Comprehensive physiological monitoring systems certainly can serve an important function for intensive patient care in postsurgical and therapeutic situations.

In almost every case, the measuring instruments used for surgery are the same as used for diagnosis and surgery.

Analysis in therapy, again, we cannot feel too confident about. Continued research soon may provide more precise predictors for the effects of a particular course of treatment, and furnish a reliable rationale for their specification.

It follows that control in therapy must be somewhat unsatisfactory, because we do not yet have efficient analysis. The recent emphasis on artificial organs, for example, has placed great stress on the need for more complete understanding of normal control processes.

Until such time as an analytical understanding of the workings of the healthy system becomes available, the best efforts to restore normal function by means of physical constructs must be far from adequate. The present state of the art in control technology far exceeds the requirements for controlling the prosthetic devices that are specified and built today. As knowledge improves and demands become more sophisticated, the challenge will sharpen, and we in the technical community feel we are prepared to meet the task.

Energy conversion and control for most of the tasks in therapy involve conventional applications. Technology is well equipped to handle these in a straightforward manner.

The real problem lies in the specification of requirements.

Structures, here, deserve special attention. It is stated above that technology can design and build practically any specified device within the limits of physical realizability and availability of suitable ma

terials.

The state of the art in materials is probably the chief current stumbling block to progress in medical instrumentation, especially in the field of prosthetics.

Technology is woefully inadequate in its knowledge of the physical and chemical properties of inert materials for long-term implantation within the body.

Technology and medicine together suffer from a profound lack of information on the properties of living materials, such as bone, tissue, and body fluids.

It is generally agreed that satisfactory devices for renal or cardiovascular replacements cannot be delivered until the short- and longterm deleterious interactions of inert and living media can be controlled.

Pertinent issues that remain to be resolved include corrosion, infection, thrombogenesis, protein denaturation, toxicology, and a host of others.

All of these are being studied vigorously and, though the present situation is somewhat dismal, the needed breakthroughs and subsequent positive developments can be anticipated with confidence.

There is strong justification for a concentrated program of research, development, and testing in the area of materials. This must be performed via collaboration of the best talents from the fields of the physical and life sciences together with their peers from medicine and engineering. To do less would be a disservice to the community.

SUMMARY

Each of the regions in the technology-medical tasks grid has been considered. The attempt has been made to characterize the coordinates of the "space" and, for each intersection, assess the current state of the art, identify trends, and imply some barriers to advancement. The approach has been, deliberately, conceptual, summary, and suggestive. Any attempt at exhaustive citation in so comprehensive a field would be presumptuous. Hopefully, it has been illuminating and provocative.

There remain several general observations and allied issues that deserve mention.

The life science researcher or clinical practitioner daily faces problems that are characterized by a degree of complexity and subtlety far in excess of those encountered in typical engineering and engineered systems.

He recognizes the rapid development of new techniques and devices recently developed by the engineer. He senses that these should be of great help to him, but he is often mystified, even baffled, as to how to take advantage of these new resources.

He resents, justifiably, the intrusion and criticism of the glib engineer with his "exact" physical laws, "exact" mathematics, and "exact" electronic computers.

The engineer, on the other hand, senses that he has much to offer the life science researcher. He resents, justifiably, the tradition and empiricism of much of life science research and its reluctance to accept what modern technology can provide.

Too often in the past has the artificial boundary that exists between the life and the physical sciences developed into a formidable barrier because of naive dilettantism and arrogance on both sides.

It has been demonstrated repeatedly, however, that impasse to cooperation and communication fades rapidly when workers identify mutual goals and become problem-solution oriented rather than pragmatic in their approach.

At present, examples of such collaborative and productive relationships are too few, but the trend is definitely for improvement, and there are no insurmountable barriers to advancement.

Recent popular literature has painted impressive pictures of some remarkable accomplishments achieved via technology and medicine. Special attention has been given to artificial organs, automation, and medical applications of exotic forms of energy.

It is suggested above, and reemphasized here, that serious workers in the field acknowledge the relatively crude nature of what has been accomplished. The very best of the new devices must be considered as temporary, stopgap measures, to be viewed with caution, skepticism, and suppressed enthusiasm.

Once more, the current position on the ladder of evolution is primitive, but the trend is highly encouraging, and the future appears limitless.

Also, one must be sobered by the realization that the full exploitation of the wondrous systems that medicine and technology can produce must be awaited with patience because of the difficulty of the problems encountered and the massive resources required.

These resources include material, money, and manpower. At present there exists a severe shortage of well-trained people at all professional and subprofessional levels to meet even the needs of today. One cannot be optimistic about the immediate future.

Little more can be said about intermediate' prospects and the longrange situation except that enlightment and decisive steps are called for now if we are to be prepared to meet the needs of the community. A serious manpower problem now is acknowledged throughout the Nation in industry, academic, and public service where it is especially

critical.

The need to seek an optimum mix of industrial, academic, and government participation is clearly established. The recipe for such a mix remains to be defined.

In conclusion, these are most exciting times in which to be a member of the scientific community. To be actively involved with the care and well-being of one's fellow is challenging, fulfilling, and rewarding. The author is grateful for the privilege.

Senator NEUBERGER. Thank you.

You refer to these screening devices which we have been seeing here today as crude devices. You mean that we are just beginning? Is that it? You don't mean to disparge their use or their possibility for the present?

Dr. GOODMAN. Certainly not. They are samples of the best available today. However, one must recognize that the systems we have seen demonstrated represent little more than straightforward mechanization of conventional techniques. Their obvious virtues justify widespread utilization today, especially in communitywide diagnosis and multiple screening. Further, these machines have helped to establish definitely the technical feasibility of what we hope to accomplish in the future. However, with regard to the level of sophistication of what might be achieved, as exemplified perhaps by the space program, these are relatively crude machines.

There is work now underway in many parts of the Nation, some of it in our own laboratories, to improve these machines, to enhance their accuracy, efficiency, and reliability, and also to reduce the volume of blood or serum required to perform these tests. And again I will point out, if I may, that the kinds of tests that these machines perform are those specified, upon the basis of empirical evidence, by the diagnostician. We, one day perhaps, will understand what these measures mean in an analytical way. And I say that one day the entire set of diagnostic measures cited as authoritative may look considerably different from what it now does.

Senator NEUBERGER. But you don't mean to say that these themselves are not a step forward from where we were 10 years ago?

Dr. GOODMAN. A crucial step of great significance.

Senator NEUBERGER. What you are saying, then, is that we should not just rest at this level, that there will be developing more and more. Is that it?

Dr. GOODMAN. We must, indeed, develop. We cannot rest.

Senator NEUBERGER. Thank you for a very comprehensive paper, Doctor. Glad to have you here.

We will now call on Dr. Wagner, who is Chief of the Bureau of Medical Services of the Public Health Service.

Do you have a paper?

STATEMENT OF DR. CARRUTH J. WAGNER, CHIEF, BUREAU OF MEDICAL SERVICES, U.S. PUBLIC HEALTH SERVICE, BETHESDA, MD.

Dr. WAGNER. I submit for the record, Madam Chairman, the statement, and with your permission I will summarize it.

Senator NEUBERGER. That would be very much appreciated, on account of the interferences we are having today.

Dr. WAGNER. Yes, ma'am.

I think, Madam Chairman, that the subject that you are considering is extremely timely and provocative, and much suffering and premature death could be avoided in our adult population if a way were to be found of insuring the early detection of chronic diseases.

As has been demonstrated, we have at our disposal a battery of sensitive, proven tests to accomplish this task, and our challenge that is before us now is to devise an effective means whereby the test can be applied to the adult population in such a way that the information is used, and it is provided at a reasonable cost.

The concept of preventive medicine in the field of chronic disease has been soundly endorsed not only by the medical profession but also to a limited extent by the people themselves.

For example, it is common now for every adult to urge the use of preventive medicine as it relates to a child, but the adult does not apply the same requirements to himself.

Studies have been made in various disease categories to determine the extent of undiagnosed conditions which exist today. Here are a few of the important facts:

Use of the Papanicolaou smear to detect cancer of the cervix would prevent thousands of deaths. In fact, it is predicted that if all cervical cancers could be discovered in this way before they become invasive, cancer of this site would be 100-percent curable. Yet, the fact remains that more than 8,000 women die each year of cancer of the cervix.

Glaucoma, a serious eye disease causing 14 percent of all blindness occurring among adults, can be identified in its early stages by a relatively simple screening measure utilizing the tonometer. Yet, the fact is that there are approximately 1,300,000 cases of glaucoma among the population over age 40.

Another example, diabetes, can be very easily detected, and its complications controlled, if it is detected early, and yet of this very progressive disease it is estimated that some 2 million undetected cases are in the population, and, moreover, that we are making very headway in uncovering these 2 million cases.

slow

For example, last year some 700,000 people were screened, with only 7,000 new cases diagnosed.

Ideally, the best way to insure the early discovery and control of many of these chronic diseases is for every person to have a thorough medical examination at periodic intervals and be under continuous medical management.

From a practical standpoint, however, even if we were to overlook and be able to handle the overwhelming costs that would be involved, such a solution is unworkable, because there are not enough physicians and not enough of the resources that would go into such a program.

Some practical alternative must therefore be found.

This was recognized 15 years ago, when a major attempt was made to determine a practical alternative.

The National Conference on Chronic Disease, in relationship to the preventive aspects, was sponsored by the Commission on Chronic Illness. A body of experts was brought together, and they concluded that the solution to the problem lay in the development of simple, inexpensive procedures for the early detection of chronic disease and the subsequent development of a community screening program.

This conference helped to focus national attention upon the fact that there was a large undetected reservoir of disease, and that the role of screening, mass screening, was a very essential tool if something were to be done about it.

In the years that followed, the Public Health Service intensified its efforts to test many of the screening techniques and to develop new and better screening procedures, including the use of the health questionnaire, laboratory tests, and more recently electronic devices and computers.

Screening demonstrations were supported as the means of creating prototypes that could be used in communities throughout the Nation, and these screening programs included tests for single as well as multiple diseases.

At the present time, the Division of Chronic Disease in the Public Health Service is spending approximately $86 million to attack the problems of chronic disease. About $53 million of this is directly or indirectly related to the early detection of disease, and $13 million is specifically being spent in the area of development and testing of screening methods, support of community demonstration projects, and through the formula grant mechanism, support of State and community screening services and programs.

A giant step forward was taken a few years ago, when the Public Health Service provided some assistance in research and development support to the periodic health appraisal program being conducted by the Kaiser Permanente Health Foundation in California. You will be hearing about this program in detail tomorrow morning, when Dr. Collen, who is program director, appears.

Essentially, this provides a mechanism whereby a multitest laboratory completes in about 2 hours clinical tests, with health history, that would take very much longer time by conventional methods.

In June of this year the Public Health Service negotiated contracts for the establishment of two health protection centers for the aged adult, based on the techniques developed in the Kaiser Permanente program.

One of these will be in Milwaukee, and will be conducted by the Milwaukee City Health Department. The other will be in New Orleans, and conducted by the Department of Tropical Medicine, Public Health, Tulane University.

The aim of these health maintenance projects is to keep the apparently well people well, and it is hoped that this health protection program will stimulate such individuals to think in terms of taking positive action toward health maintenance.

Finally, negotiations are currently in progress for the creation of two similar demonstration projects in other communities.

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