Investigations Branch. The Georgia population from which case prevalence figures were calculated is that estimated by age for 1964.

There

3. Heart disease, the first cause of death.-There is no question that this is the major public health problem confronting us today. It causes more deaths than all other diseases combined and even under age 65 is the leading killer. are about 110,000 known cases in Georgia today according to the National Health Survey (Tables II and III).

4. Hypertension.-Studies in Georgia have indicated that 13% of our population over 17 years of age have significant hypertension. More than 2% of these have never known prior to the survey that they had this condition. Hypertension represents one of the most successfully treated of the cardiovascular conditions today, with the mortality during the last 10 years decreasing by 42%. Therefore, it is very important to identify in our population those who have the condition so that the proven successful methods of therapy may be applied before irreversible damage is done to the brain, kidneys, or heart.

5. Cancer, the third cause of death.-Delay in securing professional guidance precludes successful therapy in many cases; in some the delay may be attributable to professional oversight. The problem is greatest among those in the low income groups. There are over 14,000 known cases in Georgia today according to National Health Survey.

6. Nontuberculous chronic respiratory diseases. In recent years the decline in deaths from tuberculosis has been offset by an increasing death rate from obstructive lung diseases (chronic bronchitis, asthma, pulmonary emphysema). Examinations under various governmental pension programs indicate that these illnesses frequently cause disability serious enough to prevent gainful employment. The prevalence is greatest in the 45-64 year age group. Because this disease develops slowly its earliest stages often go unrecognized and progression is insidious for a period of years. Eventually undue shortness of breath becomes apparent, at first only during exertion, later with less and less exertion, and ultimately even the simple acts of talking, eating or dressing cannot be accomplished without it. Such persons are permanent respiratory cripples. There are 552,000 known cases in Georgia according to National Health Survey (tables II and III).

7. Diabetes. Diabetes may be present for years, unknown to the individual until definite symptoms cause him to seek medical care. In most diabetics symptoms do not become apparent until after age 40 or older. By this time irreversible permanent damage may have been done. Diabetes is the seventh cause of death in the United States and the third cause of blindness. Early death from diabetes is estimated to cause an annual loss of 415,000 life years. The prevalence of diabetes will become greater as the population over forty increases. Symptomatic diabetes and its complications (blindness, kidney disease, cardio-vascular lesions, gangrene, etc.) cannot be prevented without early detection and proper treatment. Overall prevalence of symptomatic diabetes is estimated to be 17 per 1,000 population, but one-half unknown. (This national estimate approximates nicely the actual findings of our multiphasic surveys in Georgia. An analysis of 241,457 persons tested showed 4,524 or 18.7 per 1,000 classified as abnormal, borderline, or previously known diabetic). (Reference: Mass Screening for Lowered Glucose Tolerance-Petrie, McLoughlin, and Hodgins. Presented at the Thirty-fourth annual session of the American College of Physicians. April 15, 1953. Published in Annals of Internal Medicine, May 1954). On this basis we estimate about 80,000 cases in Georgia, over one-half unknown. This also approximates nicely the 34,257 known cases according to the National Health Survey (tables II and III).

8. Glaucoma.-Simple chronic glaucoma is an insidious condition occurring most frequently in people over 40 years of age. It affects approximately 21 per 1,000 of the population. Increased intraocular tension gradually destroys the function of the eye. By the time changes are noticed most useful vision is lost. Fourteen percent of all blindness is traceable to this cause. It is the second greatest cause of blindness in the U.S. Early detection through adequate screening with referral for proper medical care could preserve the sight of thousands. There are 4,373 known cases in Georgia according to the National Health Survey (tables II and III).

9. Arthritis and rheumatism.-There are more than 12 million cases in the U.S. according to a recent survey. More than $250,000,000 is spent by victims on misrepresented drugs and useless treatment. Each year it forces more than 3,000,000 persons to restrict their activities, another 1,500,000 become partially

disabled, another 250,000 become completely disabled. There is no laboratory screening test for arthritis, but with early case finding, education and proper medical care much of the suffering and disability can be materially reduced. There are 244,000 known cases in Georgia according to the National Health Survey. (Table II and III).

Is a multiphasic health-screening program feasible? The answer is a qualified yes.1 There are basic cardinal principles which must be worked out with all parties concerned-understood-agreed to-and followed. In Georgia the principle of multiple-test health screening is approved only if it is correctly understood and only if it is performed in a professionally ethical manner under medical supervision, and only in those geographical areas where the procedure has the endorsement of the local health department and the local medical society. Some cardinal principles mutually agreed to are listed below for your consideration. These principles are adhered to in the sceening program of the Georgia State Employees' Health Service and in public screening surveys. 1. Laboratory tests are to augment a complete physical examination by the private physician, and not to supplant an annual examination of this type. Such tests, however, may be performed by qualified technicians under medical supervision.

2. No individual can secure maximum benefits from the screening services without a medical interpretation which can be secured from the personal physician of his choice.

3. No employer can secure maximum benefits from the screening services without medical judgments as to suitability of employment, matching the physical capacities of the worker to the physical demands of the job, which can be secured from the medical consultant or medical director.

4. Test findings identifying individuals shall be treated confidentially and shall not be reported by the screening service except to the individual concerned, or personal physician of his choice, and the medical director or medical consultant of his employer. The screening service may withhold confidential information even from the physician if he fails to protect the ethical rights of either the employer or the employee.

5. The principal public health reason for health test screening is health education aimed toward prevention. Each individual should learn: 1) his own inescapable responsibility for his own health; 2) the limitations of his own resources; 3) where to turn for help.

All persons screened are taught that health tests are not in themselves a physical examination. Failure to pass a test is not a diagnosis of disease, nor is passing all a complete bill of health. . . . they require medical interpretation which an individual can secure from the personal physician of his choice. The physician must make his own examination and conduct his own tests to evaluate more completely what has been revealed by the health tests.

As a follow up each employee screened should be issued a personal report indicating which tests he had passed and which he had failed. This report can re-emphasize and further develop understanding of the real meaning of the tests. He should also be issued a personal pocket health record identification card including record of his immunizations and sensitivities, blood type, and special conditions which should be kept up to date.

The results of tests, with the permission of the employee, should be forwarded to the personal physician of his choice. The more a physician knows of an individual's normal health, the better he is prepared to accurately diagnose and properly treat the sickness or injury.

We wish to acknowledge very valuable assistance from the Council on Occupa tional Health of the American Medical Association in working out the above cardinal principles, and their assurance that they would support a program based on similar principles in any community where the program is supported by the local medical society.

An overwhelming vote of confidence was given our community-wide-multipletest health surveys in Georgia in 1945-1953 under the above principles. We accepted a commitment to survey a community only upon written confirmation from both the health department and the medical society. The service was so popular that in 1953 we had commitments for a full schedule eighteen months in advance. These were for repeat surveys in communities which had been

1 Costs are reasonable. 1945-53 Georgia surveys averaged $1.03 per person tested.

surveyed several years before. But we discontinued the surveys for two major

reasons:

1. Sharp reductions in appropriations.

2. Follow up was inadequate to identify and control the key factors which interrelate to affect the occurrence and course of the diseases, and to assure availability of adequate medical diagnosis and care to the patients. Merely finding persons suspected of having a disease is useless if nothing is done about it.

Another good question is "What tests should be included in a multiphasic screening battery?" We have guidelines here. Ideally the decision regarding baseline tests to be used should be separately made for each community and for each age and sex group. Tests to be considered must be economically feasible, scientifically sound as to reliability, validity, sensitivity, specificity, and yield, and the prevalence of the disease in the sex and age group in the community should be verified. No physical examination should be considered complete unless it includes the health tests designed to discover otherwise hidden cases of diseases which are prevalent in the sex and age group in the community. Probably no more effective battery of tests than that offered by the Permanente Medical Group has been developed. Also, the Section on Pathology and Physiology of the American Medical Association has released an excellent brochure recommending selected clinical pathology tests in health evaluation.

I can see little reason for the government to assume all of the expense of health screening for industries and businesses and the professions and the labor force, and the members of their households whom they support with their dividends and their salaries and wages. All of us who work for a living are members of the labor force. Industrial leaders, as at the Kaiser Industries and the Permanente group, have demonstrated that they can organize themselves to do the job, and pay for most of it out of earned income by teaming up with government. This is as it should be in the American tradition of freedom. We can no longer afford to ignore the occupational health approach for it deals with those who produce the wealth we need and at the same time represent and support the population we serve. The following statistics verify this:

1 In any State a sizable segment of the labor force is employed in the educational system of State and local governments. In Georgia the university system employs approximately 15,000 of 40,000 State employees and local schools employ 63,000 of over 100,000 local government employees.

NOTE.-Health and safety must be practiced where the people are, and they are most abundantly at work. In Georgia our 1.5 million labor force supports the 1.1 million households where our 4 million citizens live. "Take Home Health" learned on the job could be of universal value.

If big business, or big industry, perfects a health screening center for its own employees, why cannot it offer contracts to all its neighbors in the area including the employees of smaller establishments (private enterprise or government)? Ninety percent of our labor force work in smaller establishments. This occupational health "know-how" would be a wonderful fringe benefit not only for all of us who work for a living but for everyone we support. Conversely, why cannot big government, if it perfects a health screening center, contract with its neighbors to make its services available to all smaller establishments in the area (business, industry, professions or government)?

I can visualize regional health protection centers being operated either by private enterprise or by government or conjointly. Group contracts could be worked out at very reasonable cost to business, industry, professional groups or labor unions as a fringe benefit to be paid for out of earned income. It is better for the recipients to pay directly at the source rather than indirectly and more expensively out of taxes. We would find the principal profit from this investment to be the increased productive capacity of our labor force.

Government can team up with free enterprise as the U.S. Public Health Service and the Kaiser Foundation Research Institute have demonstrated through the Permanente Medical Group. They have opened the gate. No one has dem

onstrated a better method to get the show on the road. I plead that any new health protection center do as they have done-learn the techniques by servicing their own personnel. They who cast out first the mistakes they learn on themselves will then see more clearly to prevent more costly mistakes in their service to others.

A recommended initial screening schedule, subject to modification according to local experience, could be

1. An initial screening of all employees at time of employment and schedule rescreening if findings so indicate.

2. Rescreening of all employees at age 40 and periodic rescreening as frequently as findings may indicate but at least every three years until age 50. 3. Periodic rescreening after age 50 as frequently as indicated but at least every two years until age 60 and every year thereafter.

Ladies and gentlemen, I have devoted my life to health service. I have seen sick call for the few too frequently crowd out health service for the many. Almost everyone gives lip service to prevention. Unfortunately most shift the responsibility to some one or anyone other than themselves. The matters we are considering have the potential for overcoming some of the public apathy but the essential cardinal principles must be adhered to.

Thank you for the privilege of presenting these thoughts. I take full responsibility for them. They do not necessarily reflect in their entirety established policies of the Georgia Department of Public Health; however, they have been reviewed by professional members of my own department and the Georgia Commission on Aging and the Medical Association of Georgia without any dissent in principle.

P.S. The following additional supporting information has become available and is appended: (1) A letter from the president of the Fulton County Medical Society; (2) Estimations of indirect costs in Georgia adapted from national estimates by Dorothy Rice.

Diseases of the circulatory system..

Arthritis and rheumatism_-_

$68,930,000 26, 800, 000 74, 680,000

28, 690,000 7,380,000

The computation of these costs rests on two assumptions and should be regarded as an hypothesis subject to test rather than as a fact:

1. Chronic illness is distributed in Georgia as it is in the coterminous U.S. as

a whole.

2. The cost of illness is the same in Georgia as it is in the coterminous U.S. as a whole.

TABLE I.-Syphilis morbidity by age group, fiscal year 1966

TABLE II.-Estimated prevalence rate per 1,000 of various chronic diseases by

age1

! Age specific rates were taken from National Health Survey data or Cancer Illness Among Residents in Atlanta, Ga., Cancer Morbidity Series 1-1950, Federal Security Agency, Public Health Service. Rates for all ages are the age adjusted rates obtained by applying national age specific rates to the Georgia population, 1964.

TABLE III.-Estimated annual case prevalence of various chronic diseases by age, Georgia, 1964 population

DEAR DR. PETRIE: Thanks for your letter concerning multiphasic health screening programs. It appears that the programs of multiphasic screening are worthwhile based on the percentage of positive findings which otherwise would not be detected.

I believe that this type of screening should be done by all physicians within the next few years in view of the development of multichannel auto-analyzers for chemical determinations. Within the near future, there should be an adequate number of twelve channel auto-analyzers in addition to other multichannel autoanalyzers, which would make it possible for all patients to be screened by multiple chemical examinations at a very low cost. These procedures should be available in the vicinity of the practice of most physicians. It is well known that it is not practical to ship such specimens because of altered results of the chemical components.

I am well aware of the Preventicare Bill and hope that it will not be necessary to embark upon this type of program in view of the fact that this can be done as a part of the private practice of medicine.

I would certainly encourage multiphasic screening by private practitioners in initial and annual examinations of all patients.