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In addition, California possesses several thousand licensed Residential Care facilities which, under proposed implementation of the Chappie Bill (AB 389. '68 Legislature) appear to offer a more appropriate type of "Intermediate Care" through a combination of board-and-room and other special services purchased and arranged to better fit the needs of public assistance recipients not needing skilled nursing home care. It is possible that this latter approach may additionally prove more economical to government than Intermediate Care per se.

Mr. ORIOL. And now I would like to call Dr. Austin B. Chinn.

It is a real pleasure to do so for many reasons. Dr. Chinn is very helpful in the discussion and early work on the preventicare bill, and was the consultant to this subcommittee on the health of the elderly in the first

in the two hearings that we conducted earlier. It is good to see you again, Doctor. Dr. CHINN. Thank you. Mr. ORIOL. We wanted to make you a "wrap-up” witness, Dr. Chinn.


Dr. CHINN. All right. If you will bear with me.

The hour is very late, of course. I don't want to take any more time than is absolutely necessary.

What I have to say in attempting to summarize this very full day would be presumptuous on my part in a full context. However, I can make a few remarks regarding points which struck me during the hearings as germane to the issues you have.

Many aspects of medicare and medicaid have been presented here. Some of them favorable, and some of them critical. To attempt to comment on all these would be, really, out of order, I think.

Dr. Todd commented on the aspects of surveillance which is being provided by organized medicine relative to the medicaid program. And you, of course, have those remarks in the record.

Dr. Littlejohn, Í think, made some cogent remarks about some of the serious effects that médicaid is having upon medical care, particularly in the ghetto areas.

He said that actually, health services are leaving the ghetto areas as a result of medicaid. This, I think, is a very serious charge, particularly since the people in the ghetto areas need medical care and health services

more than people anywhere. We all know that the incidence of disease in the population of deprived people is infinitely higher than it is in any other group in the United States. To witness removal of those health services that do exist seems to me to be a very, very serious thing.

Dr. Giorgi gave us a sweeping survey of the entire health situation. I wouldn't really feel it appropriate for me to comment on what she said.

A couple of things that Dr. Breslow said I would like to mention. He talked about the quality of medical care in this country and the need for quality control and the influence of medicare and medicaid on quality control.

One of his thoughts which I would like to emphasize, has to do with the remarks he made about preventive health services. In this context, I think it is accurate to say that there has been in this country, in the past 25 years or more, a vast increase in medical knowledge and skill.

The problem has been really to deliver the fruits of this knowledge and skill to the people of the Nation.

A factor influencing the delivery of this knowledge is of course the increase in the population, particularly the increase in the very young and the very old. The urbanization of the population has also been an influential factor and has been a direct impediment to the delivery of health services.

The shortage of health manpower has been a distinct impediment. There have also been social and economic forces which have impeded the delivery of these fruits of knowledge and skill to the people.

Included among these are attitudes and understanding on the part of people about health services. Distances from health services, particularly when old people had to travel, are involved with transportation difficulties, are also problems that are relative to this.

The organization of health services and the attitudes of people of the health professions with respect to older people have sometimes been impediments to the delivery of services.

Poverty, it goes without saying, has been an enormous influence on the delivery of health services.

In the stimulation and support of the delivery of care, however, we have the normal humanitarian instincts that exist in the minds of people in this Nation.

These civilized and humanitarian instincts have, of course, predominated with respect to most of us and counter the other influences which tend to impede.

Also, a promising increase in health plan power and a promising evolution of different kinds of manpower, such as the doctor assistant and the nursing assistant, is emerging. A better use of manpower is undoubtedly coming about and there are promising organizational changes, such as the establishment of better institutions as here in California. For example, the Long Beach General Hospital, which is devoted entirely to the care of elderly people is an excellent institution, and that kind of thing, I think, is emerging.

We are also having better kinds of health services such as home care, home-health services, and ambulatory services, all of which leads toward the development of better utilization of this knowledge that I was talking about earlier.

THE VOID: INACTION ON PREVENTION But it seems to me, the most important void in all of this—which Dr. Breslow touched upon and also Dr. Giorgi and has been referred many times here today, is the prevention of illness.

This, it seems to me, of necessity has to be approached realistically in this country sometime within the near future.

Most attention to illness and disease in this Nation has been directed to the immediate treatment of the sick-with hospitalization, nursing care, medicare, and such other measures necessary to bring about a cure.

Historically, however, the greatest progress in health in the world has been made on the one hand by the primary prevention of disease as the acute infectious diseases—smallpox, typhoid fever, diphtheria,

and so forth-brought about by immunization, sanitation, and quarantine, and on the other hand the identification of disease in its early or presymptomatic stage. Those two principles have influenced the health of the world more than any other influences that have been known since the dawn of mankind.

When I talk about the identification of disease in its early or primary or presymptomatic stage, we have as graphic illustrations of this the diseases of tuberculosis and syphilis.

Both of these of course are chronic infectious diseases and their control has been largely brought about by their identification while in a nonsymptomatic stage. The identification of pulmonary tuberculosis in its earliest stage where it is only a minor shadow on an X-ray film is in marked contrast to an advanced stage of the disease, with cavitation, and other evidence of widespread disease.

The medical contrast between those two situations is graphic beyond belief as is the contrast in cost of their management.

The same thing is true of the other chronic disease that I named, syphilis. The identification of this disease by simple blood test as contrasted to its symptomatic stage with nervous system or cardiovascular system involvement is strikingly different.

The contrast between management of the chronic infectious diseases in their early nonsymptomatic stages with their management in symptomatic stages is graphic. There is no reason why the chronic, noninfectious diseases may not fall into similar categories of management.

The same principles of early identification of noninfectious chronic diseases are as vital and as applicable as the early identification of the chronic infectious diseases.

Such diseases as hypertension, coronary artery disease, glaucoma, cancer of the uterine cervix and breast, and mouth, pulmonary emphysema, and a host of others can all be identified in an early or presymptomatic stage. The technology is available, and there is no reason why it cannot be applied.

These hearings have been directed toward the principle of cost. It seems to me that if we are thinking of increasing cost of medical care, as it presently exists, we can think only in terms of building, increasing numbers of hospital beds, of educating increasing numbers of physicians, nurses, and other professional people and of increasing efforts directed to the care of the already sick.

We will thus have increasing costs of hospital beds—and these other services for the sick for the foreseeable future. Where do we wind up? The Nation is increasing at the rate of millions of people every decade, and all that we can expect is to increase the number of beds and doctors and professional people to take care of them.

The cost, on the other hand, of early identification of these diseases, which are filling the hospitals, causing morbidity, and mortality must be looked at in comparison.


I think that the cost of this, though substantial initially in the effort to find the disease, and in the event the disease is found, to move the individual into the receipt of health care, is minuscule compared to the management of that same individual months or years later follow

ing the development of an advanced stage of the disease with the prospect of long periods of hospitalization, or other institutionalization, physician services, nursing services, and on and on and on.

It seems to me, Mr. Chairman, that we are at the point wherein we must face the issue of whether we want to do what we are doing now, or whether we are willing to sponsor the support and development of this type of health service as we did with biomedical research some 25 years ago.

I would like to remind you that for all practical purposes, biomedical research was in its infant stages immediately after the Second World War. I think the Cancer Institute had its origin before the war, and maybe the Heart Institute, but the effort was really in its infancy.

Out of this has grown a stupendous body of knowledge in 25 years. But it would never have come about if we had sat back and done what we were doing in the late 1930's and early 1940's.

Today, we are at the same stage, essentially, with respect to this segment of health services that we were 25 years ago with respect to biomedical research. I would urge the committee to consider what steps it might take with respect to these humanitarian and the social and economic interests.

Thank you.

Mr. ORIOL. Doctor, we thank you. I think it is apparent to the few hardy survivors here yet remaining why we asked Dr. Chinn to give us not only testimony but wisdom and à vision of what we hope will be the future. I have many questions, and some of them will find their


to you in the form of the mail, but one question I would like to try out on you now: There has been much discussion today about how you cannot separate health care for the elderly from health care for all. It is regarded as part of the total health system. But in terms of organization, the attention given to health services for the elderly at the Federal level-is there some advantage to having a unit of government at a very high level devoted to the health care of the elderly? And I say that knowing full well that you are the former chief of the Adult Health and Aging Branch of the Public Health Service, but in view of the rising numbers of the elderly, in view of the increased attention being given to health costs simply because we now have medicare, do we not get similar benefits if we use the kind of quality health services given to the elderly as one way of raising the quality of services for all?

Dr. Chinn. I think it is, as has been said here today, that medicare has not only done a great deal for the older person, but has done a great deal for medicine and medical care in this Nation as a whole.


As you well know, the health problems of older people are quantitatively infinitely greater than they are for any other age group. Qualitatively, one might argue about whether they are different, but quantitatively they are different, and there are many more complexities relative to these health problems.

I don't consider physical health problems alone; I am also talking about social health problems and mental health problems. All of these things interdigitate with respect to the influence of one area upon another.

It seems to me that quantitatively if we are looking for the greatest health problems that exist in the Nation, one can profitably look toward the elderly population. If we can solve these problems or can come even close to solving them, or develop mechanisms for solving themthen this cannot help but have a large impact on the rest of the population,

I would be the first to say that the health problems of elderly people- whether they be physical, mental, or social—do not necessarily begin when they are 65—when an individual gets to be 65. They begin in younger years, certainly, in the fifth and sixth decades of life, or maybe even in the third or fourth decades. Therefore, the problems as we know them in elderly people are qualitatively not peculiar to older people but there are more of them. I would endorse emphatically the fact that if one can focus down upon them, the impact of this upon the health of the Nation as a whole would certainly be profound.

Mr. ORIOL. Another question I wanted to raise :

The Kaiser Permanente-or Kaiser Foundation health multiphasic screening program has been mentioned here quite often today. I think it is important for the record that we note that the persons receiving this screening are members of a prepaid group health plan.

When we talk of widespread multiphasic health screening, possibly along the lines suggested by the Preventicare—or more specifically along the lines that are now at work in three or four pilot health screening programs, which were initiated, I believe, while you were with the Public Health Service—with all those, you are dealing with a group that is not organized into a prepaid package. How can you hope to get widespread participation ? What are the difficulties here?


Dr. CHINN. Well, I don't think that all of the difficulties are known. And this is, I think, one of the reasons that the four prototypes that you mentioned, which are now in operation in communities, will serve to disclose a great many of the problems that are inherent in an openended community program. The lack of close physician participation and the lack of proper understanding of many people who would be coming to such a screening operation present real problems.

Factors about the delivery of the information and the followup and utilization of the information all of these factors, I think, are unknown. However, I would say this: It took a great many years, many centuries, as a matter of fact, before the value of hospitals came to be recognized as something other than "death houses."

Prior to and including the 17th century, and indeed into the 18th century, one didn't go to a hospital to get well

, one went to die. And it took 150 to 200 years before people learned to go to hospitals to get well. Formerly it wasn't recognized as a place to help the sick individual; it was a place to which to remove the dying person from society and hide him away.

This is an exaggerated statement, of course, but it seems to me that what we are talking about here today may require a long period of acceptance. But once it has been shown to the public that the identification of disease before it is symptomatic has proven its value, we won't have more trouble with public acceptance.

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