essential to promote the programs. Two community health workers persuade area residents of the advantages of a health screening examination and organize the neighborhood for optimum scheduling of appointments.

(4) It is essential to reiterate, to the public and to medical practitioners, that this program provides screening only and does not substitute for a complete medical examination. There is little question in my mind that the best place for these screening tests to be carried out is the office of the family physician; however, it seems unlikely that this procedure will take place, at least for a high percentage of our citizens.

The obvious question then arises as to whether there exists in many communities the health manpower readily available to meet this increased demand. This question is not easy to answer, but I am sure you will find that there are many in the health field who do not believe that an adequate supply of manpower currently exists for this purpose and who would furthermore state that the number that do exist might preferably devote their time to handling the acute medical problems that need immediate treatment.

(5) Safe and efficient operation of the program depends on adequate trained personnel and detailed planning for staff shortages since any absence of community health workers, screening technicians, clerks, or follow-up staff severely hampers the daily operation.

(6) It is essential to provide periodic evaluation of the types of tests done and the criteria for referral in order to avoid needless and non-productive overreferral for diagnosis.

(7) Screening tests employed should be simple, rapid, acceptable to the screenee, relatively inexpensive, and should yield results readily categorized as referrable or non-referrable. In this respect, automation wherever possible is a boon.

(8) Periodic evaluation of data collection and tabulations, and also policies and procedures is necessary to insure valid and meaningful statistics.

(9) Even though the yield in numbers of cases found is greater in older age groups, our data indicate that there is a significant amount of chronic disease detected in the fourth and fifth decades to warrant their inclusion in screening programs. However, we will obtain additional information on this subject when we begin to collect prevalence data. In addition, we need to know, by detailed prospective studies, the long-range benefit to individuals in whom certain chronic diseases are detected at an early age.

The problem still remains of the lower income persons referred for further evaluation, who are not eligible for public services but who cannot finance private care. These persons, though perhaps few in number, require hard work on the part of our follow-up staff to insure that diagnostic and care services are received.

A third, similar multiphasic screening program is being planned for the outpatient department at D.C. General Hospital, to provide on an annual basis a battery of screening tests for those patients cared for in various clinics. Such a program will be closely coordinated with the two existing ones to avoid duplication of effort and to provide comparable data.

Since our program began, we have been able to automate at least one procedure with the acquisition of an autoanalyzer. Blood sugars are now done more efficiently than with the former equipment. With the arrival of additional attachments for the autoanalyzer, we will be able to automate the hemoglobin determination and possibly add additional tests not now done, such as cholesterol, blood urea-nitrogen for renal disease and cytological smear for cervical cancer. Furthermore, we are exploring the possibility of automating the interpretation of the electrocardiogram and possibly of spirometry testing for breathing capacity, by a cooperative arrangement with the Instrumentation Field Station, Public Health Service, to utilize their computers for rapid automatic interpretation and reporting.

Finally, we are conducting one methodological research project into the feasibility of using the self-administered, irrigation type cervical smear for the detection of cancer and a second project is evaluating the use of a simple urine test to detect infection which may be indicative of chronic kidney disease.

As a result of our experience with multiphasic screening, we feel that such a program is successful in detecting previously unknown diseases at an early enough stage so that future disability may be prevented, as well as in finding persons who need to return to medical supervision for previously unknown conditions. The program has been well received by the public and the health professions.

It is my belief that the multiphasic screening program, including the educational and follow-up components, is an essential part of a comprehensive community health program. It should be readily available, along with other adult health services in the community where people live and work.

Senator NEUBERGER. The next witness is Dr. Forrest Brown. Dr. Brown is the chief of the Community Health Service of the Oklahoma Department of Health, in Oklahoma City, Okla.

We are glad to have your testimony. I have looked at your statement and look forward to hearing your comments.

STATEMENT OF FORREST BROWN, M.D., CHIEF, COMMUNITY HEALTH SERVICE, OKLAHOMA DEPARTMENT OF HEALTH, OKLAHOMA CITY, OKLA.

Dr. BROWN. Madam Chairman, I appreciate the opportunity to do this. And since we do have our formal statement, I, too, would like to talk extemporaneously.

I have enjoyed hearing the speakers before and seeing the direction in which your interest has grown in the problems as you see them in this area.

We are perhaps fortunate in Oklahoma-this is a mobile unit operation of a multiphasic screening program-in that with an existing tuberculosis survey program, in which Oklahoma was a pioneer, each and every county had had chest X-ray surveys for tuberculosis.

At that time we began to look at our returns on this and the cost of discovering the cases of tuberculosis seemed rather exorbitant by this method. Easily grafted onto this were other screening programs, which could be done.

Therefore, we had an advantage, speaking from the public health standpoint, on the question of the acceptance of other screening programs by the private practicing physicians. Since this was a program grafted onto the one which had been long accepted by them, it is true, perhaps, the only reason being that tuberculosis was a contagious disease and, therefore, had been accepted for a long time as being a public health problem.

It has been our policy from the beginning to try to face these known problems of acceptance by the public and by the physicians and to try to devise these screening programs in such a way as to get involvement of the public and the physicians.

Our procedure that has been developed with experience over a time requires that we must have some organization, a voluntary organization, in each community that is willing to take care of appointmentmaking and publicity relevant to the program. In order to assure followup in this program we must also have an invitation from the local health department.

And I think Dr. Grant made a very important point here. There is no use of doing screening unless you are going to insure that these people are going to get care afterward. An invitation from the medical society in the county in which the program is to operate is also a required essential.

Now I think this is a most important phase of the program, and the adaptation of screening levels and so forth is talked over with the physicians, this is an opportunity to call to their attention what the

program is and how it will operate. There is the old adage "seeing is believing." But once these problems have been discussed we get rather reluctant acceptance in some instances-we have not run into an instance where once a physician has had an experience with a screening program and its referral system, he has any reservations afterward. And in many instances they have been high in their praise. Because of limited resources we have primarily used screening as a health education tool. One of the most important educational aspects, we think, is the more or less-I don't like to use the word "forcing" of the individual to be screened to choose a physician who will care for him if there is anything found that needs care.

We think this reflects in education to that individual who is not found to have anything, in that we made him go through the process of choosing. And it is surprising, particularly in some of our rural communities in Oklahoma, that we will run as high as 50 percent of the people who cannot offhand tell you who their family physician is. They can be rather quickly taken through a series of questions which will cause them to choose one.

One of the most important things that we can think of to keep a screening program going and to have acceptance is to tailor make it to the particular community in which you are operating. By this I mean the general educational level, both of the general public to be screened and the physicians in the community. We think that one of the most deadly things that can happen to a screening program, that will almost surely kill it, is to have overreferral. In other words, people referred to physicians for suspected conditions, which upon the examinations performed by that physician leads him to the opinion that they do not have that disease.

Senator NEUBERGER. Say that again.

Dr. BROWN. Maybe I can make this statement a little bit clearer by making this reference by definition of diagnosis. A diagnosis is an opinion arrived at by a physician upon the basis of the evidence that he has at hand, a little evidence or a lot of evidence, good or bad evidence.

So this is what results in diagnosis. This is what happens when the screenee is referred to the physician. He either receives a diagnosis of the disease or a negative diagnosis of absence of disease.

There are two factors involved. One is the sensitivity or the accuracy of your testing procedures, and the other is the diagnostic ability of the physician to whom they are referred.

Senator NEUBERGER. His interpretations of the results.

Dr. BROWN. Right.

Senator NEUBERGER. Well, they cannot be so

Dr. BROWN. Well, it goes a little further, Madam Chairman, than just the interpretation of the results. This is said in the sense that there is no such thing as a diagnostic test. This can be universally agreed upon. But it does fit into what I have given as the definition of a diagnosis.

I realize I am getting rather involved here.

Senator NEUBERGER. I am not quite clear on the overreferral.

Dr. BROWN. Overreferral: If a particular procedure is used as screening for diabetes, and you refer all who have a blood level, positive 100 milligram percent of sugar in their blood, and in this partic

ular community the physicians these people are going to are not getting diagnosed unless they have a level of 120 or 160; if you refer at levels of 110, they do not get diagnosed for diabetes.

Now, your technical and your human error element also, you need to protect in this.

In a case of diabetes, again, that is referred, it will not be uncommon for a physician who really does a good workup on the patient to have a bill of $80 to $110 for diagnosing the absence of diabetes, while if it is a clear-cut case of diabetes he may make the diagnosis of diabetes for much less than that.

Senator NEUBERGER. Is it valuable though if the blood sugar doesn't reach that line; 120 or whatever you said? It is valuable to know what the blood count is anyhow?

Dr. BROWN. Oh, yes. In the medical sense it is.

Senator NEUBERGER. Well, what is the point you are making? That the patient may be alarmed that he has potential diabetes? I still am not clear on the point you are making.

Dr. BROWN. My point is this, Madam Chairman: There are communities in which-and we have had this happen-the patient has accused both the physician to whom they were referred and the State health department as being in collusion, by trying to make the doctor "business."

Senator NEUBERGER. But how does the patient come to the screening thing first? It was through his own volition? He wasn't referred. Dr. BROWN. Right.

Senator NEUBERGER. This patient didn't want to know? Is that it? That he had potential diabetes?

Dr. BROWN. I don't know what the motivation behind it was. The instances that we have had to this-all you know is what you are accused of, but the accusation came to the physician to whom they were referred.

Senator NEUBERGER. But now, that isn't very general, is it? Isn't that some kind of a neurotic sort of person?

Dr. BROWN. This is an unusual sort of person.

Senator NEUBERGER. That is like when the doctor tells you you have appendicitis, pulling out a gun and shooting the doctor. It seems to me that it will be a rare person who had of his own volition climbed the steps and went into the unit, who didn't then want to discuss it with the doctor. Of course, if he were that neurotic, that he didn't want to know about some terrible disease he had, he wouldn't want to go in there in the first place. He wouldn't even want to go near the place, because he might find out.

Dr. BROWN. I don't know whether I have made this at all clear to you. These patients did not have the disease for which they were referred.

Senator NEUBERGER. I would rather pay $5 to find I didn't have something than $105 to find out I did, it seems to me.

Dr. BROWN. Most people do feel this way about it, but you do have those who do not.

Senator NEUBERGER. But you go to the dentist, you pay for an examination, and you are so thankful when you don't have a cavity. You take your car to the garage, and it comes out that it doesn't need to be repaired. I still think that is a quirk.

But what we obviously need here is some education going on, on how to follow this. All right, you many continue.

Dr. BROWN. Along this same line, just to relate some experiences— and again the explanation of all of these; I do not have all the answers by any means-the question of overweight, which from the medical standpoint is a real important factor in many diseases. We started out with a policy of referring individuals only when they were 20 percent overweight, according to average weight and height tables for the age. And this, as related this morning, is the highest percentagewise of the abnormalities found.

After doing this for a while and after talking with the physician to whom they have been referred, we quit referring the patient on the basis of overweight only, if this was the only abnormal finding that we

had.

It was simply reported to his physician.

Our procedure is to report the findings to the physician, and merely to notify the patient that he needs to contact his physician relative to some positive finding. This does not state even what it is.

But most physicians have had so little success in the situation of the person who is only overweight, to persuade them to go through a weight-reducing regime, that they consider this almost impossible. In practically every instance the physician said, "The patient already knew it; I already knew it; and we have talked this over many times, but apparently it does no good."

And so an office call would not be particularly indicated. I will just call her up and remind her of it over again, that she is overweight, or he, as the case may

be.

I believe, other than that, Madam Chairman, I might be able to answer some specific questions.

Senator NEUBERGER. Well, you have given me a very interesting picture of your own experience, and all of this is very valuable to us in adding to regional reports in this area.

I believe it was Dr. Collen who said that in the obesity thing you just discussed, 12 percent of the men tested and 20 percent of the women are involved. This startled me and I didn't question about it at the time, because we think the women because of vanity and fashion are worrying about it. But you were talking about not just being plump, but being obese.

Dr. BROWN. Right.

Senator NEUBERGER. Then do you advise this obese person of the effect on her health?

Dr. BROWN. Oh, yes. We try to, during the entire stay of the individual in the trailer from the time they walk in the door, to educate them relative to this. An obese woman going through the trailer, when she gets to the diabetes station, is going to be specifically talked to about the possibilities of overweight predisposing to diabetes. When she goes by the heart station, it is going to be called to her attention again. It is going to be called forcibly to her attention several times.

Senator NEUBERGER. And yet she has come voluntarily to this unit, hasn't she?

Dr. BROWN. Yes.