FOREWORD

Medicare began on July 1, 1966, and within 100 days more than 1.5 million persons had received benefits and in excess of 17 million persons had received the peace of mind which comes with the knowledge that their major hospital and medical bills will be paid under an insurance system.

It is easy to agree with the Under Secretary of Health, Education, and Welfare, Wilbur Cohen, who described such results as truly momentous. We in this Nation can take some pride in the fact that we have, at last, taken historic action to relieve one of the most haunting problems of advancing years-inability to pay the high costs of care during and after catastrophic illness.

But the long struggle over Medicare has, perhaps, diverted some of our attention from other aspects of health care in the United States. Now that emotions and arguments about Medicare are less heated than they were before its passage, perhaps we should now turn our attention to measures designed to reduce the toll taken by chronic disease among older Americans.

The Subcommittee on Health of the Elderly of the Senate Special Committee on Aging has an obvious interest in examining and evaluating potential health advances.

Aware of great and growing interest in comprehensive health screening programs, the subcommittee conducted hearings on this subject this year and heard from distinguished witnesses familiar with individual programs and national needs.

This report is a summary of major points made by witnesses at the hearings and others who wrote to the subcommittee. It offers recommendations for legislation to accelerate development of several kinds of health-screening programs.

Clearly, screening alone will not end all health care deficiencies in this Nation. But it can become, as one witness described it, a "new entity" providing a much-needed service while it alerts both public officials and private citizens to the need for preventive medicine.

As I said at the hearing, we now live in a golden age of treatment and a dark age of preventive medicine. It is time that we express our national interest in efforts that will reduce the price we pay for permitting disease to debilitate its victims before we finally deal with it. This report should help us to see that national interest more clearly. MAURINE B. NEUBERGER, Chairman, Subcommittee on Health of the Elderly.

V

HEARINGS

This report is based on subcommittee hearings conducted by Senator Maurine Neuberger, subcommittee chairman, on September 20, 21, and 22, in Washington, D.C.

Additional statements and letters are included in an appendix to the hearing record.

The transcript of hearing testimony will be referred to as "hearings" in this report. References to pages of hearing transcript will be identified as (H. p.-).

DETECTION AND PREVENTION OF CHRONIC DISEASE UTILIZING MULTIPHASIC HEALTH SCREENING TECHNIQUES

PART I

INTRODUCTION

Technological wonders abound all around us-in industry, in space exploration, in the instruments of war, and in other ways in which this Nation demonstrates its ingenuity.

In medicine, too, progress has been dramatic and in some ways awesome. Mechanical devices, performing the functions of human organs, have already saved lives. Surgery becomes more and more dependent upon engineering marvels. Our researchers study life itself with the help of new instruments unknown only a few years ago.

Within recent years, growing numbers of experts from several disciplines of science have asked with increasing intensity whether we can now turn our new knowledge and instruments to uses that will help combat chronic disease.

To many, it seemed that the new technology had come at the time of greatest need, as Americans look forward to an increased lifespan and a concurrent increase in susceptibility to diseases that disable or weaken.

Why, they asked, should we continue to think and act primarily in terms of treating illness. Why not prevent disease if we can?

Obviously, early detection could become an effective weapon in preventing disease if applied on a wide scale with effective techniques. For that reason, multiphasic screening programs have received increasing attention and specific study by this subcommittee.

MULTIPHASIC SCREENING-DEFINITIONS AND DISCUSSIONS

There is a profound difference between screening and diagnosis. Dr. William J. Peeples, commissioner of the Maryland State Department of Health, gave the subcommittee the following description of differences in single purpose screening, multipurpose or multiphasicscreening, and diagnosis:

Screening tests are procedures which sort out those persons who may have abnormalities from those who probably have none. Multiple screening is the simultaneous use of two or more screening tests. Its major aim is the early detection and subsequent treatment of disease found. Screening programs were first developed as case finding tools in the control of syphilis and/or tuberculosis. Techniques and tests are now available which make it possible to screen for many diseases. The term multiple or multiphasic screening refers to the use of some of these tests when an individual is screened for more than one disease at a single visit (H 41-42).

The commissioner made it clear that screening is not aimed at the ill, but at the apparently well:

The fact that any given test, technique or procedure is available as an aid in the diagnosis of a particular disease does not automatically qualify this test for use as a screening tool or device. The primary purpose of screening is not diagnostic. It is directed at selected populations of apparently well individuals. It is a selective elimination to find those people who should undergo diagnostic procedures. A screening procedure must be reasonably capable of selecting from a large population those persons most likely to have the disease for which the procedure is used. Such individuals, many of whom are unaware of any illness, are then referred to their physicians for definitive diagnosis. This enables the person with suspicious screening findings to obtain maximum benefits from early diagnosis and treatment. Studies have shown that screening tests have brought many people with asymptomatic but significant disease, especially chronic diseases, to medical attention (H 42).

Frederick C. Swartz, M.D., chairman of the Committee on Aging of the American Medical Association, gave the subcommittee another authoritative definition:

In our office, we recognize and subscribe to the definition of the National Commission on Chronic Illness of "screening" as the presumptive identification of unrecognized disease or defect by the application of tests, examinations, or other procedures that can be applied rapidly (H 146).

Dr. Swartz also said that tests used in the multiple screening program should be simple to administer; easy to interpret, relatively inexpensive, require little time to perform and should meet criteria on reliability, validity, yield, and cost suggested by the Commission on Chronic Illness.

Dr. Robert H. Ebert, dean, Harvard Medical School, explained the role of screening:

This is a screening; it is not really diagnosis. What it attempts to do is to either indicate that there may be disease present or there probably is not disease present, at least of the diseases that have been screened for, but it does not as a rule make a specific diagnosis (H 13).

Merlin K. DuVal, M.D., dean, College of Medicine, University of Arizona, in a letter to the subcommittee states:

I do think it is important, however, to note that multiphasic screening is essentially a technique for combining and compacting objective measurements of the human body. It does not, of and by itself, prevent anything and those who would misrepresent it in this fashion do it a disservice. In other words, when multiphasic screening reveals a positive finding, if it is sustained, it indicates the presence and not the imminence of an abnormal situation, illness, or disease. Naturally, as a tool which can result in remarkably early diagnosis, it may have inestimable value in preventing secondary complications or expressions of an illness when it results in early therapy for the primary condition (H 340). [Emphasis added.]

C. J. Wagner, M.D., Chief of the Bureau of Medical Services in the U.S. Public Health Service, emphatically noted that screening is meant to identify disease prior to the onset of clinical symptoms:

Let me give some examples. An individual can have glaucoma or coronary heart disease and have absolutely no symptoms of the disease. Similarly, cervical cancer is completely asymptomatic in its early stages. Screening tests such as tonometry, electrocardiography, and cervical smear can greatly aid in the identification of the pathological evidence of these diseases.

Screening of apparently well persons, particularly among the aged, can also lead to detection of advanced, but unrecognized diseases, often symptomatic and even disabling, but sometimes attributed by the individual to "old age." While recognition of previously unknown advanced disease does not provide the opportunity for early intervention in the disease process, it can still be beneficial if, for example, a diabetic's leg or a glaucoma patient's sight can be saved even for a few years. Detection of previously unknown diseases, even at an advanced stage,

often provides an opportunity to halt further progression of the disease, to extend the useful years of life, and to rehabilitate the patient (H 141).

WHAT IS ILLNESS?

WHAT IS CHRONIC DISEASE?

Dr. Austin Chinn, Chief of the Gerontology Branch of the U.S. Public Health Service, made a fundamental distinction between illness and disease:

Disease
The

We use these terms interchangeably very frequently, and erroneously. is a process; sickness is a series of symptoms emanating from that process. early detection of disease may be influential and importantly influential in the retardation and, indeed, in the prevention of sickness and disability from disease (H 298).

Dr. Swartz in defining chronic disease stated:

The proposed definition of "chronic condition" is as follows: "Any condition that (a) is outside the pale of normal variance and that is abnormal in a recognizable, functional or structural way, either before or after a complete history, physical and laboratory examination, and (b) has been present for or can reasonably be expected to persist for some period of time” (H ̊143).

Dr. George James discussed the total history of disease:

The first stage is composed of the risk factors, the one in which Senator Neuberger and I have labored together, the role of cigarette smoking being the first phase in the natural history of six or more major diseases.

*** far more can be done to control first stage factors by the more complete use of human ingenuity. Fluoridation of public water supplies has engineered dental caries control. Seat belts and other automobile safety features can reduce the toll from highway accidents. Research in cigarette filtration and the chemical content of tobacco may someday reduce the toll from lung cancer and heart disease, and the food industry even now possesses the technical knowledge which would make possible an extensive reduction in the saturated fat content of the average diet without affecting palatability.

The second aspect of disease, the stage 2, begins as these processes start to develop within the patient. By means of detection tests, scientists are becoming increasingly adept at finding these early symptomless signs of early illness. In fact, many of these same tests can also detect changes so early that they are more nearly indicators of a possible risk factor than a developing disease. Valid detection tests, as Senator Neuberger has mentioned, exist for a large number of illnesses; diabetes (our seventh leading cause of death), glaucoma (our second leading cause of blindness), hypertension, coronary heart disease, anemia, tuberculosis, lung cancer, syphilis, nephritis, cervical cancer, gout, and many more. Some indicators of first-stage risk, such as higher-than-average blood sugars, serum cholesterol, and uric acid may also be a first step in a program for the maintenance of health.

**The third stage of the natural history of disease is the regular clinical medicine period. It is what most people think of when they think of medicine, doctors, medicare, veterans medical care, and what medical schools are supposed to teach.

But clinical medicine is greatly dependent upon the symptoms for its opportunity to get at the patient.

However, in chronic disease the symptom is a poor indicator of both the significance of the disease and the best time at which to attack it. One study of patients with cancer indicated that people from certain cultures are twice as willing to seek medical care after a given symptom as those raised in a different cultural pattern right within the United States.

Moreover, in many types of cancer and numerous other chronic diseases the practice of waiting for the symptom to appear can greatly lessen the chances for survival and increase the risk of disability.

Just to complete the four stages the fourth stage of the natural history of isease is the chronic period when hope of cure is replaced with the goals of

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