In the United States the cost of illness, disability, and death is now about $93.5 billion annually. That sum, the latest available estimate from HEW, includes the probable losses in income related to death or disability.

If we were to do absolutely nothing about reducing the incidence of chronic disease within the next 10 years, our total for the direct costs of death and disability would almost double by 1975.

We have passed Medicare and medicaid. One program rescues the elderly from calamitous costs of some health care after 65. The other assures some treatment to those most in need of it.

You know, we have provided for a heart, stroke, and cancer treatment coordination program.

President Johnson has promised that early next year he will offer new ideas for better delivery of health treatment. He has also appointed a commission to study medical manpower shortages.

But when do we turn the corner from treatment to prevention? When will we maintain health as devotedly as we now fight disease? When will we make the most of our medical manpower by reducing the time spent in taking routine tests and histories?

What we are here to explore is, can we adapt, our computer and automation technology to screen millions of Americans every year and thus finally encourage an entire Nation to think in terms of preventing illness?

I will move at this point to include those letters and supporting material in our hearing record, if there is no objection.

I will also say that the authors of many of the letters responded with an enthusiasm which is most encouraging. (See Appendixes.)

We are very sorry that Congressman John Fogarty will not be present to testify. The press of business in the House of Representatives requires his presence there. He has however, submitted a statement which will be included in the record at this point.

(The statement referred to follows:)

STATEMENT OF HON. JOHN E. FOGARTY, A MEMBER OF CONGRESS FROM THE STATE OF RHODE ISLAND

Madam Chairman and members of the Subcommittee on Health of the Elderly: during the next few days, you will hear much about preventive medicine, about early detection of chronic diseases, and about the "new look" in health testing with electronics and automation.

What you hear may not sound as dramatic as the story of some new "miracle cure." A relatively simple pressure test on the eye, a blood test, an X-ray or cell smear may sound routine and unexciting. But, when these are combined with other procedures of preventive medicine we create great power to delay, minimize or prevent the crippling, the blinding or even the fatal consequences of many chronic diseases. Add all this to the fact that the chronic diseases are fast emerging as the greatest health threat confronting the Nation today, and we begin to see how truly enormous and far-reaching are the implications of the health protection story.

Each year I listen to the testimony of the Public Health Service with respect to the appropriations needed to strengthen our attack on the chronic diseases. Each year I become increasingly concerned with the seriousness of the problem and with its continued growth. We simply are not moving fast enough even to stand still against the insistent menace of cancer, heart disease, arthritis, diabetes and a whole host of their fellows. We have yet to turn the tide of chronic diseases, and we cannot do it by merely reacting to these conditions after they have hit full stride. The key is to catch them before they start or when they are just appearing.

As long ago as 1947 four major professional organizations issued this joint statement: "The basic approach to chronic disease must be preventive. Otherwise the problems created by chronic diseases will grow larger with time, and the hope of any substantial decline in their incidence and severity will be postponed for years."

In the 20 years since this declaration many others with similar conclusions have followed. But our progress toward broad application of preventive medicine has been halting and painfully slow. We have in fact had more endorsements of the concept than action to back it up.

Furthermore, we are told and it is true that we don't have enough trained manpower to meet the immediate demands for treatment of those already sick and in distress. We are told that we don't yet know enough about the chronic diseases to deal with them effectively. We don't have to be told of the depth of public resignation and apathy to the chronic diseases.

So many people have for so long accepted arthritis or heart diseases or other serious chronic ailments as just as much a part of growing old as baldness or bifocals.

Certainly, our knowledge is incomplete. We have to give the research scientist time and full support to find more answers. We have to care for those already sick-we have to deal with apathy and resignation. But we also have to break a vicious chain. We have to stop the upward climb of the chronic diseases in order to catch up with the burden of sickness and disability we already bear. And we are not helpless in this effort. We have vast, untapped potential as well as considerable knowledge of chronic disease.

We already know, for example, how to prevent thousands of deaths from cervical cancer; we can stop many of the personal and social evils caused by unnecessary blindness or sight impairment caused by glaucoma; we do not have to permit the hopeless invalidism we now accept in thousands of survivors of stroke or heart attack.

But with mounting demands for treatment from the already sick and with proportionately fewer professionals to provide the care, how do we meet the problem?

Endorsements, slogans and exhortations alone will not succeed. We learned this long ago in providing better care for the young. With our children we are not content merely to preach the values of preventive medicine. Neither are we willing to accept excuses about manpower shortages and incomplete knowledge as a substitute for action. As a result, serious sight and hearing impairments are prevented, crooked limbs are straightened, and rheumatic hearts repaired. We are not doing enough, no doubt, but by comparison, vastly more for children than for adults.

What makes the child when he becomes 40 or 50 or 60 less worthy of protection. less entitled to all that medical science makes possible to keep him productive and useful and free from suffering and death before his time?

What I have said is not to belittle the spectacular gains that have been made in therapeutic medicine. We can be justifiably proud of the achievements in this area-and we continue to be challenged to find still more effective ways to treat illness when prevention has not or cannot be achieved.

Medicare is truly a major part of our progress in providing better care to adults. It is heartening to know that at least a part of the burden of sickness is being lifted from the shoulders of older people. More than this, most of us believe that many of our senior citizens will now get needed treatment which before was unsought through fear of financial embarrassment.

We hope that the current attack on the killer diseases-heart, cancer and stroke through development of the Regional Medical Centers concept will extend the best and latest curative methods throughout the Nation, not just within the walls of the relatively few and most advanced teaching hospitals, clinics and

research centers.

All this is solid progress-and vital. Certainly, I am not saying we need less progress in treatment. Rather, we need more progress in prevention. For in a very real sense, the long-range goal of medical science is not the treatment of disease but the preservation of health.

One pioneering development in preventive medicine I had the privilege of observing not long ago is an imaginative program being carried out by the Kaiser Permanente Health Foundation in California. There we saw a health testing program which utilizes automated equipment and computer techniques for providing a comprehensive battery of tests to large numbers of persons with a

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minimum of time and cost. The findings help the physician complete the health examination of more individuals in less time by providing him with documented results of many tests performed by technicians on apparently well persons. This program was supported by a Public Health Service grant, and I am sure you will be hearing more about it in later testimony.

Recent advances in the field of automation clearly present us with most welcome opportunities to make medical testing services more widely available, to heighten their effectiveness, and I hope, to bring down costs. I suspect, however, that we still have a long way to go to achieve general acceptance of some of these new-fangled approaches to medical care. Although Americans have a reputation for loving gadgetry and mechanical contrivances, we are still conservative about making changes in what we consider to be basic institutions. For this reason, the role of the innovator in such fields as education and medicine (especially the latter)—is not always easy or comfortable.

Nevertheless, the trend is clear-automation must be wedded to medical care and the public will come to accept new methods of receiving care. Otherwise, we will not meet the challenge of making available to every American the best that medical research has to offer and doing so in time to prevent or curb the risk of disease and disability. Meeting this challenge to stretch limited resources, to satisfy the rising demands for health protection for growing numbers of people all this must be the next major phase in the development of health care in this Nation.

It is my fervent hope and belief that the expert witnesses whom you have called upon will deal with these issues in detail during these important hearings. Along with you, I will be looking for answers to some very serious problems.

What, for example, are the values and limitations of periodic health appraisal in preventing untimely death, long-term illness and disability? Can we measure these? Is it really impractical to think of preventive care for all of our adult population? Is it really a question of simple arithmetic-too many examinations X(times) too many people X(times) too few doctors? Can we bring to bear the results of research and new developments in medical technology so that what looks at times to be an impossible equation emerges as just another difficult problem to be solved? Can we afford the time required (under the best of circumstances) for massive preventive programs when we have so many sick people who need more and better attention right now? Conversely, can we afford the loss of life or lessened capacity to live as productive human beings which will surely continue if we do not pay greater heed to health protection for the adult? I had the opportunity of expressing my convictions about health protection when I introduced the Adult Health Protection Act in the House. (Your colleague, Senator Harrison Williams, introduced a companion bill in the Senate.) My bill would authorize the Surgeon General of the Public Health Service to make grants to medical schools, community hospitals, health departments, and other nonprofit agencies to establish and operate adult health protection centers. It would authorize grants for the establishment and operation of these centers for a period of five years.

The system envisioned in my bill will do more for preventive medicine and health protection than anything yet proposed. In addition to many other features, it will bring modern instrumentation and computer use to bear on the recognized, growing health problem represented by chronic illness and the increasing scarcity of professional health personnel.

I propose for the first time to provide Federal assistance in the establishment and operation of regional and community health protection centers for the de tection of disease; to provide assistance for the training of personnel to operate such centers; and to provide assistance in the conduct of certain research related to such centers and their operation.

While these adult health protection centers are intended to provide an efficient means for the detection of abnormalities or indications of disease, they would not replace full examinations. Their purpose is to place in the hands of the examining physician a summary of basic data and to place promptly under a physician's care a person with indications of disease conditions.

The health protection centers would conduct training programs in the operation of technical disease detection procedures and would research and develop new disease detection tests and equipment. Additional grants to the centers would be authorized for operational research and for the establishment of internships to give on-the-job training to physicians, nurses, and technical personnel. The centers would also conduct community education programs on preventive health care.

Finally, a 12-man Advisory Council on Adult Health Protection would be established to advise the Surgeon General of the Public Health Service in the administration of this program. This Council will include men who are leaders in the fields of medicine, public health, public welfare, or representatives of national organizations concerned with the interests of the aging. And it shall include one or more national leaders known for their dedication to the national interest and the welfare of the Nation's citizens.

The basic idea behind the act, put simply, is this: to launch a genuine, nationwide preventive medicine campaign. By making these testing services available to any person age 50 or above, on a voluntary basis, we will encourage men and women approaching retirement to take regular health examinations and we will facilitate the giving of full examinations by practicing physicians.

When I introduced my bill in the House, I said essentially what I have said here: that the chronic diseases pose the greatest threat to health today, that prevention and early control is our only true weapon against these diseases and that, as a result, the means must be found to extend the best of preventive medicine to the greatest numbers of those who run the risk of chronic illness and disability.

I firmly believe this, and I believe, too, that these hearings will serve to speed the day when preventive medicine will be practiced more than it is preached to the end that all Americans will not only live longer but enjoy longevity.

Senator NEUBERGER. From talks with many of the witnesses who will now testify, we know that the topic of these hearings has generated excitement and interest in the medical community. We believe the time has come for us to share that mood with the Senate and the people of this Nation.

Our leadoff witness is Dr. Robert Ebert, who is dean of the Harvard Medical School. In addition, Dean Ebert serves as a trustee or director of numerous societies and foundations and he is a member of the President's National Commission on Health Manpower.

So, I welcome you, Dean Ebert, as our leadoff witness. If you will, come up here to this table, please. I am sure the witnesses will say, and I want to say it also, that I believe, in exploring this problem, we should differentiate between screening tests and a physical examination, and I think we have to keep that in mind.

Dean Ebert.

STATEMENT OF ROBERT H. EBERT, M.D., DEAN, HARVARD
MEDICAL SCHOOL, CAMBRIDGE, MASS.

Dr. EBERT. Senator Neuberger, Senator Williams, I wish, first, to thank you for the privilege of appearing before this committee. I would agree with all of the remarks that have been made about its intrinsic importance.

I thought what I would do this morning, with your approval, is to attempt to put this, the matter of early disease detection, multiphasic screening, in some perspective in terms of health needs. I think all of us would agree that our Nation's most important asset is people and while we are blessed with great natural resources, only people can really be creative and productive and our ultimate future depends upon the welfare of our citizens.

If this human asset is to be nurtured, the best possible environment must be created for the individual and this must include adequate health services for all.

A defense can be made for any program which contributes to the Nation's health and if our resources were limitless, there would be little point in assigning priorities to one program or another. Since we must

face the limitations of money and manpower, some choice must be made and priorities must be set on the basis of what is feasible and what accomplishes the most for the Nation's health. No one would argue that disease prevention is the most valuable contribution which medicine can make to society. The work of Enders, Weller, and Robins followed by the development of a vaccine against polio by Salk and Sabin was a far more important contribution to the health of the world than all the treatments devised for the acute and chronic care of the polio victim.

Similarly, immunization against smallpox, diphtheria, and most recently, measles, represents milestones in the prevention of disease. Immunization has not been the only weapon in the conquest of disease. Mosquito control can prevent malaria, pure water can control typhoid fever and other enteric infections, and adequate nutrition can eliminate beriberi and pellegra. It is probable that the control of air pollution and elimination of smoking could eliminate certain kinds of cancer, as well as emphysema. It does not take a statistician to prove the advances you can make in the field of health.

Perhaps the next most important contribution which medicine can make is the specific cure for illnesses which may be fatal or which have a high morbidity. By far the greatest excess of great curative medicine has been in the field of disease. Rapid cure of syphilis thereby created the means of controlling this crippling disease. It remains a public health problem, but the development of potent drugs such as isodycin and streptomycin not only offers a cure, but an additional weapon against the spread of the disease. There are other examples of advances which have been made in the field of curative medicine, but these represent two of the most dramatic.

Unfortunately there are many diseases which we cannot prevent and many which we cannot cure. Hopefully the money spent on biological research will provide the basic understanding for the ultimate conquest of these diseases. Meanwhile, it would seem reasonable to apply as widely as possible the medical knowledge and skill which we possess to cure the diseases we know how to cure and to curtail, whenever possible, the progress of disease for which there is no specific cure. Yet it is the daily experience of anyone working in a large general hospital to see the late stages of disease which, if discovered earlier, might have been controlled so as to prolong productive life. Death and chronic debilitating illness are always tragic, but the tragedy is compounded if the physician knows that the patient sought medical attention too late. As a Nation we will always wish to provide the best care we can afford for the chronically ill, but it should be noted that the treatment of the end stages of disease is the least productive investment a nation can make in the field of health. There is a limit to the amount of money and manpower which any nation can devote to health. It would seem reasonable, therefore, that the highest priority should go to disease prevention and to early detection and early treatment of disease.

I hope I have made it clear that I consider the early detection of disease as one of greatest importance for I would now like to address myself more directly to this subject.

In the past there has been much interest and considerable activity in disease detection, but for the most part this has been done on a cate