But how can other communities enjoy similar centers? Dr. Collen, who has been with the Permanente project from its infancy, has cost figures indicating that a population of 200,000 or more people can support a commercially operated automated laboratory, if physicians would use it. Several widely spread communities, in fact, might share a central computer through telephone wires connecting it to small centers where the actual examinations would be conducted. Meanwhile, such centers may be forced into existence by rugged demands that Medicare will soon press on doctors and hospitals. For them, automated laboratories can save time and energy by taking over routine physicals, but most important, automation's widespread possibilities for preventive medicine can mean that fewer people will suffer the diseases that are now the heaviest burdens for physicians and their facilities.

With all this in mind, Senator Harrison A. Williams of New Jersey and Congressman Fogarty recently introduced Federal legislation to foster establishment of community health examination centers for people over 50. Nicknamed "Preventicare," the legislation would provide grants to medical schools, community hospitals and other nonprofit agencies to help them establish and operate such centers. The legislation was written after careful study of the Kaiser Foundation and the Permanente Center.

The U.S. Surgeon General Dr. William H. Stewart, who would distribute Preventicare funds, believes such a program is essential to the Nation's health. "Many lives can be prolonged," he stated recently, "and many disabilities prevented, postponed or minimized, through early detection and prompt treatment of many chronic diseases. Projects which apply the great potential of automation to health maintenance are especially promising. We in the Public Health Service are keenly interested in helping to make the best in preventive services available to people across the nation."

When I saw my doctor to discuss the final results of my automated examination, the session required less than a quarter of an hour. He had already read the summarized medical data condensed by the computer to a letter-sized sheet of paper. One of the blood tests left a question in the doctor's mind, so he had a sample of blood drawn from my arm and sent to a local laboratory for double checking. When the results came back he phoned to say I had a clean bill of health.

During my visit I reminded the doctor of my last abortive checkup conducted close to midnight. If automated health care could prevent such sessions, agreed the physician, he was all for being replaced-in that role-by a computer.

Senator NEUBERGER. I will now call on Dr. Murray Grant, who is Director of Public Health for the District of Columbia Department of Public Health, and who some of us have met on the mobile unit. Dr. Grant, we welcome you.

STATEMENT OF MURRAY GRANT, M.D., D.P.H., DIRECTOR OF PUBLIC HEALTH, DISTRICT OF COLUMBIA DEPARTMENT OF PUBLIC HEALTH, WASHINGTON, D.C.

Dr. GRANT. Thank you, Madam Chairman.

I would like to say that I am very pleased to be here to speak on a subject that is of some interest to us in the field of public health. In fact, I would say very considerable interest, Madam Chairman.

I have already submitted a written statement, but what I would like to do this morning, if I may, is to speak extemporaneously about this subject, and perhaps, if I may, tell you a little about a program that we started in a county adjoining Washington, because of the fact that this county has both urban and rural portions, and because I think that it may be of interest to you to know how this disease prevention program can be carried out in rural areas as well as in urban

areas.

And then after that I would like to speak a little bit about our program in the District of Columbia and some of the results of this program as we visualize it thus far.

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Senator NEUBERGER. Please proceed.

Dr. GRANT. In 1959, when I was health officer of Prince Georges County, Md., we approached the medical society to see if they would have an interest in supporting us in the development of a diabetesdetection program.

They did support us. And shortly afterward we contacted some of the ophthalmologists in the county to see if we could secure their support in relationship to the development of a glaucoma-detection program. And again, they were very supportive of this program and helped us considerably.

We took a person who had previously been employed as a sanitarian. We gave him some special training in glaucoma detection and in blood testing. And we began a program just as simply as that, Madam Chairman, with this one individual, assisted by a member of our health education staff.

Prince Georges County, I should tell you, had a population of some 400,000 back in those days, consisting, as I have indicated, of both urban, semiurban, and rural portions, and it was our intent to try to develop this program for the county as a whole, for people primarily over the age of 40 who wished to take advantage of this program of their own volition.

We preceded the program with a substantial educational drive. We enlisted the support of the Lions Club in the case of the glaucoma program, and of local church groups and other groups in connection with the diabetes program. We stationed this individual that I have referred to in shopping centers, in churches, in just about any kind of facility we could locate throughout the county. We preceded his arrival there by about 2 months of education in an effort to insure that the people at large in the area knew of his arrival and would be willing to participate, and we then scheduled the program.

And I would say, Madam Chairman, that this program was a very successful one, and I think I would like to cite one figure that I have never quite forgotten, because in all of my experience in the field of public health I have never known a program to be as successfully accepted as the glaucoma-detection program.

In a period of 2 months we made 750 appointments for people over the age of 40 who wished to avail themselves of this program. And in that period 749 of those people turned up for the appointment, and the 1 person that didn't was a lady who called us to tell us why she couldn't. I have never had an experience similar to that anywhere since I have been in the field of public health.

So this program, then, I mentioned specifically because of the fact that it was started in a very small way, using really one individual that we especially trained for this purpose. And because I think it was really a successful program, carried out in a population I should say that is relatively wealthy, Prince Georges County, one of the wealthiest counties of Maryland, and a program that was carried out with support of the medical profession and carried out in both rural and urban areas.

I assume, Madam Chairman, that you have already heard testimony relating to the problems of chronic disease, its extent and its cost; and because of this assumption on my part, I don't propose to speak to this point.

I therefore propose to move into the District of Columbia program, which was started in April of 1963, utilizing a large mobile trailer that we acquired on loan from the U.S. Public Health Service.

We equipped this trailer with a staff that we acquired as a result of some Federal funds we had in another program that I diverted to this program and, as I indicated, we began the program in April of 1963. At that time the total funds that we had available were some $70,000. And it was with this that we began to employ some staff and began the program.

If I had one concern at that time, my major worry was that people would not accept it. We have had long, hard experience, Madam Chairman, in running programs in the field of public health that we felt were needed and desired, only to find that people weren't motivated to take advantage of them, particularly people in the lower socioeconomic groups. And this was where we were planning this unit, at least in its initial phases.

So that we launched this program with a rather carefully developed educational program. We employed at that time two individuals, community health workers. We launched them into the neighborhood. We worked with churches and with civic groups in the area to stimulate the populace in the area to the desirability of taking advantage of the program.

In this effort I may say we were very substantially assisted by the news media, and I must say, Madam Chairman, that they have been tremendously helpful in helping us inform the populace at large of the desirability of this type of program.

I needn't have worried, however, because, as it turned out, within a very short time the unit was oversubscribed.

We had first planned to place the unit in a location and let anyone that wished come in and go through it. It came very rapidly to pass that we couldn't continue this program in this manner, because we had long waiting lines, and so we began to set up the program on an appointment basis. And very rapidly the appointments were scheduled about a month or so in advance.

We saw approximately 40 persons per day at the unit and we still see about 40 persons per day, on an appointment basis, and we are as a rule scheduled approximately a month in advance. We stationed a unit at this location and retained it there at, the first location, as I recollect, for about 3 months. Then we moved it to another location, and we subsequently moved it, of course, several times in the approximately 32 years in which it has been in operation.

We have seen during that 31⁄2 years at our mobile health center program, a program which, I believe, Madam Chairman, you had an opportunity to see for yourself-we have seen some 30,000 people go through this unit in the 32 years in which it has been in operation. About 18 months ago, we established a second program, at what we call our Southwest Health Center. This is not a mobile unit. This is a stationary health center located not too far from the Capitol, where we located an additional program using some funds emanating from the MAA or Kerr-Mills program. And this program, too, Madam Chairman, has been very successful. It is seeing about 10,000 persons a year.

This program is open to any person in the District of Columbia over the age of 40, and we have had a very great deal of success in enlisting the assistance of news media again in developing this program. And as I say, we have again found ourselves in a situation where we are making appointments 3 to 4 weeks in advance.

In connection with this program at the Southwest Health Center, I should make the point that we are also transporting certain persons to that unit, persons that we feel would have some difficulty in getting there themselves. I refer specifically to persons, old age individuals, in public housing projects and in nursing homes. We are arranging for their transportation to this unit in order for them to take advantage of the program.

But the vast majority of individuals who come to that center come under their own steam.

In terms of the results of the program, I can briefly indicate that some 75 percent of the individuals who have gone through the program, we have found, have one or more finding. As you know, Madam Chairman, the kinds of screening we carried out in this program take approximately a half an hour for each person to go through. It includes height and weight measurements, visual screening, testing for glaucoma, blood testing for diabetes, syphilis, and anemia and an electrocardiographic reading for a possible heart condition, a physical inspection by a physician who staffs the unit and a blood pressure examination and a chest X-ray for possible lesions of the chest, including cancer, tuberculosis, and so on.

We have found, then, that some 75 percent of the individuals who have come through have some kind of problem.

However, of this number we find a considerable number of these individuals, actually about 20 percent of this 75 percent number, previously have been under care and currently are under care for their problem. And so, Madam Chairman, I would say that of the total number of individuals that have come to the unit, 54 percent have actually been referred to a physician for care. This 54 percent includes those persons who have defects that were found anew; in other words, the individual didn't know he had any problem whatsoever, and it also includes the individuals who knew they had a problem, were previously under the care of a physician, but lapsed from such care. We think that both of these referrals are of value.

We found that approximately 90 percent of the individuals that we have referred in the District of Columbia find their way into the offices of private physicians for continuing care, and we have found during a 6-month followup of these individuals that some 86 percent follow through to see the physician and are under care by that time.

This then very briefly explains the program, Madam Chairman; in terms of its costs, I should indicate to you that it is costing us approximately $12 a person to go through the total screening examination, and this includes the health education program that precedes it and the followup program that succeeds it. I shall add, too, Madam Chairman, that to my way of thinking, these two programs-these two aspects of the program are perhaps among the most important. Getting the patient to the unit, in other words, the health education program, to sell the people on the idea of going there; and most important, the followup.

There is no point whatsoever, of course, in developing a screening program of any kind unless you follow these individuals up and try to insure that they receive care. We are devoting approximately 25 percent of our total budget to this latter part of the program.

I think, Madam Chairman, that this perhaps might explain enough about the program to permit you to ask questions, to which I will be glad to try to respond if I can.

Senator NEUBERGER. Now, yours differs from some of the other screening that you have heard about in that it does not require a referral by a physician.

Dr. GRANT. No, it does not require a referral by a physician. That is correct, Madam Chairman.

Senator NEUBERGER. Therefore, would most of your participants come because they want to find out, or because they have a pain, or what would be your estimate of why they come?

Curiosity?

Dr. GRANT. Well, I think there are many reasons, Madam Chairman. I want to make this point before I respond to your specific question. Most of us in the public health field have felt for a long time that these kinds of detection programs that I have mentioned to you belong in the offices of private physicians. We think that if private physicians could do this, and if patients would go, this would be an ideal arrangement to have these programs carried out in their offices.

Be this as it may, and in spite of the fact that we in the field of public health have been endeavoring for many years to sell people on this idea, from a practical point of view we recognize the fact that this is not going to happen except in a certain number of people. It is not going to happen for a number of reasons.

One is the fact that people are not motivated, and the second reason is because it costs money, and sometimes it costs a great deal of money. So it is because of these reasons that we have moved ahead to develop these kinds of publicly organized and publicly financed disease detection programs along the lines that we have developed in the District. In response to your specific question, in terms of why people go to the unit, obviously there are many reasons. One of them is that a neighbor went. They heard the neighbor went through. It took her only a half an hour. She went through a battery of tests. It didn't cost anything. And "why shouldn't we go and get the same kind of service?"

We have tried to motivate these people by having our workers go out into the field. We have had pastors speak from the pulpit. We have had all kinds of educational material available, so that people could be motivated to want to take this kind of service, which is free to them, in view of the fact that it doesn't cost them anything out of their own pocket.

Some of them obviously have a pain or ache that they worry about, and come to the unit to find out what it is all about. Some of them have been referred specifically by physicians for this service.

So there are many reasons, Madam Chairman. The extent of these reasons in terms of the percentage, for one reason or another—I don't know the answer to this question at all-but I am sure there are many reasons, including some of the ones I have mentioned.