Senator NEUBERGER. The next witness is Dr. Henry Packer. Dr. Packer is the director of chronic disease screening of the Memphis-Shelby County Health Department screening program. I believe you are also chairman of the Department of Preventive Medicine. at the College of Medicine, University of Tennessee.

Dr. PACKER. That is correct, Madam Chairman.
Senator NEUBERGER. All right, Dr. Packer.

STATEMENT OF HENRY PACKER, M.D., DIRECTOR OF CHRONIC
DISEASE SCREENING, MEMPHIS-SHELBY COUNTY HEALTH DE-
PARTMENT SCREENING PROGRAM, MEMPHIS, TENN.

Dr. PACKER. I am afraid I am at somewhat of a disadvantage in being so late on the program. The other speakers have stolen all of my thunder.

Senator NEUBERGER. Well, there is beginning to be some repetition, but you would be surprised at the variance. But we like it to come regionally, too. It all adds to the record.

Dr. PACKER. I have prepared a brief statement of our program in Memphis, and with your permission, I would like to go over it and elaborate on it a little bit.

Senator NEUBERGER. Fine.

Dr. PACKER. And then answer any questions about aspects that you have some question about.

Senator NEUBERGER. All right.

Dr. PACKER. Screening for chronic diseases of one kind or another has been carried out in Memphis for over 25 years. During the early years, the main emphasis was upon infectious chronic diseases, such as syphilis and tuberculosis. In recent years, the emphasis has changed to detection of noninfectious chronic diseases, such as cervical cancer, diabetes, and glaucoma.

At the present time, tests for these five diseases are provided by a chronic disease detection unit based in the city of Memphis hospitals, which is the teaching hospital of the University of Tennessee College of Medicine. This unit works in close cooperation with the local health department, each supplementing the other in reaching as many groups in the community as possible.

Our screening program in Memphis has developed in a step-by-step manner, rather than by launching a broad program at a single point in time. We have been opportunists in initiating various aspects of our detection program, taking advantage of favorable circumstances as they presented themselves from time to time.

Our program first began before World War II with mass blood testing for spyhilis, when this procedure was considered an effective case-finding method in the control of this disease. The health department and the city hospital collaborated in a community-wide blood-testing program, using both mobile units and stationary clinics to reach as many people as possible.

I might say that this program served as a pattern for later programs in relation to other chronic diseases.

A few years later, the local Tuberculosis Society began to promote mass screening for tuberculosis by means of chest X-rays and provided mobile units for this purpose, and also a stationary unit for the city hospital. The chest X-ray was added to the blood test for syphilis in our screening program at that time. Last year our hospital X-ray unit screened about 40,000 persons and picked up over 80 cases of new active tuberculosis which were previously unknown.

In 1952 Memphis became the site of the Nation's largest communitywide screening program for cervical cancer, using the Pap smear. This was a cooperative project between the University of Tennessee and the National Cancer Institute to evaluate this method of detecting cervical cancer. Since the beginning of this project, about 75 percent of the women in Memphis and Shelby County have had one or more Pap smears. The rate of cervical cancer has been reduced by almost 50 percent since this project started. This test is routinely used in our screening program now.

In 1955 the Public Health Service loaned us an instrument known as a Hewson Clinitron for automated testing of blood specimens for diabetes. This enabled us to add diabetes to the list of diseases for which we carried out screening. About 2 years ago the local health

department purchased an AutoAnalyzer for doing automated testing for diabetes, and this replaced the Clinitron.

Our hospital screening program is served by this equipment, which is stationed in the health department laboratory. Last year 17,695 persons in the community were tested for diabetes by this instrument, and 361 new diabetics were discovered. This represents over 2 percent of those tested.

In 1956, about 10 years ago, we added screening for glaucoma to our chronic disease screening program. We were impelled to do this because of the increasing number of partially blind persons who were coming to the eye clinic of our hospital. Little could be done for these people in this stage of the disease. We knew that blindness could have been prevented if this condition had been discovered early, and that there was a simple test, using a tonometer, for doing this.

We began to use this test in our screening program, after getting some financial assistance from the National Society for the Prevention of Blindness to do a pilot study. This pilot study proved beyond doubt the value of this procedure.

In our program, this testing was first done by nurses who had been trained in this procedure by eye specialists in our clinic. More recently, due to the shortage of nurses, we have been training technical assistants to do this procedure. They are doing an excellent job, and this is in line with the philosophy of using paramedical personnel whenever possible in screening programs, in order to reduce costs and save the time of physicians.

During the past 10 years, we have screened over 40,000 persons for glaucoma, and have discovered over 800 persons who had this disease and were not aware of it. We feel that this should have an impact upon reducing disabling blindness from this disease in this community. Not only this, but by having a glaucoma detection program based in our teaching hospital, our medical students, interns and residents have become familiar with this procedure, and we hope they will use it in their practice later on.

I would like to digress at this point, with reference to the matter of acceptance by physicians. I think one reason physicians do not accept, or are reluctant to accept, some of the newer screening procedures, is because they were not taught these things in medical school. I think it is important that we do teach our medical students, who are going through school today, how to interpret these tests and their value. This is what we are doing in our program. It is an advantage, I think, to base a chronic disease screening program in a teaching hospital, for this reason.

We have also used our glaucoma detection program for research purposes. We had a 3-year contract with the Public Health Service to evaluate the use of various screening levels in glaucoma detection programs. One of the decisions which has to be made in any screening program is what screening level to use in referring patients for further evaluation.

This has reference, Senator, to your question about overreferral, and I hope this may explain a little bit about that. It is a very complex situation, which even physicians often do not fully understand.

In glaucoma screening, for example, there is no sharp dividing line between normal and abnormal values of eye pressure, yet a single

screening level must be chosen. This means that if too low a level is chosen, there will be many false positives, that is, many persons will be referred for costly and time-consuming examinations, only to be told that nothing is the matter with them, and this always arouses a great deal of resentment.

I have known patients to get very angry when told that nothing was the matter with them after a positive screening test caused them to incur the expense of a thorough examination. Also, physicians often lose confidence in a screening procedure when they find many false positives.

In other words, many patients are referred to them for evaluation, and after a thorough examination they are forced to tell some patients there is nothing the matter with them, that they do not have the disease even though the screening test was positive. This often causes them to question the value of the procedure.

On the other hand, if the screening level is set too high, many persons who have the disease will be missed. These problems are inherent in all screening programs, and must be understood by both the public and the physician, if such programs are to meet with acceptance. I think this is one of the major reasons why physicians sometimes are critical of these programs. This is because so often patients are referred to them with borderline values, by screening programs.

In clinical medicine usually the levels are pretty definitely normal or abnormal, but in screening programs many borderline values are referred to the physician, and oftentimes he has difficulty in interpreting them. This is a fundamental difference between screening and clinical diagnosis, as seen by the physician.

The part of our screening program which is based in the city hospital serves a number of groups at the present time. These groups are as follows:

1. Patients admitted to the outpatient department, who routinely receive screening tests. About 40,000 persons are admitted each year to our outpatient department. We are trying to provide as many as possible of these people with these screening tests. 2. Applicants for city government employment, who receive these tests as part of their preemployment examination.

3. Food handlers, who are required by law to have tests for syphilis and tuberculosis in our State. We also include tests for cancer, diabetes, and glaucoma, and we issue a "health card" with the five diseases listed and the dates they received the test. People son become familiar with this report and they call it a "health card." They carry it around in their wallet, and it gives them something tangible to show that they have had these tests, and when they need to have them done again.

4. Employees of the city of Memphis hospitals, who are given screening tests annually as part of an employee health program. In conclusion, I would like to say that while we believe that multiphasic screening programs such as ours have uncovered a great deal of disease in the early stages, and that such programs have great potential for reducing disability and the costs of medical care, the latter does not automatically result from such a program.

Detection of chronic disease is not an end in itself, but should be part of a total plan. There must be a followthrough, as other speakers