STATEMENT BY Surgeon GeneRAL LEONARD A. SCHEELE, UNITED STATES PUBLIC HEALTH SERVICE

Mr. Chairman, members of the committee, I appreciate the opportunity of appearing before you today as you study our request for funds for Public Health Service programs for the fiscal year 1956. I shall present a general report on the state of the Nation's health and progress in health research and programs, and I shall highlight some of the major health problems on which intensified effort is needed.

STATE OF THE NATION'S HEALTH

The Public Health Service, through the National Office of Vital Statistics, the Division of Public Health Methods, and other statistical research units, keeps official records on the Nation's health and many of its health needs and health

resources.

Preliminary estimates of death and birth rates and other vital data for 1954 show a continuing general improvement in national health. The death rate from all causes for 1954 is estimated to be 9.2 deaths per 1,000 population, the lowest in the Nation's history.

Over 4 million babies were born in the United States last year-the first time in our history that live births have reached and passed the 4 million mark. This means that the estimated birth rate for 1954 is 25.2 per 1,000 population, the second highest in 28 years, and only about 5 percent below the peak year, 1947. The estimated infant-death rate for 1954 is 26.6 per 1,000 live births-another new low in annual mortality records.

The general death rate for 1954 represents a decrease of 5.2 percent below the rates of 9.6 or 9.7 per 1,000 which prevailed in the preceding 5 years, 1949-53. An important reason for the drop is that the country was spared a major influenza epidemic in 1954. This good fortune is reflected by significant reductions in pneumonia deaths and in deaths due to diseases of the heart. Many individuals with heart disease are likely to succumb under the strain of influenza in epidemic years.

We are doing a better job in reducing the tuberculosis-death rate than in reducing the number of cases. At present, the annual number of reported cases of tuberculosis is declining by only 3 percent in contrast with a 20-percent drop in the death rate each year since 1951. The tuberculosis death-rate for 1954 is estimated to be 10.6 per 100,000 population-the lowest on record. Last year is the first in our history when tuberculosis did not rank among the first 10 causes of death.

In spite of this good showing, we have not won the battle against tuberculosis. We will not have won it until we achieve comparable success in reducing the large reservoir of tuberculosis infection still prevailing in most parts of the country. We can do this-but only through a continued and concerted effort to find and treat larger numbers of people annually in the early stages of their disease. The trend in newly reported cases from 1930 to 1954 remains fairly constant as contrasted with the dramatic drop in tuberculosis deaths.

Diseases of the heart, cancer, and vascular lesions affecting the central nervous system-such as stroke-continue to top the list of principal causes of death. Deaths from these causes occur most frequently in the older age groups, so that with the aging of the population these diseases will probably hold first rank for many years to come. During the period 1950 to 1954 there were decreases in the death rates due to certain cardiovascular diseases. This reflects, in part, the discovery and increasing use of new drugs in the treatment of such conditions as rheumatic fever, some types of coronary disease and high blood pressure. It also reflects earlier diagnosis and generally improved surgical and medical care of heart patients.

Although we can report some progress in life-saving, I would remind you that we have scarcely begun to move forward against the chief killing and crippling conditions. For example, an estimated 780,000 persons died of cardiovascular diseases in 1954, and not less than 10 million had some form of heart disease. Approximately 235,000 persons died from cancer last year and it is estimated that this year about three-quarters of a million will be under treatment for that disease. Over 900,000 persons are in institutions for the mentally ill and the mentally retarded, and another 600,000 are treated in outpatient clinics and physicians' offices for mental illness. Many millions have serious mental or emotional problems but are not under treatment.

RECENT PROGRESS IN RESEARCH AND PUBLIC-HEALTH PROGRAMS

The Nation's greatly increased medical research effort of the past 9 to 10 years is yielding new knowledge that will be as effective against our major health problems of today as earlier research accomplishments were against insanitary conditions and epidemic diseases of the past. There has been progress also in research on some of the enivornmental health problems of the present day; but as in medical research, much more remains to be done in health research before we are in a position to cope with such problems and with the onrushing problems of our continued industrial expansion.

The research facilities and staffs of the Public Health Service, as well as our aid-to-research programs, are playing a significant part in the national effort to fill the gaps in medical and public health knowledge as rapidly as possible. Through cooperation with official and voluntary health agencies, universities, medical schools, hospitals, and other institutions, the Public Health Service is also helping to bring about the speedy application of new findings for the prevention of disease and promotion of health.

I should like to mention a few recent advances in which our Public Health Service research programs have played a part-directly or indirectly.

A means of preventing retrolental fibroplasia, cause of more than half of the cases of blindness in children, has been proposed by a study group of ophthalmologists and pediatricians in 18 hospitals. This research project was supported jointly by our National Institute of Neurological Diseases and Blindness, the National Society for the Prevention of Blindness, and the National Eye Research Foundation. Retrolental fibroplasia occurs primarily among premature infants. The research group reports that up to 85 percent of the cases can be prevented by giving oxygen to the premature babies only when such treatment is indicated clinically rather than as a routine procedure in management of the premature infant.

Last year, a research project, which involved the National Microbiological Institute, the National Institute of Neurological Diseases and Blindness, and the Walter Reed Army Medical Center, opened the way to effective treatment of another important cause of blindness-granulomatous uveitis, a serious infection of the eye.

In recent years, physicians and pathologists have suspected that a diseasecausing organism-toxoplasma-might be involved in this form of uveitis. Dr. Leon Jacobs of our Microbiological Institute had worked on this infection for several years and had had good results in treating laboratory animals infected with toxoplasma with a combination of pyrimethamine and sulfadiazine. In 1954, he succeeding in isolating toxoplasma from a human eye which had been removed at Walter Reed Hospital as a result of uveitis; and in cooperation with ophthalmologists at our clinical center, he has reported encouraging results in treating patients with granulomatous uveitis with the same drugs in combination. We are proud that as a result of this research, the United States Chamber of Commerce has selected Dr. Jacobs as a recipient of an Arthur S. Flemming Award for distinguished achievement by Government employees.

Before the close of 1954, our National Institute of Arthritis and Metabolic Diseases demonstrated the effectiveness of two new steroid compounds-metacortandralone and metacortandracin-in the treatment of arthritis patients who had not responded to cortisone or other forms of therapy. The new steroid compounds appear to produce marked and prompt improvement, without the toxic effects of cortisone. Dr. Floyd Daft, Director of the Arthritis and Metabolic Diseases Institute, will tell you some of the details of this work when he appears before the committee.

I mentioned earlier the importance of new chemical agents in the treatment of certain heart ailments. Within the past 3 years, the active principle of Indian snakeroot, Rauwolfia serpentina, has been isolated as a pure crystalline alkaloidreserpine. Rauwolfia, either alone or in combination with other drugs, is now being used with considerable success on more than 500,000 patients with high blood pressure. It has also shown marked effectiveness in calming victims of mental disease.

Although cancer cures cannot yet be attributed to chemotherapy alone, chemical agents are being used on an increasingly widespread basis, alone or in combination with surgery or radiation or with both of these older forms of treatment. Many new radioactive materials are also being used in conjunction with surgical removal of the pancreas, the adrenal glands, and other organs.

Notable progress has been made in chemotherapy of acute leukemia in children, chronic lukemia in adults, Hodgkin's disease, and advanced cancers of the breast

and the prostate gland. Many American scientists have cooperated in the cancer chemotherapy study authorized by Congress for the fiscal years 1954 and 1955. This study is guided by a Committee of Cancer Chemotherapy Investigators, appointed in 1953. Dr. Heller, Director of NCI, will give you a fuller report.

A new insecticide, DDVP (dimethyl-dichloro-vinyl-phosphate) has been discovered by research chemists at the Savannah laboratory of our Communicable Disease Center, with headquarters at Atlanta, Ga. DDVP appears to be more potent in killing insects and less toxic to humans and farm animals than are many other modern insecticides. In recent tests, it proved highly efficient in killing insects known to be resistant to DDT.

During the past few years, our Arctic Health Research Center worked out the practical application of engineering principles to the problem of water distribution in permafrost regions. As a result, the city of Fairbanks, Alaska, has installed a new type of water distribution system which through continuous circulation keeps the water in motion and thus prevents freezing. This means a more adequate water supply and better protection from water-borne diseases for the citizens of Fairbanks.

This last example of recent work in Public Health Service research facilities is a good bridge from the search for new knowledge to the application of findings. The Service has made many contributions to improved public health practice through technical assistance to the States, with emphasis on practical use of new scientific methods.

The States, for example, in cooperation with the Public Health Service and the American Heart Association and its local groups, are launching a renewed attack on rheumatic fever and rheumatic heart disease, to take advantage of advances in antibiotic therapy. They are providing preventive, case-finding, diagnostic, and followup services to assist the private physician in his management of rheumatic children. Through the prevention of streptococcal infections in rheumatic fever patients, it is possible to prevent an untold amount of suffering and invalidism, and to reduce still further the deaths due to rheumatic fever and rheumatic heart disease.

Many local health departments have conducted community-wide case-finding programs for the detection of diabetes, as a means of placing hitherto unknown cases under the care of private physicians. They are using recently developed devices, which have been tested in cooperative demonstrations with medical societies and the Public Health Service. The Clinitron makes possible rapid blood-sugar determinations and the Dreypak is a rapid method of urinalysis.

Some health departments are serving as focal points in the organization of community health facilities and resources for a broad-scale attack on chronic diseases and long-term illness. The aim here is to bring to bear all existing services-case-finding, diagnosis, treatment, and rehabilitation-upon the problems of long-term patients.

The present favorable situation with respect to tuberculosis mortality is the result of modern case-finding techniques, developed some years ago and applied intensively since 1945; and it is the result of tremendous advances in the chemotherapy of tuberculosis. The Public Health Service has contributed substantially to these developments by our demonstrations of new case-finding techniques and by our cooperative therapy evaluation program, in which 78 hospitals have cooperated with us in determining the effectiveness of new drugs. Isoniazid-first introduced in 1952-and other newer drugs bid fair to revolutionize the approach to tuberculosis control. With these new drugs, it is possible to treat selected patients on an ambulatory basis in clinics and physicians' offices, without sanatorium care. Home care, of course, requires repeated X-ray and bacteriological examinations, as well as careful medical supervision. In the past, State and local health departments had no way to get newly discovered cases under isolation and treatment-unless tuberculosis beds were available. Too often, patients had to wait until their disease had advanced dangerously. Now, they can obtain prompt, effective treatment for every single tuberculosis case reported by physicians or discovered in case-finding programs-whether beds are available at the moment or not.

This means that State and local health departments will have to revise and expand their tuberculosis services. In discharging their legal responsibilities for preventing the spread of tuberculosis, they will have to make sure that patients selected for ambulatory treatment receive the necessary supervision; that proper isolation is observed to protect families and associates of home-care patients; and they will have to provide continuing followup to prevent relapses and further spread of the disease. There is no doubt that we shall see further

reduction of tuberculosis mortality. Whether the Nation will gain the full benefits of the new opportunities to eradicate the disease depends upon the ability of State and local health departments to do a thorough scientific job of applying the new techniques.

PROBLEMS NEEDING INTENSIFIED EFFORT

I wish now to call attention to several other problem areas in which intensified effort is needed and for which we have asked increased funds under existing authority. In several instances, these programs would be further strengthened should the President's 1955 health legislative proposals become law, and should supplemental budget requests be acted upon favorably.

Each year since 1946, under the authority of Public Law 410, as amended, the Congress has made appropriations to the Public Health Service for support of research on noncategorical problems of major importance to national health. Part of these non categorical grants has been devoted to research projects on methods to improve the administration of health services, to studies in the broad field of environmental health, and to basic medical research. These projects have been reviewed and recommended for support by the National Advisory Health Council and appropriate study sections.

Since the appropriation for noncategorical grants must cover a very wide range of problems, it has become increasingly clear that additional support of research in certain critical areas is needed, if our States and communities are to have scientific bases for solving some of their immediate health problems.

The committee is aware, for example, of the long-continuing problem of providing sufficient nursing service in all categories. The demands far exceed the supply, and it is not expected that the demand can be met solely through efforts to increase the number of professional nurses. Ways must be found to improve our utilization of the present supply of professional nurses.

A few research projects on nursing service and its management, conducted in recent years by the Public Health Service in cooperation with various nursing organizations, hospitals, and educational institutions have proved that such studies can produce results. New methods have been developed and have been adopted enthusiastically by many institutions because their application does reduce the gap in services.

Studies in nursing methods and the management of nursing services, as well as studies in the selection and training of nursing personnel, of all types, are urgently needed. The Public Health Service's Division of Nursing Resources has been a pioneer and leader in this new field of research. As in other areas of health research, however, we are well aware that the major effort must be in the Nation's universities, colleges, and other qualified institutions. We believe that augmentation of our aid-to-research program to support additional studies in this field would pay dividends in findings that would be immediately applicable to the Nation's effort to provide better nursing services in hospitals, clinics, and homes.

A very much stronger national research effort on the problems of water pollution and air pollution also is urgently needed. The control of water pollution is emerging as a primary factor in the total problem of the Nation's water resources development. Sometimes water shortages can be met by constructing dams and storing water for future use. By and large, however, the solution must be found in preserving the quality of our streams so that water can be used repeatedly as the streams flow from city to city and from industry to industry. This is necessary not only to assure adequate water supplies for human consumption, but also to preserve adequate supplies for growing industrial needs and for recreational

use.

The Water Pollution Control Act, 80th Congress, 2d session, recognized the importance of the control of community and industrial wastes. The act authorizes a maximum of $1 million for grants to State and interstate agencies annually, to assist them in conducting the field surveys, investigations, and other types of research which must be the base of progressive action in water pollution control. However, such grants have been available in only 3 of the 7 fiscal years since 1948 when the act was passed, and progress has been slow, in relation to the growing problem. If the intent of Congress in passing the original legislation is to be carried out and demonstrated needs are to be met, it is our belief that funds up to the maximum authorization should be available to permit the intensification of State and interstate programs.

In addition, the Nation's universities and other nonprofit research institutions need increased support for research in this important field of water pollution, including the problems of industrial wastes. For this reason, the Public Health Service is requesting additional funds for research grants through the National Institutes of Health.

Air pollution has become a chronic, massive problem for virtually every large city in the country. Public concern about air pollution has grown during the past 6 years, and in fact has reached fever pitch in some urban areas. Preliminary investigations have shown that there are survey techniques and analytical methods which could be put to good use in determining the nature of the problem in specific

areas.

However, air pollution is an exceedingly complex situation, involving chemical, meteorological, and engineering problems which require a comprehensive research attack. Moreover, the definitive effects of air pollution on human health are not well known and epidemiological and medical studies are needed to provide the

answers.

Our States and cities need help to solve their air pollution problems, through research both in the natural environment and the laboratory. and through technical assistance on specially difficult problems. The Public Health Service has been collecting important data on the extent and nature of air pollution. We have provided some States and communities with expert consultation, as requested. We are anxious to strengthen our research effort in this field, so that the States may tackle their air pollution problems more effectively as new knowledge and techniques become available. We are asking for an increase in funds to support

this work.

The time has come when there should be a stepup of assistance to the States for the development of community mental health services, as well as for training of personnel in this vital field. Although Federal mental health grants have been available for only 6 years and have never been large, the mental health program has progressed with remarkable steadiness in all the States. The result has been a continuous increase in public interest and demand for additional services, as the people have become aware of the tremendous costs of mental illness on the one hand, and of the value of preventive mental health services on the other. Last year, this growing interest culminated in two significant conferences of State governors on mental health problems, and the development by the Council of State Governments and the Southern Regional Education Board of specific plans for future State action on mental health programs, training of personnel, and research.

It is hoped that the Public Health Service will be enabled to increase its technical assistance to the States as they press forward in their efforts for better mental health services. Technical assistance and increased financial aid, however, requires also increased training of mental health personnel. If the constructive plans of the States are to be implemented, a major advance on the training front must have high priority.

HOSPITAL AND RELATED CONSTRUCTION

Amendments to the Public Health Service Act, passed in 1954, have increased the scope of the hospital survey and construction program. The new legislation authorized the appropriation of funds for surveys and construction in the States to increase the supply of chronic disease facilities, diagnostic-treatment centers, nursing homes, and rehabilitation facilities. The total authorization for construction grants is $60 million annually for each of the 3 fiscal years, 1955 to 1957. The 83d Congress made available $23,250,000 in supplementary appropriations for this purpose in 1955. We are requesting for 1956 the full authorization—$60 million-for these special categories of facilities, as well as $65 million for the the regular hospital facilities construction program.

We expect the new program for the construction of chronic disease facilities, diagnostic-treatment centers, nursing homes, and rehabilitation facilities to go forward rapidly, on the basis of the experience gained by the communities, institutions, and States in conducting the Hill-Burton program over the past 9 years. Most of the State agencies have begun their survey and planning activities, and we expect some State plans and project applications for special facilities before July 1, 1955. The Public Health Service is prepared to act promptly in review, approval, and allocation of construction grants from the existing supplemental appropriation.

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