United States
of America

PROCEEDINGS AND DEBATES OF THE 89"? CONGRESS, SECOND SESSION

 

 

Vol, 112

 

ADULT HEALTH PROTECTION ACT
OF 1966

Mr. WILLIAMS of New Jersey. Mr.
President, the 89th Congress convened a
little over a year ago with a clear call
from the President and people of this
Nation. Our job was to act effectively
on urgent legislation essential to a so-
ciety in search of greatness. And high
on our agenda for action were the medi-
care bill and proposals to increase health
resources of the Nation,

In short order, we passed:

Medicare, which is expected to cost at
least $3.5 billion by 1967, with a supple-
mental appropriation of $9 million for
the development of needed out-of-hos-
pital services and facilities.

The killer diseases program, with over
$300 million to be spent for research
and treatment of heart diseases, cancer,
and stroke.

Amendments to the Health Professions
Educational Assistance Act of 1963 to
extend the authorized construction pro-
gram and student loans for 3 more years,
and to create new scholarship grants and
improvement grants to medical and
allied professional schools.

Amendments to the Health Research
Facilities Act of 1956, authorizing con-
struction grants of $280 million.

Amendments to the Community Men-
tal Health Centers Construction Act of
1963 which authorize grants to improve
facilities and services for the mentally
retarded and handicapped children.

Amendments to extend community
health services to control the communi-
cable diseases and to develop better and
more widely distributed health care for
the chronicaily ill and aged.

But the work done by the health Con-
gress of 1965 was a new breakthrough
yather than a final triumph. Our major
advantage now is that we are better able
to judge what must yet be done. Just
as Newton once said he could see far-
ther than his predecessors because he
could stand on their shoulders, Con.
gress has built an observation platform
high enough to give us new perspective
on the health needs of a nation.

We can now recognize more clearly,
for example, that cur medical resources
are already strained at this critical mo-
ment of increasing demand. Dr. How-
ard A. Rusk, director of the Department
of Physical Medicine and Rehabilita-
tion at New York University, summed up
the medical manpower situation in his
column of January 2:

WASHINGTON, FRIDAY, FEBRUARY 25, 1966

 

Increased training of health personnel is
essential.

To maintain our present ratio of 140
physicians for every 100,000 persons, 330,000
physicians will be needed by 1975.

This will necessitate the annual gradua-
tion of 11,000 students, 3,600 more than the
1959 total.

However, estimates indicate that by 1975
our annual graduation rate will be oniy
9,185,

The Surgeon General’s Consultant Group
en Nursing estimated in 1963 a projected
need for 850,000 practicing professional
nurses by 1970. This compares with a na-
tional supply of 550,000 in 1963, of whom
117,000 were working only part time.

Also reporting on the nurse shortage,
the New York Times said in an editorial
on November 9, 1965:

It is hoped that the Nurse Training Act of
1964, providing $283 million in aid to schools
of nursing over the next 5 years, will bring
the total number of registered nurses in
practice by 1970 to 680,000, But even if this
goal is reached, it will provide for only 38
percent of hospital patient care.

As doctors and others become inereas-
ingly alarmed about Manpower de-
ficiences, we also hear questions about
the heavy demands made upon the
precious time of the physician. At the
recent White House Conference on
Health, for example, Dr. Robert M. Zol-
linger, professor and chairman of the
Department of Surgery at Ohio State
University, said:

No physician can today or in the foresee-}
abie future have the time to take total care
of his patients, and he must depend upon
auxiliary help. I foresee that, by special
training now proposed for the physician in
family practice he will serve more and more
as triage officer by directing his problem
patients to special centers for definitive
treatment.

The Surgeon General of the United
States, Dr. William H. Stewart, addressed
the same Conference and said:

Year by year, our top professional per-
sonnel are being trained to perform still
more complex tasks. How long can each pro-
fession afford to hang onto its simpler func-
tions—the routine filling of a tooth, for ex-
ample, or the several easily automated steps
in @ medical examination? How can we
train the physician or dentist to make full
use of the skills available in other people,
freeing himself to perform only those duties
for which he is uniquely qualified?

Demands on physicians and other pro-
fessionally trained persons are further
intensified by what might be called our
system of crisis medicine. It is a systern
that demands superb skills, advanced
Knowledge and training, and excellent

No. 33

3921

facilities for the care of the sick, but it
is a system designed for maximum effec-
tiveness at a time of emergency: illness
or accident. For many of the very poor—
the slum dweller, the migrant worker,
the elderly pensioner—our advanced
medical system might as well have been
en another planet. In a nation now
committed to delivery of best possible
health care to all citizens, obviously
much more must yet be done.

if we are to improve dramatically the
health and the health care of our N ation,
there is one simple fundamental step we
can take: a concentrated effort at the
early detection in order to help prevent
the onset of serious illness and the reduc-
tion of its severity.

Obviously, it is impossible to prevent all
chronic ilnesses—and it will become in-
creasingly difficult to deal with them,
using present methods, as larger numbers
of Americans add more years to their
lifespans.

But such illnesses could be held to a
minimum, and the extent of disability or
limitation of activity could be controlled
or delayed if—

This Nation does all possible to keep
people out of hospitals, not only for
humanitarian reasons but also to keep
the costs of medicare to a minimum.

This Nation anticipates that shortages
in medical manpower, together with in-
creasing demands for professional treat-
ment as the aging population of this Na-
tion grows each year, will cause an in-
tensifying need to make the best possible
use of the experience, human under-
standing, and special training of those
professionally trained persons who fight
illness and death every day.

For these reasons I am introducing
today a bill to establish a national pro-
gram for health maintenance.

THE ADULT HEALTH PROTECTION ACT OF 1966

Mr. President, it has been said that war
is the tragic consequence of failure by its
preventive diplomacy. If I may draw a
parallel, the costly and often futile treat.
ment of long-term illness and disability
represents the failure to prevent, or at
least control, chronic disease and to
maintain health.

Preventive medicine is not a new idea.
One aspect of preventive medicine famil-
iar to all is environmental—purifying our
water supplies, reducing air pollution,
exterminating mosquitoes. Almost every
child is painfully familiar with the pre~
ventive medicine of the smallpox vace
cination, the diphtheria shot, and the
yneasies shot. The dramatic results of
this sort of preventive medicine can
be seen in the increased life expect-
ancy of today’s American, and the
virtual elimination of some diseases
within cur borders. But the heavy em-.
phasis on this aspect of preventive med-
icine has had some other obvious reper-
cussions. As some diseases have been
conquered, others have taken their place.
The drastic rise in the number of deaths
caused by heart disease and by cancer
can in part be explained by the simple
fact that more people live longer, escap-
ing the killer diseases of childhood. In
concentrating on environmental health,
immunization, and other primary pre-
ventive measures, we have done part of
the job: we have created a healthful
environment for the individual but we
have neglected an equally important
task: the maintenance and preservation
of the health of the individual. This is
an increasingly essential complement to
the program of environmental health.
As far as we know now, heart disease and
cancer cannot be conquered by environ-
mental health measures alone. But they
can be forestalled or effectively treated
by early detection in the individual. We
have the techniques, the knowledge, and
the equipment to.detect the early signs
of these and other crippling chronic dis-
eases such as glaucoma, diabetes, and
hypertension. The kind of preventive
medicine I am discussing is already being
practiced on a limited scale in many
parts of the Nation. It is not visionary
but eminently practical and vitally
necessary.

Therefore, in my judgment it is time
that we had a national program for the
early detection of tendencies toward ser-
ious illness. If this Nation established
such a program now large enough and
effective enough, we could then have the
facts and the new techniques necessary
to prevent and reduce chronic illness in
middle and iate years.

Accordingly, I have drafted a bill to
amend the Public Health Service Act by
adding a new title authorizing a pro-
eram to protect adult health through
the establishment of locally operated
health protection centers for the detec-
tion of disease.

Any person past the age of 50 would
be eligible for such screening if he wished
to have it.

Centers would use automated or semi-
automated screening techniques which
have already proven their worth in every-
day use.

Eventually, millions of Americans
could thus be encouraged to think in
positive terms about the prevention of
jiiness at a time in their lives when
prevention is possible.

The beginnings of such a program are
contained in the provisions of this bill.

SUMMARY OF PROVISIONS

This bill would authorize the Surgeon
General to make grants to medical
schools, community hospitais, health de-
partments, and other public or non-
profit agencies to establish and operate
health protection centers.

RECIONAL HEALTH PROTECTION CENTERS

The regional health protection centers
would provide a series of basic tests to
detect abnormalities in the cardiovascu-
Jar, respiratory, gastrointestinal, geni-
tourinary and musculoskeletal systems,
as well as defects in metabolism and
organs of special sense. Specific diseases
or conditions to be tested for might in-

clude: First, hypertension, heart muscle
enlargement, and disease; second, mouth,
jung, breast, cervical, and other cancer;
third, diabetes; fourth, kidney disease;

fifth, glaucoma; sixth, tuberculosis;
seventh, rheumatoid arthritis; eighth,
gastrointestinal bleeding; ninth, ane-

mia: tenth, obesity; eleventh, respira-
tory insufficiency; twelfth, vision im-
pairment; thirteenth, hearing impair-
ment; fourteenth, hypercholesteroclemia ;
and fifteenth, gout.

The tests would be administered by
technicians, nurses, and medical special-
ists using automated or semiautomated
equipment which has already been
proven to give swift, accurate, and reli-
able results. The results of these tests,
along with data provided by the person
undergoing the health appraisal, would
be fed into a computer. It is estimated
that the battery of tests could be admin-
istered within 24 hours.

The results of the tests, summarized
by the computer, would be referred to
the private physician of the persen
tested. In cases where the person either
did not have a private physician or was
medically indigent, the test would be re-
ferred to a physician in accordance with
local practice.

The regional health protection centers
are intended to provide an efficient means
for the detection of abnormalities or in-
dications of disease. They would not
replace full examinations. Their pur-
pose is to place in the hands of the exam-
ining physician a summary of basic data
and to place promptly under a physician’s
care a person with indications of possible
disease.

The centers would be under the super-
vision of physicians, but they’ would be
principally staffed by technical person-
nel. Health counselors would be on the
staffs of the centers to explain the pur-
pose of the tests, to insure proper refer-
ral and to follow wp those cases where
prompt medical treatment was indicated
by the tests.

Health appraisals and disease detec-
tion tests would be available to any per-
son age 50 or above on a voluntary basis.

The regional health protection centers
would conduct training programs in the
operation of technical disease detection
procedures and would research and de-
velop new disease detection tests and
equipment. Additional grants to the
regional centers would be authorized for
operational research and for the estab-
lishment of internships to give on-the-
job training to physicians, nurses, social
workers, and technical personnel. The
eenters would also conduct community
education programs on preventive health
care.

The availability of these testing serv-
ices would be intended to encourage men
and women approaching retirement to
take regular health examinations and to
facilitate the giving of full examinations
by practicing physicians.

COMMUNETY HEALTH PROTECTION CENTERS

The Surgeon General would be au~
thorized to make grants to medical
schools, community hospitals, and other
community health service agencies for
the establishment of community health
protection centers. They would be linked
by data transmission lines to the regional
centers and could use the more sophisti-
cated electronic equipment and other
facilities of the regional centers for the
evaluation of some tests.

One of the criteria for the awarding
of grants to regional centers would be
their ability to provide services to the
smali-coramunity centers. Although the
community centers would be directly con-
nected to the regional centers, they would
not necessarily be operated by the same
institutions which ran the regional cen-
ters. One purpose of the community
centers would be to make the services of
the regional centers more widely avail-
able to a greater number of people.
Special facilities might be developed to
méet particular needs. For example,
mobile units might be used in rural areas.

OTHER PROVISIONS

A 12-man Advisery Council on Adult
Health Protection would be established
te advise and assist the Surgeon General
in the administration of this program.

The Surgeon General would be author-
ized to contract with educational insti-
tutions or other appropriate organiza-
tions for the conduct of educational pro-
grams. He would also be authorized to
contract with profit and nonprofit orga-
nizations for the research and develop-
ment of equipment, systems, or processes
which would improve disease detection
procedures,

Let me emphasize—this point bears
emphasis-——that the centers would not be
treatment centers. ‘They would not be
diagnostic centers. They would be lab-
oratories which give data to physicians,
who would interpret that data and deal
directly with patients when consultation
would be needed.

The bill I am introducing requires that
in every case the results of the screening’
test be given to a practicing physician.
The health protection centers would not
be equipped or intended to provide treat~.
ment, although the staff of the centers
would be expected to follow up cases and
to make sure that a participant was
promptly brought under a doctor’s care
if treatment was indicated by the tests.
Even should the screening tests show no
indications of possible disease, the data
would provide basic information to a
physician on his patient which would be
extremely helpful for a full physical ex-
amination by a doctor or as base line
data in future examinations.

Doctors would thus be given more time
to perform the executive, expert func-
tions that only they can perform. They
would be given more time and more facts
to help more people.

As the population continues to In-
erease-—~especialiy the elderly popula-
tion which is most susceptible to chronic
disease and disability—physicians and
oth im the health professions will need
all the time they can get.

COST OF CHRONIC ILLNESS TODAY

Before proceeding with our discussion,
we should be aware of the important dif-
ference between the terms “disease,” and
“iliness.” Tisease is a pathological proc-
ess which may not necessarily produce
symptoms, Tllness—or sickness—is a
condition that comes from disease.
Present knowledge does not permit us to
prevent the onset of the majority of
chronic diseases. However, available
Enowledge can be utilized as a potent
weapon to prevent, mitigate, or delay the
onset of the illness which is a byproduct
of these diseases. An example is athero-
sclerosis, or hardening of the arteries.
An individual may have advanced ath-
erosclerosis with no cbvious symptoms of
the disease. He thus has a chronic dis-

 
ease without illness. Diagnosis in the
crucial preclinical stage can have a far-
reaching effect upon the future health
status of that individual.

Our failure to provide a nationwide
program of health appraisal leading to
early diagnosis may be directly charged
with the high cost of chronic illness to-
day.

Here are some appalling facts:

Chronic disorders afflict about 74 mil-
lion Americans, some of whom have more
than 1 ailment.

Among individuals 65 years old or
older, more than half are functionally
limited to some degree.

Last year, more than 990,000 persons
died of heart diseases.

It is estimated that as many as 25
percent of the Nation’s adults are cur-
rently afilicted with heart disease.

Cancer takes 250,000 lives each year.

The President’s Commission on Heart
Disease, Cancer, and Stroke has re-
ported that these diseases alone cost the
Nation close to $30 billion each year in
lost productivity and lost taxes due to
premature disability and death.

Arithritis now claims 13 million suf-
ferers—and costs the U.S. economy over
$1 billion yearly. It cripples more people
in low-income families than in other
groups and disables more people than any
other chronic disease.

More.than 20 million people are af-
fected by blindness, deafness, epilepsy,
mental retardation and other neurolog-
ical disorders.

Two million are known diabetics.

Almost 1.5 million over 40 years of age
are afflicted by glaucoma.

Presently, we are spending $4 billion
a year for maintenance and medical
care of disabled people through public
assistance programs, in annual compen-
sation and pension payments to veter-
ans by the Veterans’ Administration,
and in Federal-State moneys for basic
support of vocational rehabilitation
services.

And, the Public Health Service is cur-
rently authorized to spend some $53 mil-
lion for various programs attacking a
number of the chronic diseases by means
of extended community health pro-
grams, for demonstrations in new care
service techniques—especially for heart
disease and stroke—for cancer cytology,
for screening for diabetes, for support
for the artificial kidney, for community
programs attacking arthritis and rheu-
matism, and for treatment facilities for
chronic respiratory disease, epilepsy,
and other neurological disorders.

Just this month, I obtained some fig-
ures on the prevalence of chronic con-
ditions among persons 45 years of age
and over. This is approximately the
age group with which my legislation is
concerned.

Prevalence of chronic disease in persons

over 45

Per 1,000
population

Hypertension including hypertensive
heart disease____-_.-2.------ eek 292
Arthritis and rheumatism_..-_--..-_u. 180
Chronic bronchitis--.--.....--..-.---- 100
Hearing impairment_..---.....---.---. 90
Coronary heart disease_. 2.222 a 58
Vision impairment. _..2.2--.20220 22. 51
Diabetes... ---- ee 50

Source: Public Health Service.

If these statistics seem to suggest that
we have already been tardy in establish-
ing detection and prevention programs,
we can draw some comfort from pioneer-~

ing work begun under private, State, or
local auspices. The most dramatic and
Significant example is the automated
multiphasic screening project operating
for the benefit of workers and their
families on the west coast to members of
the Kaiser Foundation health plan,
This program, in fact, almost serves as
a pilot precedent clearly showing the
practicality and value of an effective
screening program.
THE KAISER FOUNDATION PROGRAM

To those who use the Kaiser program,
the word “muiltiphasic” merely means
“comprehensive.” Within 214 hours
they receive a battery of tests compara-
ble, and in some respects superior, to
traditional testing made without benefit
of automation.

I will describe the procedure in some
detail because of its direct relationship
to my legislative proposal.

In the multiphasic health checkup,
one patient registers every 212 minutes,
and is through in 2% hours.

Upon arrival at the screening center,
each participant registers at the recep-
tion desk. He receives a series of ques-
tions on. IBM cards to which he will re-
spond during waiting intervals between
tests and, when completed, to be fed into
the computer.

The first procedure involves an electro-
cardiogram and heart sound recordings
for the detection of heart abnormalities.

After the test is completed, the partic-
jpant is asked to drink @ measured
amount of. chilled, carbonated sugar
solution. This is in preparation for the
drawing of a blood sample 1 hour later
for the blood sugar test for diabetes. Be-
fore coming to the center, the individual
was instructed to fast for a minimum of
4 hours in preparation for this test. A
timecard is stamped to record the exact
time the sugar sclution is taken.

Weight, height, and body build meas-
urements are recorded directiy on the
IBM card. This information is impor-
tant for future use, as changes in these
base measurements at a later date could
indicate the onset or development of a
chronic disease.

A chest X-ray is then taken. This pro-
cedure is important not only for the de-
tection of tuberculosis, but can yield
significant information on other types of
pathology in the lung, heart, large blood
vessels in the chest cavity, and bony
structure of the chest.

For women over 40, there is mammog-
raphy, an X-tay examination of the
breast. This procedure has proved to be
a valuable aid in early diagnosis of breast
cancer and other breast conditions.

The eyes are next tested. Visual acuity
is recorded, and eye pressure tests are
conducted for the detection of glaucoma.

A test to measure lung capacity fol-

lows. This test is aimed at the detection -

of emphysema.

Hearing is then tested with an audi-
ometer, and results are recorded on a
graph and then transferred to the com-
puter card. The computer is programed
to read out results in terms of hearing
loss.

At this point, the 1-hour interval after
drinking the sugar solution is reached.
Blood is drawn and used for several
groups of tests. Blood serum frora this
sample is placed in the autoanalyzer,
and eight complicated testis are con~-
ducted simultaneously, with results avail-
able in 11 minutes.
findings, these tests indicate the pos-

Among other vital

sibility of diabetes, high cholesterol lev-
els, chronic liver disease, gout, kidney
disease, loss of calcium from the bones,
and certain digestive diseases. Whole
blood is used to determine the hemo-
globin level and the white blood-cell
count, thus throwing light on the pres-
ence of diseases such as anemia and
leukemia,

A urine sample is then taken and
tested for evidence of kidney infection
and other diseases of the kidneys, as well
as diabetes. Results are automatically
recorded on the IBM card,

_ Following this procedure, a photograph
is taken of the inside of the eye which
has the value of not only visualizing the
optic nerve, but also the condition of the
small blood vessels which are represent=
ative of those throughout the body. This
test can yield important information
about the presence of a wide variety of
systemic diseases, including | diabetes,
leukemia, advanced hypertension, and
even increased pressure within the head.

As a finale to the screening line, the
blood pressure and pulse rate are re-
corded, and the information is correlated
by the computer with other tests and
diagnoses.

In the case of certain tests, and com-
puter is so programed that where ab-
normalities are identified, the person
may be immediately called back for re-
lated tests or a recheck of the test taken.
When all the results are completed and
the information is recorded and fed into
the computer, a printout is received
from the computer which gives a health
profile of the individual. The printout is
provided to the physician for use in
initiating the diagnostic and therapeutic
measures indicated.

The efficiency and effectiveness of this
automated system may lead one to think
that this is a thoroughly depersonalized,
assemblyline procedure. Fortunately,
this is not so. The technicians and
nurses have been carefully selected not
only for their specialized abilities but
for their personal qualities, as well.
They are abie not only to perform their
tasks skillfully, but to maintain a cheer-
ful attitude.

Though still in its early stages, the
program has already yielded important
summary findings. Almost 50,000 multi-
phasic examinations have now been
completed.

Do these automated health estimates
actually lead to diagnoses?

Among 9,760 participants on whom
completed diagnostic examination
records were available, the doctors con-
firmed the health appraisal findings as
follows: .

Verified diagnoses from findings of multiple
screening procedures

Rate per
1,000

Hypertension and hypertensive heart
disease.....------ pee eee ee 88.6.
Anemia (women)-.--.--.-..---.--.. 51.4
Emphysema and bronchitis (men)_... 34.2
Coronary heart disease....0..0-0 uu. 28.1
Diabetes... eee eee 28.0
Gout (men)... eee 9.5

1 Program conducted by Permanente medi-
cal group in Oakland, Calif.

Here is concrete evidence of the price-
less value of the preliminary health esti-
mates in the utlimate control of heart
disease, arteriosclerosis, diabetes, and
many other degenerative diseases of
aging,
The electrocardiogram found heart ab-
normalities in almost 18 percent of the
women examined and in about 21 per-
cent of the men.

Women examined showed a consist-
ently higher percentage of impaired vis-
ual acuity than males, about 7 percent of
persons in the age group 50 to 59. Photo-
graphs of the inner eye revealed some ab-
normalities in almost 1 of every 10 per-
sons, including retinal arteriosclerosis—
an important index to other aging and
arteriosclerotic processes—in 3 percent
of all patients.

These are just a few facts pulled at
random out of the multiphasic program’s
most recent report. The electronic brain
used to report out this information can
also combine the results of a wide range
of tests and pose probabilities—which are
infinitely helpful to the individual physi-
cian in his task of performing a more de-
tailed examination leading to diagnosis.

In the year between September 1964
and the end of August 1965, a preventive
health service research program was in-
stituted by Kaiser directed toward in-
vestigating the preventive aspects of
chronic illness and disability. The health
protection centers established by my bill
will do this kind of research into the
techniques of health appraisal and pre-
ventive medicine.

But one of the strongest arguments for
support of health appraisal services is
this: the availability of a centralized,
complete health estimate facility serves
to motivate people to come in for pre~
liminary testing, particularly people whe
would not go to a doctor unless they were

- eritically ill or experiencing acute pain
or other frightening physical symptoms.
Neither the stigma of supposed hypo-
chondria, nor the guilt of taking up a
doctor’s time unnecessarily, are present.

EXPERIENCES WITH OTHER PROGRAMS

Mr. President, I first addressed the
Senate on “Preventicare”’ in September
1965. Soon after, I wrote to physicians,
educators in medicine, public health di-
rectors, and others asking for their opin-
ions and experiences. The replies were
for the most part enthusiastically recep-
tive. I ask unanimous consent that a
number of these replies be printed at the
conclusion of my remarks. In addition,
several letters give information on the
effectiveness of screening programs that
were limited to a relatively smail geo-
graphical area or to one or & limited
number of diseases.

For example, the Federation of Jewish
Philanthropies of New York reminds me
that Mount Sinai Hospital in that city
has instituted “the practice—which
many hospitals have adopted—of doing
a coraplete battery of tests on pa-
tients—when—admitted. The belief is
growing that the cost of doing this, in-
stead of the individually selected tests
related to a patient’s clinical needs is no
higher and the higher productivity of
meaningful results enables the physician
to render a better qualitative service to
his patient.”

Dr. John A. Cowan of the Michigan
Department of Health writes that his
State has been doing multiple screening
examinations since 1954 among appar-
ently healthy young adults employed in
small industries.

The results have been very satisfying—

He says—
and have revealed that many people who
pelieve they are perfectly weil have condi-

tions which predispose to chronic diseases
or have beginning chronic diseases which
have not as yet become symptomatic.

While a battery of health tests cannot
replace the complete history and physi-
cal examination of a knowledgeable per-
sonal physician, Dr. Cowan sees in my
proposal “the means of detecting asymp-
tomatic disease” and “to promote health
to a large group of our populatin.”

Dr. A. i. Chapman, now with the
Commonwealth of Pennsylvania De-
partment of Health, writes me about an
early demonstration project he devel-
oped in a housing project in Indianapolis
in 1949.

Among the first 1,000 apparently well
aduits who were screened, about 1,200
conditions were found. Of these, one-
third were serious: nephritis, heart dis-
ease, hypertension, diabetes, tuberculosis,
syphilis, arthritis, glaucoma. About
two-thirds were vision and hearing de-
fects, overweight, and other less se-
rious—but correctible—conditions.

Shortly after that, Dr. Chapman
writes, a comparative study was done at
the Boston Dispensary. A group of
1,000 apparently well adults received
3 different types of examinations con~-
ducted by 3 different teams. The first
was a $10 routine physical examination;
the second, an abbreviated physical cost-
ing $5; and, the third, a multiple screen-
ing examination conducted largely by
technicians and costing about $1. An
evaluation of the effectiveness of these
three types of examinations showed that
more pathological conditions were found
py multiple screening than by either of
the—-then—miore orthodox physical ex-
aminations.

~E also have a letter from Dr. Murray
Grant, Director of Public Health for the
District of Columbia, enclosing a recent
article—which I shall request to be in-
eluded in the Recorp—concerning a
screening program that has been under-
way here in the District for the past 244
years and with which some of us are
familiar.

Dr. Grant believes that this “bears con-
siderable similarity” to what I am pro-
posing, and calls our attention especially
to the cost figures, the evaluation, and
the results of the operation thus far.

Further than this—

 

He writes—
I have within the past few months initiated
an even larger disease detection program at
our Southwest Health Center, which is now
operating a full time program of this na-
ture for all persons in the District of Colum-
bia over the age of 40.

Dr. Grant also mentions that this pro-
gram is rather unique and is not yet du-
plicated in many other communities.

Recently I learned of a multiple
screening program conducted in a low-
income area in New York City to detect
previously undiagnosed illnesses among
adults. I was shocked to learn that al-
most one-third of the persons whe par-
ticipated in the screening program had
important health-related conditions that
had not come to light pricr to the pro-
gram, The findings indicate that of
every 1,000 persons in the area, one
could well expect to uncover the follow-
ing rate of previously undiagnosed il-
nesses: 107 cases of high blood pressure;
1@1 cases of diabetes: 19 cases of ab-
normalities of the heart; 30 cases of ¢

 

coma: 5 cases of active tuberculosis; and
5 cases of cervical cancer.

I was also impressed with a recent re-
port about a diabetes detection pregram
im San Jose, Calif. Within 28 months,
8,008 persons past the age of 35 were
screened, One out of 6 persons-—1,436
in all--were referred to private physi-
jans for more definitive diagnosis.
Positive diagnosis of diaketes was made
for 347 patients, or 27 percent of the
1,280 patients on whom reports were re-
turned by the physicians.

The Health Insurance Plan of Greater
New York offers a periodic general phy-
sical examination which they believe 20
te 25 percent of their subscribers avail
themselves of. HIP also informs me of
twe recent programs to detect unsus-
pected glaucoma and breast cancer, the
latter an intensive program to determine
the value of periodic screening. Parly
results suggest that the breast cancer
program js discovering a significant num-~
ber of breast cancers that would have
otherwise remained undiagnosed, of
which a large preportion were still lo-
calized when found.

Mr. President, many of my correspond-
ents offered valuable suggestions, some
of which I have incorporated in the
present bill. A few raised cogent ques-
tions which I would like to discuss now.
These points will, I am sure, be fully
discussed and explored during hearings
on the bill.

TIMELINESS OF THE PROPOSAL

Several of my correspondents felt that
my proposal is ill timed. They pointed
to the large number of health service
programs for which we appropriated
funds at the iast session, on top of al-
ready existing health legislation. Some
urged that we wait to see how well our
jJocal hospitals, health agencies, and uni-
yersity medical centers are able to cope
with new community care programs al-
ready authorized before asking them to
assume still another health service re-
sponsibility.

In my view this is somewhat like say-
ing that because we are busy giving polio
and flu immunizations we cannot add
routine PKU testing as a means of pre-
venting mental retardation in children.
It is totally inconsistent with the Amer-
ican spirit to put off doing something
vital to national welfare.

For generations we have faithfully and

persistently reached one frontier of
medicine after another. Prevention of
communicable diseases has long since
become part and parcel of the objectives
of public health. But the prevention of
nic diseases remains a hidden fron-
tier, one we have not yet crossed despite
all the time, effort, and money we are
spending in research and in experimen-
tation to find ever more successful treat-
ments.
; My bill does not propose immediately
to establish hundreds of elaborate health
appraisal centers all around the country.
Within 5 years we would have five re-
gional centers and 20 related community
centers in progressive operational stages: .
These will demonstrate the feasibility of
extending similar services to other re-
gions of the country as needed.

I am convinced that this is an emi-
nently reasonable way to begin an attack
on chronic disease. To delay now will
only postpone the eventual day of reck-
oning, and the longer we delay the more
we will burden our. health service facil-
ities with the provision of care for illness

a

 

et
Cx

 

  

  
and impairment which might have been
avoided or minimized.

I might add that the length of time it
took to enact medicare is a good argu-
ment for immediate consideration of
ways to offer preventive health services
The hour is already late.

SUPPORT FROM THE MEDICAL PROFESSION

No health program-—neither my pro-
posal nor any other—is going to succeed
fully without acceptance and use by med~
ical practitioners. Time and time again
it has been demonstrated that the feder-
ally assisted programs which succeed are
those which enlist the participation of
local physicians and their medical socie-
ties during planning stages.

I recognize the same need and the
same opportunity in planning for the
health protection centers provided for in
my bill. I think we can demonstrate to
the private physician the time-saving
virtues of preliminary health estimates
as an aid to the diagnostic work he must
do personally. Automated surmmaries
are not diagnoses. Rather, they offer a
detailed health estimate’on which a more
complete, more accurate diagnosis may
be based.

MANPOWER SHORTAGES

Almost all of the medical experts who
had reservations about this proposal
brought up the problem of recruiting and
training personnel and the possible drain
on already limited health care
personnel.

I am well aware of the statistical
shortage of doctors, nurses, aids, and
medical rehabilitation specialists, and
the estimated additional numbers need-
ed, for example, by 1975. ‘There is a siz-
able school of thought, however, which
veaches beyond the numerical shortage
and asks whether we are using our avail-
able supply effectively. In the field of
nursing alone, many studies have shown
the waste of professional nursing time in
the performance of clerical services or in
duties which do not demand their level
of professional skill and judgment. I be-
lieve it is also common knowledge that
many doctors are continuing to perform
services which a nurse or technician
could safely provide.

So we need to look at how we are using
our health manpower resources as well
as at how to recruit and train more of
them. .

Chronic illness care has not attracted
practitioners as has acute medicine and
surgery. But I believe there will be a
strong attraction to the proposed multi-~
phasic testing projects—because auto-
mation is new, because results of the
tests are produced rapidly, and because
dramatic findings of heretofore asymp-
tomatic disease often turn up in the pa~
tient’s health estimate summary.

My proposal also has a built-in safe-
guard. The health protection centers
will receive grants to train their own
professional and technical personnel to
adapt basic medical and allied knowledge
to the demands of the automated pro-
cedures.

Now, as to the risk of draining already
short supplies of medical manpower in
order to offer more efficient preventive
services.

It seems to me that our entire national
philosophy is geared to the prevention of
undesirable circumstances or conditions.
We seek to prevent war, to prevent pov-
erty, unemployment, air and water pol-
lution, crime—-even te prevent national
and local environmental ugliness.

We have never faltered in our forward
movement toward these goals for fear
of being unable to recruit skilled profes-
sional or technical personnel to do the
job. We have created the programs-—
and people have come forward to staff
them.

I submit that the comparatively small
numbers of medical and paramedical
personnel can be found without jeopar-
dizing existing health services, and they
will be people with sufficient vision to
want to be part of a team which is not
undoing damage but preventing it.

Extensive Federal support is being pro-
vided to increase supplies of medical
manpower of all kinds and to give them
training in the management of chronic
illness and disability prevention. Surely,
these efforts must not and will not bypass
the most fundamental service of all—
early appraisal leading to early detec-
tion of incipient chronic diseases.

AGE LIMITATIONS

My bill provides that any adult aged 50
or over may be admitted to the multi-
phasic testing program in the region in
which he resides.

Many correspondents suggested that
younger individuals should be included.
They pointed to the advantages of early
identification of abnormalities In men
of draft age or, for example, of applica~
tion of cancer cytology to young women.

However, it would be unrealistic at this
time to hope toe reach an entire popula-
tion——as some have suggested—from in-
fancy onward. Actually, pediatrics prac-
tice is in large part preventive and offers
sound periodic health maintenance and
care services to children.

I have no desire to eliminate the young
adults to whom we must hand the future.
But in order to keep the size and number
of the health protection centers within
realistic bounds and still to come up
with useful results, I thought it advisable
to start with the critical decade, the
fifties, and to include our older citizens
as well, whose limited financial means
may keep them out of any program of
systematic health examination.

L see this as immediate and essential
to back up medicare; to identify the
chronic diseases before they become a
major care problem, heavily overtaxing
community health reosurces, and to
bring people into desirable treatment
programs before they reach the age of
eligibility for social security health in-
surance benefits.

RELATIONSHIP WITH NEW HEART, CANCER, AND
STROKE COMPLEZES

Some experts have suggested that the
health protection centers shquid be part
of the regional heart, stroke, and cancer
complexes established by truly historic
legislation last year.

As I understand that program, whicn
is just beginning, its principal purpose
is to provide for the cooperation of medi-
cal schools, clinical research institutions,
and hospitals se the latest advances in
the treatment of heart disease, cancer,
and stroke may be brought to the patient
through locally or regtonaliy adminis-
tered programs of research, training, and
continuing education.

This excellent program is directed at
the treatment of ilmess and is a co-
ordinated attack on three major killers.
My proposal is aimed at early detection
and ultimate prevention, the mainte-
nance of good health rather than the
treatment of illness. I think that ib is
wiser, so that we can have the fullest

discussion and study of the goals and
methods of preventive medicine, that
the Adult Health Protection Act be con-
sidered separately from the heart, stroke,
and cancer bill.

It is cbvious that the two programs as
they develop should be closely coordi-
nated. I think that in actual practice the
health protection centers and the heart,
stroke, cancer complexes would be in
close touch for the exchange of informa-
tion and new techniques. Certainly
both programs share the same basic
goal—the improvement of the Nation’s
health. Ultimately, they would be
joint partners in working toward that
goal.

COMPUTER RELIABILITY

Several people have challenged the
reliability of computerized health data,
pointing out that only a physician is
qualified to interpreb medical findings,
establishing significant relationships by
use of his professional judgment.

Please let rae reemphasize. The com-
puterized health estimate is not a diag-
nosis. It is a service to the physicians
who will make the diagnosis. Further-
more, the health protection centers will
be under medical direction. Where
determinations are necessary on any of
the data, a physician will make them.

= do not think it necessary to defend
computer accuracy in the field of health
any more than in industry or in space
science. We have ample evidence from
many reports, however, that the com-
puter readings—of blood chemistry, for
example—may be more consistently cor-
rect than manual readings which can-
net be completely free from a margin
of human error.

Dr, Ralph Thiers, of Duke University,
reported last September that chemistry
tests run at three hospitals, both manu-
ally and by automatic analysis, proved
that the automated method can detect
unexpected abnormalities often enough
to significantly help physicians to under~
stand and treat their patients. Dr.
Thiers said that the data leave little
question that a significant number of
additional clinical chemistry abnormali-
ties are being discovered by automation
which manual analysis had missed.

This is one one example.

You are probably aware that the Pub-
lic Health Service is already developing
and testing additional electronic screen-
ing methods fer detection cr messure-
ment of disease—the spirogram, to record
tung function important in bronchitis-
emphysema: the phonocardiogram, to
record heart sound; the electroencepha-
logram, to record electrical impulses
given off by the brain.

Some of you may recall a demonstra-
tion in New York cf an electronics sys-
tem for analyzing electrocardiograms.
Over 700 civil leaders participated, in-
cluding Governor Rockefeller, and my
distinguished colleague, Senator Javits.

ta this demonstration, ECG’s were
taken, recorded on tape, transmitted by
long distance telephone to a tape receiver
and computer at George Washington
University, here in the District. The
computer took 20 seconds to compare
the incoming ECG with thousands of
similar cases stored in its memory. In
8 minutes plus 4 seconds, the heart’s
ability to transmit electrically, discharge,
recharge, and drive itself had been de-
termined and printed electronically in
Mew York, The computer also sent back
the average number of heartbeats per
minute and gave a brief analysis of the
data.

Thus, we find not only efficiency in the
use of computers but economy as well.

So much for the major objections
which have been raised.

Mr. President, recently I read a most
provocative article in the New York
Times magazine by Prof. Jean Mayer,
Harvard professor of nutrition and lec-
turer on the history of public health. He
indicts the health professions as nourish-
ing “an obsession with death which dis-
regards the greater importance of the
value and significance of life.”

Priorities for health programs, he says,
“ought not be established on the basis of
mortality statistics which make such
conditions as blindness, deafness, tooth
decay, mental illness, and arthritis ap-
pear insignificant,” but on the basis of
real human needs.

He points out:

We are not yet used to thinking of sub-
jecting our whole population to competent
and continuous preventive care.

Yet this is the only type of medical
care which makes sense. More than
anything else, Dr. Mayer believes, we
need discussion leading to a national plan
for prevention, treatment, and rehabili-
tation.

L respectfully suggest that my “pre-
venticare” proposal will carry us one step
closer to this goal.

Our object was well expressed during
the White House Conference on Health
by Dr. George James, adviser to the
President and former New York City
commissioner of health. He said that
the ideal system would put comprehen-
sive medical service within the reach of
everyone. The emphasis would be on
preventive medicine and on a continuous
effort to identify and treat disease at
the earliest possible moment. The pur-
pose? A useful and satisfied human be-
ing as well as a healthy body.

Let us replace obsession with death
with devotion to life. Modern science
has given us a longer lifespan; now
modern preventive medicine can give us
the good health so that those years need
not be years of suffering and decline but
years of health and well-being.

Mr. President, I ask unanimous con-
sent that a number of articles and let-
ters relating to this proposal be printed
in the RrEcorp.

The PRESIDING OFFICER. The bill
will be received and appropriately re-
ferred: and, without objection, the arti~
cles and letters will be printed in the
RECORD.

The bill (S. 2983) to amend the Public
Health Service Act by adding a new title
X thereto which will establish a program
to protect adult health by providing as-
sistance in the establishment and opera-
tion of regional and community health
protection centers for the detection of
disease, by providing assistance for the
training of personnel to operate such
centers, and by providing assistance in
the conduct of certain research, related
to such centers and their operation, in-
troduced by Mr. WriLiraMs of New Jersey
(for himself and Mr. MeTcaLF), was re-
ceived, read twice by its title, and re-
ferred to the Committee on Labor and
Public Welfare.

The articles and letters presented by
Mr. WiLLiaMs of New Jersey are as fol-
lows:

STATE OF GEORGIA,
DEPARTMENT OF PUBLIC HEALTH,
Atlanta, Ga., January 10, 1966.
Hon. Harrison A. WILLIAMS, Jr.,
US. Senate,
Washington, D.C.

Dear SENATOR WILLIAMS: Your similar let-
ters of November 23, 1965, to the director of
our chronic illness and geriatric service, Dr.
Albert H. Robinson, and to me, enclosing
your proposal for health protection centers
have been studied. We are stimulated and
encouraged. This letter represents our com-
bined thinking.

I have been working for over a quarter of
a century attempting to develop an effective
health maintenance plan for all Georgians
and your letter has given me a glimpse of
what could well mean a major breakthrough
into an optimum sickness prevention pro-
gram,

Prevention seeks to eliminate a cause;
treatment seeks to minimize a result. This
is the keystone of health protection, for it
is always many times more ecoonmical to
prevent illness than to treat and rehabilitate
the ill. It follows, then that we must not
let “sick call” for the relatively few crowd
out health maintenance for the many.

There is no possible question that the
aged sick need the medical care which medi-
care legislation was hopefully designed to
provide for them, but it must not be thought
of as a wand that we can wave on the
citizen’s 65th birthday, magically bringing
him health and well-being. We must—we
can only—build the foundation for that good
health during his younger most productive
years. Any other course will inevitably kad
to an oppressive national financial burden,
a caseload level too heavy to be handied by
available, or conceivably available, medical
resources, and finally, by injustice to the
over-65 citizen himself.

The key to achieving medicare’s goal is to
insure that each group that reaches its 65th
birthday, each succeeding year, comes from
a healthy population. I am convinced that
your proposed multiphasic screening health
protection centers could play a major role
in reaching this objective, provided that their
facilities were available to what is, in Geor«
gia’s experience, the primary population
group, the labor force.

Georgia has a total population of slightly
more than 4 million people, ving in 1.1
million households. These homes are sup-
ported by the salaries and wages of Georgia’s
1.5 million labor force. The 1.5 million wage
earners, generally heads of these households,
exert more influence upon the remaining 2.5
million Georgians than any other forces.
They, therefore, should be the initial primary
beneficiaries of any health maintenance pro~
gram. The labor force not only produces
the wealth we need, but also most effectively
represents the population we serve.

Emphasis on the prevention of illness
among the wage-earning group has a two-
fold objective: (1) The productive member
of each family is kept in health so that
income needed for support is provided inter-
nally and the need for outside financial
assistance is minimized; and (2) the wage
earner, as the most influential member of
the family, becomes a natural and effective
medium for teaching other members of his
family the “take-home health” he has learned
on the job.

Within the Georgia Department of Public
Health we have developed and are operating
an employee’s health service which is pro-
viding this type of health protection. All of
our 30,000 State merit system employees are
eligible for periodic screening for early detec~
tion of illnesses. Unfortunately, geographic
distamces prevent the service from being
readily available to many of them, under-
lining, on our cwn. doorstep, the need for
such a comprehensive program as your pro-
posed centers would Implement.

Our experience to date has confirmed the
value of our Georgia State Employee’s Health
Service. It is well evidenced by the con-
tinued valuable service of a growing number

of employees, including a number of key
administrators, who probably would have
been lost as State servants and family pro-
viders except for early detection of serious
illnesses. Early case finding usually enables
the employee to keep his job and pay for his
needed treatment out of earned income.
This is infinitely more desirable than the
alternative of waiting until advanced disease
forces him to give up his job and become a
nonproductive burden on his family and on
our economy.

Senater WiuiLiams, I have long been con-
vinced that each individual has an inescap-
able responsibility for his own health that
he cannot delegate to any other person or
agency. However, it is equally true that each
individual has limitations on his own re-
sources for maintaining health, regardless of
his status in life. Whenever the demands
exceed his personal resources he must turn
te community resources for the additional
assistance he needs. It must be remembered
that individual resources are not limited to
money alone, but include education, knowl-
edge, skills, technique, equipment, and even
the desire to maintain good health.

Your proposed health protection centers
could be of inestimable value as a com-
munity resource to help Americans to live
up to the inescapable responsibility each has
for maintaining his own health.

Medicare will demand the investment of
Jlarge sums of taxpayer’s money, as well as
the use of a substantial portion of our
national medical resources. It is good busi-
ness practice—and good, solid humanity—to
enable persons approaching the eligibility
age for medicare to take reasonable care of
their own health prior to becoming eligible.
Periodic multiphasic screening for early de-
tection and rexerral to early treatment for
potentially disabling disease is the best way
i know te assure the maximum return from
the medicare program.

A recommended screening schedule could
be: (1) An initial screening at the age of
40, and unless the findings indicate more
frequent intervals, rescreening once every
S$ years until 50; (2) a screening every 2
years while in the fifties; and (3) a screen-
ing ohce a year beginning at age 60. This
schedule, subject to modification with ex-
perience, would initiate screenings at the age
when the majority of chronic illnesses begin.
to manifest themselves, accelerating the fre-
quency of screenings with advancing age
until, during the years of greatest risk from
chronic illness, at least annual screening
would be required. Emphasis should ini-
tially be placed on screening wage earners
within each family, then expanded to other
family members as facilties and skills are
developed.

Our experience with the multiphasic
screening of 1.4 million Georgia citizens dur-
ing the decade 1945-54 proved to us that
screening by itself is not our objective:
Any screening program must have a well-
organized referral and follow-up system as
ap. integral part of the program if its objec-
tive of health care for all those found to
need medical attention is to be attained.
@ur health referral program for medical
rejectees from the Armed Forces provides
us with conclusive evidence that this is still
the case. Discovery of an illness or defect
does not of itself assure that the patient will
automatically seek the required medical care.
In most instances professional guidance
such as is provided by our health referral
consultants, is necessary to motivate the
patient to seek adequate care.

Equally essential for effective case finding
is epidemiological followup of contacts and
suspects, as demonstrated by the work of
our communicable disease investigators in
venereal disease detection and referral to
treatment and, more recently, the startling
effectiveness of a similar technique in tuber-
culosis. Similar investigations of blood
relatives of cases with hereditary metabolic
disorders such as diabetes mellitus show
promise of comparably effective results.

Senator WILLIAMS, my answer has been ex~
tensive because I believe in what you are
trying to do. In fact, I sincerely hope that
the State of Georgia may be selected to
pioneer a State-wide, automated multipha-
sic screening program with provision for re-
ferral to treatment and follow-up such as I
Ihave described. I believe that the know-
how we have acquired is unique.

We have within the Georgia Department of
Public Health the leadership needed to de-
velop the program. I know that most of us
realize that much illness can be prevented,
and that prevention is more economical of
money and human suffering than is treat-
ment. We must use prevention of disease
and illness as the control mechanism to keep
medicare manageable. By using multipha-
sic screening on a scheduled basis according
to age, we can keep it manageable. And we
can concurrently achieve another major ob-
jective—maintaining the health and pro-
ductive capacity of our labor force.

Please accept my personal thank you for
devoting your attention and energies in this
field of preventive medical services that so
badly needs your assistance. Do not hesitate
to call upon me if I can help you in any way.

Sincerely yours,
Lester M. Perris, M.D.,
Director, Branch of Preventable Diseases.

 

MICHIGAN DEPARTMENT OF HEALTH,
Lansing, Mich., December 9;1965,
Hon. Harrison A, WiLLIAMS, Jr.,
U.S. Senate,
Washington, D.C.

Dear SENATOR WILLIAMS: I was very happy
to hear about your proposal for providing
screening and preventive medical services to
the adult population. We have, as you im-
plied in your speech in the CONGRESSIONAL
Recorp, accomplished a great deal in terms
of legislation for caring for the sick and
disabled. Under the amendments to the
Social Security Act we have medicare and
other maternal and child health services.
The sick are given the benefits of modern
curative medicine in the two extremes of
life—early life from conception until the age
of 21 and later for the older person 65 years
of age and over. Very little is being done for
the group in the great productive years from
21 to 64 to conserve the health of those who
must work and pay the taxes to care for the
two groups aforementioned. Any program
that can assist in the conservation of this
group should pay rich dividends both to the
individual concerned and to society as a
whole. The provisions of medicare and the
new legislation for regional health programs
for heart disease, cancer, stroke, and related
diseases will not solve our problem of pre-
venting disease and disability. Multiple or
multiphasic screening activities are how an
important component for the early detec-
tion of incipient chronic disease and dis-
ability. They separate those persons who
presumably have abnormalities from those
who presumably do not. Such activities save
the time of the physician who can spend his
time in a more productive manner for those
who need his diagnostic and treatment skills
and acumen rather than use a dispropor-
tionate part of his time for examination of
healthy individuals. When such tests can be
done by technicians and automated, they
can be done expeditiously and at very modest
cost,

In, Michigan we have been doing multiple
screening examinations since 1954. These
have been done mostly in apparently healthy
young adults employed in small industries.
The results have been very satisfying and
have revealed that many people who believe
they are perfectly well have conditions which
predispose to chronic diseases or have begin-
ning chronic diseases which have not as yet
become symptomatic. Ideally, screening ex-
aminations should be done on all people 30
years of age and over but as a beginning I
think they should start not later than 45
to 50 years of age. Until the medical pro-
fession as a whole has also seen the value
of such screening examinations, the ideal of
a complete annual physical inventory for
every person is not susceptible to practical
attainment for obvious reasons. Physicians

have been trained to diagnose and treat overt
disease and disability. They have had little
training in preventive medicine and not
oriented to conservation of health. Our
population as a rule is not motivated to go
to a physician unless they are either sick or
have pain. For these reasons, as well as the
fact that if all persons went for an annual
physical examination there would not be
enough physicians available to treat the sick,
it makes the provision of annual physical
examinations for the population purely
idealistic. It is necessary to find some prac-
tical substitution for such complete yearly
examinations. A battery of health tests is
not as satisfactory, of course, as a complete
history and physical examination by a
knowledgeable personal physician. Never~
theless, it can be the means of detecting
asymptomatic disease and in promoting
health to a large group of our population.
In my opinion the time has come for us to
prevent sickness rather than spending all of
our time in patchnig up those who are al-
ready sick or disabled. The greatest thing
that could be done for the older population
is to find, treat, and counsel those in the
great middle years when they are incubating
the diseases which will later cause them to
require prolonged care and hospitalization.

Iam enclosing some statistics from some
of the multiple screening programs that have
been done here in Michigan.

Incidentally, if you plan to have hearings
on this legislation when it is introduced,
the Association of State and Territorial
Chronic Disease Program Directors, of which
I am the current president, would appreciate
an invitation to testify.

Sincerely,
Joun A. Cowan, M.D.,
Director, Division of Adult Health.

 

TULANE UNIVERSITY,
ScHoon Of MEDICINE,
New Orleans, La., December 1, 1965.
Hon. Harrison A. WILLIAMS, JY.,
U.S. Senate,
Washington, D.C.

Dear Senator: I wish to acknowledge re-
ceipt of your letter of November 23 and the
attached copy of your Senate speech outlin-
ing the need for a health maintenance pro-
gram. I will appreciate it if you will send
me information on the proposed legislation
as it develops.

I fully agree with your views and can only
reinforce your suggestion that the passage
of Public Law 89-97 makes a program of
early case finding both necessary and a sen-
sible economy. Meanwhile, I wish to in-
clude a copy of Vaérmland study carried out
in Sweden. This was a preliminary study
and it seems that in 2 years’ time this is in-
tended to cover all of the Swedish popula-
tion. The meeting in Varmland in Septem-
ber was attended by Dr. James W. Sweeney,
director, Tulane biomedical computing sys-
tem, because the Swedish study is tied in
with the Tulane computer. Many of the
automated techniques of recording have
been worked out by Dr. Sweeney. You will
therefore understand our interest. We are
presently negotiating with the Public Health
Service the establishment of a multiple
screening program for elderly persons in New
Orleans.

May I add my congratulations for your
leadership in developing this excellent pro-
gram.

Yours sincerely,
J.C.S. Parerson, M.D., F.R.C.P.,
Associate Dean and Director.

 

THe UNIVERSITY OF ALABAMA
MEDICAL CENTER,
Birmingham, Ala., December 13, 1965.
Senator Harrison A. WILLIAMS, Jr,,
U.S. Senate,
Washington, D.C.

Dear SENATOR WILLIAMS: You are to be
congratulated on your interest in the need
for a health maintenance program for Amer-
icans. Automated centers such as described
by Dr. Collen at Permanente may well pro-
vide a partial answer to improving health.
I would personally be very pleased if I lived

close enough to take advantage of the com-
prehensive screening process described by
Dr. Collen.

If one considers the economical value of
keeping our most productive people on the
job, this factor alone could justify consid-
eration of such massive screening starting
even earlier than 50 years of age. If a pre-
ventable disability is detected at age 40 when
there are still 25 years of productive work
years to be expected, this may prove to have
more impact on our economy than the de-
tection of the person who has only 15 years
of expected productivity, or who has tetired
from active work in the labor market.

I would like to have any information you
have in regard to the proposed bill to pro-
vide disease detection centers. I hope the
bill will include specific provisions for the
educational programs which are necessary for
such disease detection centers to be truly
preventive in nature. The educational com-
ponents should consider both those neces
sary for education of professional people and
for education of the lay public.

I shall appreciate any information you can
send me about the developments in regard
to your proposed bill. Please accept my best
wishes for your success,

Sincerely,
HELEN L.. Trnnin, Ph. D.,
Assistant Professor of Preventive Medi-
cine and Public Health,

 

FEDERATION OF JEWISH PHILAN-
THROPIES OF NEw YorK,
New York, N.Y., December 8, 1965.
Senator Harrison A, WILLIAMS, JY.,
U.S. Senate,
Washington, D.C.

DEar SENATOR WILLIAMS: Thank you very
much for the opportunity to comment on
your proposal to establish an adult health
education program under the terms set forth
in the summary which accompanied your
letter of November 23, 1965.

When we examine the natural causes of
disease we find that one of the stages is the
period during which the disease is develop-
ing but goes unrecognized. It is not accom-
panied by recognized symptoms, nor does the
involved person feel the need for medical
care,

The above stage may very well antedate
age 60, and I am in agreement with you that
the need for a sound health maintenance
program could bring substantial benefits to
individuals at age 50.

I regret that my present professional serv-
ices do not afford me the chance to have case
studies and statistical data applicable to
your project. I can, however, advise you that
hospitals are beginning to introduce the
practice of doing a complete battery of tests
on patients admitted to their inpatient ac-
commodations. The belief is growing that
the cost of doing this, instead of the individ-
ually selected tests related to a patient’s
clinical needs, is no higher and the higher
productivity of meaningful results enables
the physician to render a better qualitative
service to his patient.

One of the hospitals which has instituted
this practice, involving automated equip=-
ment, is the Mount Sinai Hospital, 100th
Street and 5th Avenue, New York, N.Y. Your
office may wish to get information about this
program directly from Martin R. Steinberg,
M.D,, director.

Tam also taking the liberty to suggest that
your office contact George. James, M.D.,
former commissioner of health and presently
dean of the Mount Sinai School of Medicine
and executive vice president of medical af-
fairs. He has spoken and written extensively
on health maintenance and has, during his
tenure as commissioner of health, helped or-
ganize plans for a municipal hospital to in-
clude in-patient services, ambulatory serv-
ices, health center programs, welfare center
activities and community mental health pro-
grams. His health center concept deals with
the problems of all age- groups in much the
manner you propose for the older groups.

I am heartily in favor of what you want
to accomplish through your proposed pro-
gram. I am, however, disposed to believe
that the health protection centers should not
be free standing facilities but integrated with
medical schools, community hospitals, ete.
They would, in this way, be kept in the main-
stream of hospital and medical activities.
The proposed health protection units might
then be the satellite resources to promote
their availability to many for whom acces-~
sibility to the larger centers would be dif-
ficult.
I hope you will find these comments and
suggestions helpful.
Sincerely yours,
M. Hineneure, M.D.,
Medical Care Consultant.

Tue BROOKDALE HospiraL CENTER,
Brooklyn, N.Y., December 21, 1965.
Senator Harrison A. WiLLIaAMS, JY.,
U.S. Senate,
Washington, D.C.

Dear SENATOR WILLIAMS: In reply to your
letter of December 10, the following informa-
tion is offered.

The Brookdale Hospital Center, at all
levels—board of trustees, medical board, and
staff—has recognized the need for dramatic
changes in the traditional role of the general
hospital as a provider of health care. We
have therefore gone on record as committed
to involvement in programing for the
health needs of the community. To further
these aims, a department of community
health has been created. This unit has full
departmental status at the same level as the
traditional departments, e.g.: medicine, sur-
gery, etc.

With the financial support of the Geron-
tology Branch, U.S. Public Health Service,
we have formulated firm plans for a hospital-
pased complex which provides sufficient por-
tals of entry for the individual in the com-
munity to meet his changing health needs.
The key characteristics of the program are:
availability, accessibility, continuity, imte-
gration, and acceptability. The health serv-
ices are to be available when the need arises;
situated so that the person can get to them;
provided a continuum of care, avoiding the
episodic health care at crises; consider the
individual in his medical, psychosocial and
economic milieu; and are utilized by the
people of the community.

The components of the hospital complex
are: general hospital; ambulatory care serv-
ices, including outpatient department and
home care; geriatric health station; extended
care facility; and day hospital. The latter
two units will be housed in a community
health center to be completed in 1969.

We have concluded negotiation of a con-
tract with the New York City Department
of Welfare to provide comprehensive medical
care to all OAA patients in the hospital’s
core area, approximately 3,000 in number.
This activity will be housed in a geriatric
embulatory care center building scheduled
for completion in the summer of 1966. This
building will be eminently suitable for ac-
commodating the geriatric health station.

This geriatric health station, originally
conceived as a traditional health assessment
facility, has been reevaluated in the light of
the Permanente project and the advances in
technology in this field. During the past
year we have been exploring the possibility
of establishing a highly automated and com-
puterized system. We have established the
feasibility of automated ECG, spirometry,
EEG, and blood chemistry, being fed into a
computer such as the IBM 1180 or 3200
system, to produce a referral scale. If coding
of a self-administered health questionnaire
is added to the above (as in the Permanente
project), an efficient economic health evalua-
tion process is achieved.

Of primary importance is the conservation
of time required from the health profes-
sionals, This permits maximal utilization
of professional skills at the appropriate levels
and expands the number of individuals who
can be evaluated many fold.

This geriatric health station or health
maintenance unit would be another portal
of entry into the hospital-based complex for
those individuals with no private physician,

The population of this hospital’s core area
is approximately 500,000 with 56,000 to 80,000
individuals 65 years of age or older. In many
parts of this area there is an es imated 990
to 95 percent incidence of ical indi-
pency. A large proportion of th population
is Negro and Puerto Rican.

There are, as expected, wnmet heaith
needs, lack of health maintenance informa-
tion, and poor or absent motivation. We 4
therefore anxious to provide a health main-
tenance program for the aged, not only as a
preventive heaith measure, but as the firs¢
step in an educational process which will
draw the individual into the mainstream of
health care. Unfortunately, we have no
funds for this part of the program.

It shouid be noted that a computer com-
plex as described above could service satellite
health stations where the various procedures
could be performed and the information re-
layed to it for processing.

The provisions of your proposal will create
services which the new Federal legislation
fails to consider and which are essential for
proper health care programing. The Brook-
dale Hospital Center and other community
hospitals throughout the country who kave
accepted the challenge of change in their
role as health care providers, will receive the
support they so urgently need to meet this
challenge.

Cordially,

 
   
  

    

Leo Girman, M.D.,
Chief, Gerontology Section.

 

HeatTH INSURANCE PLAN OF GREAT~
ER NEw Yor#,
New Vork, N.Y., December 22, 1868.
Hon. Harrison A. WILLIAMS, JY.,
U.S. Senate,
Washington, DC.

My Dear Senaror Witiiams: This is in
response to your recent letter concerning
your proposal for a health maintenance pro-
gram for Americans.

One of the benefits covered by the pre-
mium in the Health Insurance Plan of
Greater New York is a periodic general phys-~
ical examination. We do not have precise
figures oh the proportion of our subscribers
who avail themselves of this benefit, but the
impression is that about 20 to 25 percent
have such an examination each year. A re-
search project conducted several years aga
in one of the H.E.P, medical groups indicated
that with special efforts this proportion
could be increased appreciably.

More recently the research efforts related
te the detection of unsuspected disease has
been directed at specific conditions. One of
the programs is attempting to integrate
glaucoma screening into group medical
practice with the aid of nonmedical per-
sonnel trained to perform glaucoma. ‘The
other is an intensive program to determine
the value of periodic screening examinations
of the breast for the lowering of mortality
from breast cancer. Each breast examina-
tion includes palpation by a highly qualified
clinician and mammography (soft tissue
X-ray). Early results suggest that the
screening program leads the detection of
a significant number of breast cancers that
would have otherwise remained undiagnosed
and that a large proportion of the cases are
still localized when found. Additional ob-
servations are being made to ses whether
these results are stable and whether mor-
tality is improved because of the earlier
detection of breast cancer,

With regard to your proposal, it repre-
sents @ means for overcoming many the
present deterrents to increasing the propor-~
tion of the adult population that periodi-
cally receives a comprehensive physical ex-
amination. ‘These deterrents include high
costs, inconvenience to the patients and a
serious drain on physician time which is
already in short supply. However, there are
several questions associated with the estab-
lishment of regional health examination
centers which deserve attention. For exam-
ple, will it be possible to spread the network
sufficiently to make the centers readily ac-
cessible to the population in rural and urban
areas, in the North, South, and West? Also,

 

   

 

 

 

   
 

 

   

how will the program relate to the physician
yesponsible for the followup care of the pa-
tient so as to avoid fragmentation and dis-
continuity of medical services? And, what
is the most desirable age for initiating pe-
riodic health examinations?

EK hope that the ceding proves useful
to you in considering the scope of your
legislation.

Sincerely yours,

  

Sam SHaAPmo,
Director, Division of Research and
Statistics.

 

STATE OF MARYLAND,
DEPARTMENT OF HEALTH,
Baltimore, Md., November 30, 1965,
Fon, Harrison A. WiLLIaMs, JT.,
U.S. Senate,
Washington, DC.

Dear Semaror Witiiams: Needless to say
I was delighted to receive your letter of No-
vember 23, 1965, expressing interest in wider
application of known techniques for compre~-
hensive screening for early evidence of cer-
tain chronic diseases. It so happens that
this is one of my chief personal interests,
and Tam trying to step up action as rapidly
ag possible among our 24 local health de-
partments in Maryland in establishing this
capability. Indeed one of our best local
health departments on the Eastern Shore
near Delaware (Wicomico County-Salisbury )
has just submitted such a special project
proposal.
year one of the major innovations in
public health services in Maryland was a
program for statewide mass eytologic screen-
tng for cervical cancer in women. The en-
closed June 1964 departmental bulletin de-
scribes this program in some detail. Both
the Governor and the legislature decided to
back us on this effort, the ambitious goal of
which is nothing less than writing an epitaph
for cervical cancer. Other reprints are in-
cluded to give you further details of the
effectiveness of this approach as described
by one of the test’s developers, Dr. Hugh d.
Davis, of Johns Hopkins Medical School.

My reason for calling this particular screen-
ing program to your attention is that the
specific target population is women 30 to 45
years of age. This well illustrates the im-
portant principle that different chronic dis-
eases and disabilities have different target
populations with respect to the age, sex, and
other characteristics of the population. It
would be a mistake, I believe, for such legis-
lation to prescribe specific age Umit. For
example, the lower limit of age 50 which is
cited in your letter would rule out the most
important screening program we are now
conducting, namely the cytologic screening
for cervical cancer in women which is de-
scribed above.

A number of chronic diseases and disabili-
ties start very early in life so that effective
preventive medical measures must be adapted
accordingly. An excell example of this is
amblyopia exanopsia (blindness in one eye)
which occurs when poor visual acuity in one
eye or muscle imbalance in the preschool
@ child goes undetected. This is a condi-
sion in which vision fusion never takes place
during the crucial developmental years.. The
image from one eye is blurred by some dis~
order such as poor visual acuity, astigmatism
or muscie imbalance so that when the child
tries to fuse this image with that of his good
eye, he does not see well. He automatically
and unconsciously suppresses the blurry
image of his weak eye, and in so doing stops
it from developing. The eventual result is
blindness in one eye unless this conditicn is
picked up by simple screening tests before 6
or 7 years of age. Blindness in this case is
therefore preventable,

If the problem is not found, the child is in
trouble. He will never have normal depth
perception, for this requires two eyes. He
may have difficulty in school. He will cer~
tainly be limited in the kinds of jobs he
can do as an adult. He will be a much less
safe driver, and more exposed to all sorts
of accidents. And should his good eye be
damaged by disease, or by one of the 300,000
eye accidents in this country each year, he
may be left viriually blind.

 

 

 

 

 
 

  

 
 

 
Here then is an excellent example of a
screening test to prevent a chronic per-
manent visual disorder which must be
carried out at 3, 4, or 5 years of age.

As you well know the country was startled
to learn from the medical examinations by
Army Air Corps doctors in World War II,
that 1 out of 25 men were blind in one eye
and usually didn’t know it. At this rate
each year 100,000 American children are pass~-
ing the point at which they can be rescued—
all for want of a simple, inexpensive and
brief vision screening test.

These two examples of screening tests are
put a few of the many examples which I could
give you to detect chronic and disabling
diseases at a stage where their disabling effect
can be prevented or greatly ameliorated.
Diabetes can now be economically and readily
detected by a screening blood sugar test.
Glaucoma, a major cause of blindness, can
be readily detected through tonometry, but
few adults have ever received this simple
test. Mammography is being utilized more
and more to detect early breast cancer.

Gadgetry is only a very small part of this
process. What is needed are programs of
organized community action by professionals
and trained technicians—in other words pub-
lic health programs. Screening techniques
should be incorporated into medical practice,
so that screening examinations are followed
py a thorough history and physical examina-
tion by a physician, thus broadening his ca~-
pacity to detect early disease.

Now that large expenditures are about
to be made for chronic illness and dis-
abilities in older citizens (for conditions
which often could have been prevented or
mitigated), your letter which strikes a note
for an early detection is most timely. De-
tection of new cases of heart disease, cancer,
hypertension and arteriosclerosis is an essen-
tial complementary component to the re-
gional medical complex bill just passed by the
Congress. Screening examinations have par-
ticular application to medically indigent pop-
ulations in case finding.

In Maryland, I look forward to the de-
velopment of broad and comprehensive
screening facilities—health protection centers
+o use your phrase—as a well established year
round service in all of our 24 local health
departments. This Department will fully
support your efforts to achieve this.

I would especially like to congratulate and
commend you for this superb paragraph from
your speech from CONGRESSIONAL ReEcorD of
September 24, 1965:

“Only a major national commitment to
apply the principles and techniques of pre-
ventive medicine on a mass basis will stem
the rising tide of an increasing burden of
medical care in terms of manpower, facilities,
and dollars. We have the technology capac-
ity to do this.”

Nothing could more fittingly describe the
pasic. philosophy of public health.

We appreciate you referring this question
to us and hope that you will call us if you
feel that we can be of further help.

Sincerely yours,
WILLIAM J. PEEPLES, M.D.,
Commissioner.
GOVERNMENT OF THE DISTRICT OF
CoLuMBIA, DEPARTMENT OF PUB-
Lic HEALTH,
Washington, D.C., November 30, 1965.
Hon. HaRRIsoNn A. WILLIAMS, Jr.,
U.S. Senate,
Washington, D.C.

Dear SENATOR WiLLiamMs: This will reply
to your letter of November 23 in connection
with the need for a health maintenance pro-
gram.

As I understand your proposal, it calls for
the development of a disease detection pro-
gram provided free of charge for all persons
over the age of 50, with referral of those
found to have health defects to their private

physician or to public facilities in the case
of those not able to afford private care.

The development of this kind of chronic
disease detection program has been a goal
of many of us in the public health field for
some time. I believe that every individual
over 40 (rather than 50) should have access
to facilities which enable them to receive
sereening tests for a variety of diseases such
as you have cited in your summary. In the
case of some of these diseases, such as di-
abetes, testing at an earlier age even than 40
is desirable. The point, of course, is that
the earlier one finds a disease entity in an
individual, the more likely is that individual
to be able to receive effective treatment. It
is clear, for example, that an individual who
develops glaucoma and has some degree of
blindness as a result can receive treatment
aimed at retarding further development of
blindness; this treatment, however, cannot
turn back the events that have occurred. In
other words, the degree of blindness already
contracted by the patient will remain. This
same basic principle is true of other disease
entities. While we must admit that our cur~
rent knowledge of some of these diseases
makes efficient treatment difficult, this should
not preclude us from doing everything pos~
sible to detect the disease at an early date
and doing everything within our power to
provide medical and ancillary services aimed
at preventing the disease from marching on
its irrevocable course to disability and even
early death. Further than this, early detec-
tion of disease may also serve to initiate steps
aimed at rehabilitation. Again, the earlier
this is undertaken, the better for the patient
and for society.

While there is little question in my mind
that the best place for these screening tests
to be carried out is the office of the family
physician, it seems unlikely that this pro-
cedure will take place, at least for a high
percentage of our citizens. Therefore, the
proposals you have outlined appear, in gen-
eral, to make a great deal of sense. I would,
of course, wish to reserve final judgment un~
til I have an opportunity to review, in de-
tail, the exact legislation you hope to in-
troduce, and I would be most appreciative
if I could receive said legislation and hope~-
fully have: an opportunity of reacting to
it.

As an indication of my interest in this
matter of disease detection, I am enclos-
ing a recent article concerning a program
that has been underway in the District of
Columbia for the -past 2% years and that
bears considerable similarity, I believe, to
what you are proposing. You may be in-
terested in the cost figures, the evaluation
and the results of the operation thus far.
It is, of course, currently an on-going opera-
tion. Further than this, I have within the
past few months initiated an even larger
disease detection program at our Southwest
Health Center, which is now operating a full-
time program of this nature for all persons
in the District of Columbia over the age of
40, I recognize, of course, that many other
communities in the country do not current-
ly have this kind of program and, as I un-
derstand it, your proposed legislation is de-
signed to meet this need.

I would point out what, I am sure, is
quite obvious to you; namely, that the de-
velopment of this program creates increas-
ing demand for health manpower, not mere-
ly to staff the units but, more important,
to arrive at a final diagnosis and provide ap-
propriate treatment. It is this latter phase
of the operation that can produce consid-
erable problems. There is, of course, no use
whatsoever in developing a disease detec-
tion program unless it is subsequently fol-
lowed, and at an early date, by expeditious
handling of the patient with a view to pro-
viding the necessary treatment and rehabill-
tation. The obvious question then arises as
to whether there exists in many communi>

ties the health manpower readily available
to meet this increased demand. This ques-
tion is not easy to answer, but I am sure
you will find that there are many in the
health field who do not believe that an
adequate supply of manpower currently
exists for this purpose and that the num-~-
ber that do exist might preferably devote
their time to handling the acute medical
problems that need immediate treatment.

May I express my appreciation to you for
allowing me to react to your proposals and
to hope that I may have an opportunity
of deliberating further in connection with
this matter at some appropriate time dur-
ing the course of the next session of Con-
gress,

Very sincerely,
Murray Grant, M.D., D.P.H.,
Director of Public Health.

 

Srare oF RHODE ISLAND AND PRO-
VIDENCE PLANTATIONS, DEPART-
MENT OF HEALTH, PROVIDENCE,
R.1.,
November 30, 1965.
Hon. Harrison A, WILLIAMS, Jr., .
New Senate Office Building,
Washington, D.C.

Dear SENATOR WinLiaMs: I was pleased
to learn of your interest in the possibility
of establishing semiautomated centers for
the early detection of certain specific chron-
ic diseases in apparently well older people.
Legislation such as you would propose would
have my unqualified approval.

As you well know, screening programs are
a limited substitute for a complete physical
examination given by a qualified, competent
physician interested in preventive medicine.
Under ideal circumstances, such examina-
tions would be desirable for all adults over
the age of 40 years. Realistically, however,
one must realize that this is not an obtain-
able objective. Therefore, we must com-
promise by applying screening tests to large
numbers of people.

The use of automated procedures in screen-
ing programs is a new and exciting prospect
in public health today. We, in Rhode
Island, have been sufficiently interested in
the program at Kaiser-Permanente to send
two members of our staff to Oakland to see
it in operation.

No person who has studied the health
needs of adults would seriously question the.
advantage of early recognition of chronic il-
ness. Only by early detection and energetic
management can we control conditions such
as health disease, cancer, and stroke.

I hope you will introduce your proposal,
and I hope the American Congress will have
the wisdom to see its merits. I hope, also,
that if this proposal becomes a reality, the’
State of Rhode Island will have the privilege
of being selected to operate one of the pro-
posed centers.

Sincerely yours,
JOSEPH B. CANNON, M.D., M.P.H.,
Director of Health.

 

Crry oF MiwavukKEE HEALTH
DEPARTMENT,
Milwaukee, Wis., December 2,1965.
Hon. Harrison A, WILLIAMS, Jr.,
us. Senate,
Washington, D.C.

Dear Siz: I have received two letters from
you, both dated November 3, 1965, relating
to a proposed Adult Health Protection Act
of 1966. One letter was addressed to me as
commissioner of health of the city of Mil-
waukee, the other was routed to me from
Marquette University School of Medicine
where I serve as professor and chairman of
the department of public health,

I have reviewed the summary of your pro-
posed Adult Health Protection Act of 1966
and, speaking generally, I am enthusiastic
about the intent and scope of the proposed
legislation. —
The Milwaukee Health Department already
possesses an appreciable quantity of auto-
mated equipment needed to carry out a
proadly based multiphasic screening ex-
amination program in this community. Cur-
rently, the principal impediment to launch~
ing a full-scale program is the lack of
financial support to employ the necessary
personnel, I am engaged in pursuant of
some limited financial assistance from the
Public Health Service for this purpose.

I certainly feel a broadly based multiphasic
screening test program should be available
to any person age 50 or over who desires to
participate. To limit the program to per-
sons 65 years of age and over wowld seriously
impair one of the primary purposes of the
program; namely, the early diagnosis of dis-
ease, Early diagnosis is an essential step to
the institution of early treatment.

The only significant criticism I have of the
proposed Adult Health Protection Act of
1966, as surmmarized in the enclosure trans-
mitted with your letter, relates to establish-
ment of five health protection centers, to be
followed at a later date by esablishment of
health protection units linked to centers
py data transmission lines. I believe that
one or two health protection centers, to carry
out the functions delineated in the third
paragraph of the second page of your sum-
mary, would be in order. The most meaning-
ful benefits of the program will ensue
through rapid development of many health
protection units in many communities.

I feel that there is no need for the health
protection units to be linked by data trans-
mission lines to the centers, where inter-
pretation of some tests, such as electro-
eardiographic tracings, could be performed by
centralized electronic equipment. Small,
highly sophisticated electronic interpreters
will scon be available at a cost so low as to
justify their placement in the individual
health protection units. For example, an
American corporation will go into production,
on or about May 1, 1966, for manufacture of
digital-analog computers which will auto-
matically record and interpret electrocardio-
graphic data. The cost of such a unit will be
approximately $4,200. When one considers
the cost of an electrocardiograph, which the
health protection unit would require, and
linkage of units to centers by data transmis-
sion lines, I am sure it would be more eco-
nomical to have the interpretations per-
formed electronically right on the testing
premises. In addition to saving in cost, there
are other advantages, which I will not at-
tempt to enumerate here.

Very truly yours,
E.R. KRUMBIEGEL, M.D.,
Commissioner of Health.

 

New Jersey OPTOMETRIC ASSOCIATION,
Trenton, N.J., December 10, 1965.
Senator Harrison A. WILLIAMS,
Senate Office Building,
Washington, D.C.

Dear Pere: I am taking the liberty of
sending you a copy of the resolution which
was passed by the New Jersey Optometric
Association at their annual meeting, Sun-
Gay, December 5, 1965.

Secondly, I am enclosing a news release
that was sent from our public information
office regarding our resolution. This was sent
to all the dailies and weeklies in the State.

Pete, I think it is of great significance and
I hope of interest to you that the preventi-
care resolution was passed unanimously by
those in attendance at our annual meeting.

The New Jersey Optometric Association is
completely in agreement with your concept
of the need for a health maintenance pro-
gram for adult Americans, You can rest
assured that when your bill is filed, this or-
ganization will be 100 percent behind it.

Hoping this letter finds you in the best
of health, I remain, with Kindest personai
regards,

Very truly yours,

Herperr L. Moss, OD

Barior UNIVERSITY,
COLLEGE OF MEDICINE,
Houston, Tex., December 4, 1965.
Hon, Harnison A. WiuLztamMs, Jr.,
U.S. Senate,
Washington, D.C.

My Deas Sewarorn WILLIAMS:
for your letter of November 23,
with a summary of legislation
drafted to establish health
centers.

The concept underlying your proposal has
obvious merit. Indeed, consideration was
given to this’subject by the President’s Cor-
mission on Heart Disease, Cancer, and Stroke,
and I would hope that further consideration
would be given in the implementation of the
centers program as authorized by recent
legislation.

Accordingly, I would support an intensive
study of this proposal toward development
of this concept as a practical means of ad-
vancing our health programs.

With kind regards.

Sincerely yours,
Micuar. B. DeBaKey, M.D.
‘THE UNIVERSITY OF TEXAS,
MepicaL BraNcn,”

Galveston, Tex., December 14, 1965,
Hon. Hargison A. WILLIAMS, Jr.
US. Senate,
Washington, D.C.

Dear SENaTOR WiniiamMs: I have read with
a great deal of interest your letter of Novem-
ber 28, and the copy of your address of Sep-
tember 24, 1965, relating to the need for a
health maintenance program for Americans.

The purpose of this letter is to express to
you what I feel to be the very great impor-
tance of programs designed primarily for the
earliest possible detection of any disease
process. Since the head of our research com-
puter center here at the medical branch is
also a member of our departmental staf, you
can understand that we fee] that a program
such as you visualize will definitely entail
the development of automated or semiauto-
mated centers.

Whereas I can understand why you would
wish to give priority to those individuals 50
years of age and over, I should also like to
emphasize the imaportance of providing such
services to all age groups. Just as a single
example, if cancer of the uterine cervix is to
be reduced as a major public health problem,
early diagnosis must be aimed at those
women in their early twenties. There are
many other examples, most of which Tf am
sure you are well aware. I merely want to
point out that in my opinion, there should be
no age restriction relative to the eligibility
of medical care of this sort.

‘You are to be congratulated for your active
interest in and support of this particular type
of health maintenance program. T hope you
will be able to keep us informed of further
developments on the proposed legislation.

Sincerely yours,
Dow W. Micks,
Professor and Acting Chairman, Depart~
ment of Preventive Medicine and Pubs
lic Heaith.

Thank you
1965, along
now being
protection

 

 

VaL_e UNIVERSITY
ScenooL, oF MEvbICINE,
New Haven, Conn., December 7, 1985
Flon. Harrison A. Wiiicams, JP,
US. Senate,
Washington, B.C,

My Dear Senator Winniams: Thank you
for your letter of November 3 and for the
copy of your important speech to the Senate.

To a very substantial degree your remarks
reflect our views. We would be inclined,
however, to go a ttle farther than you.
For instance, although we agree that medi-
care is a vital step and that the heart, str
and cancer prograom is of great importax
both of these are essentially therapeutic pro-
grams and are not oriented to the prevention
of the chronic diseases of aging which are so

 

  
  

  

 

important today. “We believe that the pre-
yentive approach to these diseases is the
only one which will produce long-lasting re~

sults. When once these diseases have started,
therapy can at best ameliorate but can rarely
cure. Very early detection is vitally impor-

tant.

Our other point of disagreement reflects
| you yourself have said in the second
graph of your letter—that further study
led you to believe that age 60 or even 50
6 be a realistic age Hmit-in a program
@ ed to detect indications of disease. For
many diseases, 50 is far too late. I would
place the optimum age for the initiation of
this program at about 35. UH, for instance,
abnormal levels of lipids are detected at this
age it is probable that the eventual develop-
ment of coronary heart disease can be made
much less likely by initiating the appropriate
diet. If on the other hand the abnormality
is not detected until the age of 50 or 60, it is
too late. I would point out that one of the
most serious trends in this country today is
the increasing frequency of cardiovascular
disease in the forties and early fifties.
The initiation of this program at the earller
age is perhaps ever more important in the
prevention of cancer, especially of the uterine
cervix. These techniques are highly effec-
tive and can, for all intents and purposes,
eliminate death frorm this condtion. How-
ever, the cellular changes which preface the
development of overt cancer can commonly
be detected in the 80-year age group.

In spite of these criticisms, which are after
ali reatters of detail, I would like to offer my
siricere congratulations on your immensely
important proposals and I would much ap-
preciate further informaation on the pro-
posed legislation as it is developed.

Sincerely yours,
ANTHONY M. M. Parnes, M.D, FR.C.P.,
Chairmat.

  
  
  

  

 

Tue Uwiversiry or Norra Carce
nina ScHooL or PusLic HeaLry,
Chapel Hill, N.C., December 6, 1968,

on, Harrison A, Wititams, Jr,
U.S. Senate,
Washington, D.C

Sin; Your recent letter to Dr. W. Fred
Mayes, dean of the University of North Caro-
lina School of Public Health, has been called
to my attention with the suggestion that it
would be appropriate to communicate to you
any views regarding the proposed legislation
dealing with adult health protection.

iam most impressed with the insight into
the natural history of most chronic diseases
which is sugeested by your proposal, inas-
much as the only possibility for significantly
altering the impact of the chronic diseases
om our population lies In early detection,
diagnosis, and treatment as indicated.

You are aware, I am sure, that much of
the bealth progress of this century has been
syed thr eh the application of public
‘procedures which either prevent dis-
vor, developing, or prevent its develop-

to a more advanced stage when treat-

    
  
 

 

gk

    

ent t
nent is noneffective or less effective.

There are hone who would wisn any less
emphasis ox. treatment, but I would hope

 
   
  

oux enthusiasm for heart, cancer, and
; Ss amd related programs could
to include appropriate atten-
on to the application of existing screening
on & broad basis. One would
ope that research for the develop-
ment of mew screening techniques and for
the most eke tive methods of organizing such
not be neglected.
way conviction regarding these
yolnots stems from my interest in the field
i control. This has led
ty to survey various patient
ioms receiving care for long-term dis-
The study of nursing home patients
. North Carolina (see enclosed reprint) re-
ied that the application of appropriate
ventive techniques at earlier periods
might bave materially delayed the onset of

 
 
  
 
  
  
 
some of the complications demonstrated by
these patients.

That we continue to record deaths from
cancer of the cervix in females, that blind-
ness due to glaucoma continues to be diag-
nosed, that we constantly need to remind
ourselves concerning the unknown diabetics
in the population—-all of these serve as justi-
fications for the program which you have
envisioned.

I will be interested in hearing how the
proposed legislation is received in Congress.
Thank you for the opportunity to express
my feeling.

Yours very truly,
CHaRLES M. CaMERON, Jr.,M.D., M.P.H.

Professor, Public Health Administration,

 

THE JoHNS HopkKINS UNIVERSITY
ScHOCL OF HYGIENE AND PUBLIC-
HEALTH,

Baltimore, Md., December 14, 1965.
Hon. Harrison A. WILLIAMS, Jr.,
Senate Office Building,
Washington, D.C.

Desar SENATOR WILLIAMS: I wish to add my
strong support for your proposal Adult
Health Protection Act of 1966. The proposed
health protection centers would represent a
most important contribution of the enor-
mous problems we face in delivering medical
care to individuals and communities effi-
ciently and effectively.

The emphasis in this country on the cate~
gorical, disease oriented, approach both to
medical research and to medical treatment,
and the emphasis on professional specializa~
tion have been associated with enormous
advances in our fundamental understanding
of disease processes. In the long haul ad-
vances in the health of the people, both
through prevention and through medical
cure, will come from such work. In the short
haul, however, this approach militates
against the provision of optimum medical
care and the prompt delivery of what knowl-
edge we now have. In the short haul it is
medical care which interests society and it
is early diagnosis which provides the great-
est opportunity for favorably influencing the
health of those now alive.

I have visited Dr. Morris Collen’s “multi-
phasic health checkup program” in Oakland
and believe in many respects it represents
an important component in the medicine of
the future. His critical. approach to the
study of the sensitivity, specificity, yield
and costs of the various tests employed are
most important aspects of the work at
Kaiser-Permanente.

I support your approach to the initial
establishment of five centers in appropriate
universities. There is still much work to
be done on the development. of health pro-
tection centers before they could be effi-
ciently utilized on a large scale by smaller
institutions. Nevertheless their full impact
can only be realized when such facilities are
made available in local community institu-
tions. For this reason the phasing of your
proposed program seems appropriate.

I hope you will keep me informed about
the development of the proposed legislation.
if there is anything I can do to add my sup-
port, please let me know.

Yours sincerely,
Kerr L. Waite, M.D.,
Professor and Director.

 

STATE OF WEST VIRGINIA,
DEPARTMENT OF HEALTH,
Charleston, W. Va., December 16, 1965,
Hon. HaRRISON A. WILLIAMS, JY.,
Senate Office Building,
Washington, D.C.

DrarR SENATOR WILLIAMS: I appreciate re-
ceiving your letter of November 23, enclos-
ing a copy of your speech in the Senate re-
garding a health maintenance program for
adult Americans.

I thoroughly agree with the concept of
objectives. I have worked in the field of
preventive medicine and public health for
the last 19 years, during which time I have
observed, personally, the effects you have
brought out in your speech.

I would appreciate a copy of your pro-
posed bill when it is drafted. Please contact
me if I can assist you in any way.

Sincerely,
N. H. Dyer, M.D., M-P.H.,
State Director of Health.

 

DEPARTMENT OF HEALTH,
Paterson, N.J., December 9, 1965.
Hon. Harrison A. WILLIAMS, Jr.,
U.S. Senate,
Washington, D.C.

DeaR SENATOR WILLIAMS: Thank you for
your letter of November 23, and the accom-
panying material on the proposed Adult
Health Protection Act of 1966. The estab-
lishment of such health protéction centers, as
are envisioned in this program, would be a
major step in the direction. of making health
services and the best knowledge of American
medicine available to the general public.

The serious gap between medical advances
and available health services is one which
this great Nation can no longer afford. Al-
though perhaps less dramatic than the sav-
ing of lives by treating the sick and infirm,
it would certainly make important strides
in orienting the attitude of the American
public and the medical profession to the
value of periodic preventive services and the
vast economy effected in this manner, The
individual and cumulative health of the Na~
tion would be immeasurably improved.

May I commend you for your foresight in
the public health interest. With ali good
wishes, I am,

Sincerely yours,
J. ALLEN Yacer, M.D., M.P\H.,
Director, Department of Health.

 

CoMMONWEALTH OF PENNSYLVANIA,
DEPARTMENT OF HEALTH,
Harrisburg, Pa., December 6, 1965.
Hon. Harrison A. WILLIAMS, Jr.,
U.S. Senate, Washington, D.C.

Dear SENATOR WILLIAMS: Your proposal to
foster the establishment of heaith protec-
tion centers throughout the United States
is as timely as it is important.

In 1949, Dr. Leonard Scheele first estab-
lished a Division of Chronic Disease in the
Public Health Service and appointed me
Chief. An intensive study of this compli-
cated problem convinced me that one thing
that was badly needed was a combined
screening operation that would pull together
those screening tests that were specific, quick
to perform, and economical. The first paper
published on multiple screening, I believe,
was the one I prepared for Public Health
Reports in 1949.

A demonstration project was developed in
a housing development (Planner House) in
Indianapolis. I predicted that more than
1,000 pathological conditions would be
found in the first 1,000 apparently well adults
screened. About 1,200 conditions were actu-
ally found. Of these, one-third. were serious
conditions—nephritis, heart disease, hyper-
tension, diabetes, tuberculosis, syphilis,
arthritis, glaucoma, etc. About two-thirds
were vision and hearing defects, overweight
and other less serious (but correctible} con-
ditions.

Shortly after that an interesting compara-
tive study was promoted and financed by
the division at the Boston dispensary. A
group of 1,000 apparentiy well adults were
subjected to three different types of exam-
inations conducted by three different teams.

The first examination consisted of a rou-~
tine physical examination then in vogue—-~
auscultation, percussion, inspection (cost
about $10).

The second examination was an abbre-
viated physical examination—-shorter in time
and less detailed (cost about $5).

The third examination was a screening
examination conducted largely by techni-
cians—multiple screening (cost about $1).

An evaluation of the effectiveness of these
three types of examination showed that more
pathological conditions were found by mul-~
tiple screening examinations than by either
of the orthodox physical examinations.

Our experiments in multiple screening were
then extended to cover population groups in
large cities. One of these was Richmond,
Va. Here a multiple screening unit was
established in a large department store and
mobile units were set up on street corners
and in factories.

The American Medical Association estab-
lished the Health Information Foundation
which financed a study of the Richmond,
Va.. multiple screening project—convinced
doctors and lay people would be opposed
to it.

Actually, a large number of physicians—
over half if I remember correctly—felt it was
a good thing. Most of the people screened
favored it. Many said they would be happy
to pay $10 to $20 a year more taxes if they
could be screened each year. The exact
statistics were contained in a one volume
report published in the early 1950’s by the
Health Information Foundation.

As an experiment, Dr. McGough, health
officer of Alexandria, Va., persuaded the city
medical society to approve a multiple screen-
ing week in November 1951. Later he tried
to abandon it because of the time drain on
the staff. However, the public and the medi-
cal society insisted that it be continued.
It was still a feature of the Alexandria city
health program as recently as 2 years ago.

Traditionally, in the training of physicians
little emphasis has been placed on preveh-
tion. Until recently few medical schools
paid more than lipservice to it. Embryo
physicians were largely taught by surgeons,
internists, neurologists, and other clinical
specialists. They saw an acutely ill patient
operated on and recover. This was dramatic.
The clinician became the hero—his footsteps
to be followed.

Hence, it is understandable that busy
clinicians in your town and mine, too busy
often to attend medical society meetings,
seldom develop an appreciation of the value
of prevention. They never really see the
social and economic value of preventing pre-
mature or unnecessary disabling complica~
tions of disease. They are firemen skilled
in their trade of putting out fires but giving
little thought.to the far greater economy of
preventing them.

Therefore, the development of the health
protection centers that you propose in local
hospitals will do more to teach physicians
the value of prevention than anything else
that could be done.

In addition, the additive experience of
person after person finding out that they
had sugar diabetes or high blood pressure
before they ever knew it would be highly
motivational to others in the community.
Personal experience, personal testimony is
the most potent type of motivational educa-
tion.

And the administration of these health
protection clinics, hopefully, would involve
the local health department, the local hos-
pital, and local physicians in a tangible co-
operative venture that could draw preven-
tive and curative medicine much closer to-
gether, something that can’t be done by
speeches.

For generations emphasis was placed on
clinical medicine. Following World War II
several fortuitous scientific and political fac-
tors converged to bring about an amazing
expansion in basic research. Through both
these eras prevention, application, and pub-
lic health stood by watching, support lack-
ing.
In typically American fashion the pendu-
lum had to swing far to one side before
swinging back. Now the shelves are brim-
ming with unused medical discoveries and
techniques. And enlightened congressional
leaders like yourself are evidencing more
awareness of this fact than the medical
profession itself.

Perhaps then, with this type of support,
health protection centers can be developed,
effective local health departments can be
financed, and the dividends from the billions
of dollars expended on basic research can
finally be used for the full benefit of people.

Sincerely yours,
A. L. CuHapman, M.D.,
Assistant Surgeon General (Retired),
U.S. Public Health Service.

 

STATE or New JERSEY,
DEPARTMENT OF HEALTH,
Trenton, N.J., December 6, 1965.
Hon. Harrison A, WILLIAMS, JY.,
Senate Office Building,
Washington, D.C.

Dear SENATOR WILLIAMS: Your proposal to
establish health protection centers is bold
and stimulating. Your presentation to the
Senate was masterful.

The logic of periodic examinations is clear.
It is strange that the mechanism is used so
little.

I have been interested in “multiphasic
screening” for a long while, but have had
very limited success. My enthusiasm has
waned, but could readily be revived.

The Kaiser Foundation pilot program
should provide new understanding with
respect to yields, acceptance and use by
people and costs per remediable defect found.
I have not seen papers coming out of the
Kaiser project. I notice that in Dr. Collen’s
letter, which you quoted, he said that con-
clusive statistical data were not then avail-
able.

We do fairly well in diabetes detection in
New Jersey, but are having a hard time on
cervical cancer testing. The latter is ex-
pensive as it is now done. Additional Fed-
eral dollars are about to be put into cervical
cytology and several New Jersey hospitals
are applying for grants.

There certainly should be more large, care-
fully operated and evaluated programs such
as you proposed.

Sincerely,
RoscokE P, Kanpbiez, M.D.,
State Commissioner of Health.

 

HeaLtTH INSURANCE PLAN OF
GREATER NEw York,
New York, N.Y., December 9, 1965.
Senator Harrison A. WILLIAMS, Jr.,
U.S. Senate,
Washington, D.C.

Dear SENaTOR WiLLIAMS: We are interested
in your proposed legislation to establish
health protection centers.

AS @ nonprofit organization with 31 medi-
cal groups providing comprehensive medical
care to more than 700,000 men, women, and
children in the greater New York area, we
are continually seeking better and more ef-
ficient ways of providing medical care. We
are eagerly awaiting the findings of the
large-scale mass screening experiment by the
Permanente medical groups in Oakland and
San Francisco.

We are currently establishing a centralized
clinical laboratory where chemical, bacteri-
ological, cytological, and tissue specimens
may be brought from all of our 31 medical
groups and where automated equipment will
be used and highly skilled personnel will be
employed. Such a laboratory, working in
connection with health protection centers
such as you propose, would be ideal,

We are also under contract with the Na-
tional Cancer Institute studying mammog-
raphy as a possible method of early detec-
tion of breast cancer and through which it
is hoped that the mortality rate from this
disease will be decreased. Thirty thousand
of our subscribers are in the study group
and 30,000 are in a control group.

For several years we have worked on
various methods of early detection of glau-

coma and have trained nurses and tech-—

nicians in the performance of this delicate
test.

We all have much more to learn about
early detection of diseases and how to apply
the many new advances being made in this
field.

HIP has long supported progressive health
legislation and your letter leads me to be-
lieve that your proposal is one we would
wish to support. We would like to work with

the Public Health Service and the Depart-

ment of Health of New York City in estab-
lishing a model health protection center
in New York City.
Sincerely yours,
JAMES BRINDLE,
President.

 

STATE OF CALIFORNIA, DEPARTMENT
OF PuBLIC HEALTH,
Berkeley, Calif,, January 13, 1966.
Hon. Harrison A. WILLIAMS, Jr.,
United States Senate,
Washington, D.C.

My Drar Senator WinLiams: Thank you
for your letter of November 23, 1965, con-
cerning a proposed health maintenance pro-
gram for adults. We would appreciate any
information you can supply ahout the bill
presently being drafted to establish centers
for disease detection.

Multiphasic screening for early detection
of disease has received a considerable amount
of attention in California for many years.
Our first report of such a program was pub-
lished in 1949 The accumulated literature
has now become very extensive.

The Commission on Chronic IlJness in 1957
described screening as “the application of
screening tests rapidly and economically to
large population groups, to identify persons
who probably have abnormalities so that
they can be referred for diagnosis and, if in-
dicated, for medical care.”2 Screening is
not a substitute for comprehensive medical
examinations. Rather, its immediate objec-
tive is to identify persons who, though un-
aware of a health problem, are likely to be
benefited by prompt medical evaluation and
care, There is a real need for careful evalu-~
ation of the possible contribution of multi-
phasic screening to health. Several years
ago we encouraged Dr. Morris F. Collen, di-
rector, medical methods research, the Per-
manente Medical Group, Oakland, Calif., to
undertake such a study.

With financial support from Public Health
Service grants, Dr. Collen and his staff
started this important research in 1962. The
principal objective is “to evaluate multi-
phasic screening as to its effectiveness in the
prevention of illness, and in the reduction of
morbidity and morality.” Several members
of the California State Department of Public
Health serve this endeavor in an advisory
capacity and regard it as one of the most
important current studies in the entire field
of chronic diseases.

1Canelo, C, K., Bissell, D. M., Abrams, H.
and Breslow, L.: A multiphasic screening
survey in San Jose, Calif. Med. 71:409-413
(Dec.) 1949.

2 Commission on Chronic Iilness: Chronic
Tliness in the United States, Vol. I, Preven-
tion of Chronic Illness. Cambridge, Mass.
Harvard University Press for the Common-
wealth Fund, 1957. p. 47,

The present results of Dr. Collen’s research
leads us to believe that 5 to 10 more projects
of the same magnitude should be undertaken
promptly. Your proposed bill would permit
this development. Then we would be better
equipped to judge whether multiphasic
screening programs merit vastly increased
support. Convincing evidence of the value
of several screening tests already exists and
these should be widely utilized in screening
programs; for others the evidence is either
tenuous or nonexistent and they should be
further studied.

Our experience in promotion and develop-
ment of screening programs indicates the
importance of adapting each endeavor to the
special interests, needs and capabilities of
the community being served. Efforts to in-
troduce comprehensive sophisticated pro-
grams will succeed in some areas but not in
others, In the latter case it is far better to
begin on a modest scale that is acceptable
and feasible. Both situations require exten-
sive planning .and preparation. Participa-
tion of local physicians, paramedical person-
nel and related official and voluntary health
agencies is essential.

You raised the question of a minimum age
of eligibility for multiphasic screening. We
feel that there should be no arbitrary age
limitation. Though in general the yield of
newly detected disease is higher among
older persons, it is not always so. For ex-
ample, amblyopia ex anopsia (“lazy eye’’) is
a disease of early childhood, The best op-
portunity for correction of this significant
cause of blindness arises when it is detected
and treated before the patient is 5 years old.
The most efficient screening programs direct
their attention primarily to segments of the
population with high prevalence of the con-
dition to be detected. Age is an important
but by no means the only factor used to
identify such populations,

We hope these comments will be helpful.
Please do not hesitate to call on us if we can
be of further assistance,

Very sincerely yours,
LESTER BRESLOW, M.D.,
Director of Public Health.