But I again want to congratulate you and your subcommittee and staff for the very splendid work that you are doing. I think you will do much to open up fields for helping detect, particularly in the elderly, illness and disease on a mass basis, which obviously will be effective, but at the same time much less expensive than present methods.

I want to again commend you and thank you for what you have done. (The statement referred to follows:)

STATEMENT OF HON. GEORGE A. SMATHERS, A U.S. SENATOR FROM THE STATE OF FLORIDA, CHAIRMAN, SENATE SPECIAL COMMITTEE ON AGING Madame Chairman, I commend the Subcommittee on Health, and its distinguished Chairman, for initiating what I believe to be a profoundly significant inquiry into techniques of health screening in our ever more complex society. As has been pointed out, much has been done by the 89th Congress to provide for the treatment of those who become ill, particularly our senior citizens. But it has been axiomatic in medicine that the prevention of disease is far better than the cure. We should, therefore, be quite concerned with utilizing more modern techniques to screen our population for medical purposes.

Mass screening techniques may very well prove to be the least expensive and most practical way to detect abnormal conditions before they become symptomatic, therefore giving both patient and doctor a better break in the treatment of the disease.

Madame Chairman, I would like to point out that at least one community in my state of Florida has done pioneer work in this area, implementing a screening program through cooperation by local physicians and county and state health departments.

The city of Monticello, in Jefferson County, Florida, established a continuous community screening program in February 1963. The program was established, with the help of area physicians, and has provided a continuous health profile screening of the inhabitants since inception.

As of July 31, 1966, some 60,131 separate tests have been made on 3,818 persons. Of these, 1,406 persons were referred to their doctors as a result of some 1,865 abnormal screening tests.

The program in Jefferson County, Florida, is supported by funds from the Florida State Board of Health and the County Health Department.

A nurse carries out the screening examinations, under supervision of the county health officer. Clerical service is handled by the county health department and laboratory support provided by the State Board of Health in nearby Jacksonville.

This rural community in north Florida has a small, but stable, population of 9,543-with 10 percent of that number over 65 years of age.

About eight percent of the population receives state welfare and more than 50 percent of those over 65 are receiving old age assistance.

Thus, it is apparent that economic levels in the community are low. In my opinion, continued operation of a screening program in this and other pilot communities may give us much valuable information needed for handling the medical problems of our elderly poor.

While the Jefferson County project is but one variant in the methodology of multiple screening, it is indicative of the kind of effort that can be made to make mass screening an effective instrument in creating a healthier society.

Senator NEUBERGER. Thank you.

We have one of our other committee members present here also this morning, Senator Yarborough, of Texas.

The Senate is going into session at 11, and we hope we don't have too many interruptions during this important hearing.

We are indeed fortunate to have as our first witness, Dr. Paul Dudley White, eminent cardiologist from Boston, Mass.

Dr. White?

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STATEMENT OF PAUL DUDLEY WHITE, M.D., CARDIOLOGIST,
BOSTON, MASS.

Dr. WHITE. Madam Chairman and members of the committee; it is a pleasure to be here. I have a statement which I will turn in, some of which I will read; I shall speak also off the cuff. But I would also like to answer questions, if they are such that I can take care of. The process of aging has interested me very much for many years, for three reasons: As a part of my professional work as a practicing cardiologist involved in a long followup of many patients, and this long followup is about to be presented in the form of a book which should and could appear in 2 or 3 months. This book is called "Hearts, Their Long Followup."

During the completion of that book, and through the years in which we have been seeing patients, sometimes for 30, 35, and 40 years and even longer and some of these patients I still see every year-we have learned many lessons which we shall present. I hope that this book may be helpful from the standpoint of aging as well as from that of the special diseases which we discuss in the cardiovascular field.

The second reason for my interest is as a scientific problem; that is, the problem of aging in need of extensive and intensive worldwide research and I emphasize worldwide. The chief diseases of old age are atherosclerosis (a rusting of the arteries), and thromboembolism, a disorder of blood clotting. Epidemiology, the study of these epidemics which have fallen upon mankind, is preeminently needed in all advanced countries.

Atherosclerosis is disease No. 1 in this country today. Epidemiology is a research tool for international use leading to cooperation, medical and lay, throughout the world. In this I have been keenly interested in the last 10 to 15 years. We have established the socalled International Cardiology Foundation, in which in each country there are enlisted-in addition to the doctors, also laymen and industrial experts, and the Government, working together in a three-pronged attack on disease. This cooperative effort is long known here, and has been practiced in the United States, but not in many other parts of the world. We are helping to cultivate it elsewhere. When these national foundations get established, they join the international group, the International Cardiology Foundation, which is more than just a meeting of the doctors. It is they with the laymen and the governments working together.

The third reason for my interest is a personal one, since I have now reached 80 myself. Some of these statements of mine will cover my own experience.

Let me now present pertinent observations derived from these experiences:

First, one doesn't die from old age alone, but always from some complication. When a certain woman died a hundred years ago in the Massachusetts General Hospital at 45, the only diagnosis was "old age." Now we might say old age at 75, but it is not old age alone even at 75. Something else has happened. It is true, however, that the older person is, as a rule, less resistant. The four complications that

are most important are (1) infections, as with pneumonia, once "the old man's friend," no longer quite so friendly because it can be controlled. Perhaps sometimes we shouldn't try so hard to control it. (2) Infarction; that is, destruction of tissue due to clotting of blood in the arteries going to the heart, the brain, the lungs, and the kidneys. That is a common cause of death in old people. (3) Cancer. (4) Accidents. Those are the four common complications.

Now the second point. There has justifiably been much emphasis both on the increasing longevity of the American people during the last generation or two, and also on our natural wish and efforts to promote the health of old people as well as simply their length of life, and not to keep hopeless and helpless invalids alive. But the fact is that with very obvious exceptions, the two-that is, longevity and good health-go together for the chief reason that hopeless invalids are much more likely to die of complications than are relatively healthy old people. But we naturally don't know or realize how many very old people are still healthy; there are a great many but we don't hear so much about them.

A good many old people whom I see are still healthy but are afraid that they are getting sick, simply because they are older. They come and want to know, "Have I got some trouble at last?" When they reach the age of 80, they don't need to worry so much.

The third point is that one can outgrow-and this is probably the most important lesson I have learned, and which we are presenting in this book—one can outgrow one's troubles as one gets older. One can actually get better rather than worse. One can be better at 60 than at 50, better at 70 than at 60. I have had many patients who have outgrown their troubles.

For example, even severe angina pectoris, recurring for months, can completely clear, as can the temporary disability from minor strokes, because of the natural, not manmade, development of a collateral circulation. This is nature's aid.

That is why I gave an address in Memphis, Tenn., in 1932, entitled "Optimism in the Treatment of Heart Disease." And, of course, man, too, can now help with the marvelous new surgical operations and the drugs that can control high blood pressure and infections and prevent thrombosis. This is perfectly true, but we don't realize how many people get better anyway. And then if you happen to do a spectacular operation or give certain drugs, you may give undue credit to those therapeutic measures. But I have nothing against them; they should be developed more.

The next point follows: One can learn to live with one's difficulties. This is for oneself a major accomplishment that we must foster in our patients and in oldsters as well as youngsters throughout the country. Patience, stoicism, and optimism must be cultivated in our American people, who have become soft, and demand, with the submission of the medical profession, tranquilizing and sedative drugs which often do more harm than good. We must stiffen our morale and our spiritual fiber.

It isn't necessary to suffer, but we can often endure more pain than we think we can. It may be good for us once in a while to have some symptoms, rather than to try to avoid all symptoms by drugs all the time.

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The next point is that the old adage about the ounce of prevention is still very true, and rather than spend all our time on the middle-aged and elderly in diagnosis, treatment, both medical and surgical—and I have been fascinated with these instruments that you have hereand rehabilitation; rather than spend all our time on those subjects, which of course we must continue to improve, we must teach our teenagers and young adults health habits which they can use throughout life.

Often I think that we are putting the cart before the horse. We must get this health process started early in life.

The health of old age is, to a large extent, dependent on the health habits of middle age, the health of middle age on the health habits of the young adult, and the health habits of the young adult are related to those of the teenager, which have, I believe, became defective during the last generation.

The health habits of the teenagers--this is where we must begin. We have had many difficult experiences with that problem.

We had a fitness institute for a week once at the YMCA camp in the Berkshires, Camp Becket, in which we met with 20-year-olders, husbands and wives. The husbands had previously been YMCA boys at the camp. We had them come back, a hundred of them, 50 couples in their twenties (we had babysitters to take care of their children) to emphasize the need of their continuing through the twenties the health habits they had learned at the camp as teenagers.

And this is the gap, the twenties. Many of them had changed their way of life, often harmfully.

Now, I shall add my own advice about all this, which has come from long experience, as well as from the research of innumerable medical scientists.

In the first place, annual examinations are, I believe, invaluable at all ages. And at least once in the older teenager or young 20-yearolder there should be, in addition to routine physical, urine and blood examinations, serum cholesterol, and blood sugar tests, such as can be taken on this instrument, and an electrocardiogram and chest X-ray film for the person himself while perfectly healthy, to keep and preserve in his own files for future comparison.

Often a doctor 25 years later wishes that he could see for comparison the old X-ray film and the old electrocardiogram taken in good health in the early twenties.

Once in a while one uncovers abnormalities in these young people. One may discover hypertension or diabetes, which it is very important to know, even though the person may feel perfectly well. I mean, in the young ages. And, of course, the family is very important. I spend much of my time not just treating the fathers and mothers, but getting after the children who may be perfectly healthy at the time, to try to keep them from having what their parents have had. This demands first priority.

My second advice concerns the diet and the weight. Despite all protestations to the contrary, these are most important and should be controlled sensibly from the age of 12, or even before. We are an overnourished Nation, and we should wake up and regard excessive food intake, as serious as it really is, an intoxication with a slow and

insidious harmful effect, not so dramatic as intoxication by alcohol or drugs, but about as serious.

The middle-aged husband today, having been brought up to eat, and told by his mother and father to clean up his plate, having been taught to eat too much of everything, naturally finds it difficult to understand why he shouldn't continue to eat too much, and he is quite likely to resent the advice of his doctor, and particularly of his wife, who has an especially hard time of it.

I am very sympathetic with the wife. We have to do better, though, than we are doing now in getting the husband instructed earlier. His habit is already fixed at 45 or 50. It is difficult to teach an old dog new tricks. Thus, we must get this point over to pediatricians, parents, schoolteachers, and public health personnel who deal with children. Thirdly, for optimal function of an alert brain a really good blood supply is needed, and this means not only avoidance of overnutrition, but also physical fitness in the way of firm and active leg muscles. It is said that if you want to know how flabby your brain is, you should feel your leg muscles. Exercise of the large muscles of the body is essential to positive health-positive health is not just the absence of disease. A walk of 4 miles, or a comparable activity, a day is, I believe, the absolute minimum needed for good health-or 28 miles a week.

You may prefer to swim or to play golf without a cart, or to bicycle. It doesn't matter which. Both physiological and psychological benefits are great. Blood-clot prevention and the delaying of serious arteriosclerosis affecting heart, brain and kidneys are clear results of this essential health habit, which needs to be emphasized far and wide in this era of our slavery to machines of all kinds. I do not mean these diagnostic machines here; these are different, but machines such as automobiles, and push button devices of all kinds, and elevators.

This advice is very important: During active use of the legs, their muscles act as pumps and carry out about 30 percent of the circulation of the blood, relieving the heart of that much, 30 percent, as experiments have recently proved. During leg exercise, their big muscles squeeze the veins. Since the veins have valves, the blood is pumped up toward the heart. The valves have been known for nearly 400 years. In fact, William Harvey announced in 1628 his discovery of the circulation of blood through his knowledge of the function of the valves in the veins.

Then comes the fourth point-and I am almost through-the avoidance of smoking and of the use of other toxic substances such as opiates and LSD-I don't classify them all quite the same-and also of excessive alcohol. All of these are to be included in our list of health habits; and now even excessive coffee and tea drinking is beginning to be realized as causing stress. And if you have too much stress, you aren't so healthy. Excessive coffee and tea drinking is excessively stimulating to some people. We are just beginning to work on that. Finally, excessive emotional stress is to be avoided, but minor stresses are not important. Fatiguing physical exercise and tranquilizing programs are important antidotes. Tranquilizing programs are of many sorts, in art and music and literature, and even in one's work.

One definition of stress is as follows: Stress is life, and you had better enjoy it. You can't live without at least some stress.