HEALTH INQUIRY MONDAY, OCTOBER 5, 1953 HOUSE OF REPRESENTATIVES, COMMITTEE ON INTERSTATE AND FOREIGN COMMERCE, Washington, D. C. The committee met pursuant to adjournment, at 10 a. m., in the committee room of the House Committee on Interstate and Foreign Commerce, the Honorable Charles A. Wolverton (the chairman) presiding. The CHAIRMAN. The committee will come to order. Today we are to discuss the important subject of arthritis and rheumatism. The purpose of this discussion is to provide this committee with current information as to just where we are and where we are going in this field, and to obtain suggestions as to what additional assistance, through legislation or otherwise, may be necessary to hasten the day when arthritis and rheumatism will no longer constitute a major disease problem. We expect to obtain information as to the medical, social, and economic significance of these diseases; the amount of funds currently expended for research, diagnostic services, rehabilitation, and training; and some idea as to the most significant recent scientific advances in relation to arthritis and rheumatism. We expect to learn more concerning the major emphasis in research, to get some idea as to where the trend of research is leading us. We want to develop information as to what the major problems, the major unknowns, may be which must be solved or discovered before the diseases can be controlled. We want to have opinions and ideas as to whether the necessary funds, facilities, and manpower are available, and what should be done if they are not. I am glad to welcome to this hearing a distinguished group of scientists and laymen who are experts in the field of arthritis and rheumatism. This committee has been impressed with the conduct of earlier hearings in this series, in which the witnesses have, in effect, chosen a discussion leader and conducted a seminar based on a prepared agenda. It seems to us that this technique for holding hearings of this sort has proved to be a very successful experiment. I understand that there is such an agenda this morning, and that the witnesses have agreed that Dr. Currier McEwen, dean of the New York University School of Medicine and past president of the American Rheumatism Association, will serve as their discussion leader. I understand further that there are several prepared statements which are to be made available to the committee. I would like at this time to make both the agenda, and the list of participants, an official part of the record of these hearings. (The matter referred to is as follows:) AGENDA: HEARING ON ARTHRITIS AND RHEUMATISM BEFORE THE HOUSE COMMITTEE ON INTERSTATE AND FOREIGN COMMERCE, MONDAY, OCTOBER 5, 1953 1. Gen. George C. Kenney, New York, N. Y., president, Arthritis and Rheumatism Foundation: "The Economic Burden and Loss of Manpower Resulting From Athritis and Rheumatism in the United States." 2. Dr. Charles Ragan, New York, N. Y., president, American Rheumatism Association: "The Present Status of Our Knowledge of the Rheumatic Diseases and the Problems To Be Attacked in the Immediate Future." 3. Dr. Currier McEwen, New York, N. Y., dean, New York University College of Medicine, and past president, American Rheumatism Association: "The Needs in the Area of Medical Education in the Rheumatic Diseases: Fellowships and Traineeships; Teaching Grants; and Construction Grants." 4. Dr. Gideon K. DeForest, New York, N. Y., medical director, Arthritis and Rheumatism Foundation: "The Program of the Arthritis and Rheumatism Foundation." 5. Dr. Floyd S. Daft, Bethesda, Md., Director, National Institute of Arthritis and Metabolic Diseases, National Institutes of Health; and 6. Dr. Joseph J. Bunim, Bethesda, Md., Chief, Arthritis and Rheumatism Branch, National Institute of Arthritis and Metabolic Diseases, National Institutes of Health: "The Program of the National Institute of Arthritis and Metabolic Diseases." 7. Dr. Paul Holbrook, Tucson, Ariz., past president, American Rheumatism Association, former member of National Advisory Arthritis and Metabolic Diseases Council: "Statement on Appraisal of the Methods Currently Employed by the Federal Government in Providing for Support of Research, Education, and Training in the Rheumatic Diseases." 8. Mr. Thomas Freeman, New York, N. Y., executive secretary, Arthritis and Rheumatism Foundation: "The Organization and Financial Policies of the Arthritis and Rheumatism Foundation." PARTICIPANTS Dr. Currier McEwen, past president, American Rheumatism Association, dean of New York University College of Medicine. Gen. George C. Kenney, president, Arthritis and Rheumatism Foundation, New York City. Dr. Charles Ragan, New York, N. Y., president, American Rheumatism Association. Mr. Thomas Freeman, New York, N. Y., executive secretary, Arthritis and Rheumatism Foundation. Dr. Gideon K. DeForest, medical director, Arthritis and Rheumatism Foundation, New York, N. Y. Dr. Floyd S. Daft, Director, National Institute of Arthritis and Metabolic Diseases, National Institutes of Health. Dr. Joseph J. Bunim, Chief, Arthritis and Rheumatism Branch, National Institute of Arthritis and Metabolic Diseases, National Institutes of Health. The CHAIRMAN. Dr. McEwen, I would appreciate it if the various witnesses would stand and introduce themselves briefly so that they may be known to the recorder and to the members of this committee. After that, I will ask you to proceed with the discussions in any way you see fit. I may say that I hope that there will be full opportunity for the committee to question the participants and for the participants to question each other, in order that these hearings may yield the maximum amount of information on the subject under discussion. Now, Dr. McEwen, will you proceed by giving us your full name, the position you occupy, and the institutions with which you are connected, and likewise with respect to the other members of the panel, and I hope that your modesty will not prevent you from giving us as full a statement as you are able to give in this respect because we are all conscious of the fact that you have as members of your panel some of the most distinguished men in the study of rheumatism and arthritis in our country and we would like the record to show just what fine witnesses they are. 1 STATEMENT OF DR. CURRIER MCEWEN, PAST PRESIDENT, AMERICAN RHEUMATISM ASSOCIATION, AND DEAN OF NEW YORK UNIVERSITY COLLEGE OF MEDICINE Dr. McEwEN. Thank you, sir. Mr. Wolverton and gentlemen of the committee, I am, as you have just heard, Dr. Currier McEwen. I am dean of New York University College of Medicine. My interest in the rheumatic diseases, arthritis and rheumatism, which we are discussing today I think can be shown by the fact that I am past president of the American Rheumatism Association, which is the professional body in the country that has in it those members of the medical profession who are particularly students of these diseases. Each one of us on this panel has a prepared statement which he will present to the committee for filing and later then in turn make some remarks about that part of the general subject on which we are most competent to speak, and I would like, as you have suggested, first to introduce the members of the panel to the committee. On my left is Dr. Floyd S. Daft, who is the director of the National Institute of Arthritis and Metabolic Diseases, National Institutes of Health. Next to him is Dr. Joseph J. Bunim, long my associate at New York University in the study of rheumatic diseases, and now chief of the Arthritis and Rheumatism Branch of the National Institute of Arthritis and Metabolic Diseases of the National Institutes of Health. Prior to joining the Institute staff he was associate professor of medicine of New York University. At present he is associate professor of medicine at the Johns Hopkins School of Medicine. Next is Dr. Charles Ragan, associate professor of medicine at the college of Physicians and Surgeons, Columbia University, and the man who took the mantle of president of the American Rheumatism Association from me this past May. He is the present president of the American Rheumatism Association. He also is in charge of the Faulkner Arthritis Clinic at Presbyterian Hospital in New York, one of the biggest clinics in our country for work in these diseases. Next to him is Gen. George C. Kenney, whose war record I will not try to go into. That, I presume, is not the main reason for his appearance here today, but he appears as president of the Arthritis and Rheumatism Foundation. The CHAIRMAN. I think with respect to General Kenney that his background, from a military standpoint, as well as his interest in this subject, is such that it would be appropriate for me to mention the fact to the committee that Gen. George C. Kenney, of New York, N. Y., president of the Arthritis and Rheumatism Foundation, is a retired Air Force officer, former commander, Allied Air Forces and United States 5th Air Force in the Southwest Pacific, and also United States Air Representative on Military Staff Commission of the United Nations, and I have to say and so forth, because there are many other accomplishments and positions that he has occupied that would increase his importance, too, as a witness. Dr. MCEWEN. The next gentleman in line is Dr. Gideon K. DeForest, who is associate clinical professor of medicine at Yale University Medical School, chief of the important arthritis clinic of that great institution, and the medical director of the Arthritis and Rheumatism Foundation. Next to Dr. DeForest, at the end of the table, is Mr. Thomas Freeman, who is executive director of the Arthritis and Rheumatism Foundation. I took the liberty of saying something about each of these gentlemen, as you said I might, because I was perfectly sure that they would not say those things about themselves, so I thought it better if I said it for them, with the hope that if there are any other things they would like to add in establising themselves as experts, why, they might do so when they speak. In addition to the individual statements, Mr. Chairman, which each one of us has prepared, and which each one of us will file with the committee as we speak, there was prepared a joint statement of a general sort which has already been submitted and which was prepared jointly by the Arthritis and Rheumatism Foundation and the National Institute of Arthritis and Metabolic Diseases. The CHAIRMAN. That will be made a part of the record at this place, if you so desire. Dr. McEwEN. Thank you, sir. (The matter referred to is as follows:) THE UNITED STATES ATTACK ON ARTHRITIS AND RHEUMATISM-A JOINT STATEMENT BY THE NATIONAL INSTITUTE OF ARTHRITIS AND METABOLIC DISEASES AND THE ARTHRITIS AND RHEUMATISM FOUNDATION Arthritis, and its related rheumatic diseases, is more prevalent among our citizens than are cancer, heart disease, tuberculosis, and diabetes combined. In the United States today it afflicts more people, cripples and disables more people, and brings more pain to more people than any other chronic disease. It disables 10 times as many persons as diabetes, 10 times as many as tuberculosis, and 7 times as many as cancer. The total number of victims, approximately 10 million, is greater than the combined populations of Chicago and Los Angeles. Of these, this devastating disease has permanently disabled 1 million. The economic cost to the Nation is well over $700 million per year. Arthritis is not new-it has been with us since the dawn of human life on this planet. It is not just a disease of old folks, as is commonly supposed. It strikes people of all ages: children, people in the prime of life, and the aged-all are potential victims, potential cripples. Selective-service reports that of the young men called up for service in the Armed Forces in Korea, 30,000 of the 505,000 rejected were unfit for duty because they were afflicted with rheumatic disease. In the United States 30 million people-one-fifth of the population-counting the families of arthritics, are affected by the medical, social, and economic aspects of this problem. The manpower lost each year in the United States because of arthritis and rheumatism is estimated as 150 million days, equivalent to an army of over 400,000 persons unable to work at any time. Over half a billion dollars yearly is lost in wages and salaries by the sufferers from this disease, in addition to the cost of medical care and relief allowances. Medical care alone costs more than $100 million per year. Arthritis brings with it not only pain and crippling but impoverishment to many of its victims. The Federal Government loses each year $77 million in income taxes because of the wage earners unable to work. In short, arthritis and rheumatism present to us a medico-socio-economic problem of the first magnitude. The question is, Are we giving it first-magnitude attention? THE RHEUMATIC DISEASE COMPLEX Just what is rheumatic disease? It is usually characterized by aches and pains in joints and muscles, often resulting in stffening and swelling of affected joints. But, in this family of disease there are many different members, each with its own vicious "character." First and foremost is rheumatoid arthritis, perhaps the cruelest of them all. It is a chronic disease which frequently lasts a lifetime, for which there is no cure, and the cause of which is still unknown. The other large group of chronic arthritis is osteoarthritis, otherwise known as degenerative joint disease. This type results largely from aging and wear and tear of the joint structures. It afflicts people past middle age. It occurs in multiple Joints and in the spine with greater or lesses symptoms in all persons who live long enough. Why some persons are severely affected by osteoarthritis and others escape it is incompletely understood and its actual cause is unknown. There is no real cure. Still another group of rheumatic victims suffer from nonarticular rheumatism, or disorders of the muscles, bursae, ligaments, tendons, or other tissues. Many others who are afflicted with rheumatic disease will have types of arthritis due to gout (gouty arthritis), injury, or infection, rheumatic fever, and sciatica. Finally there is a group of serious and fatal conditions that belong to the family of rheumatic diseases known as "collagen diseases." In these cases the connective tissue which constitutes the supporting structures or framework of the body is attacked, inflamed, and often destroyed. The cause is again unknown and the cure as yet undiscovered. It is safe to say that there are very few families in the United States in which some member is not suffering or has not suffered from one of these rheumatic diseases. EARLY ORGANIZATION The earliest attempt to do anything in an organized manner about arthritis in the United States dates back only to 1928, with the formation of the American Committee for the Control of Rheumatism. This committe worked actively to arouse the interest of the medical profession in the magnitude of the sociologic problem presented and to extend knowledge of the rheumatic diseases by means of publication and exhibits. By 1930 it was apparent that there should be a national society for the study and control of rheumatic diseases, and from this committee the American Rheumatism Association was founded. It was and remains a strictly professional organization of about 800 physicians with a special interest in the rheumatic diseases. Just before the entry of the United States into Word War II, a committee of the American Rheumatism Association was appointed to study the possibility of undertaking a national fund-raising effort to support research, teaching, and more adequate care of patients with the rheumatic diseases. This important undertaking was delayed by the outbreak of hostilities, but after the end of the war rapid progress was made. Early in 1948, with the initiative and stimulation derived from the American Rheumatism Association, a separate organization, the Arthritis and Rheumatism Foundation was established, with a board composed of physicians and prominent, public-spirited laymen for the purpose of organizing an appeal for funds on both a national and local level. The year 1948 marks the beginning of the modern era in the attack against the rheumatic diseases in the United States. It was in this year that the momentum necessary to generate real action was initiated. And, it has been in the short 5 years since 1948 that more progress has been made in this field than in the previous 50. It was in 1948, too, that a National Research Council Committee for survey of research on rheumatic diseases was formed which conducted, at the request of the American Rheumatism Association, the first comprehensive analysis of activities in the rheumatic diseases in this country. As reported by this committee, the results of its 1948 survey revealed the following facts, among others: "Other countries have recognized the prime importance of the rheumatic disease problem and have formulated plans for nationwide attacks. The Scandinavian countries have a well-organized plan for treatment and control. This is also true of Great Britain. Canada too has initiated action in establishing a rheumatic disease program. "The magnitude of this problem is manifested by the incidence of the disease and by the many reflections in the social and economic aspects. The rheumatic diseases group is one of the oldest described in medical writings, but it is also |