and so forth-brought about by immunization, sanitation, and quarantine, and on the other hand the identification of disease in its early or presymptomatic stage. Those two principles have influenced the health of the world more than any other influences that have been known since the dawn of mankind.

When I talk about the identification of disease in its early or primary or presymptomatic stage, we have as graphic illustrations of this the diseases of tuberculosis and syphilis.

Both of these of course are chronic infectious diseases and their control has been largely brought about by their identification while in a nonsymptomatic stage. The identification of pulmonary tuberculosis in its earliest stage-where it is only a minor shadow on an X-ray film is in marked contrast to an advanced stage of the disease, with cavitation, and other evidence of widespread disease.

The medical contrast between those two situations is graphic beyond belief as is the contrast in cost of their management.

The same thing is true of the other chronic disease that I named, syphilis. The identification of this disease by simple blood test as contrasted to its symptomatic stage with nervous system or cardiovascular system involvement is strikingly different.

The contrast between management of the chronic infectious diseases in their early nonsymptomatic stages with their management in symptomatic stages is graphic. There is no reason why the chronic, noninfectious diseases may not fall into similar categories of management.

The same principles of early identification of noninfectious chronic diseases are as vital and as applicable as the early identification of the chronic infectious diseases.

Such diseases as hypertension, coronary artery disease, glaucoma, cancer of the uterine cervix and breast, and mouth, pulmonary emphysema, and a host of others can all be identified in an early or presymptomatic stage. The technology is available, and there is no reason why it cannot be applied.

These hearings have been directed toward the principle of cost. It seems to me that if we are thinking of increasing cost of medical care, as it presently exists, we can think only in terms of building, increasing numbers of hospital beds, of educating increasing numbers of physicians, nurses, and other professional people and of increasing efforts directed to the care of the already sick.

We will thus have increasing costs of hospital beds-and these other services for the sick for the foreseeable future. Where do we wind up? The Nation is increasing at the rate of millions of people every decade, and all that we can expect is to increase the number of beds and doctors and professional people to take care of them.

The cost, on the other hand, of early identification of these diseases, which are filling the hospitals, causing morbidity, and mortality must be looked at in comparison.

COST "MINISCULE" IN RELATION TO BENEFITS

I think that the cost of this, though substantial initially in the effort to find the disease, and in the event the disease is found, to move the individual into the receipt of health care, is minuscule compared to the management of that same individual months or years later follow

ing the development of an advanced stage of the disease with the prospect of long periods of hospitalization, or other institutionalization, physician services, nursing services, and on and on and on.

It seems to me, Mr. Chairman, that we are at the point wherein we must face the issue of whether we want to do what we are doing now, or whether we are willing to sponsor the support and development of this type of health service as we did with biomedical research some 25 years ago.

I would like to remind you that for all practical purposes, biomedical research was in its infant stages immediately after the Second World War. I think the Cancer Institute had its origin before the war, and maybe the Heart Institute, but the effort was really in its infancy. Out of this has grown a stupendous body of knowledge in 25 years. But it would never have come about if we had sat back and done what we were doing in the late 1930's and early 1940's.

Today, we are at the same stage, essentially, with respect to this segment of health services that we were 25 years ago with respect to biomedical research. I would urge the committee to consider what steps it might take with respect to these humanitarian and the social and economic interests.

Thank you.

Mr. ORIOL. Doctor, we thank you. I think it is apparent to the few hardy survivors here yet remaining why we asked Dr. Chinn to give us not only testimony but wisdom and a vision of what we hope will be the future.

I have many questions, and some of them will find their way to you in the form of the mail, but one question I would like to try out on you now: There has been much discussion today about how you cannot separate health care for the elderly from health care for all. It is regarded as part of the total health system. But in terms of organization, the attention given to health services for the elderly at the Federal level-is there some advantage to having a unit of government at a very high level devoted to the health care of the elderly? And I say that knowing full well that you are the former chief of the Adult Health and Aging Branch of the Public Health Service, but in view of the rising numbers of the elderly, in view of the increased attention being given to health costs simply because we now have medicare, do we not get similar benefits if we use the kind of quality health services given to the elderly as one way of raising the quality of services for all? Dr. CHINN. I think it is, as has been said here today, that medicare. has not only done a great deal for the older person, but has done a great deal for medicine and medical care in this Nation as a whole.

HEALTH PROBLEMS OF OLDER PEOPLE

As you well know, the health problems of older people are quantitatively infinitely greater than they are for any other age group. Qualitatively, one might argue about whether they are different, but quantitatively they are different, and there are many more complexities relative to these health problems.

I don't consider physical health problems alone; I am also talking about social health problems and mental health problems. All of these things interdigitate with respect to the influence of one area upon another.

It seems to me that quantitatively if we are looking for the greatest health problems that exist in the Nation, one can profitably look toward the elderly population. If we can solve these problems or can come even close to solving them, or develop mechanisms for solving them— then this cannot help but have a large impact on the rest of the population.

I would be the first to say that the health problems of elderly people-whether they be physical, mental, or social-do not necessarily begin when they are 65-when an individual gets to be 65. They begin in younger years, certainly, in the fifth and sixth decades of life, or maybe even in the third or fourth decades. Therefore, the problems as we know them in elderly people are qualitatively not peculiar to older people but there are more of them. I would endorse emphatically the fact that if one can focus down upon them, the impact of this upon the health of the Nation as a whole would certainly be profound. Mr. ORIOL. Another question I wanted to raise:

The Kaiser Permanente-or Kaiser Foundation health multiphasic screening program has been mentioned here quite often today. I think it is important for the record that we note that the persons receiving this screening are members of a prepaid group health plan.

When we talk of widespread multiphasic health screening, possibly along the lines suggested by the Preventicare or more specifically along the lines that are now at work in three or four pilot health screening programs, which were initiated, I believe, while you were with the Public Health Service-with all those, you are dealing with a group that is not organized into a prepaid package. How can you hope to get widespread participation? What are the difficulties here?

PUBLIC ACCEPTANCE OF PREVENTICARE

Dr. CHINN. Well, I don't think that all of the difficulties are known. And this is, I think, one of the reasons that the four prototypes that you mentioned, which are now in operation in communities, will serve to disclose a great many of the problems that are inherent in an openended community program. The lack of close physician participation and the lack of proper understanding of many people who would be coming to such a screening operation present real problems.

Factors about the delivery of the information and the followup and utilization of the information-all of these factors, I think, are unknown. However, I would say this: It took a great many years, many centuries, as a matter of fact, before the value of hospitals came to be recognized as something other than "death houses."

Prior to and including the 17th century, and indeed into the 18th century, one didn't go to a hospital to get well, one went to die. And it took 150 to 200 years before people learned to go to hospitals to get well. Formerly it wasn't recognized as a place to help the sick individual; it was a place to which to remove the dying person from society and hide him away.

This is an exaggerated statement, of course, but it seems to me that what we are talking about here today may require a long period of acceptance. But once it has been shown to the public that the identification of disease before it is symptomatic has proven its value, we won't have more trouble with public acceptance.

As it stands now, the public hardly accepts any preventive health. measures. People won't stop smoking-people won't stop overeatingpeople won't stop drinking excessively-so when one says this thing will soon be clasped to the breast of the general public, it is sheer

nonsense.

But the fact of the matter is that there never has been any health measure that I know of, which has been accepted, nor should it be until it has been proved to be of value. I think this is essentially where we are today.

Mr. ORIOL. It was said earlier today that it is the same old cardplayers around the same old table in the terms of people or groups of people involved in our health effort.

Do you think old cardplayers can learn new tricks? Do you feel the same sort of concern that was expressed earlier?

Dr. CHINN. I do not necessarily; I am old, and am still learning new tricks. I see no reason to think that everybody else can't.

I think that the health professions are on the verge of learning new tricks.

I would like to say a word about the ferment that is going on in medical education today. Medical educators are aware of this card table and these tricks-old tricks. They are doing something, really, very intensively about it. There is an enormous amount of activity going on toward the revision of medical curriculums, revising educational programs to fit into and to be in accord with the tempo of the

times.

And I think that all these educators are not necessarily young. Some of them are rather advanced in years--such as myself.

So I think they can learn new tricks. I think there is a climate here today that has no parallel since the Flexner report of 1912.

CHANGES IN MEDICAL EDUCATION

I think that the whole system of medical education is about to undergo a radical revision and to try new approaches to what it is supposed to be doing.

What kind of man or woman is supposed to be turned out of a medical school? What are they going to do after they leave medical school? Mr. ORIOL. You mentioned the Flexner report just then, and that set the stage beautifully for this question:

Within recent months an attempt was made to establish a presidentially appointed Commission-we will call it Health Maintenance and Disease Prevention-the idea being on that high level, much as the Commission that produced the heart, stroke, and cancer legislation-this Commission produced a report so comprehensive, so overwhelming, that it would set the stage for every kind of action you described in terms of disease prevention.

Do you think that this Commission is a good way to begin, or would you rather see an action program begun to make the point dramatic cally, or do you think it might be a combination of both?

Dr. CHINN. I think it should be a combination of both. I don't see how you can really have one without the other.

The Commission study would be worthless unless it could be implemented-whatever its recommendations were.

At the same time, I think you have isolated islands of activity going on without a national image. It will also take decades to get this idea across to the public.

I think that the two in concert would be the proper answer to this, and I would endorse it enthusiastically.

Mr. ORIOL. Do you have any questions?

Well, I would like to thank you, Dr. Chinn, especially for your contribution as well as all the other witnesses, in absentia, for a really good record which will give the subcommittee much to work with in the months ahead.

I would also like to correct an outstanding deficiency of the day by introducing Mr. Shalon Ralph, the professional member of the committee. This is his first hearing.

Mr. Ralph was retired until he joined the committee recently.

I also wish to introduce to you Mrs. Slinkard, our chief clerk. And once again, thanks to all.

(Whereupon, at 5:15 p.m., the subcommittee adjourned, subject to the call of the Chair.)