CHRONIC DISABILITY

Question. What proportion of our adult working age population-between say ages 21 and 65-would you estimate is suffering from a serious chronic disability, one which has lasted more than a year? Would you give us a breakdown by major disease categories, neurological disorder, serious hearing loss, nearsightedness or blindness, mental illness, arthritis, mental retardation, etc.?

Answer. Of an estimated 61,590,000 persons who would usually have been working in 1962-63, acording to the National Health Survey, 3,976,000 or 6.5 percent were limited in the amount or kind of work they could do and 224,000 or 0.4 percent were unable to work at all, due to chronic conditions. The three principal chronic conditions causing activity limitation among persons usually working were heart conditions reported by 13.6 percent of those limited; impairments, except paralysis, of back or spine, 12.1 percent; and arthritis and rheumatism, 10.6 percent. The conditions next most frequently reported were impairments, except paralysis, of lower extremities and hips, 7.3 percent, other diseases of muscles, bones, and joints, 6.2 percent, and mental and nervous conditions, 5.8 percent. There may be some duplication in these percentages because some persons may have specified two or more conditions as causes of their limitation.

PREVENTING DISABILITY

Question. We have placed a lot of emphasis on the value of research in saving lives. This is important, but perhaps we have not put enough emphasis on preventing disability. Can you give us a synopsis of what the Public Health Service is doing to prevent diseases which usually disable rather than kill and what it is doing to alleviate disability where these diseases are taking a toll?

Answer. The Public Health Service is currently participating in the support of many activities designed to prevent or alleviate disability resulting from chronic diseases and conditions. In fact, the Division of Chronic Diseases now has the responsibility for developing and implementing control programs for 12 of the 25 most prevalent chronic conditions which cause disability limitations. Perhaps the most promising potential for reducing the death and disability toll from heart disease, lung cancer, and emphysema rests in the success of efforts to get people to stop smoking cigarettes. As you know, we have just begun an intensive effort in this area.

In general, the following disease control efforts by the Service are significant in size and impact and are directed toward disability prevention and the extension of useful lives for people who suffer from diseases such as:

1. Diabetes. The early detection of this disease has the goal of preventing later disability complications.

2. Glaucoma, one of the leading causes of blindness, which can be arrested to prevent blindness. Early detection programs are receiving widespread promotion. Blindness or serious vision loss can be prevented in 85 to 95 percent of the cases discovered.

3. Arthritis. Some of the crippling effects of rheumatoid arthritis can be postponed and alleviated through early detection and application of appropriate splinting techniques.

4. Rheumatic heart disease. The early use of prophylaxis can prevent rheumatic heart disease and a national effort is being conducted in this area.

5: Kidney disease. Chronic kidney disease patients can be maintained through artificial hemodialysis; a new program is being generated by the PHS. 6. Cervical cancer. Early detection of cervical cancer utilizing the Papanicolaou smear technique is preventing premature death and disability and is the major goal of our expanded cervical cancer detection program.

7. Stroke rehabilitation and stroke prevention efforts are showing significant potential for preventing disability from strokes.

8. Mental retardation. The use of the PKU test among infants to detect metabolic abnormality which can cause mental retardation and which can be corrected, is being stimulated utilizing PHS funds.

9. Coronary disease. The use of intensive-care units for coronary victims can reduce the number of deaths from this disease and is the responsibility of one of our newer programs.

In addition, a program combining a number of screening tests and applying automated procedures is being subjected to research and further demonstrations.

Generally speaking, community demonstrations and research efforts are being conducted by the PHS, principally in the Division of Chronic Diseases, in most of the disability areas to hasten the application of proven control procedures.

MANAGEMENT OF CONSTRUCTION AND TRAINING PROGRAM

Question. Generally speaking, do you believe that grant programs for training or for construction should be directed by the agency that has the responsibility for the support and stimulation of the corresponding program?

Answer. Needs for new or improved facilities or training programs in a particular program area depend on program needs defined in terms of services to be provided. Program needs dictate not only the number of facilities or training programs required but also their type and their location. To place the responsibility for construction and training grants in the agency having responsibility for program development helps assure expenditure of the grants in furtherance of program goals. In general, I think it desirable that grant programs for training or for construction should be directed by the agency that has the responsibility for the support and stimulation of the corresponding program. In the health field, for example, the Public Health Service should administer grants for the construction of health facilities and for the training of health manpower. Within the Public Health Service, it may be appropriate to "group" certain types of construction or training programs for administrative purposes. As you know, the internal organization of the Public Health Service is now under discussion.

SURGEON GENERAL'S VIEWS ON A BUREAU FOR MENTAL HEALTH

Mr. FOGARTY. Now according to this environmental health letter, you are going to take the Child Health Institute and Mental Health Institute out of NIH.

Dr. STEWART. The proposal was, and I again emphasize that those were my ideas

Mr. FOGARTY. I thought this arrangement had been working out pretty well.

Dr. STEWART. As far as the Mental Health Institute goes I think myself that it would be better if the Mental Health Institute was a bureau. My suggestion was that the National Institute of Mental Health become a bureau rather than a division.

Mr. FLOOD. What would be in it?

Dr. STEWART. Just the National Institute of Mental Health. This is different from the other Institutes in that they have the whole range of activities from basic research to all of these services. My own feeling is that this fits in more with this revolution in the care of the mentally ill that we were talking about earlier, that the major emphasis needs to be on that area. The research needs to be augmented, too.

Mr. FLOOD. Is this the whole spectrum of mental health, retardation, and so on?

Dr. STEWART. The mental illness and the prevention of mental disease, this whole spectrum. The mental retardation programs are located in the Child Health Institute and some Bureau of State Services programs, and also the Children's Bureau.

PROPOSAL REGARDING CHILDREN'S BUREAU

Mr. FLOOD. You propose to do something with the Children's Bureau, too.

Dr. STEWART. My suggestion to the Secretary was that there be five bureaus and in addition to this, thought should be given to the

forming of a fusion between the health services of the Children's Bureau and the National Child Health Institute to begin to develop the same spectrum that we have in the Mental Health Institute. It also would serve to begin to pull together some of the mental retardation activities. This is my thinking behind this.

MODIFICATION OF PERSONNEL SYSTEM

Mr. FOGARTY. Regarding modification of the personnel systems, what kind of modifications do you have in mind? There is a very wide range of people working for the Public Health Service. Can they all fit into the same personnel system? If you use nothing but the regular civil service won't you lose all the bright young doctors who prefer to do their military service in your commissioned corps? If you put everybody under civil service the corps won't get bright young scientists from the universities to come to work for you in future years. There is an exchange of scientists between NIH and academic institutions which is good for both and probably helps research.

Doesn't the security and prestige of being in the commissioned corps help you to recruit people for your medical service program? How do you propose to meet all of your needs with a single personnel system?

Dr. STEWART. First, the proposal is not a single health personnel system.

What our problem is, that we are trying to face, Mr. Fogarty, is that at the present time in the commissioned corps, since we are tied to the rank and pay system of the military, we are presently bringing in young physicians at the full grade or the major. This is after internship. We can, in effect, promise them two promotions in a 30year career. We have a compression of this.

SYSTEM DISCOURAGES MOVEMENT TO AND FROM UNIVERSITIES

Secondly, the other elements of the Public Health Service besides the scientists need interchange between universities and other areas as part of their career plan. A man who is in the commissioned officer system now who gets in 5, 6, 7 years, since he has not invested in his retirement cannot leave the Public Health Service to spend 5 years with a university with the idea of coming back, because he can't afford to lose the retirement he had earned. It works the other way, too. Since it takes 20 years to have retirement in the commissioned system, after you reach a certain age there is a reluctance for a man from a university, a large hospital, or other area to come into the Service, because he may only want to spend 10 years or 15 years, or something like this. So we find that lateral entry and lateral leaving is very difficult in the commissioned system.

LEADERSHIP DEVELOPMENT LACKING

Thirdly, it is true that we are quite dependent on the draft for physicians and dentists, particularly, and 52 percent of our physicians now in the system are serving their draft obligation. In dentists it is somewhat similar. This has been very helpful as far as staffing

many areas is concerned. On the other hand, we are not retaining enough physicians and dentists for careers in the Public Health Service to continue the growth and development of the senior people who run these programs eventually, the division chiefs, the branch chiefs, and

so on.

DEMAND FOR PHYSICIANS IN OTHER GOVERNMENT AGENCIES

Fourthly, the Department now has health programs in every agency, and we are being asked to staff many of these with professional people. Jim Goddard is interested in getting some physicians from the Public Health Service, the Welfare Administration is having difficulty getting physicians. Mary Switzer is quite concerned that we have not been able to meet her needs for health professions. The difficulty is that if they hire their own they have no career pattern for a physician. They say you do this medical job for us but there is no other way of going forward in that organization. The career in health is in the Public Health Service.

We also are supplying health personnel to the Peace Corps, AID, to many other agencies outside HEW. So we become really a health personnel system involving most of the agencies of the Department as well as many other agencies in the Federal Government.

What we hope to do is to design a personnel system where a person can have a career which will take him to FDA for a period of time, then to a disease prevention program, which will take him to a pharmacology center in a university for a few years and finally to come back at a higher level.

We will have some flexibility in career development. This is the idea.

HEALTH FACILITIES

Mr. FOGARTY. You did not say much in your statement about health facilities. This is the worst cut of all; is it not?

Dr. STEWART. Health research facilities?

Yes, sir.

Mr. FOGARTY. Last year we raised the authorization for that program from $50 million to $100 million. Now the budget estimate asks for only $15 million, is that right?

Dr. STEWART. That is correct.

Mr. FOGARTY. Which is only enough to keep the program alive but certainly not enough to do what clearly needs to be done. How are we going to use all the research people we are training if we do not build the facilities in which they can do their work.

You say on page 3 that the Public Health Service must be organized, staffed, and determined to advance the delivery of top-quality health services, and the purpose of the heart disease, cancer, and stroke amendments is to bring research and medical practice closer together. How can you do that if you practically cut out the construction of new research facilities? I remember during the Korean war the same thing happened. The budget made the deepest cuts in construction of all kinds.

COST OF DELAYING CONSTRUCTION PROGRAM

Some committee of Congress made a study of that and said it should not have been cut out because by cutting off for 2 or 3 years they lost about 10 years or 12 years' progress.

Dr. STEWART. Mr. Fogarty, in the decisionmaking process of the total budget and the inflation constraints and the need to finance the fighting in South Vietnam, we decided in our own priorities

Mr. FOGARTY. When I ask you this question that demands a professional answer, not taking into consideration these problems you just raised.

Dr. STEWART. If it is demanding a professional answer it means. we are postponing the development of research facilities. It means that the growth of the workshops or places where scientists work will be delayed.

Mr. FOGARTY. What effect will that have on the health of the people of our country?

Dr. STEWART. It depends on how long the postponement is.

I think perhaps 1 year won't have too much effect, but if it goes on for more than 1 year it will obviously begin to have an effect.

Mr. FOGARTY. Do you remember experiences during the Korean conflict about how a cut in construction affected some of the programs? Dr. STEWART. No, sir; that was before I was really involved in this. I am aware of what the cut was at that time and I am aware of the study that was done. I cannot remember who did that study. Also, the conclusions that were made by it. We are going to use the $15 million as much as we can in the expansion of new schools and to capacity of existing schools because we have in our own mind felt within budget constraints that it was higher priority to support the manpower development capacity and to, in effect, defer the construction which is solely the base for research development.

MEASLES VACCINE

Mr. FOGARTY. I am glad to hear you are making good progress for the measles vaccine. I hope there is enough money in the budget for this program so you can carry it to completion and eliminate this disease. This can be eliminated, can it not?

Dr. STEWART. Yes, sir.

Mr. FOGARTY. Where do we stand now on German measles? We put more money for the development of a vaccine in this year's appropriation. I think we raised it in the conference by rearranging the funds at that time to give you $500,000 more.

Dr. STEWART. That is right.

Mr. FOGARTY. Someone told me it was 20 times worse than this drug, thalidamide. I understand there is only one major pharmaceutical company in the country, or was at that time, spending much money on it and they did not want the Government to get into it. Dr. STEWART. They were having difficulty developing a vaccinea live vaccine-that was not infectious itself.

Mr. FLOOD. Are you speaking about prenatal vaccine?

Dr. STEWART. This would be German measles, vaccine. You immunize the children, the female children particularly, so you do not have any disease around. So when they become adults and are pregnant they do not get German measles.

Mr. FLOOD. This is different from the prenatal problem where the mother has the disease and these terrible deformities result.