and aged population. Thus this type of diabetes is certainly less dramatic that the child who becomes blind or has renal failure after 20 or 30 years of the disease but in gross economic terms and its total impact on the population, it leads to a much greater degree of morbility and economic loss. For example, single gangrenous limb usually results in approximately $5,000 to $7,000 worth of hospitalization, not to mention the loss of time and earning power of the individual suffering from the problem. Again the difficulty of this type of diabetes has been the lack of public appeal due to its insidious nature, however its overall impact on the total population cannot be overemphasized.

Hon. DANIEL J. FLOOD,

JOSLIN CLINIC, Boston, Mass., February 27, 1976.

House of Representatives, Chairman, House Labor HEW Appropriations Committee, Washington, D.C.

DEAR CONGRESSMAN FLOOD: As a clinician working directly with diabetic patients for nearly 30 years, and as one of the many participants in the datagathering process for the National Commission on Diabetes in preparing its report to the Congress of the United States, December 10, 1975, I would like to place on record some specific concerns as to the implementation of certain recommendations of the Commission. In particular, I would like to focus upon the hesitation of all those fine people making up the National Commission on Diabetes who wanted to have some real impact upon the problems posed by diabetes, and who then for some inexplicable reason failed to provide for adequate funding. It is incredulous that the Commission would point out the significant contribution of diabetes to death from heart disease and stroke and disability from gangrene, and then essentially ignore it. Evidently the thinking was that the National Heart and Lung Institute would somehow, without people or dollars, turn its current budgetary and personnel effort, already stretched by existing priorities, into research related to the diabetes component of the vascular disease producing almost as much death and morbidity as all other diseases or conditions but together.

The Commission identifies the problem of diabetes on page 1 as affecting 10 million Americans and shortly thereafter its contribution to blindiness, kidney disease, gangrene, and heart disease. Somehow one of the most disabling and devastating problems in potentially all families in the country; namely, that of stroke, was not mentioned. Finally, on page 18 under "Complications of the Vascular System", the section labeled "Macroangiopathy", "The National Commission on Diabetes recommends that the National Heart and Lung Institute increase its support for (1) those research efforts in heart disease, perihperal vascular disease, atherosclerosis, hypertension, and blood coagulation that relate to diabetic morbidity and mortality and (2) those studies already underway which are unique to diabetic macroangiopathy".

Herein lies the disclaimer by the Commission of an interest in diabetes as a major contributory factor to these types of blood vessel disease. Such a message could be construed as giving the National Heart and Lung Institute no mandate whatsoever, if as some have proposed the basic vascular disease is the same and there is little to be learned from studying it in the diabetic. On the other hand, the full report of the Commission, particularly volume III, provides sufficient evidence of differences in the vascular disease of the diabetic to warrant greatly expanded study of its pathogenesis in the diabetic as a means of learning more about the problem as it affects all others. Furthemore, a more precise definition of the role of diabetes in affecting the development of vascular disease in all Americans may open up whole new areas of research as yet unsuspected. Finally, a seeming intellectual nihilism as to the possibilities of finding out just what causes these larger blood vessel lesions seems to pervade the thinking of the Commission, as if accepting that such vascular disease has been studied and studied for years and years, so what is the use? At least the Commission has made certain, if its recommendations are followed, of almost shutting off further study as to the role of diabetes.

Still further emasculating the effort to solve the vascular complication problems on page 22. "The National Commission on Diabetes recommends that the National Institute of Arthritis, Metabolism, and Digestive Diseases, the National Eye Institute, and the National Institute of Dental Research expand their intramural research programs relating to diabetes", no mention is made of the National Heart and Lung Institute. Also, on page 22 "The National Commission on Diabetes recommends to the National Institute of Arthritis, Metabolism and

Digestive Disease, the National Eye Institute, the National Institute of Neurological and Communicative Disorders and Stroke, the National Institute of Dental Research, and the National Institute of Child Health and Human Development that they make every effort to expand the fellowships and special awards in the area of diabetes-related studies in accordance with the levels indicated". What happened to the National Heart and Lung Institute?

To illustrate failure to implement efforts to solve the diabetes problem on page 28 under "Additional Administrative Support", the National Heart and Lung Institute is asked to add one professional and one clerical position "to coordinate diabetes related programs". Curiously the National Institute of Neurological and Communicative Disorders and Stroke is similarly blessed in the recommendation, even though the most common complication of diabetes is neuropathy, which in a number of individuals is disabling.

In its budget summary on page 59, the increased funding recommended by the Commission is clearly identified as being primarily for the National Institute of Arthritis, Metabolism, and Digestive Diseases. The statement is made "Other substantial increases would go to the National Eye Institute and the National Heart and Lung Institute, -", but for the National Heart and Lung Institute over a period of 5 years the total increase recommended is less than $4 million (page 70). Such support represents more a zero than "substantial" funding.

It seems clear that the National Diabetes Commission is immensely impressed with its recommendation of increased funding for diabetes from the fiscal year 1975 to 1979 in the amount of $83 million, and one respects its efforts to avoid making unrealistic or exaggerated requests from the Congress. In so doing, it is obvious that some priorities were established by the Commission, in this case so weighted that a large portion of the additional funding is recommended for the National Institute of Arthritis, Metabolism, and Digestive Diseases. Except for the National Eye Institute, those which should deal most directly with almost all of the remaining serious complications of diabetes, specifically the National Heart and Lung Institute, and the National Institute of Neurological and Communicative Disorders and Stroke, are recommended for nothing more than token support.

Not intended as adverse criticism of the Commission's efforts, which have certainly been gargantuan and have provided a tremendous store of information as a base for launching the diabetes effort, I would like to point out that the Commission's recommendations essentially ignore those complications making diabetes such as significant and growing health problem in the United States; namely, heart disease, stroke, gangrene, and neuropathy. This may well have occurred inadvertently because not a single member of the National Diabetes Commission, professional or public, has had in-depth experience with the serious manifestations of diabetes at the clinical level.

Sincerely yours,

ROBERT F. BRADLEY, M.D.

APPENDIX C

MATURITY-ONSET DIABETES

(By George F. Cahill, M.D., professor of medicine, Harvard Medical School; president, American Diabetes Association; coauthor, National Commission on Diabetes Budget)

Of the total diabetic population, 10 percent have the more complete insulin deficiency which results in dependence on exogenous insulin and this type of diabetes is present mainly in younger people and hence the term juvenile-type diabetes. The other 90 percent is more pernicious and affects mainly the middleaged and older populations. This type of diabetes is associated with accelerated atherosclerosis in addition to many of the problems which afflict the juvenile type of diabetic; namely, retained and renal degeneration. The problem that this milder type of diabetes has had over the years is its very insidious onset usually presenting itself as one of the complications of diabetes rather than the diabetes itself, which would be evidenced by high blood sugar and sugar appearing in the urine. Of the 5 million or so with the maturity-onset type of diabetes, their life expectancy is cut by about one-third and the morbidity associated with gangrene of the extremities as well as severe infections elsewhere, accelerated atherosclerosis leading to twice the incidence of stroke as well as accelerated involvement of the coronary arteries, leads to a tremendous morbidity of the middle-aged and aged population. Thus, this type of diabetes is certainly less

dramatic than the child who becomes blind or has renal failure after 20 or 30 years of the disease but in gross economic terms and its total impact on the population, it leads to a much greater degree of morbidity and economic loss. For example, a single gangrenous limb usually results in approximately $5,000 to $7,000 worth of hospitalization, not to mention the loss of time and earning power of the individual suffering from the problem. Again, the difficulty of this type of diabetes has been the lack of public appeal due to its insidious nature: however, its overall impact on the total population cannot be overemphasized.

Mr. STENZLER. I would like to digress a bit from my prepared testimony in order to comment upon issues of vital importance that are not included in the report.

Perhaps because the matters I wish to bring to your attention are not a principal charge of the Commission, or for other valid reasons, their omission may be, of course, understandable.

Nevertheless, their significance is more or less important:

(1) The Commission did not adequately define or describe diabetes mellitus, or properly identify the composition, (diagnosed or undiagnosed) of the diabetic population in the United States today.

(2) The Commission did not innovate new priority research, nor did it effect a mechanism that could innovate a new concept.

(3) The Commission did not seek advice, counsel, or recommendation from international authorities whose disciplines are heart, kidney, neurology, genetics, vascular degeneration, and nutrition.

(4) The Commission failed to establish priority research projects for vascular degeneration, neurologic disease, kidney poisoning, research into environmental genetic factors, and new exploration into the causes of diabetes other than insufficiencies and metabolic imbalance.

(5) The Commission failed to establish or define priority need and the priority use of money.

And in a tight money market it is very important to establish where and what should come first.

(6) The Commission failed to recommend early vascular detection and education centers for the early detection of eye and foot problems and hypertension; and the competent education and counsel for diabetes learning to cope with a life-long problem, with special attention to maternity and marriage.

(7) The Commission did not recommend expansion of the National Diabetes Research Centers to include input from discipline other than acute overt diabetes.

The two discoverers of insulin, Dr. Banting and Charles Best, would be canceled out because they did not satisfy the criteria of the present National Diabetes Centers.

(8) The Commission completely overlooked the needs and problems of 16 million chemical diabetics with arteriosclerotic heart disease whose dependency on health service delivery drains millions of dollars from our national economy this year.

(9) The Commision failed to accent the urgent need for collaborative genetic and environmental research, not one word. Yet, all of the testimony begins with genetic predisposition and environment.

(10) The Commission did not recommend a much needed health protection agency with responsibility to inventory assess cost and determine impact on the Government and people by all major diseases including diabetes, that would identify the order of importance of

these diseases, and that would establish measurable criteria for allocation of funds for research and service delivery.

With due respect to the generally fine work of the Commission, I feel obligated to raise these concerns in light of three major issues for the national interest: Let me intrude a word. I believe, and my colleagues believe that health is a personal problem, and that only when health becomes a threat to the national interest should the Government intervene.

As of this time there is no measure as to when or where or how much or if at all.

(1) The lack of adequate health data for establishment of objective criteria for determination of health expenditure priorities and the allocation of limited national resources for health service delivery.

The Pennsylvania Diabetes Institute recommends the creation of a disease index which will give any disease measurable dimension which can determine whether or not the disease is a national problem and the amount of funds which should be allocated for research. This function should be carried out by the Health Protection Agency noted above. There is already condemnation and conflict at the higher levels of the National Institutes of Health with the figure presented, 10 million diabetics.

There is great contention that is inaccurate.

(2) The need for innovative biomedical research in all the National Institutes of Health which would provide knowledge and basic information for the development of prevention, arrest or remedial therapies and cure, and decreases in current losses to the GNP as well as reduction of other Federal subsidies for health service delivery. We recommend total additional appropriations to all institutes of $123 million— approximately $11 million for each institute.

We often make the mistake of turning to only established organizations for our research efforts. While we need to rely on such groups for a major portion of our efforts, we must not make the mistake of overlooking less conventional resources.

Innovation is the key to successful research, and often, this comes only from new thinking, new ideas, unhampered by preconceived notions about the problem.

James Webb, former outstanding administrator of NASA in our successful space ventures, proved this point convincingly by initiating basic research and providing resources to carry it out to large numbers of institutions without previous track records in any given scientific field. Most informed observers credit this approach for the many rapid breakthroughs in space technology. We have a similar situation in connection with our research efforts in the field of diabetes.

(3) For all health expenditures, the loss to the GNP in 1976 was approximately $105 billion in the form of loss productivity, $3.5 million in uncollected Federal tax revenues, and $118 billion for demand services. For diabetics alone, $9 billion for the GNP, $200 million from uncollected tax revenues, and an estimated $12 billion in Government health care subsidies.

"U.S.A. Health-1975"-published by HEW, contributed this statement: "In calendar year 1973, the United States spent $99 billion for health and medical care-four times the total amount spent in 1960, roughly eight times the total amount spent in 1950." The current rate of growth is 10.4 percent.

70-075 76 pt. 7 26

As I learned only the other day, the present expenditure for health care and delivery is now $118 million.

In brief, 9 million onset diabetics, plus 16 million chemical diabetics, last year in this Chamber Dr. Cooper testified that 50 to 75 percent of all of the patients with arteriosclerosis probably were diabetic, there is no question that they suffer from chemical diabetes, which is abnormal carbohydrate tolerance, in brief, 9 million onset adult diabetics plus 16 million chemical diabetics, a significant part of whom are crippled to the point of effecting a $9 billion loss to Gross National Product, and a cost of an estimated 10 to 15 percent of the $18 billion spent for health care and delivery, are a serious jeopardy to our national interest.

Such a reoccurring annually ascending loss is an unacceptable threat to national fiscal stability.

The combined loss of GNP, expenditures for demand services in the form of health care and health delivery, and reduction in Federal tax returns sums to an intolerable taxpayer burden of $223 billion, which can be expected to recur with a 10 to 20 percent increase during each subsequent year.

Thank you very much for allowing me to appear here today. If you have any further questions, I would be happy to meet with any of your staff, or to submit additional written statements.

Mr. FLOOD. Thank you very much.

Mr. STENZLER. Thank you, Mr. Chairman.

Mr. FLOOD. Is Dr. Richard Field here?

Mr. STENZLER. Dr. Field called here yesterday saying he would be here, he called me last night and said he would be in on the 1 o'clock plane.

I don't know what has occurred and he has not appeared; he just isn't here.

Mr. FLOOD. Daniel Hawkins?

Mr. CHACON. Mr. Chairman, Mr. Hawkins couldn't be here, and I will be taking his place.

Mr. FLOOD. We will insert Mr. Hawkins' statement into the record at this point.

[The statement follows:]

SUMMARY OF PREPARED STATEMENT BY DANIEL R. HAWKINS, Jr.

Having spoken with other Migrant Health Care Project Directors throughout the country, I have found that we are unanimous in our frustration at not being able to fully serve our patients' needs, given the present Federal funding level— which has remained constant for the past 3 years. I offered two major points for your consideration in this regard:

(1) While the census of migrant workers had declined somewhat in recent years, the combined effect of inflation and recession, and the resulting unemploy ment have displaced thousands of former migrants from job training and stable employment opportunities, forcing them to again join the migrant labor force in search of work this past summer. Many have returned even more destitute than before, due to inclement weather and a surplus of manpower at harvest time.

(2) While Federal allocations have remained constant at $23.7 million over the past 3 years. inflation in overhead and supplies costs, malpractice premiums and specialty referral charges has spiraled, with rates in some categories exceeding 100 percent. Whereas before, some supplemental funds were available at year's end, this source has rapidly dried up as projects experience budget deficits for the first time in history. State and local governments, considering the migrant problem as a Federal problem, are unreceptive to our requests for assistance;