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As the result of the agreements reached at that time the Heart Association began to identify certain of the areas in which community service activity could well be arranged.

It was recognized at the outset that the numbers of people who were involved, because of the widespread nature of these diseases, made it impossible for us to get into the field of direct care of patients.

Therefore, our policies have, from the very beginning, forbidden the use of Heart Association funds for the payment of medical fees or the payment for drugs and other medical services.

Our function, as we have conceived it has been that primarily of introducing programs through community conferences and facilities, not undertaking the problem of actual care, but, rather it has been our function to stipulate, to encourage and to set standards and criteria for effective methods of the care and treatment and to identify where those areas are most badly needed.

I think the first outstanding instance is in the field of rehabilitation, notably what we call our cardiac-in-industry program where it has been the intent of the Heart Association, through community resources to bring together the representatives of management, labor, industry, and medicine, the medical profession itself, and other interested community agencies to share with us in thinking through how it is possible for people suffering from heart disease to remain as useful people who are not a drain on the community.

That has resulted, in many instances up to the present time, in the development of what has been called work classification units, whereby a trained cardiologist, and frequently with the assistance of a psychiatrist, medical and social workers, and public health nurses, to evaluate the working capacity of an individual very carefully. Then there is recommended to him the kind of work or occupation that is suited to his physical limitations. That kind of work is increasingly being encouraged throughout the country.

Another area of interest in the field of community service was one touched on this morning by Dr. Jones in regard to stimulating the widespread dissemination of information relating to methods of preventing rheumatic fever, and particularly the recurrence of attacks of rheumatic fever. That kind of activity is being gradually intensified and stimulated across the country.

More recently there has been a wave of interest in the problem of weight control and several of our associations are now undertaking well-controlled problems under the guidance of physicians looking toward dealing with the question of obesity and the matter of overnutrition that was touched upon again in the discussion this morning.

The remaining thing that I think I should say regarding community services is that in all instances, whether the planning is done nationally or within our State associations or within the local community by affiliates of those associations, program committees of the various community interests sit to consider the planning of these activities. Those committees always contain members of the medical profession, because, as has been said before, this program is essentially a medical program, and it is the intent of the Heart Association that at all points the medical profession will share in the forum, but we will save areas of activity for the benefit of people who suffer from heart disease.

Dr. WRIGHT. Before we ask questions of Mr. Betts I would like to call upon Dr. Perdue, from Miami, who has been interested in certain aspects of community service as well as other things. I think it will be worthwhile to hear her views as a person practicing in a different type of atmosphere than we have at the central office as represented by Mr. Betts.

The CHAIRMAN. We will be glad to hear Dr. Perdue. Please give your full name and your background so it will appear in the record.

STATEMENT OF DR. JEAN JONES PERDUE, MEMBER OF BOARD OF

DIRECTORS, MIAMI HEART INSTITUTE, MEMBER OF BOARD OF DIRECTORS, MIAMI HEART ASSOCIATION, AND PRACTICING PHYSICIAN, MIAMI BEACH, FLA.

Dr. PERDUE. I am Dr. Jean Jones Perdue of Miami Beach, Fla. I am a member of the board of directors of the Miami Heart Association and of the Miami Heart Institute.

As practicing physicians we have to carry to our patients what has been presented to us here today. It is difficult for a practicing physician to always have this information and it has been one of the practices of the Miami Heart Association, along with the Public Health Service and the Miami Heart Institute, to hold seminars which last 2 or 3 days, where speakers have been brought to give this information to the physicians so that they can give it to their patients and take care of them.

We see patients with the end results of hypertension and arteriosclerosis. We see them with their heart attacks, we see them with the drugs we have, and we see them with heart failure. We want to know where to turn to give them the best care. We know that our community needs proper hospitals and proper rehabilitation facilities for them, and I think that is one thing we would like to keep in mind that this committee talks over the needs of the community.

Dr. WRIGHT. If there are any questions on the community-service program from either viewpoint we would be glad to have them.

The CHAIRMAN. Are there any questions, gentlemen ?

Mr. HESELTON. How many States are there that do not have heart associations?

Mr. BETTS. All but three have them. Nevada, North Dakota, and Wyoming do not have them, although there is some activity beginning to take place in North Dakota which may finally result in such an association.

Mr. HESELTON. All of your funds come through contributions or legacies?

Mr. BETTS. Legacies and memorial contributions and general contributions.

Mr. HESELTON. Is a drive conducted annually!

Mr. BETTS. Yes; it is put on annually, during the month of February, which has been local heart month.

Mr. HESELTON. I noticed somewhere among your publications that there are approximately 7,000 physicians who are members of the association and only something like 7,000 laymen. It is surprising to me that there are not more who are not professional people who are interested in it.

Mr. BETTS. Actually the number of people who are actively engaged in assisting heart associations in their activities is far greater than the membership. The voting membership, as we regard it, will never be a very large group of people, but should consist of those who are sufficiently interested to become working active members in the full sense of that term. I would suppose that you could multiply the number of 7,000 by at least 10 if you want to get at the total number of those who are actively participating in one or another form in heart association activity, and that includes assistance in the raising of funds.

(A report of heart association activities for 1952 follows:)

TO LIVE AND TO WORK—1952 ANNUAL REPORT, AMERICAN HEART

ASSOCIATION

FOREWORD

Are we winning the war against heart disease? That is what the public wants to know as we intensify our struggle against the greatest health challenge of this era.

The very fact that this question is now so prominent in the mind of the public indicates that one major goal is being achieved. Our vital cause is arousing keen interest and extraordinary dedication on the part of lay and professional citizens alike. This is rapidly replacing the former attitude based on fear, ignorance, and indifference. The change created by a sound, long-range program has been immeasurably aided by the splendid cooperation extended to the American Heart Association by every media of communication.

The 1952 Annual Report of the American Heart Association indicates definite accomplishment in all phases of the carefully conceived plan to fight heart disease that we call the heart program. This program is aimed primarily at saving human lives. This is the first and most important objective. But it is not enough to keep a heart patient alive. The American Heart Association has accepted an equally great additional challenge, namely, to develop techniques and a sympathetic and understanding public which will help the patient maintain himself as a self-respecting and self-supporting citizen-an asset, not a burden, to his family and his community.

The phrase-to live and to work-does not refer to work in an economic sense alone, but also in a personal and social sense. Our community service and educational efforts are aimed to help the heart patient maintain his dignity and value as a human being.

Alert business and labor groups have given increasing support to help cope with these diseases that deplete the trained and skilled supply of workers and strike a deadly blow at the core of industrial management at the peak of executive capacity. Heart disease - especially coronary heart disease responsible for the majority of heart attacks—has taken an alarming toll among the men and women who formulate and execute the plans and policies of business and Government, often cutting them down as they enter the greatest period of their potential contribution to our civilization.

It is especially urgent that this challenge be faced and accepted by all groups concerned because of its significance in meeting the present need for skilled leadership and labor to achieve the defense goals of industrial production.

The waste of available manpower through failure to utilize the services of the many cardiacs who can work, and the importance of a self-supporting job in the rehabilitation process, have led to the development of the association's cardiac-in-industry program. This has proved to be one of the most vital undertakings of the heart program, an area in which dramatic and practical application can be given to the resources of medicine and science.

Scientific knowledge, gleaned from research, is the cornerstone to prevention, treatment, rehabilitation, and all other aspects of a truly sound program. The quest for new knowledge, new methods of care and prevention, must go on unceasingly although, as this report reveals, very important dividends in the form of definite discoveries and progressive steps in the control of certain of the heart diseases have already been achieved. Thanks to mounting public awareness and support, it has been possible almost to triple the sums allocated by the American Heart Association to the research program over the past 4 years.

An inspiring example of the fruits of research is presented in the opening section of this report, in which the role of the association in the rheumatic fever

preventive program is outlined. In a move hailed as a milestone in health progress, the association has taken national leadership in starting a broad campaign to achieve widespread use of approved preventive measures that will save countless lives and lessen disability both in the younger- and middle-age groups.

In this rheumatic fever program, we have an example of how research, first of a basic nature and then as applied research, can be utilized by the association to provide practical working assistance to physicians in dealing with their patients more effectively and in placing within their grasp the most recent and practical knowledge about the cardiovascular diseases. Other examples of this type of service by the association have been applied with some modifications. It constitutes a truly great contribution to the American public—one which they frequently benefit from indirectly but which they may not know is the ultimate source of their help.

In all heart and circulatory diseases, there is need for more professional and lay education so that new knowledge about diagnostic advances, prevention, and treatment can, without loss of time, reach the practicing physician and his associ- . ated professional workers as well as the patients, their families, and the public at large.

You are most cordially invited to read this report, digest its contents, and communicate your reactions and interests in it to the officers of the American Heart Association. To complete your understanding of the total heart program, you are also invited to consult the annual report or bulletins of the affiliate of the American Heart Association which serves your community.

Working hand in hand, the national and community heart associations are moving steadily toward their goals with the accent on life, not on death-on work, not on waste on knowledge, not on fear-and on help, not on despair,

IRVING S. WRIGHT, M. D.,

President. To LIVE

SAVING YOUNG LIVES

Heart disease in childhood is one of the most serious challenges to be faced in striving to reduce the tragedy of premature death and avoidable disability. How more appropriately can this account of the fight against heart disease begin than with the story of the salvage of the hearts of our children? Here is truly good news for our youngsters and their parents, carrying an implied message of hope for heart disease sufferers of all ages.

A most important scientific development of recent years has been the prevention of rheumatic fever through the use of penicillin or the sulfa drugs in combating streptococcal infections. Rheumatic fever, usually starting between the ages of 5 and 15, is responsible for most of the heart disease in children and a large share of heart trouble in early adulthood. In the total heart-disease picture, rheumatic fever sufferers are not as numerous as those with high blood pressure and hardening of the arteries, which afflict the older-age groups, but their number is greater than the victims of other more publicized childhood diseases. Of the total of 10 million persons estimated to have some form of heart or blood-vessel disease, half a million of these are children of school age.

The springboard to prevention was the discovery that rheumatic fever, a recurrent disease, is usually preceded by an infection of the nose or throat caused by a germ known as the beta hemolytic streptococcus. The effort to prevent the initial as well as recurrent attacks of rheumatic fever and consequent damage to the heart has therefore centered around the early and adequate treatment of strep infections.

At least 3 out of every 100 who get strep infections develop rheumatic fever several weeks later, if they are not promptly treated. Among those who have suffered a previous attack of rheumatic fever, the incidence is much higher. Guide to prevention

In recognition of the magnitude of this problem, the association's council on rheumatic fever and congenital heart disease set to work mustering the knowl. edge and the weapons available to launch a concentrated attack on one of the most vicious diseases of our time. A special committee of the council drew up a statement on prevention of rheumatic fever, a fusion of varying points of view regarding the best procedures to be followed in the use of penicillin and sulfa drugs for this purpose. The statement was completed toward the end of 1952, in time to be given wide circulation before strep infections reached their customary winter and spring peak.

Because of the greater dangers of strep infection to known rheumatics, the council also prepared and distributed a companion statement addressed specifically to children's and general hospitals, suggesting protective measures to be taken for rheumatic fever patients cared for in wards. Major health problem

Despite the progress in prevention and treatment of rheumatic fever, it still ranks high as a major health problem and will continue to do so for years to come.

In the rheumatic fever field, no less than in other areas of heart and circulatory ills, basic causes are still unknown, and therefore much additional research is needed. Although scientists have turned their big guns on streptococcal infection as the forerunner of rheumatic fever, they canont yet explain the exact chain of events that leads from the strep infection to the ultimate development of rheumatic fever. ACTH-cortisone study

No miracle drugs have yet been found to cure rheumatic fever once it has developed, but scientific investigators have been studying the effectiveness of hormone agents in treating the symptoms. The association's council on rheumatic fever, in conjunction with the British Medical Research Council has been conducting a 3-nation cooperative study, begun in 1951, to observe the comparative effects of ACTH, cortisone, and the salicylates (aspirin) in the treatment of the acute stage of rheumatic fever. The cooperative research study, first of its kind in the rheumatic fever field, was conducted at 13 centers in the United States, the United Kingdom, and Canada. Final results are being gathered and evaluated at a central coordinating center at the office of the American Heart Association, Preliminary report

In an interim report, the investigators noted that although acute symptoms subsided with all three agents, it was still too early to draw firm conclusions regarding the most effective drug. The investigators hoped in their further studies to find some answer to the crucial question-how effective are these drugs in preventing the damaging effects of rheumatic fever on the heart?

Much additional community program development is needed to put into action all available knowledge about rheumatic fever. The educational and community program aspects of the campaign to combat rheumatic fever are dealt with in a later section of this report.

RESEARCH: KEY TO PROGRESS

The life-saving advances that have been made in the prevention of rheumatic fever have inspired those who are fighting against heart disease to new efforts and new hope for success in other areas of this complex field-areas which not so many years ago seemed hopeless both to the physician and the public alike.

The key to progress against heart disease is scientific research. Research opens the door of knowledge to reveal the causes and mechanisms responsible for disease conditions, and thus makes it possible for medical scientists to develop suitable measures for prevention and treatment.

Cardiovascular research is the most complex kind of scientific investigation because of the many forms of heart and blood vessel disease. Three major disorders—rheumatic fever, hypertension (high blood pressure), and arteriosclerosis (hardening of the arteries)—are responsible for over 90 percent of all heart diseases. The national research-support program of the American Heart Association and its affiliates is, therefore, concentrated in these areas.

The public, which is always eager to learn about dramatic cures, wonder drugs, and miracle operations, should bear in mind that the accounts of spectacular developments in the public press represent in many cases only incomplete, indefinite, and often inconclusive steps toward what may in time become an ultimate medical triumph. Behind many of these incidental successes that look toward major victories are months and years of false starts, blind experiments, frustration, and even heartbreak on the part of scientists who are struggling so that the hearts of others may be saved. Bright hopes for future

The following are a few examples to indicate in a general way the kinds of research paths that are being followed in the cardiovascular field and the broad problems facing the research scientist. The American Heart Associa

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