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Compensation and pension payments to veterans in 1950 because of heart-disease disabilities were $168,250,000.

The proportion of insurance claim payments for deaths from heart disease has been steadily rising. In 1951 a major company paid the beneficiaries on account of heart disease a total of $173,680,000. This is just one company. This sum was about 312 times the amount paid for the same disease in 1931, showing a very marked increase in the disability cost of these diseases.

At a hospital rate of $12 a day, according to an estimate and example, 1 patient with chronic heart disease costs about $4,300 a year to maintain in a hospital. This would mean that if 50,000 patients and that is not an excessive number—with heart disease received hospital care for a year, the cost would, in 1 year, equal $219 million for the hospital care of these patients.

Sixteen thousand dollars per case, or a total of $640 million, was the cost of the cases of the 40,000 men inactivated by rheumatic fever alone during the World War period.

Now, this is a small indication of the importance of heart-disease disability: The Bureau of Public Assistance of the Social Security Administration, Department of Health, Education, and Welfare, after a cross-section survey of 13,200 of 93,359 recipients of aid under its program for the permanently and totally disabled in the productive age bracket between 18 and 65 years reported very recently that diseases of the heart were found more frequently than any other group of diseases or impairments.

Cardiovascular disease accounted for the major or secondary impairment in over 42 percent of the recipients, and was the major impairment in 37 percent. Almost 71 percent of the recipients with a disease of the heart were aged 55 or over. Over one-fourth, however, were in the age bracket between 35 and 54.

For about 1 in every 4 of the recipients with heart disease the impairment was of 10 years or more duration. In other words, these diseases are long-term diseases, very frequently at an enormous economic and sociological cost to a community.

Now, I think it is worth while at this point to make a brief statement about what happens to a family; just a reminder as to what may happen to an individual and a family when that individual is stricken with heart disease. By this, I include many diseases of the blood vessels and also what are commonly known as strokes, or disease of the blood vessels of the brain.

For instance, if a man in the productive years of his life with perhaps three children in college, having had a reasonably good earning capacity, is suddenly incapacitated because of one or another of these diseases, it produces in most families a catastrophic situation. The children often have to be taken out of college. The economic stability and social relations of the family are disrupted. The man is lost from his productive years in business, frequently. Instead of being a producer, an earner, and taxpayer, he becomes not infrequently the recipient of aid and support from others, by compulsion. This is reflected in the entire economy of a community or a country when it is realized that approximately 1 million people in this country have suffered from hemiplegia, paralysis from a stroke; and that 10 million people have heart disease.

Fortunately that picture does not hold for a considerable proportion of individuals who have either a heart disease or a stroke. Many of them are able to return to livelihood, but frequently they are markedly handicapped in their productivity.

If it is a child the family activities must from that time on center around this child in an endeavor to restore the child to reasonable health or perhaps arrange for the care of this child throughout its remaining years.

I feel now that it is important to ask some of the gentlemen who have come with me to dilate on some of the problems which relate to more specifically the major diseases; rheumatic heart disease, high blood pressure, and hardening of the arteries or arteriosclerosis. I am, therefore, going to call upon Dr. Duckett Jones to speak on this subject of rheumatic heart disease; what it is; its importance; what we know about it; the way of prevention and treatment; where we are working in the direction of research; and what we need to know in the future.

Unfortunately, time does not permit a very complete dilation on these subjects, but we hope to outline them so that they are challenging and interesting

Dr. Jones.

STATEMENT OF DR. T. DUCKETT JONES, MEDICAL DIRECTOR,

HELEN HAY WHITNEY FOUNDATION, NEW YORK CITY Dr. JONES. I will try to stick to the agenda items to give more or less a bird's-eye view from my own personal opinion.

Rheumatic heart disease is a common heart abnormality or difficulty which results from the disease rheumatic fever, which is very common, especially in childhood, but may occur at any age. The cause is unknown, although it is very clear to most observers that it closely follows, within 2 or 3 weeks, infection of the upper air tract (the chest, throat, or head), by the so-called hemolytic streptococcus, a common producer of respiratory infection.

In the last 15 or 18 years a tremendous volume of knowledge of considerable importance has been gained through measures which indicate that if you give daily prophylaxis, daily doses of either the so-called sulfa drugs or penicillin, that the number of clinically obvious illnesses of repetitive rheumatic fever—and repetition is one of its chief problems can be curtailed to a very large extent, probably 85 or 90 percent. I am very pleased to note that one of the individuals who first

gave prophylaxis in the early sulfanilamide days to the early patients is in the audience, Dr. Caroline Bedell Thomas.

A great deal of this information and strengthening of the concept concerning the importance of preventive measures came as the result of studies done during World War II in the Armed Forces. Prior to that we had looked largely at only rheumatic-fever populations, particularly in rheumatic-fever hospitals and institutions and rheumatic-fever clinics.

In addition to that we have learned in the last several years that if the new therapeutic agents—the antibiotics, of which penicillin is a common one—are used in treating a streptococcal sore throat, that

clinically evident rheumatic fever following this infection can be partially reduced. That is very valuable knowledge which came from i or 2 of the rheumatic-fever institutions, and was conducted on a very large scale and was strengthened greatly by work in the Warren Air Force Base in Wyoming under Dr. Charles Rammelkamp, working for the Armed Forces Epidemiological Board, Commission on Respiratory Diseases.

We then have some important preventive knowledge, and it seems very likely that there is presently a diminution in the amount of at least clinically evident severe rheumatic fever. I would believe that it looks as though the number of early deaths—which used to be 20 percent within 10 years after one contracted the disease-is being sharply curtailed.

The Heart Association is trying very hard to get these preventive knowledges utilized. There is no known measure as to how effective or on what scale this is being done, but the Heart Association is doing everything in its power to see that clinics and physicians utilize this important knowledge. However, we do not know yet whether these preventive measures will prevent the appearance of most or much of rheumatic heart disease in early adult life, because a great deal of the rheumatic heart disease develops as the result of the so-called silent or unrecognized rheumatic fever.

Important as these preventive measures are—and the fact that I believe we can now do a good deal—we do still have the problem and we do not know nearly all the answers.

I would say that the research which is presently going on, if it is continuously and adequately supported, strongly points to the probability of learning a tremendous lot more about the fundamental tissue changes and chemical interactions that occur in the important connective tissues of our body which are altered in this severe disease problem.

There are many avenues of research which are open to a large number of exceedingly good workers, and I would say that the amount of funds available at the present time are inadequate to assure the necessary continuity and stability which these and new and potentially able scientists need in order to pursue this problem to its most effective end, which would be to learn a great deal more than we presently know about the problem.

Dr. Wright. Thank you, Dr. Jones. Are there any questions at this point?

The CHAIRMAN. Dr. Wright?
Dr. WRIGHT. Yes, Congressman.

The CHAIRMAN. Í note the presence of Dr. Scheele, the Surgeon General of the United States Public Health Service. I have invited him to come and sit with the staff. And now, Mr. Dolliver would like to ask a question for the record.

Mr. DOLLIVER. Doctor Jones, I did not quite catch what you said about the progress which had been made in controlling heart disease as a result of rheumatic fever. Would you elaborate on that, or perhaps repeat what you said?

Dr. JONES. I think, sir, at the present time we have no very accurate data on how much rheumatic fever is being prevented with these new knowledges. I think it will take a few years for us to determine that.

But I am sure that the great majority of workers in the field believe that a considerable volume is being prevented at the present time.

However, there is one very difficult feature. In order to treat a streptococcal infection early, and hence probably prevent the rheumatic fever that may succeed it, the streptococcal infection has to be clinically recognizable by the physician. One-third to one-half of such infections are the so-called silent infections and do not cause disease symptoms, and hence there is no possible opportunity for that method to prevent the initial attack in those instances in which it is preceded by a silent infection. On the other side, it should be said that there are many, many cases of streptococcal infection which can be recognized and treated early.

We, however, do not rely on early treatment of streptococcal infections in an individual who has been identified as having had rheumatic fever or rheumatic heart disease. We give them daily prophylaxis, either the sulfa drugs or penicillin, so that they will continually be protected from these types of infection.

I am quite sure that though these knowledges in prevention are of extreme importance and are very helpful, that they are not the full answer that we need. In other words, to take a drug, a preventive drug, continually is quite a difficult problem. It is expensive, also. We yet have not determined how much we are preventing.

I think the problem is still with us, and it has many complexities, but I think that tremendous progress is being made in this area.

That is true, also, in the rehabilitation of adults who have old rheumatic heart disease. Surgical correction of valve deformities at the present time is an important feature in helping some of the adult individuals with crippling heart disease to reassume reasonably active existence.

Dr. WRIGHT. Dr. Andrus wishes to address a question to Dr. Jones.

Dr. ANDRUS. Is it not true, Dr. Jones, that the reported incidence of rheumatic fever is diminishing ?

Dr. JONES. I think that is true, Dr. Andrus, but I am not at all certain that the records are very accurate on it, because diagnostically it is extremely difficult. I think all I could say is that it seems definitely to be decreasing. Certainly the number of early deaths, prior to adolescence, seems very much less.

Mr. DOLLIVER. Thank you very much.
Dr. WRIGHT. Any other questions?

Mr. DEROUNIAN. Dr. Jones, would an ordinary cardiograph reveal the existence of a rheumatic heart?

Dr. JONES. If you have a definite rheumatic heart disease cardiographs are usually abnormal, but the heart disease is of such a degree when that happens that you know perfectly well that the individual has a rheumatic heart disease.

As a help in rheumatic fever the temporary changes which occur and which are to some extent shown by electrocardiograms are one of the diagnostic features; and that is being used very extensively, sir.

The CHAIRMAN. Mr. Heselton?

Mr. HESELTON. Doctor, you are with the Helen Hay Whitney Foundation ?

Dr. JONES. Yes, sir.

Mr. HESELTON. Is there any connection between that foundation and the American Heart Association?

Dr. JoNEs. Well, only that the purposes are very mutually connected. The Whitney Foundation is presently directing its attention toward the support of research in rheumatic fever; and the secretary and treasurer of the Helen Hay Whitney Foundation, Mr. Frederick Trask, is, I believe, chairman of the finance committee of the American Heart Association.

And I am in the Heart Association and serve as a vice president. I think there has been a very close cooperation.

In fact, in the Whitney Foundation office for a period of some years now there has been a cooperative effort between the council on rheumatic fever of the Heart Association and the Whitney Foundation to get as accurate data as possible on all those services throughout the country which are being directed toward rheumatic fever individuals. That has been a very close tie.

Mr. HESELTON. You referred to the necessity of adequate contributions in order to maintain continuity of research. Would you care to speak more about that?

Dr. JONES. I think I could speak very briefly.

In 1947 there was approximately $300,000 for rheumatic-fever research from agencies outside of medical schools, and so forth. We never know exactly the total amount. There were about 25 individuals who had established themselves as being able investigators with an interest in this field. There were only 3 men out of the 25 who had any real position or stable job. All of the others were being supported by very short-term grants from agencies outside of the sponsoring institution.

In 1952 the volume of research support had a little more than quadrupled. It was $1.3 million, approximately. The number of able investigators had increased from 25 to somewhere between 50 and 60. You realize that these are evaluations of a scientist's ability, and that is a pretty personal evaluation.

The number of stable positions had increased from 3 to 7. Today we have, with 50 or 60 able research workers of various and very different ages, working mostly in our medical schools and research institutes, only 7 jobs which give them any sense of security or continuity. I think they are all very secure intellectual individuals, but whether they continue to do this work is dependent upon some group of individuals sitting far away from the place where the work is initiated and carried on. That is one of the serious difficulties today with relation to research support. In addition to that, their

running expenses are subject to shortterm decisions by individuals outside of their own institutions and their own group; and I would believe that rheumatic fever, like all other areas of research in the health field, very badly needs funds which can be designated for use in such ways as to give assurance of continuity, so long as work is of a very high level of contribution.

In addition to that, a number of places are very badly handicapped through lack of facilities: Laboratories and equipment. That is a very difficult type of money to get. The private agencies can afford to do very little of it.

So far as I am aware in the heart field, the only construction funds of any magnitude or importance were in the 1949 or 1950 fiscal budget for the National Heart Institute, when I think about $6 million was

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