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which existed many years before the Easter decision, remains inundated with court-referred alcoholic patients. Prior to the Easter decision this facility, though very inadequate to serve the needs of the community, did provide helpful therapy to alcoholics who were not homeless, who still maintained families and jobs and were still productive members of society, but who were, in fact, problem drinkers. Now, these patients have no public facility from which they can receive the kind of help which they so desperately need. They have been displaced by the thousands of cases referred by the courts. The District of Columbia, despite the tremendous increase in the number of beds and facilities available to help the city's alcoholic population, still has inadequate programs and facilities to meet the need.

The House of Representatives on December 13, 1967, unanimously passed HR14330, a bill introduced by Congressman G. Elliott Hagan of Georgia, to provide adequate services for the treatment of alcoholics in the District of Columbia to meet the needs resulting from the Easter decision and to implement the recommendations of the President's Commission on Crime. This bill will also serve as model legislation for rates and communities in coping with similar problems throughout the nation. For indeed, no state or community in the land is yet prepared to meet these needs. Of the forty-four state-level programs on alcoholism and the many municipal alocholism programs in the nation, not one state or community is adequately equipped to handle the problems, and not one will be able to establish the very minimal facilities and resources necessary without signficant aid from the federal government.

Additional model legislation is being developed by a joint committee of the American Bar Association and the American Medical Association which will also serve as a much-needed instrument in guiding legislators on the needs at the state and community levels.

NAAAP feels strongly that the federal government cannot and must not assume the total responsibility for providing the necessary facilities and other resources to meet this pressing need. We believe that the states and communities have an essential responsibility in this area. However, the federal government does have a clear duty to help other governmental jurisdictions to meet the needs of our society. Enactment, implementation and funding of Title III, Part A, of HR15758 will be a significant step by the federal government in fulfilling that duty. Passage of this Act, along with the excellent model legislation introduced by Mr. Hagan and that being prepared by the AMA and ABA, will provide much needed impetus for the states to expand their own existing alcoholism care and control programs and to the establish of new facilities and resources to meet the impending need.

EMERGENCY CARE: SUGGESTIONS CONCERNING PROVISIONS OF HR-15758

Because of the major emphasis placed on the need for detoxification services by the Crime Commissions, which was graphically demonstrated in the District of Columbia following the Easter decision, it is felt that such emergency care facilities should be specifically designated as one of the types of facilities eligible for federal assistance in the construction, staffing, maintenance and operation provisions of Title III, Part A, of HR-15758. We, therefore, strongly urge that Congress specify this eligibility within the appropriate section of the Act. We would point out in this regard that the ideal location for such emergency care facilities would be in existing general medical facilities, such as general hospitals and comprehensive health clinics, or at least closely affiliated with them. Without a specific provision authorizing construction of emergency care facilities, the possibility of adequate care for intoxicated alcoholics will be substantially reduced.

EXISTING HEALTH, WELFARE AND REHABILITATION LEGISLATION Comprehensive federal assistance to the states and communities can also be generated through the whole spectrum of federal health and welfare programs. These include the Justice Dpartment, the Veterans' Administration, the Department of Housing and Urban Development, the Social Security Administration, the Office of Education, the Office of Economic Opportunity, and the Social Rehabilitation Administration, as well as the Public Health Service and National Institute of Mental Health. Congress has passed much sound legislation relative to the activity of these agencies under the provisions of which alcoholism programming assistance is ostensibly available. In practice, however,

alcoholism related project applications for assistance are receiving almost no consideration by many of these agencies and they enjoy only a very low priority in a majority of the others. Evidence of this is seen by the fact that a total of only 11.2 million dollars was spent by the Department of Health, Education and Welfare during the current fiscal year, despite the fact that the former HEW Secretary has called alcoholism the most neglected health problem facing the nation. For the same fiscal year the amount of appropriations to the activity of the National Cancer Institute was $183,356,000. Added to this figure were millions of dollars appropriated to the Cancer Control Branch, PHS, the Veterans' Administration and the Atomic Energy Commission. There are currently approximately one million citizens under medical care for cancer with an expected additional half million new cases for the coming year. Alcoholism with an estimated 5 million victims-3 times the incidence of cancer-is currently receiving less than five percent of the federal attention which cancer receives. Similar statistics can be given for heart disease, vocational rehabilitation and mental retardation. These are all worthwhile endeavors for which more federal activity is indicated. But alcoholism should be accorded far greater recognition than it currently receives. We would, therefore, strongly urge the Congress to reassert in HR-15758 its intent that existing social, health, welfare and rehabilitation Acts must and shall be utilized to aid in programs of alcoholism care and control where applicable.

TRAINING PROGRAMS

Training of professional personnel to staff alcoholism treatment facilities is a special and crucial need in the field. Because of the historically low governmental agency priority for alcoholism projects, only the most highly dedicated and motivated people have been able to withstand the frustrations heaped on the professional worker in this field. Consequently, a very limited number of professionally qualified personnel are now devoting time and energy to the problems of alcoholism. This, coupled with the now acute problems posed by the court decisions, makes mandatory the training of large numbers of professional workers in the field.

Suggested Preamble:

The above points, we respectfully submit, could be covered in a preamble to Title III, Part A, of HR-15758 such as follows:

The Congress hereby finds that—

(a) Alcoholism is a major health and social problem afflicting a significant proportion of the public, and is not receiving the attention required from federal, state and local governments.

(b) Alcoholism treatment and control programs should: 1) be community based whenever possible, 2) provide a comprehensive range of services, including emergency treatment under proper medical auspices on a coordinated basis in existing and new facilities, and 3) be integrated with and involve the active participation of a wide range of public and non-governmental agencies.

(c) The handling of chronic alcoholics within the system of criminal justice perpetuates and aggravates the problem. A public health approach permits early detection and prevention of alcoholism and effective treatment and rehabilitation, relieves police and other law enforcement agencies of an inappropriate burden that impedes their important work, and better serves the interests of the public.

The Congress further declares that

(a) Major federal action and federal assistance to state, regional and local programs are required 1) to conduct and foster research relating to the cause, prevention, diagnosis and treatment of alcoholism, 2) to develop and demonstrate new methods and techniques for the prevention of alcoholism and the treatment and rehabilitation of alcoholics, 3) to improve and coordinate services for the prevention of alcoholism and the treatment and rehabilitation of alcoholics, 4) to support programs for the training of persons to carry out the purpose of this Act, and 5) to promote full and equal access to humane care, effective treatment, and eventual rehabilitation for all alcoholics regardless of their circumstances.

(b) In addition to the funds provided for under this Act, other federal legislation providing for federal or federally-assisted state research, prevention, treatment or rehabilitation programs in the fields of health and disease

must and shall be utilized to help eradicate alcoholism as a major health problem.

The inclusion of such a preamble would, in our judgment, greatly strengthen the bill without affecting the amount of funds necessary to be appropriated by Congress. We respectfully urge your consideration to include such a preamble.

SIGNIFICANT EXISTING FEDERAL EFFORTS

Two significant developments took place as a result of the President's Health Message to Congress of March 1, 1966. One was the establishment of the National Advisory Committee on Alcoholism, the purpose of which is to advise the Secretary of Health, Education, and Welfare on appropriate alcoholism related activity of the Department.

The second was the establishment of the National Center for the Prevention and Control of Alcoholism within the National Institute of Mental Health.

Both of these actions were administratively implemented. NAAAP believes that these important governmental activities should be made statutory by Congress and that the amount of appropriations and size of the staff of the National Center for the Prevention and Control of Alcoholism should be substantially increased to a level permitting the degree of services and research commensurate with the magnitude of the problem.

CONCLUSION

Although the court decisions have pointed up the immediate need to establish adequate facilities and staff to handle large numbers of patients found to be alcoholics, it must be pointed out that the chronic alcoholics repeatedly coming to the attention of the courts make up only a small, though very visible, part of the entire alcoholic population.

Enactment of this legislation will be of great help in the nationwide efforts to control this disease and care for its victims. This action will stimulate professional people to become involved, and the resulting awareness and concern from all sectors of society will insure that progress will be made on this most complex problem.

Mr. ROGERS. Thank you very much for an excellent statement, Mr. Dimas. Some of your suggestions are well taken and they will be helpful.

In your projection of how this problem should be met, do these treatment centers effect a cure?

Mr. DIMAS. Are you referring to the detoxification centers, or the compressive centers, sir?

Mr. ROGERS. Either.

Mr. DIMAS. We feel the terms altering behavior or controlling behavior are much better used. If services commensurate to other services in the community with people with illnesses and problems, the rate of success in helping people is just as effective.

Mr. ROGERS. I was wondering how many times we have to run a man through this—————

Mr. DIMAS. In dealing with the chronic offender, I think we have to take into consideration the term "chronic," as we do have the chronic heart patient, the chronic diabetic and the chronic in many other kinds of illnesses, which means there is going to be some kind of a repetitive factor.

I think one of the philosophies of treatment is how you control the problem over a longer period of time. I would say in some cases some of these chronic offenders can be rehabilitated and never return to this chronic kind of problem. I would say other kinds of individuals, the period probably will be prolonged, from 1 week to 6 months to a year.

Mr. ROGERS. Should we have a provision in the law that if these facilities are used, it must be at the request of the person?

Mr. DIMAS. Well, I would say that we do have present laws for involuntary basis, or a basis in which the crisis could be created so the person could be referred to the service. We do have our present commitment laws which allow us now to take a chronic alcoholic and commit him for his own protection.

Mr. ROGERS. What I was thinking of was if a person agreed to begin a treatment that he must have, and in that voluntary commitment agreed to the conclusion

Mr. DIMAS. I would say if he does not agree to stay to its conclusion. If he does not, some other measures might be taken.

Mr. ROGERS. Would you give us your thinking on how that might be incorporated in what we are trying to do?

Mr. DIMAS. I think the St. Louis experience shows that nearly 91 percent of these clients accept the treatment and complete the detoxification treatment.

Mr. ROGERS. I would be interested in seeing how many repeats there

are.

Mr. DIMAS. I think this afternon or tomorrow you will be hearing from Dr. Pittman, who is the founder of the United States first detoxification center.

Mr. ROGERS Dr. Carter?

Mr. CARTER. No questions.

Mr. ROGERS. Thank you very much.

The next witness, Mr. Nathan J. Stark, group vice president for operations, Hallmark Cards, Inc., Kansas City, Mo.

STATEMENT OF NATHAN J. STARK, CHAIRMAN, MISSOURI
REGIONAL MEDICAL PROGRAM

Mr. STARK. My operations have nothing to do with medicine.

Mr. ROGERS. I am not so sure. Don't you give get-well cards or something?

Mr. STARK. I have been accused of that.

I am pleased to have this opportunity to be at this hearing on regional medical programs. I am, as you note from the title, a nonexpert in the health field.

A businessman interested in health programs is my category. As I listen to all these experts, many of whom I have heard of, and several of whom I have known, I asked myself the question, "What am I doing here?" But perhaps this is the new look in the nonprofessional's view of the health field.

I think that the need for citizen participation has been rather unfamiliar to most of those in many parts of the health field, but I believe it is fast becoming consumer oriented.

My credentials in the health field are as president of the Kansas City General Hospital and Medical Center, and as chairman of the Missouri regional medical program, and it is to this latter role that I wish to address my remarks.

My statement will be restricted to the Missouri program, since this is the one I am most familiar with, and it may be typical, or may be typical of what other programs are.

The final focus of our program is on the cooperative delivery and planning of the best possible health care to patients suffering from heart disease, cancer, stroke, and other related diseases, regardless of economic, educational, or geographical status.

The program utilizes maximum local planning and initiative with regional emphasis upon coordinaion of efforts and review of the quality of endeavors. Policy is set by a council representative of the public and professional leadership with advice from all groups in the region who have a bona fide interest in the delivery of health care.

Because of the stated intent of the program which was to improve care by increasing the effectiveness of present systems, attention in the Missouri program was directed to early detection of disease, methodology for systems to provide maximum economy and effectiveness, and initially a small number of models of delivery systems, planning for a service to a specific population of people without regard to the exact place in which that service might be rendered, but with emphasis on delivering the care as close to the patient's home as is consistent with economy and quality. In other words, we are people oriented.

Primary emphasis has been placed on the development of supportive services which utilize the newest in scientific technology. This includes a variety of services which can be furnished both to the physician and to the patient quickly and economically at any time anywhere in the region.

The present testing of computerized interpretation of EKG's for physicians in rural areas is a precise example. For screening purposes, and for the first time in history, the private practitioner participating in the model system has consultation for heart disease immediately available to him at every hour, 168 hours a week, at an estimated cost of less than $3 per interpretation.

Each interpretation can be backed up by a dial-a-phone lecture reference source, recorded on tape and also automatically available at all hours at the cost of a phone call.

These backup lectures will develop on a demand basis in accord with experience. A model of delivery systems is found in the Smithville project. Here building upon an existing rural system, maximum effort has been placed by the local advisory group and the State university medical school upon a sophisticated consultation and referral program. In Smithville, the system extends into home care utilizing all available ancillary and auxiliary personnel. Faculty members of the university teach and consult with the local staff.

Financial assistance was given with a specific terminal date, at which time the system of care is projected to be self-supporting. The program provides for careful change of quality of care as a result of intensified support.

It is the plan of the Missouri program to establish and terminate final support for all demonstration projects in this manner in order to provide the opportunity for cooperative programs with a maximum of communities in the region.

Supporting services and later innovations will continue to be made available on a financially self-supporting basis to these cooperating communities so long as these are found to be mutually helpful.

A final facet of the program is the interdisciplinary research group in the university who are studying intensively the delivery system

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