different proteins, each of which, in turn, is a skein of
several hundred amino acid molecules assembled in a specific and invariant
order. And how much more difficult is it to ascertain, in reliable fashion, some-
thing of the biclogy of a given man in a clinical setting and then to establish
whether that information is unique to that individual or true of men generally.

It is for this reason that guarantees or promises that, next year or that fol-
lowing, we shall understand cancer, or heart disease, or arthritis, or schizo-
phrenia are both extravagant and irresponsible.

One day, we almost certainly shall possess such understanding. But, whereas
cancer and heart disease have probably been with man since first he appeared
on this planet, biomedical science is virtually a newborn babe. About 90 percent
of all the biomedical scientists in history are alive and working today, and most
of them began working after 1945. The gtudies in which they are engaged are
immensely complex and difficult. Utterly desirable as attainment of their goals
may be, their research, which can be facilitated and even somewhat accelerated,
simply cannot successfully be hurried and none can say when the labor will be
completed.

Second, whereas it is clear that our hope that means may be found to cope
successfully with cancer and atherosclerotic disease rests upon our ability ulti-
mately to wrest understanding of these disorders from unwilling nature, promises
that such understanding will certainly lead to means of prevention or cure are
equally extravagant and irresponsible and can only be viewed as a disservice to
the American people.

To be sure, there are clues and Jeads at hand and others will surely suggest
themselves as understanding increases. But it does not necessarily follow that
these abnormal processes are truly susceptible of control and promises to such
effect have no current validity. What can be promised, in clear conscience and
good faith, is that if the effort is not made, there can be no hope of cure, No
hope of prevention. If the effort is successful, then the boon to humanity will
be beyond measure and whatever the cost, the price will have been low indeed.

ON THE NATURE OF RESEARCH

he term “research” is well entrenched in the American vocabulary, but. is
rarely given definition. Indeed, it connotes quite different activities within var-

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COMBATING HEART AND OTHER MAJOR DISEASES 279

ious spheres of endeavor. A student speaks of doing “regearch” when he goes
to the school library to ferret out a piece of information. A manufacturer of
consumer goods speaks of “research” as he gages public reaction. to several pos-
sible new packaging forms of his product. And it is commonplace to cite the
research and development component of the Federal budget, a phrase which, by
its existence, implies some distinction or difference between the two processes,
yet fails to indicate what that may be.

In a general sense, scientists use the term “research” to describe the process
whereby questions are asked of nature, however the answers may be obtained,
thereby enriching man’s knowledge of the physical and biological world. The
information obtained is usually recorded in one of the numerous scientific
journals. The driving motive in performance of this activity is the interest
and curiosity of the investigator.

“Development,” in contrast, is the sum of those activities required to create
some new product, such as microscope, electroencephalograph, hyperbaric cham-
ber, or drug, utilizing information and understanding already in hand.

In the performance of research, the investigator must first clearly state what

it is that he wants to know, e.g.: “How is it that, during embroyic life, eells with
identical genetic information, assume quite different morphological (struc-
tural) and functional character?” or “Is there a relative mixture of dietary
saturated and unsaturated fats which permits pleasant and adequate nutrition
while keeping the serum cholesterol at a minimum ?”’.
Those so engaged may ask, for example: “What are the attributes of a drug
build a microscope with sharper resolution than those presently available?’
“How can one build an instrument which, with a minimum of human attention,
could precisely measure the concentration in a single sample of blood, or choles-
terol, sodium, albumin, and insulin?” In each such development, in formulating
the question, the questioner has a specific use in mind and hopes that the basic
information required for his answer has already been provided by past re-
search,

Admittedly, there is an intermediate zone of activity, frequently called applied
research, in which those primarily interested in development find that the
supply of fundamental information is insufficient to the task at hand and, ac-
cordingly, engage in what is quite truly basic research, but with the specific
end in view of obtaining information applicable to a specific product or service.
Those so engaged may ask, for example: “What are the attributes of a drug
which could halt the growth of a tumor yet not interfere with the life of the
normal cells of the body?’ In many instances, research so conducted has
proved to be a vital significance in understanding nature.

Although the approaches, techniques and even the problems undertaken may
be quite similar, the chief difference between those engaged in “applied” and in
“basie” research is one of motivational attitude. The latter know no stopping
place in their quest for understanding; the former may halt when the specific
information required for product development has been secured.

Within biomedical science, the lines separating research from development are
not sharply drawn. Instead, a hierarchy of activities, each of which shades into
the other, may be assembled somewhat as follows :

1. Fundamental inquiry into the nature of living cells.

2. Investigations of the integrated physiology of the mammalian organism,

3. Laboratory investigation of experimental disease states.

4, Clinical and epidemiological investigation of disease as it occurs in man.

5. Experimental pharmacology: Studies of the mechanism of drug action.

6. Synthesis and experimental trial of new drugs.

7. Development of instruments and procedures for use in investigation, diag-
nosis, or the clinical care of the ill.

8. Clinical trial of proposed preventive and therapeutic procedures or mate-
rials.

9, Clinical care by accepted procedures.

Each of these activities feeds the others at all times. For example, knowledge
of the problems of the diabetic led to isclation of insulin, determination of its
structure, and ultimate synthesis, while at the same time it set the stage for
understanding of carbohydrate and fat metabolism. Hereditary diseases,
“nature’s experiments,” have been of profound significance in elucidating the
molecular basis for genetic mechanisms. Interest in the mode of action of

antibiotics has resulted in elucidation of the structure and biosynthesis of bac-
terial cell walls. The search for effective cancer chemotherapeutic agents haa

 

    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
 
  
  
  
 
 
 
  
 
  
 
 
 
   
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280 COMBATING HEART AND OTHER MAJOR DISEASES

provided compounds which have been of great utility in the study of intermediary
metabolism.

Far more frequently, however, studies of normal biochemistry and physiology
have set the stage for understanding of human disorders. Research at the first

three levels cited above has provided the tools and methodology as well as the

conceptual framework which have permitted ever-increasing sophistication of
clinical research and practice. Indeed clinical research cannot be mounted as an
independent venture. Valuable and essential as it must be, it can progress no
faster than the fund of general biological knowledge will allow.

A clear trail of research, commencing with seemingly abstruse and recondite
studies of the most fundamental aspects of living cells and animals, can readily
be portrayed for the actual development and current clinical use of each of the
hormones, vitamins, antibiotics, cancer chemotherapeutic agents, and antiviral
vaccines, as well as modern surgical techniques and diagnostic devices and pro-
cedures. ‘To the extent that it is true that a random patient encountering @
random physician today has an excellent chance of penefiting from this encounter,
this fortunate circumstance is entirely due to the biomedical research hierarchy.

With respect to this functional hierarchy, then, one may properly ask, “Which
of these activities presently limits progress in understanding and treating
cancer, heart disease, aud stroke?’ ‘Those who are most knowledgeable in such
matters are agreed that this limit is imposed chiefly by the rate of progress in
the first three activities cited. Difficult as are the problems of scientific com-
munication, in every major medical center there are knowledgeable individuals
who can and do rapidly translate the findings of fundamental research (activi-
ties 1, 2, and 3) into their clinical settings and apply them in Glinical research
(activities 4-8).

This Subcommittee and its consultants are unaware of any significant pody of
fundamental information which is stagnantly awaiting clinical application by

eompetent practitioners. Indeed, it considers that the art of clinical investiga--

tion consists, in large measure, of a considered, deliberate judgment of the
utility and applicability of such fundamental information and careful avoidance
of the meaningless, feckless, and indeed harmful activity which is the conse-
queuce of ill-considered attempts to apply the inapplicable.

At all times, such pasic and applied research are limited by the capabilities
of the instruments and apparatus available. Development of a new instrument
(cineradiography, electron microscopy, electron spin resonance spectrometry )
invariably touches off a great wave of previously impossible research. Although.
there has been no major breakthrough accomplished by research related to can-
cer, heart disease, cr stroke which currently awaits application, it is agreed that
there is a lag between development of improved clinical procedures in the great
medical centers and the general adoption of such procedures in medical practice.
But, to reiterate, the most serious bottleneck, the major limiting factor, is the
rate at which fundamental understanding is provided by research on the struc-
ture and function of normal organisms and coordinate studies of experimental
pathology. :

Accordingly, it is recommended that, whereas progress in understanding, and
hence clinical control of cancer, heart disease, and stroke, is limited by the
inadequacy of fundamental information concerning the structure and function
of living organisms, every effort should be made to support and quicken the pace
of research addressed to these problems.

ON THE CONDUCT OF BIOMEDICAL RESEARCH

Only yesterday, biomedical research was largely the province of the gifted’

amateur. Clinical research was conducted by physicians with no training other:

than that required to polish their clinical skills and with no tools other than
those commonplace to hospital, bedside, or epidemiological practice. Study of

pathology required little more than the dissecting table and the light microscope..

Physiological and biochemical research were conducted in part by physicians, in
part by scientists trained in the university graduate schools. The training of
the former was utterly inadequate for this purpose and that of the latter was
meager. And they worked in hospitals, medical schools, and occasionally in
biology or chemistry departments or in a few research institutes.

These earlier circumstances have been altered dramatically. The likelihood
that the most gifted amateur can contribute significantly to the progress of bio-

medical science without having invested in years of training specifically tailored.
to his research aspirations and without the complex paraphernalia of the modern.
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COMBATING HEART AND OTHER MAJOR DISEASES 281

“piomedical laboratory has been reduced almost to zero. If we may quote a dis-

tinguished English scientist, “Alas, the day of the gifted English amateur is over.”

Once the avocation of an occasional physician whose primary responsibility
was medical care or that of an occasional professor whose primary responsibility
was instruction of the young, research today must be a major, if not the major,
responsibility of those who are so engaged. Moreover, the investigator cannot

-merely be a graduate of a medical curriculum devised for the education of prac-
‘tioners; he must also have devoted additional years and effort to acquiring the

knowledge, lore, and skills of one of the research disciplines as well as the habits
of mind characteristic of the investigator.

This is patently the case for the biochemist or microbiologist but is no less
true for the clinical investigator. The latter must not only be skilled as a physi-
cian, he must also bring to bear all of the concepts and technics of the discipline
most suitable to his problem. In dealing with cardiovascular disorders, he should
be competent as either a physiviogist or biochemist. In seeking understanding
of the fundamental basis for cancer, he has no choice but to approach the prob-
lem as a biochemist, cytologist, microbiologist, or geneticist. However he may
have secured the additional 2 to 4 years of training required—and there is no
lack of controversy concerning how this should best be done—there can be no
shortcut if ultimately he is to warrant the support of society as he pursues his
investigations.

Moreover, if indeed he is to be successful, he requires about him a suitably

-equipped laboratory, a coterie of technical assistants, a substantial sized peer

group with whom to discuss problems of common interest, other colleagues equally
proficient in related disciplines, and a supporting organization which can provide
diverse services such as accounting, purchasing, animal keeping, a library, sup-
plies of consumable items, instrument shops, and sterile glassware.

Accordingly, it will at once be apparent that the pool of investigators and of
institutions qualified to undertake programs of fundamental applied or jinical
research is limited indeed. By far the greatest concentration of such individ-
uals is to be found in the faculties of the medical schools and the graduate schvols
vf our great universities and a lesser pool in a restricted numver of research-
oriented hospitals and research institutes. Research directed toward the devel-
opment of new drugs (categories 5 and 6 of the hierarchy cited earlier) is largely
conducted in industrial laboratories or in research institutes especially orga-
nized to this end.

Within the university, the most powerful and successful arrangement pres-
ently conceived for the prosecution of research consists of a professor and his
group of fellows and graduate students. They combine the wisdom and cun-
ning of experience with the imagination, enthusiasm, and energy of youth while
leaning on all the other resources of the institution in which they find themselves.
For them, research and education are the same process and their presence and
activity enriches the experience even of those students, fellows, interns, and
others who are not directly engaged in the research enterprise. In those hospitals
and research institutes which lack a university affiuation but which enjoy
success in biomedical research, again the critical etements are found to be a
seasoned investigator surrounded by younger associates almost exclusively en-
gaged in research, a critical mass of peer colleagues in similar or related dis-
ciplines, and a sufficient supporting organization.

The research upon which this minimal research unit, the seasoned investi-
gator, and hig immediate associates, may be engaged is dictated, in the last
analysis, by the investigator’s own interests and motivation. He must be free
to follow his own bent, to identify what he considers to be the major questions
which should be addressed to nature, and for which the times permit possibility

. of successfully seeking an answer.

If such studies properly fall in categories 1 to 3 as defined above, they may
equally well merit support from an agency devoted to furthering understanding
of radiation effects (the Atomic Energy Commission), cancer (National Cancer
Institute or American Cancer Society), or hereditary disorders (National Insti-
tute of Arthritis and Metabolic Diseases). Indeed, such an investigator may
actually, and properly, we supported by each of these sources, providing the
total of such support is compatible with his competence and need,

Te be sure, the consequence of this permissive system is support of more than
one investigator in pursuit of the same goal. This does not constitute unneces-
sary duplication. It is essential to the process. The titles of their research
grant applications may be identical, but also invariably the detailed approach
will he different. And none can predict, in advance, which approach wiil find

  
 
 
 
 
 
 
 
 
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
     
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282 COMBATING HEART AND OTHER MAJOR DISEASES

suecess. Moreover, one can be confident that there will be continuing com-
munication among those so engaged, to the mutual benefit of their endeavors.

No scientist wittingly undertakes to pursue the same problem in the same
manner as another. He knows that the end product is publication in a scientific
journal, a journal which will not accept for publication a second paper describing
exactly the same findings obtained in the same manner. The scientist’s status
js determined by his peers, and there is no reward for ‘me-tooism.” Thus, ex-
cept for occasional accidents, the ethos of the scientific community is safeguard
against real duplication of effort.

These thoughts must be considered apart from the essential, deliberate repeti-
tion of the work of others which is an integral part of the scientific process. No
finding may be considered valid until it has been confirmed in another laboratory +
no scientist will undertake to puild upon the work of others until he has con-
firmed their findings for himself, else vast amount of effort may be wasted.

It is appropriate here to comment upon another aspect of alleged duplica-
tion, the phenomenon noted above wherein several agencies, both governmental
and private, may undertake support of similar areas of research. This is not
unnecessary duplication but a desirable overlap of interest. Such overlap is
minimal as the research is strictly related to the mission of the agency; ¢.8..
eancer chemotherapy or vascular surgery, and entirely understandable and nec-
essary when considering the most basic aspects of biology, the aspects of cellular
biochemistry or organ physiology. Moreover, as in science generally, it should
be a matter of policy that research be supported by a variety of agencies rather
than by a monolithic department of science or @ single national institute of
health.

The present structure of mission-oriented agencies, each aware of its prime
responsibility and each acutely aware of the necessity for much more funda-
mental knowledge if it is to achieve its mission, is efficient and effective as a
means of progress while, at the same time, it provides a series of juries so that
a scientist whose ideas have been denied support by one group can appeal, as
it were, to another, thereby assuring that neither the prejudices of any onc
group, nor personality conflicts, will impede progres.

Within the intramural research program of a mission-oriented research insti-
tute; ie., an institute devoted to cardiovascular disease or cancer, research is
somewhat more programatic. Within the walls of a single such institute, by
intent, individuals will engage, for example, in experimental vascular surgery.
testing of drugs which may lower the blood pressure or the blood cholesterol
level; examining the metabolic activities of adipose tissue or the muscular
tissue of the heart; attempting to correlate the electrical signals of the electro-
cardiogram with metabolic events, in the heart, which must generate those sig-
nals; and studying, at the enzymatic level various aspects of the metabolism of
carbohydrates and fats. This is a balanced program, deliberately arranged.
But it is not foisted upon the investigative staff. Those responsible for the in-
stitute, having outlined the nature of such a balanced attack on the problems
of vascular disease, then examine the scientific community and, if possible.
recruit scientists with these research interests. Much as in a university or
medical school, the institution must provide freedom and opportunity if the
research program is to be successful.

One final general aspect of biomedical research need be noted. Derek De
Solla Price has called attention to the differences between big science and little
science. It is little science which predominates in biomedical research today.
the thousands of research projects each of which involves a principal investiga-
tor, his senior associates, fellows, and graduate students. The total cost of each
such project depending on its scope, varies from $5,000 to $500,000 per year with
perhaps 90 percent of all projects costing $15,000 to $100,000 per year. Little
science then. is the classic approach of university science and, within biology
and medicine, is also the main theme in research institutes as well. Big sci-
ence which originated in the conduct of physical research, can be identified,
albeit rather arbitrarily, as any project which, by its nature must cost in excess
of perhaps $500,000 per year, 4 fact. which reflects either (1) that central to it
is a large, complex and extremely expensive apparatus of which our Nation
has but a few and which can and must serve the needs of a large group of
investigators or (2) a problem of such nature that research devoted to its
solution demands a large group effort and an extensive physical facility.

It was the large instruments which engendered big science in high-energy phrs-
ies (reactors, accelerators) and in astronomy (optical telescopes, radiotelescopes }

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COMBATING HEART AND OTHER MAJOR DISEASES 283

but these are rare in biology or medicine. Originally, we became aware of big
biological science for the second reason. Thus, the early programs of the Atomic
Energy Commission at Oak Ridge and Argonne, designed to ascertain the effects
of ionizing radiation of varying energy levels in single or multiple doses, whole
body or restricted to a single organ, in young or old animals, as acute or long-
term effects, predictably demanded huge numbers of animais, many technicians,
and a wide variety of scientists. An endeavor of this nature was foreign to the
academic world and, accordingly, the Oak Ridge, Argonne, Hanford, and Los
Alamos biological laboratories were brought into being.

It is imperative that projects which are, inherently, big science, be recognized
as such and be implemented accordingly. The pattern of the Biology Division
of the Oak Ridge National Laboratory can serve as a successful model: a large
core program, surrounded, as it were, by competent scientists who approach
the central problem by diverse means. The major effort at cancer chemotherapy
is of this nature, demanding biochemists, organic chemists, pharmacologists,
biological screening procedures and, finally, clinical testing. Certain large-scale
efforts at clinical trial of therapeutic procedures in vascular disease similarly
must be conducted as packaged, big science.

Increasingly, biomedical research will be dependent on relatively large re-
sources: a primate colony, a large computer, or a wholesale attempt at the study
of human genetics. As such opportunities are manifest, it is imperative that
they be recognized as such, funded as such, and so located and managed as to
maximize their utility and success. Indeed, in general the corollary is also
valid; halfhearted funding of such endeavors in piecemeal fashion is both in-
efficient and wasteful.

ORGANIZATION AND SUPPORT OF BIOMEDICAL RESEARCH

The organization and support of biomedical research in the United States have
developed as a patchwork over a relatively short period. As we have briefly
seen, biomedical research is conducted in medical schools, graduate schools, in-
dustrial laboratories, and private and Government research institutes. The total
annual cost of this activity now approximates $1 billion which is provided by
university endowments, State legislatures, individual and corporate gifts, philan-
thropic foundations, public voluntary agencies, and the Federal Government. Of
these, the last now provides somewhat more than half of all the funds employed.
This structure which rather awkwardly expresses one of the major aspirations of
the American people, the prevention and alleviation of disease, functions rather
clumsily, yet the extent and manner in which it should be altered are question-
able.

In other countries (Germany, England, France, the Soviet Union), the re-
search talent of the country is virtually all sequestered in especially organized
research institutes, largely under governmental auspices. Several major criti-
cisms may be leveled at this arrangement. Perhaps most serious is the removal
of research personnel from the educational process. No more distinguished
laboratories may be found in the world than the various units supported by the
Medical Research Council in England. But these units and their outstanding
staffs are at—not of—the universities where they are located, and the only “stu-
dents” to be found there are advanced postdoctoral fellows. How much more
could be contributed by these giants if bright young minds could be exposed to
their incisive and imaginative thinking.

Second, such institutes frequently develop and cultivate a “cult of personality.”
They tend to be dominated by their directors and young, imaginative energetic
investigators may be subservient and deprived of opportunity and self-expression.
This stands in direct contrast to the typical American academic department
wherein the chairman is chief administrator but not scientific director and his
academically junior colleagues are free to follow their own research bents and
seek financial support for their own enterprises.

The current position of leadership of American biomedical science derives
largely from this fact, together with the availability of the supporting funds
and the growth of a supporting industry which provides chemicals, apparatus,
and equipment. However, that the “cult of personality” is not an inescapable,
intrinsic feature of a research institute divorced from the educational enter-
prise will be apparent, for example, from an examination of the intramural
program of the National Institutes of Health. The table of organization of each
Institute makes provision for substantial numbers of independent investigators
at varying stages of development and responsibility and the freedom of each

 
  
  
 
 
 
 
 
 
 
 
 
  
 
 
 
 
  
 
 
 
 
  
  
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
 
 
  
  
  
  
  
 
   
 

284 COMBATING HEART AND OTHER MAJOR DISEASES

to raise his own questions and pursue the answers has been jealously safe-
guarded.

The diversity of both our research institutions and of the sources of their
supporting funds should be considered one of our great national assets. The
variety of institutional character has permitted “fitting square pegs into square
holes.” The investigator who functions best as a lone wolf can find a milieu
in which this is possible. Those who require stimulation from repeated con-
tact with their peers—by far the greatest number—gravitate to the appropriate
institutions. Those who wish also to teach can do so while others, who so
prefer, can avoid this function. Some can engage in full-time research ; oth-
ers divide their efforts variously among clinical care, teaching, and research.
This tailoring of opportunity to personality possesses obvious advantage and
should be maintained at all cost.

Another aspect of our system is noteworthy. At this time, our spectrum of
organization appears to extend from the completely private institution through
State institutions to fully Federal organizations. But the differences are more
apparent than real. Most non-Federal institutions engaged in research today
employ their own funds largely as a form of entrepreneur capital. Private and
State funds are used for construction only to the extent dictated by current
“matching” policy. Salaries are assured only to a cadre of tenured staff. Vir-
tually all operating funds, for equipment, consumable supplies, research asso-
ciates and technicians, or travel, must be procured by the individual investi-
gators from external sources, most frequently the Federal Government.

Clearly, this mode of operation offers several great advantages: maximal
use of the institution’s own funds; large-scale use of Federal funds without
Federal control; opportunity for even the youngest qualified investigator; and
assurance that, in determining the fact or level of his financial support, each
investigator is judged by a jury of his peers assembled from other institutions,
each of whom is truly competent to make the required scientific judgment and
none of whom are rivals, on the local scene, for prestige, salary, space, or in-
fluence.

But there are also grave disadvantages: instability of funding with conse-
quent apprehension in the minds of all so employed and the all too real tempta-
tion for the investigator to address himself to studies which promise a quick
return rather than the difficult, long-term investigations of which he may
dream; the increasingly burdensome tasks of application, reporting, and
recordkeeping (see the treasurer’s report of any major university for the number
of individual research grants in an active department of medicine or biochem-
istry); an increasingly cumbersome system for evaluation of research grant
applications, involving the time and efforts of thousands of investigators and
staff; considerable difficulty to the institution in embarking upon new research
ventures or areas of research; and the failure, for lack of appropriate funding,
of most institutions to develop and maintain supporting organizations sufficient
to their own research enterprises. The latter is a serious handicap and reflects
the historical accident whereby universities, for example, have entered the
modern era of research by a series of small steps rather than by deliberation
and commitment to a responsibility which formerly was trivial in comparison
with their educational responsibilities.

Although research has been conducted in American universities for about
150 years, until only recently the trustees, faculty, and public generally regarded
instruction as the prime, unrivaled function of the university. From 1920 to
1940, the pace of academic research was increased substantially but it was
World War II ana its aftermath which witnessed the major development of
universities and their medical schools as centers of research, with common
recognition of the public expectation that universities should serve not only to
store and transmit knowledge but to generate new knowledge. With the recog-
nition that a vigorous ongoing research program enriches the teaching program
at the same time that inquiring young minds enhance and stimulate research,
the university became the chosen maior instrumentality for investigation in
the United States. The means by which this was accomplished was permissive
acquiescence by the university administration as members of its faculty seized
the opportunities afforded by the grant-in-aid programs of foundations, volun-
tary agencies and the Federal Government.

But today that system is in crisis. While the American people, through the
voluntary agencies and the Federal Government, wish to prosecute biomedical
research with all the vigor at our command, there remains insistence that the
university be a financial partner in the enterprise. And this, at a time when
COMBATING HEART AND OTHER MAJOR DISEASES 285

the financial resources of the university are stretched to the breaking point by
its instructional responsibilities. It is therefore financially impossible for the
university to respond to both calls in the manner expected, or indeed as it
should prefer to do.

Thus, never having deliberately embarked on a large-scale research venture,
no university has planned or provided the ancillary supporting organization
which is to be found in every major research institute and industrial laboratory.
‘With a salary structure tied to its educational responsibilities, no university
has the means to expand the size of its faculty so as to meet its teaching
responsibility while maximizing its research enterprise. Few universities can
create, out of their own resources, new research groups in such scientific areas
as biometry, biophysics, or genetics, for example. No university, unassisted,
can afford to bring into being a multidisciplinary group which will address
itself to the problems of vascular disease or cancer. Few can afford the salaries
of research professors relatively free of responsibility for undergraduate in-
struction, None possess hidden assets or a capital reserve with which to bring
into being or maintain a computer center, a bioengineering group, or a colony
of esoteric animals maintained for research purposes. Hard pressed to provide
dormitories for an ever increasing horde of freshmen clamoring for admission,
‘where is a university to find the funds to use for matching a grant to assist
it in construction of a new or expanded medical research building? The Sub-
committee therefore submits that—

Whereas at this time, the financial resources of the universities are insuffi-
cient even to meet their educational responsibilities ; and

Whereas no program of direct Federal support to higher education is
currently available; and

Whereas it is the avowed intent of the American people to have bio-
medical research prosecuted in as vigorous a manner as our national pool
of trained talent will permit; and

Whereas universities, their medical schools, and various research in-
stitutes are the instruments most suitable to this task ; and

Whereas from their own resources, universities cannot underwrite the
large costs of major research programs, including: salaries of senior in-
vestigators in numbers greater than those dictated by the basic educational
programs of these institutions; creation of new disciplinary departments
or of interdisciplinary research groups; establishment of adequate research
supporting organizations; or construction of necessary new physical facil-
ities; and

Whereas if the tempo, magnitude, and scope of the biomedical research
enterprise are to be expanded in a manner compatible with our potential
national capability, funds greatly in excess of those currently available
will be required.

It is, therefore, recommended that Federal and other agencies in support
of biomedical research in universities and research institutes identify, rec-
ognize, and provide the total direct and indirect costs of such research in
an amount commensurate with our national capabilities.

It would seem, therefore, that the time is at hand for a serious examination
of our national program for the organization and support of biomedical research.
The present patchwork should be consolidated into a more workable mechanism
while retaining the highly desirable features which have facilitated the great
strides made in the recent past. We must retain the diversity of institutional
character, tighten the coupling between research and education, maximize oppor-
tunity for talented young investigators, and increase the number of institutions
in which truly significant research is conducted, while reducing current adminis-
trative burdens, arranging for adequate supporting organizations, and assuring
both the institutions and individual investigators of stable, relatively long-term
support.

To this end. the Subcommittee on Research offers a series of specific recom-
mendations which are presented below.

Role of individual research grants

The Subcommittee considers that the individual research grants program,
which entails a relationship between the Government and each individual inves-
tigator. is the heart of our national research endeavor and responsible for the
preeminence of American biomedical science. Regardless of all other considera-
tions and funding devices, the subcommittee recommends that the national

43-469— 65-19

 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
    
 

286 COMBATING HEART AND OTHER MAJOR DISEASES

program of individual research grants be continued and expanded commensurate
with the pool of competent, training investigators.

Funding devices in support of research

The Subcommittee has considered various alternate schemes for the funding
of biomedical research and concluded that the present diversity of funding
devices, which came into being in response to expressed needs, remains appro-
priate to those needs. Rather than single, large packaged grants to each uni-
versity or research institute, the Subcommittee recommends that Federal agen-
cies in supporting biomedical research continue to do so by diverse means includ-
ing individual research grants, fellowships, career awards, training grants,
center grants, general research support grants, construction grants, etc., devel-
oping new modes of support as these are identified and found to be suitable.

Training and support of investigators

While requiring facilities, apparatus, assistants, etc., research is conducted,
essentially, by the minds of trained scientists. It is in the national interest,
therefore, to insure a continuing and expanding supply of biomedical scientists
adequately trained to insure the quality of biomedical research tomorrow, scien-
tists well grounded in biology and medicine, knowledgeable in chemistry, physics,
and mathematics, alert to the concepts and methodology of the biological re-
search disciplines.

(a) The funding instrument most suitable to the task of assisting the uni-
versity, or other research-educational organization, in providing such advanced
training is the “training grant.” This instrument permits local identification
of young men and women with research potential, provides them with appro-
priate stipends, and, equally important, by diverse means assists the institution
to improve the quality of research training while enlarging its capacity for so
doing. The National Institutes of Health (NIH) program of training grants
has resulted in a pronounced upgrading of research training in the last 5
years. Its continuation and growth is vital to the entire biomedical research
enterprise. Indeed, failure at this time to expand such training support must,
automatically, limit the magnitude of the entire national biomedical research
program in subsequent years.

Accordingly, it is urgently recommended that the national program of re-
search training grants should be enlarged and expanded at a rate commensurate

with the training capacity of organizations so engaged and the national pool

of young investigators desirous of such training.

(8) The basic curriculum by which medical schools educate physicians and
which leads to the award of the M.D. degree is decidedly insufficient as a
training for an investigative career. Recognizing this fact, universities have
developed a variety of mechanisms for enriching the experience of potential
physician-investigators. The most formal of these lead to the award of both
the M.D. and Ph. D. degrees; other programs provide essentially similar train-
ing but lead to the award of only the M.D. degree. In either case, the student
so engaged must devote several additional years to this experience, as well as
satisfy the requirements for the medical degree, undertake several years of
postdoctoral training, and perhaps serve his obligated military experience
before actually embarking on a research career. This is demanding not only
of his time but of the financial resources of his family. Without additional
support, clearly, the pool of clinical investigators becomes limited to those
whose families possess the financial resources to underwrite this lengthy and
expensive program.

Accordingly, it is recommended that a continuing national program should
be developed to provide full financial support to those qualified students who
aspire to an investigative career in medicine and for whom the institution
provides a clearly defined, special program which combines medical education
with research training.

(c) The budgets of universities are rather closely tied to their educational
responsibilities; the number of continuing faculty positions provided by the
budget, therefore, is directly related to the number of students and courses
to be taught. Although the university is the best setting known for the con-
duct of biomedical research, there is no necessary relation between the scale
of the educational and research enterprises in a given institution. In view of
the financial straits of the universities, they simply cannot be expected to fund
staff positions in numbers greater than that required by their instructional
COMBATING HEART ANI (TIInN May IN lish tse Ss

 

function. If, therefore, the biomedical researcn et : L
magnitude to which we aspire, it becomes imperative that ail..

be funded by external means, utilizing funds appropriated in su;
search. Moreover, the positions so created must be sufficiently stabi
permit pursuit of long-term inquiries, undisturbed by the thought that the
investigators’ salaries may disappear in the next fiscal year.

A variety of mechanisms to this end have presented themselves, e.g., in-
clusion of stable salary support in training grants; a contract between the
granting agency and the university whereby, on request, the agency auto-
matically provides some fixed proportion (eg., 50 percent) of the salary of a
principal investigator after award of a research grant, inclusion of staff
salaries in general research support grants, continuation and expansion of the
program of research career awards. Each device has merit, each provides
a partial solution to the problem.

Accordingly, it is recommended that Federal agencies in support of bio-
medical research should proceed rapidly and vigorously to establish mecha-
nisms to expand the number of reasonably stable, continuing positions for
responsible investigators in institutions which sponsor programs of biomedical
research.

To this end, it is further recommended that, at an early date, officials of
Federal agencies in support of biomedical research convene a conference of
representative officials of institutions engaged in such research to explore
and determine those mechanisms which appear most satisfactory as a means
of expanding the number of the aforesaid positions.

     

General research support grants

Several years ago, it was recognized by the Congress and by the administra-
tors of the National Institutes of Health and of the National Science Founda-
tion that the pattern of funding of research generally and of biomedical
research in particular had failed to provide opportunity for the university
to embark on wholly new research ventures, to develop appropriate organiza-
tions in support of the research enterprise, to underwrite initial exploration
of a research idea which is, as yet, insufficiently grounded to warrant major
support in the usual manner, or to recruit new staff in research areas unrep-
resented in the present organizations.

Both agencies developed a program of institutional general research grants,
the amounts to be related, by formula, to the magnitude of the research
enterprise at each institution. Within the institutions eligible for such awards,
there is virtually unanimous enthusiasm for this program and its aeccomplish-
ments.

With the passage of time, however, the magnitude of such awards hks not
been increased in the manner authorized by the Congress although, as suggested
earlier, the need is ever greater, Hence, universities cannot readily undertake
new ventures as had been hoped, Scientists complain increasingly of the serious
inadequacies of the supporting organization and services in their institutions
which might otherwise facilitate and expedite their research and, for lack of
which, they are increasingly forced to devote their energies to activities better
left to others.

As described earlier, present funding devices have not permitted expansion
of the continuing research staff. Moreover, whereas an increasing fraction of
significant biomedical research is done in graduate departments outside the
schools of medicine, dentistry, and public health, such activity is not reckoned
in the present computation by NIH and these graduate schools do not participate
in the desirable features of the general research support program of this agency.

Accordingly, it is recommended that-~

(a) The magnitude of the general research support grants programs of Fed-
eral agencies should be expanded as rapidly as possible, at least to the full
extent originally authorized by the Congress.

(b) Graduate schools and departments engaged in biomedical research sup-
ported by grants from the NIH should be included in the general research sup-
port program.

(¢) General research support grants should be awarded in two categories:

(i) Unrestricted funds to be devoted to research as at present, and
awarded on a formula basis.

(ii) Negotiated awards, based on documented applications, to defray
the direct and indirect costs of the supporting organization and services

  
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 

28S COMBATING HEART AND OTHER MAJOR DISEASES

provided by each institution to facilitate the conduct of research and which
are not ordinarily chargeable as indirect costs.
Libraries

The end product of a research project is publication of the findings and
conclusions in an appropriate medium, i.e, a medical or scientific journal or as
a monograph, Such publication constitutes the enduring record of research in
progress. It is available to other investigators engaged in immediately related
research and to all others who can utilize the information so provided. Hence,
it is not archival; it is the living means of general communication within the
scientific communty.

The library, then, is an indispensable research tool and must be as readily
available as microscopes, spectrophotomers, or experimental animals. With
the increase in scale of biomedical research has come, ipso facto, a torrent of
publication which exceeds the capacities of our libraries and librarians while
demanding ever-increased use of the library by those engaged in research.
Nevertheless, despite the fact that the results of research crowd the shelves
while investigators crowd the stacks and reading rooms and badger the librar-
ians, no ongoing program provides support for this endeavor. Consequently,
biomedical library services the country over are deteriorating. Neither the
National Library of Medicine, the National Institutes of Health, ner the National
Science Foundation presently operates a program in support of the beleaguered
libraries despite the fact that such support, in good conscience, should be a
legitimate charge against funds appropriated in support of research.

The inadequacy of payments for indirect costs precludes use of such funds
for libraries. Meanwhile, the institutions engaged in biomedical research rarely
ean obtain private funds for such purpose.

Accordingly, it is recommended that a national program in financial support
of biomedical libraries should be initiated at the earliest possible date.

It is recognized that much effort is currently invested in studies of informa-
tion retrieval systems based on computer operation. The present recommenda-
tions are not intended to delay or substitute for such activity. However, al-
though the Subcommittee cannot prognosticate the form which scientific com-
munication will take after 1980, it is convinced that the present form of the
biomedical library will, nevertheless, retain its utility and vital significance for
many years to come,

Centers and institutes

The Subeommittee has carefully examined the current organization of bio-
medical research and compared this with needs, opportunities, and capabilities.
On the one hand, it recognizes the need for an increasing number of research cen-
ters, ie, organizations dedicated to a large task, a research problem which exist-
ing institutions are unlikely to undertake, or a special resource which properly
can be categorized as “big science,’ and which serve national or regional re-
quirements. At the same time, it considers that whereas educational institu-
tions, even in their present format, are excellent locales for the conduct of “little
science,” rarely do they take maximal advantage of the opportunity and occa-
sional necessity for multidisciplinary research. Accordingly, two sets of recom-
mendations are offered in this regard.

A. Specialized national or regional research centers

The Subcommittee recommends that the current program of specialized research
and resource centers of the National Institutes of Health be expanded and ex-
tended as need arises and opportunity affords. Certain instances can readily
be identified.

i. Primate centers—These represent a relatively new and essentially, as yet,
untried venture. Those already authorized should be fully funded and sup-
ported ; new centers should be created only as need arises.

ii. Other animal centers.—The Subcommittee is aware of the need for a va-
riety of special animals not presently available in quantity. Attention is, there-
fore, directed to the possible need for centers for the maintenance and breeding
of genetically standardized, highly inbred, strains of dogs, rabbits, and other
small animals, and the responsibility to be alert to other such requirements. If
such centers are created, the pattern of university management developed for
primate centers seems eminently acceptable. At least one center for maintenance
of colonies of exotic animals with unusual deviations of the cardiovascular
system and another for maintenance of animals with unusual malignancies might
—— UU

 
  
 
 
 
 
 
  
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   

COMBATING HEART AND OTHER MAJOR DISEASES 289

well be of service to the entire program of research in cardiovascular disease and
cancer.

iii. Towicology centers.—A serious lack in our Nation is a center or centers
devoted to long-range study of toxicology, the effects of herbicides, pesticides,
new and widely used drugs, rare and trace elements, as well as common chemi-
cals. The critical need for such information has repeatedly been documented,
perhaps most clearly in a report of the President’s Science Advisory Committee.

In the present context, such a need will continually arise as new, promising
drugs are introduced for cancer and cardiovascular therapy. But the philosophy,
technics, and facilities required for these therapeutic agents are essentially
identical to those necessary to acquiring sufficient information concerning the
acute and long-term effects of the diverse organic chemicals which are introduced
into man’s environment for other reasons. Each year in which we lack such
information may, conceivably, bring us that much closer to a national disaster.

The intrinsic nature of the required effort is truly “big science.” Several
centers, appropriately organized, could be established in one of several patterns,
industrially managed (e.g., Oak Ridge), managed by a consortium of universities
(Brookhaven), on a university campus (Argonne), part of an intramural pro-
gram of the National Institute of General Medical Sciences, or become a corner-
stone of a new National Institute for Environmental Health. But the need is
urgent and, accordingly, it is recommended that several national centers for
toxicology be established at the earliest opportunity.

iv. Bioengineering centers—It was stated earlier that each major new instru-
ment provided to the research community has resulted in a wave of previously
impossible research. ‘The need for such instrumentation is by no means satisfied,
and a great variety of opportunities would be afforded were a group of competent
biologists, physicists, and engineers to engage in collaborative development.

Accordingly, the Subcommittee recommends that there be brought into being
several centers for bioengineering. The most likely pattern for success is con-
sidered to be a center under joint auspices of a medical and an engineering
school. ‘The number of such centers would best be established by experience.
At this time, it would seem that perhaps half a dozen such centers, each with a
complement of 15 to 20 responsible scientists would be commensurate with
national need. As national expenditures fer the defense and space efforts decline
there should be released more than sufficient numbers of qualified physicists and
engineers to staff such centers.

As an incidental but extremely important function, such centers could properly
undertake to train substantial numbers of instrumental technicians and service
personnel as well as technicians skilled in specific aspects of biomedical tech-
nology, such as electron microscopy, uwltracentrifugation, or radioactivity
determination.

v. Microbiological resource centers—Much current research demands the
availability of large quantities of a given species of bacterium, of a given animal
cell type. or of viruses which infect them. Development and management of a
center which could provide animal cells or their infecting viruses seem desirable,
but unduly costly at this time. However, a resource center, analogous to the
New England Enzyme Center, which could undertake to produce on request large
quantities of bacteria or bacterial viruses would provide an invaluable service,
and it is recommended that at least one center for microbial production be
supported.

vi. Center for human genetics —The last 15 years have witnessed a remarkable
growth of knowledge of genetic mechanisms. Dozens of genetic markers have
been identified in human beings. Yet there has been no systematic large-scale
approach to human genetics. The Subcommittee suggests that the time may be
apropos for creation of a National Center for Human Genetics which would in-
clude a computer-based tabulating center to make possible diverse correlations
which are presently impossible.

Accordingly. the Subcommittee recommends that there be convened a planning
conference on human genetics to explore, in depth, the desirability and feasibility
of establishing a National Center for Human Genetics.

vii. Information retrieval centers.—As suggested earlier, the Subcommittee
is in complete sympathy with all attempts to expedite information retrieval.
As a corollary to the medlar system, it is suggested that retrieval centers of
limited capability and specialized interest be established. One such—for human
genetics—was cited above. Additional limited and hence, hopefully manageable
centers might include toxicology, properties of drugs, physical properties of
organic compounds.
290 COMBATING HEART AND OTHER MAJOR DISEASES

B. Multidisciplinary university-based rescarch institutes

i. Clinical research centers, located at medical schools and other medical
research institutions, of both a general and categorical nature, have already
demonstrated their inherent merit. Such clinical research centers should be
continued and the number increased as new medical centers truly become eligible.
In no instance, however, should the magnitude of such a center be increased
without unusually close examination of the capacity of the institution to make
use of such resource.

li. Multidisciplinary university-based research institutes.—Repeated reference
has been made to the inability of universities to mount multidisciplinary research
programs or to found new disciplinary research departments, largely because
their organization and budget are rigidly related to their educational responsi-
bilities. Confronted with the need to assure that each discipline and sub-
discipline of biological science is represented on the faculty, and hence, presented
to its students, no university can also arrange, from its own resources, to gather
and house a multidisciplinary group which, in concert, will attempt to ascertain
how an enzyme works, or the fundamental nature of the cancerous change in
cells, or a correlation between the metabolism of the heart and the signals evident
in the electrocardiogram, ete.

It is the considered judgment of this Subcommittee that the most promising
means of expanding the national biomedical research effort, particularly that
directed at cancer, heart disease, and stroke, is the establishment, at qualified
institutions with a record of research productivity, of fully supported biomedical
research institutes.

The scope and mission of each such institute would be determined locally. It
is anticipated that some institutes might be of a general biological character
(e.g., cell biology), some restricted to a more limited area (e.g., genetic mecha-
nisms, macromolecular structure, mechanism of enzyme action, cardiovascular
physiology, or neurophysiology), whereas others would be distinctly categorical
(e.g,. cancer, stroke, cardiovascular disease, metabolic disease, or allergy and
immunology). To implement such a program requires that each such institute
be fully funded, including construction of the necessary physical plant. Were
both supporting funds and physical facilities for these institutes available, the
national capacity to mount this program would then be limited only by the
availability of sufficient numbers of competent, trained manpower.

The appended budget projections seem commensurate with the current and
expected pools of appropriately trained scientists from our national educational
enterprise. In the firm belief that the coupling of research and education
enriches both, the Subcommittee urges that the senior staff of such an institute
be members of the university faculty, expected to participate in the normal aca-
demic program and to welcome into their laboratories both graduate students
and postdoctoral fellows.

No. device known to this Subcommittee. offers equal opportunity for dramatic
expansion of the national biornedical program while insuring its quality yet
without draining teacher-investigators from the educational enterprise.

Accordingly, it is strongly recommended that, at the earliest opportunity
there should be brought into being a national program of university-based bio-
medical research institutes. ‘

iii. Computer centers.—It is abundantly evident that computer technology
will shortly ‘pervade. much of biomedical research. Every institution with an
ongoing research program of sufficient magnitude will soon be seriously handi-
capped if it lacks at least a minimal computer of a configuration appropriate to
its requirements since such technology adds a new dimension to many aspects
of biomedical research; e.g., cardiovascular physiology, and cencer therapy.
Since large computers invariably exceed the ability of any one research group |
to employ its capacity, computers, except in unusual instances, should be pro-
vided as institutional resources.

Centers of excellence

The recommendations above would, if implemented, permit a marked expan-
sion in the magnitude of the national biomedical research program while insur-
ing its quality. However, as in almost all such programs, there is the inbuilt
property that, of necessity as one insures proper use of public funds, the “rich
automatically get richer.’ A few years ago, the Seaborg report of the Presi-
dent’s Science Advisory Committee noted the increasing tendency to place
research and training funds in a restricted number of institutions and suggested
that, as a means of expanding the research base of the Nation and also achiev-

 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

COMBATING HEART AND OTHER MAJOR DISEASES 291

ing more equitable distribution of research funds without diminution in the
quality of the research effort, special assistance be provided to a group of per-
haps 20 institutions of demonstrated potential so that they might achieve the
same standards of research performance as the present topmost 20 institutions.
This suggestion will shortly be implemented by the National Science Foundation
in its science development program whereby each year a few schools will receive
a single “no year” grant of no more than $5 million to support the school’s own
program of science development and research improvement. However, for this
program the NSF can look forward only to an appropriation of about $28 mil-
lion per year, hardly sufficient to this end.

Accordingly, it is recommended that the NIH should enter into a cooperative
arrangement with the NSF in its science development program in which the
NIH assumes responsibility for the biomedical aspects of such a program.

Management of Government-university relations

The Subcommittee shares with the entire scientific and medical community
eoncern for the threat posed to the research enterprise by an evermore burden-
some enmeshment of research in bureaucratic regulation both by the Government
and by the universities. It shares the belief that this situation can be relieved
only by transfer of such responsibility to university administrations accompanied
by full acceptance of such responsibility.

A set of guidelines and principles with respect to university-Government re-
lationships has been presented by the National Academy of Sciences, Committee
on Science and Public Policy in the report entitled “Federal Support of Basic
Research in Institutions of Higher Learning.” This Subcommittee on Research
warmly endorses the recommendations presented in that report.

Animal care

An ample supply of healthy, humanely treated animals is a sine qua non for
biomedical research. To the best of its ability and the extent permitted by its
resources, every responsible institution attempts to meet this need. Hopefully,
sufficient funds will be provided to permit each institution to bring operation of
its facilities to the quality all agree to be desirable. In this regard, however, it
is noted that there is an acute shortage of properly qualified and trained veteri-
narians to assume responsibility for such animal facilities.

Accordingly, it is urgently recommended that authority and funds be sought
to support a few centers for the specific training of veterinarians in the manage-
ment of central animal facilities in biomedical research centers.

In addition, it is agreed that the physical facilities available for central animal
facilities are rarely of desirable quality. It is, therefore, earnestly recommended
that, an especially funded program for support of renovation of old animal quar-
ters and construction of new quarters for animals used for biomedical research
be established at the earliest opportunity.

The Subcommittee sees serious dangers inherent in regulatory legislation con-
eerning animal experimentation. <A vocal group of American citizens is request-
ing the Congress to establish an elaborate mechanism to police the care and use
of laboratory animals in biomedical research and teaching when supported by
Federal funds. The most actively promoted bill would prohibit the use of verte-
brate animals unless the desired information could be obtained by other means,
would require that animals used by surgeons-in-training be killed before they
regain consciousness, and would allow a Federal official to determine how many
animals might be used in any particular study. Such legislation would dan-
gerously frustrate and seriously impede biomedical research and teaching. All
concerned should be alert to prevent passage of legislation which would hamper,
needlessly, the use of animals in biomedical research.

International biomedical research

Several Federal agencies which support health related research and research
training—National Institutes of Health, National Science Foundation, Office of
Naval Research, Atomic Energy Commission—operate international programs
of some magnitude. It is precisely because these programs were not conceived
as a form of foreign aid that these programs, perhaps more than most, require
frequent reexamination with regard to principle, practice, and order of magnitude.

The Subcommittee affirms the principle that support of research outside of
our country by competent foreign nationals, collaborative research involving
American and foreign laboratories and training of American scientists in foreign
laboratories and of foreign scientists in American laboratories is most certainly

  
 

292 COMBATING HEART AND OTHER MAJOR DISEASES

in our national interest and the Subcommittee endorses these programs designed
to such ends.

The arguments in favor of an international biomedical research are neither new
nor novel. They include:

(a) Biomedical science, by its nature, is international.

(6) Our Nation has no monopoly on scientific talent. The “revolution in
biology” may well have matured in this country but, in large measure, it was
spawned in Europe. Aided by American funds, foreign nationals have made
many of the most significant contributions to fundamental biology as well as to
knowledge of the specific diseases of concern to this Commission. Indeed, many
laboratories outside the United States can boast unusually productive research
directors and staffs. There is no more distinguished laboratory in the world
than the Medical Research Council unit at Cambridge and many of our brightest
young investigators have received both training and inspiration there, as well
as in the great laboratories of Paris, Stockholm, Oxford, Copenhagen, Munich,
Naples, and Tel Aviv.

(¢) It is platitudinous but no less true to note that a finding significant to
fundamental biology or to the understanding or control of heart disease, cancer,
or stroke, made in a European or Latin American laboratory, is as relevant to the
health of the American people as if it had been made in Boston, St. Louis, or
Berkeley.

(d) It is quite clearly in the national interest to have a significant fraction
of young American scientists receive research training in laboratories abroad
where they may be exposed to scientific philosophy, points of view, and methodol-
ogy not encountered within our own borders. Granted this premise, we must not
be reluctant, indeed we are obliged to support, in some measure, the research
programs ongoing in the laboratories to which they are attracted. In this regard,
it is encouraging to note that, of the 300 American biomedical scientists engaged
in postdoctoral research training in foreign laboratories in fiscal year 1964,
250 are in laboratories which have American research support. Thus European
laboratories have been scrutinized by two independent groups: our prospective
young scientists, and the research grants reviewing committees. It is clear that
the two sets of judgments are in excellent agreement and that in supporting
research in these laboratories we truly are supporting the training of American
scientists.

(¢) There are dramatic differences in the geographic distribution of many
diseases, e.g., of various forms of cancer, of essential hypertension, and of athero-
sclerotic disease.. Research directed at understanding of the cultural environ-
mental. or genetic bases of these variations should shed much light on the
origins of these disorders and exploitation of such unique research opportunities
is virtually mandatory in our national medical research program,

(f) Research directed at understanding of those tropical diseases which are
exotic in an American. setting but which affect more than a billion people about
the globe is justifiable on several grounds. A humanitarian concern for the
welfare of immense numbers of wretched fellow human beings should be self-
evident. Of immediate but lesser consequence, perhaps, is the need for sufficient
knowledge to protect the health of Americans in tropical areas, be they there as
tourists, on business, or in Government service. Finally, from the purely finan-
cial point of view, it must be remarked that if one could remove the heavy hand
of disease which enervates entire tropical nations, the gain in their national
vitality, economy and, hence, trade relations with this country would dwarf the
relatively meager research costs which may be required.

(g) It will be self-evident that it.is in our national interest to welcome into
our own laboratories, for training, foreign clinicians and investigators who may
return home to. undertake research particularly germane to their own countries.
This must ultimately lighten the burden on us to support investigation in those
countries and, if the total effort is successful, must diminish the necessity for
conventional foreign aid programs.

(h) At the same time, the combination of research support for foreign scien-
tists and training of young foreign scientists in our laboratories may be regarded
aS meager recompense for the annual immigration, gratefully accepted by our
country, of about 1,600 physicians and a yet greater number of trained scientists
without whom it would be impossible to man our hospitals and laboratories.

(4) Finally, it must be noted that, in the sense generally employed, a program
of support for international research is not a form of foreign aid but it is an
almost unique and superb mechanism for continuing improvement of our for-
 

 

COMBATING HEART AND OTHER MAJOR DISEASES 293

eign relations. Foreign scientists who have received part of their training here
return home as our friends and supporters; this group includes many who have
become influential figures in their home countries. Young American scientists
abroad are effective spokesmen and excellent examples of the American ideal
while enjoying an easy rapport with their foreign counterparts. The notion that
this country voluntarily appropriates funds for support of health research, con-
ducted the world over, preserves and extends the humanitarian image of this
country abroad. Indeed, it is unfortunate that means have not been provided
to direct more public attention to the program. In any case, in these several
ways. dollars invested in support of international biomedical research yield a
handsome return.

Granted the many virtues of a program in support of international biomedical
research. it will at once be apparent that this country lacks the means to under-
take total support of biomedical research, independent of national boundaries,
and further that we should not do so in any case since one of the goals of such
a program must be to assist other nations in developing their own national capa-
bilities. Accordingly, this program must be limited to a scale commensurate
with both cur means and our goals. What then are these limitations?

(ai Since total funds in support of biomedical research are inadequate, even
the mest ardent proponents of support of biomedical research abroad agree that
the magnitude of our international research support program should never be
such as seriously to limit our domestic program.

(b} Accepting the philosophy that our research-support programs should be
designed t- assist other nations in developing and sustaining their own programs,
the Interca‘ienal Science Panel of the President’s Science Advisory Committee
suggesied :Lat our own support should gradually be phased out, although the
time scate «f this activity was not determined. Further, it was suggested that
the time La~ arrived to begin this process in several of the Western European
nations wh:--h enjoy economic prosperity and have vigorous, growing biomedical
Tesearvh pr <erams.

However. ': is these very nations—United Kingdom, Sweden, France, West
Germary. !-aiy—which can presently boast the most productive and distinguished
laboratories ontside our bounds. It is to those laboratories that young Ameri-
cans g« iz «arch of additional training and it is from those laboratories that
there .<n- 2+ this country the most welcome additions to our scientific work
form. I: +<+< imperative then that these laboratories be assured of the
Stability mx, ustte to their training function. Moreover, it would be unthinkable
to retreat In<m support of those laboratories engaged in studies which may ap-
propria‘+iy te deemed intrinsic aspects of our own national program of bio-
medal m-anch unless they are assured of adequate support by their own
countries zr] we are assured of the same ease of intellectual. access afforded by
CUITeER? peace. /

ice To tw “f national concern with the balance of payments and the outward
flow .* i. it bas been argued that this, of itself, constitutes sufficient reason
to limit «cr javeram of oversea support of research. This argument is irrelevant
to siyqert 2 msearch in those relatively underdeveloped countries. in which
there bss i++ accumulated substantial amounts of counterpart funds which, by
Public Liew +1 can be used for research support. It is relevant to the more
advar-s] -.-cxu:ries of Western Europe wherein the most dynamic medical re-
seareh .s := jeveress. However, the argument, in the view of this Subcommittee,
lacks f-~ when one considers the trivial magnitude of this total program
as o-ryearmei lor example, with the total expenditures of American tourists in the
sale ~vit‘r¥s, The subcommittee shares the view expressed by Senator Hum-
phrer 2° t2- ::geupriations hearings for fiscal year 1965.

“es © Scere ggain. this year, I renew my recommendation to the Bureau of the
Budg=—3- =< allow concern for America’s balances-of-payments problem to
intrad- .=°° 2 relatively tiny—from a fiscal standpoint—but relatively crucial—
from. a =si~%i <andpoint—area of NIH contribution. I refer to its support of
Oversea Teu mA exchange, and training.”

In vee “2 ‘be above considerations, the Subcommittee submits the following
TeCOM tmeroela ly GE:

1. I:  vemmended that the United States should vigorously support all
forma:. .:°+914:~Hal mechanisms and devices which exist to promote interna-
tional ~m2tt-action in the field of biomedical research and international co-
operarit+ *+ tt<12es% in the conduct of research.

(In th.« ~gacrdk the subeommittee has in mind the activities of the various
interza*. <4 «--n:ific unions, and the World Health Organization.)

 

    

 
 

 

   

   
  
 
  
 
 
 
 
  
 
 
 
 
 
 
  
  
 
 
 
 
 
 
 
 
 
 
  
 
 
  
 
   
 
  
  
 
 
 
 
 
 
   
  
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
   
294 COMBATING HEART AND OTHER MAJOR DISEASES

29, Since the number of trained scientists must limit both our national and all
foreign programs of biomedical research, it is recommended that those programs,
whereby Americans are trained abroad and foreign scientists are trained here,
should be fostered and expanded as the number of competent, qualified ap-
plicants increases. A doubling of both activities by 1972 seems commensurate
with the opportunities.

3. Research projects which are collaborative ventures between American and
foreign scientists seeking to take advantage of some unique research opportunity
outside our borders are, in effect, direct extensions of our domestic research
program. Accordingly, it is recommended that cooperative research projects
and programs representing joint efforts of American and foreign investigators
should be budgeted from funds appropriated in support of domestic rather than
international research.

4, Support of biomedical research and research training in relatively under-
developed countries, which can be paid for with counterpart funds, presents an
exceptional opportunity to aid such nations, improve foreign relations, and seize
the unique advantages of disparate factors which contribute to unusual incidence
of diseases of interest to this Commission, all at essentially no cost to this country.

Accordingly, it is recommended that biomedical research and research train-
ing in those nations, wherein there are substantial amounts of Public Law 480
funds, should be supported to the maximum extent possible within limits im-
posed only by their resources of trained manpower and research facilities.

5. As noted previously, biomedical research and research-training opportuni-
ties are maximal in those countries of Western Europe which are enjoying
economic prosperity but which attract our own young scientists for training and
from which emigrate, to the United States, thousands of trained physicians and
scientists annually. Although we cannot and should not undertake to support
a proportion of the medical research and research training in these nations of
the same order as that in economically and scientifically less privileged countries,
it is imperative that we continue to support such efforts in some degree.

Accordingly, it is recommended that :

(a) Federal agencies, in support of research and research training, continue
to support some such activities in all nations in which such opportunities exist.

(0) The criteria for judging applications for research grants from such coun-
tries should be unusually rigorous with respect to the quality of the project
proposed and the competence of the investigator-applicant.

(ce) The magnitude of our biomedical research-support program should reflect
local opportunities and the needs of agency programs rather than an arbitrarily
fixed fiscal ceiling.

(d) Prior to payment of research. grants overseas, a representative of the
agency concerned, together with our science attaché in that nation, should enter
into negotiation with appropriate officials of the nation concerned with a view
to establishing the terms and limits of the research support in question.

The following table summarizes the appropriation recommendations necessary
to implement some of the key recommendations presented in this report. It
should be noted that some of the recommendations made in this report appear
with suggested appropriation figures in reports of the other subcommittees (e.g.,
animal resources is found in the report of the Subcommittee on Facilities) :
for this reason, they are not included in the table below. /

 

 

 

  
 

 

 

 

 

 

 

 

Year
1 2 3 4 §

Biomedical research institutes. ..-....------------------------- 17.5 15.0 22.5 30.0 37.5
Bioengineering centers. .-.------ 1,25 1.6 2.0 1.5 L5
Centers of excellence... _-.---- 3.0 6.0 9.0 10.0 12.0
Research grants, NIGMS 2 3.0 5.0 7.0 | ....---|--------
Training grants and fellowships, NIGM 6.9 9.25 | 12.5 15.5 18.5
Stabilization of research positions. 4.0 6.0 8.0 10.0 12.6

Total..__-..------- +o eon e n  ne neeenen eneneee 24.75 | 42.85 | 61.00 | 67.00 81. 50

 

 

1 Figures in millions of dollars over and above current appropriations.
2 Figures represent minimum ones, sufficient to support current programs only.
 

APPENDIX B

SUMMARY OF APPROPRIATIONS RECOMMENDATIONS IncLUDING THOSE FoR NEW
PROGRAMS AND INCREASES FoR EXISTING PROGRAMS AND COMPARISON WITH
ESTIMATES OF CURRENT LEVELS OF SUPPORT

 

 

 

Chapter Estimated Year
current —
level of
No. Title support 1 2 3 4 5
(1965) 1

 

3 | A National Network for Patient
Care, Research and Teaching
in Heart, Disease, Cancer, and

Stroke__-_._..-.----_.---2-.-f.--. oa eee 2158.25 | 287.875 | 364.475 421.4 453.45
4; Application of Medical Knowl-

edge in the Community______ 18.5 49. 65 61.65 63, 15 45,15 53.15
5 | Development of New Knowl-

edge._---._.------ eee ee 152.8 56. 56 83.7 107.9 40.2 49.5
6 | Education and Training of

Health Manpower._..____.-_- 37.7 45.05 63. 95 78.15 93.75 110. 65
7 | Additional Facilities &

Resources 52, 25 56. 00 61.00 66. 00 72. 50

Total....-.---------------- 356.75 | 503.175 | 674.675 666. 50 739. 25

 

 

 

 

 

 

 

 

 

 

? Includes only programs for which specific appropriations recommendations are made in this report.
2 Figures in millions of dollars.

Furthermore, it became apparent to us that the Public Health Service and
particularly the National Institutes of Health would be absolutely unable to
initiate the sweeping recommendations we endorse in the body of this report
unless its personnel force is increased appreciably, and unless present Federal
salary ceilings are raised significantly to both retain existing personnel and to
attract new personnel. We are aware of the fact that the National Institutes
of Health is still losing some of its top scientists and administrators because its
salary scales do not compete with salary scales for comparable positions in medi-
cal schools, universities, and industry.

The major problem seems to be an insufficient number of high-level policy posi-
tions to provide effective leadership and coordination of the Department’s many
programs which are basic to the internal strength of the nation. The Depart-
ment has only five such positions: Secretary, Under Secretary, two Assistant Sec-
retaries, and an Advisory Special Assistant to the Secretary (Health and
Medical Affairs). It also has a ‘career Administrative Assistant Secretary and a
General Counsel. ,

These people are expected to provide effective leadership of a Department with
over 80,000 employees, with about 130 programs (over 40 in health), and with
annual expenditures of $6 billion from budget appropriations and about $15
billion from trust funds.

Even from a casual study of the situation, and certainly in comparison with
other Departments of Government, it seems obvious that strengthening of the
Department of Health, Education, and Welfare at the top is greatly needed.
Recommendation

The Commission recommends that a reorganization of the Department of
Health, Education, and Welfare be effected to provide specific high-level policy,

direction and coordination of health programs, with adequate supporting policy
positions.

295

  
 
 
 
 
 
 
  
 
 
 
  
    
   
 
 
 
 
    
   
   
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
   
296 COMBATING HEART AND OTHER MAJOR DISEASES

CHAPTER 3: A NATIONAL NETWORK FOR PATIENT CARE, RESEARCH AND TEACHING IN
HEART DISEASE, CANCER, AND STROKE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Recommendation Year
No. Title 1 2 3 4 5
1 | Regional Centers for Heart Disease, Cancer,
and Stroke._.__--.------------------------- 187.5 126.5 198.1 208. 9 230.7
2| Diagnostic and Treatment Stations---..----- 36.75 66.875 | 106.125 138. 25 133. 75
3 | Development of Medical Complexes_-.-.----- 25.0 37.5 50.0 62.5 75.0
4 | Development of Additional Centers of Ex-
cellence.___..------------------------------ 3.0 6.0 9.0 10.0 12.0
5 | A National Stroke Program Unit..-..------- 1.0 1.0 1.25 1.75 2.0
{
Subtotal.._.-..------------------------ 153.25 | 237.875 | 364.475 421.4 453. 45
{ Figures in millions of dollars.
CHAPTER 4: APPLICATION oF MEDICAL KNOWLEDGE IN THE COMMUNITY
Recommendation Year
No. Title 1 2 3 4 5
6 | Community Planning Grants.__...-.-------- 11.0 1.0 1.0 1.0 1.0
7 | Community Health Research and Demon-
stration_____...---.------------------------ 5.0 6.0 7.0 8.0 10.0
8 | Support of Community Programs. 18.5 24.5 18.0 24.0 30.0
9 | Statewide Programs for Heart Disease Con-
trol. ._--- 2.5 2.5 $5 [ioe ee eee
10 | National Cervical Cancer Detection Pro-
gram... 5.0 7.6 10.0 |...-------]----------
11 | Continuing Education of Health Professions. 10.1 12.1 14.1 8.1 8.1
32 | Public Information on Heart Disease, Can-
cer and Stroke...-...-.-- 7. 55 8.05 9. 55 4.05 4,05
Subtotal. _._...--2-----.--- eee eee 49. 65 61. 65 63.15 45.15 53. 15
1 Figures in millions of dollars,
Cuaprer 5: THE DEVELOPMENT OF NEW KNOWLEDGE
Recommendation Year
‘No. Title 1 2 3 4 5
13 | Biomedical Research Institutes. ...---------- 17.5 15.0 22.5
14 | Specialized Research Centers 7 4.05 6.7 9.4
15 | Research Project Grants.__-._..-----.------- 35.0 47.0 56.0
16 | Contracting Authority for Research and
Development-..--------------------------- 10.0 15.0 20.0 |_-.-------|----------
Subtotal._-.--.------------------------ 56. 55 83.7 107.9 40. 2 49.5

1 Figures in millions of dollars.

 

 

 

 

 
  

HEART AND OTHER MAJOR DISEASES

- Ji TCATION AND TRAINING OF HEALTH MANPOWER

  
 

 

 

 

 
   

 

 

2 Year
1 2 3 4 5
--.-. Professions. .____ 11.0 2.5 5.0 7.5 10.6
-z in Medical and
eens 7,05 7.55 8.05 8. 55 8.55
- 16.1 21.4 27.1 32.7 88. 5
- 10.0 12.0 14.0 17.5 20.0
8.0 16.0 18.0 20.0 24.0
1.4 2.8 4.2 5.6 7.0
1.0 1.0 1.0 1.0 1.0
5 7 9 1.0
cen ee eee eee 45. 05 63. 95 78.45 93. 75 110. 65

 

 

 

 

 

?3 7: ADDITIONAL FACILITIES AND RESOURCES

 

 

 

Year