Another example: Diabetes can be very easily detected, and its complications controlled, if it is detected early, and yet of this very progressive disease, it is estimated that some 2 million undetected cases are in the population, and, moreover, that we are making very slow headway in uncovering these 2 million cases (H 136).

Mrs. Rice reported on the findings of a study giving hypothetical savings that could result from wide-scale application of screening programs for one major chronic disease:

Considerable savings can be realized by detecting disease in its early stages before symptoms become apparent, before disabling complications have developed and while it is amenable to treatment. If a death is prevented, the potential savings are high, especially if death would have occurred during the productive years.

The estimates of earnings losses presents a framework for evaluating screening programs which are designed to detect and diagnose illness at an early stage, thereby reducing or deferring disability and preventing premature death.

Preliminary results of a new study of benefits associated with a 5-year cervical cancer screening program show that the anticipated pay off would be high$9 dollars returned for every dollar invested. This study was conducted by an ad hoc committee in the Department of Health, Education, and Welfare as part of the Department's efforts to examine the objectives, benefits, and costs of existing and alternative programs. The report has not yet been released, but the findings are of special interest to this committee.

Costs of a 5-year cervical cancer detection program, involving inpatient and outpatient hospital screening and special screening projects, were developed in considerable detail.

The program anticipates that a total of almost 7 million women would be examined, over the 5-year period, more than 80,000 cervical cancer cases would be found and approximately 34,000 cervical cancer deaths averted.

The dollar benefits associated with this program were estimated in terms of savings of high treatment costs for invasive cancer and savings from death reduction. The procedure was laborious and detailed, but the expected payoff illustrates clearly that screening programs are a good investment not only from a health, but also from an economic, viewpoint (H 73). [Emphasis added.]

Dr. Michael DeBakey stated in his testimony that he had treated approximately 15,000 heart disease patients during his career. He stated:

I am convinced that if we had had the knowledge and the tests to detect many early stages of disease, a large number of illnesses could have been avoided. No doubt about it, in my mind (H 39).

Dr. DeBakey further stated:

For example, we know certain forms of heart disease, due, say, to rheumatic fever, and this is a condition we could prevent if we could do it on a mass detection basis and methods for doing this are available. If we could also treat these people at an early stage, we could prevent most rheumatic heart disease. We could prevent it today (H 41).

Finding 5

At best, less than 3 billion is spent on all forms of preventive medicine. There is a great need for additional efforts to prevent chronic disease on a national scale. Early detection appears to offer the most practical approach

Making all possible allowances, Mrs. Rice made an authoritative estimate about the extent of programs and projects now underway to curb chronic disease:

Precise figures on expenditures for prevention of disease are difficult, if not impossible, to estimate. By stretching the imaginations and the figures a bit, and classifying as prevention expenditures all public and private expenditures for medical research, for public health activities, and for physicians examinations without sickness, the total amounts to less than $3 billion in 1963, about 8 percent

of our total national expenditures [for health.] This is clearly an overestimate of health prevention expenditures because public health activities include many demonstration and treatment programs. In addition, a not insignificant portion of current medical research is also for research in improved treatment methods (H 72). [Emphasis added.]

Distinguished witnesses made it clear that a major imbalance exists in allocation of health resources. They urged greater emphasis on prevention. Some excerpts:

Robert H. Ebert, M.D., dean of Harvard Medical School:

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 (H 12).

George James, M.D., dean of the Mount Sinai School of Medicine and consultant to the President's Office of Emergency Planning:

I think it is important to note that today the full force of modern medicine is able to effect a major, year-by-year impact upon the trend of only a very few of the 20 leading causes of death and against none of the major causes of disability. The fullest application of what we are now capable of doing in therapy holds less promise than the hope offered by the new approaches of some future day *** Now, because of the relative impotence, then, of modern medicine to make a major impact against our modern cripplers and disab.ers, we find it more useful in the medical and public health field to consider that the present quality of medical care is poor *** You will have to say it is poor. It is poor because it is so far incapable of dealing effectively with our present killers and cripplers. We need to look for some new approaches (H 18).

Each of us at all times is in the various stages of the natural history of a dozen or more diseases. Generally, the term "preventive medicine" has been reserved for the attacks on the first two stages of disease. However, in a larger framework we might accept as preventive medicine any procedure which interrupts the natural history of disease at any stage in favor of the patient (H 22).

Dean Beattie:

The establishment of programs which have as their goals the prevention and early treatment of the chronic diseases should do much to prevent the tragic social consequences of such diseases for all in the population, and in particular for those in their later years * * * Many of the tragic conditions found among today's aged are closely associated with our past and present emphasis on treatment of chronic disease after the fact (H 24).

Cardinal Ritter:

If we have the necessary foresight and fortitude to disavow our present fireman's approach to the problem of chronic illness, we truly recognize the shifting pattern of illness today and give proper recognition and attention to the maintenance of good health as a priceless possession for ourselves and for our children. If the development of a national plan for early detection and prevention of chronic illness could be implemented which would but partially alleviate or minimize the awesome social, economic, health, and personal losses, it would be a blessing to the Nation. It would be a first step, but a meaningful one to restore the worker to industry, the citizen to society, and the man to himself (H 32).

Dr. Michael de Bakey, professor and chairman, the Department of Surgery, Baylor University, Tex:

But this simply exemplifies the need for more aggressive effort in this general area of detection, and development of better methods of finding diseases, to provide for more effective prevention. Obviously, it is impossible to prevent something that you cannot expect is going to take place, but if you can detect it early enough you can find means of preventing it.

This is true, for example, in the stroke area, an area in which we have had considerable experience. As you may recall from the report of the President's Commission on Heart Disease, Cancer, and Stroke, we indicated it would be possible to reduce the incidence of strokes considerably if detection centers could be developed all over the country and the available knowledge directed to a large segment of the population (H 37).

Morris Collen, M.D., director, Permanente Foundation Multiphasic Health Screening Clinic, Oakland, Calif.:

Diabetes tends to be primarily an inherited, family condition. But what we hope and one of our epidemiological spin-off research studies is directed exactly to this: If we can detect early diabetes before it has developed symptoms in the patient, some of the newer drugs hopefully will prevent or postpone the clinical diabetes, the complications of diabetes (H 221).

Dr. Chinn:

For a preponderance of the chronic diseases, the scientific cause is not yet well enough understood to permit us to initiate large-scale efforts for the primary prevention of the disease process itself. The onset of these diseases is generally insidious that is, a long, pathological, preclinical period generally precedes the acute painful, disabling phase of diagnosed illness. Halting or retarding progression of the process before it causes symptoms and disability is a very tangible form of prevention, and a great many of the chronic diseases lend themselves to such an approach. The concept of prevention is therefore based on the assumption that the progression of a disease from its early to its more severe stages may be retarded and even prevented through early detection of an abnormality, hopefully prior to clinical symptoms, supplemented by appropriate guidance and care. Controlling a chronic disease in this manner can serve to eliminate a measurable degree of sickness and disability that would otherwise occur, and can prolong the productive lives of the affected individuals (H 301).

Finding 6

Multiphasic screening shows great promise as a practical method for early detection of chronic disease. Widespread increases in multiphasic screening will result in technological advances and accelerated effectiveness

Multiphasic screening, as has already been noted, is the application of two or more tests at one examining site for presymptomatic evidence of defects or abnormalities that may be indicative of disease.

Screening programs are not new. Dr. C. J. Wagner, Assistant Surgeon General in the U.S. Public Health Service, told the subcommittee that the National Conference on Chronic Diseases helped focus national attention 15 years ago on the need for early detection of hidden disease. Dr. Wagner described subsequent developments:

In the years that followed, the Public Health Service steadily intensified its efforts to test many of the existing screening techniques and to develop new and better screening procedures, including questionnaires, laboratory tests and, more recently, electronic devices and computers. Screening demonstrations were supported to create prototypes as models for communities throughout the Nation. These included both single disease and multiple disease detection programs. They have ranged in scope from 5-year programs to demonstrate high quality diabetes screening procedures and exhaustive work in the instrumentation of electrocardiogram reading through relatively large multiple screening programs for urban areas, to a limited multiple testing program for a Spanish-speaking poor population in New Mexico (H 141).

Dr. Wagner said that during fiscal year 1966 approximately $13 million was spent by the Public Health Service on the development and testing of screening methods, support of community demonstra

tion projects and, through the formula grant mechanism, support of State and community screening services and programs.

The subcommittee also received testimony indicating extensive screening activities in California, Georgia, Michigan, Maryland, Oklahoma, Tennessee, and the District of Columbia. Letters from health officials in other States described current screening programs, and some expressed hopes for broadened health testing projects.

RECENT ADVANCES

Although some programs mentioned above date back to the late 1940's, witnesses made it quite clear that major advances-made within the last few years-have considerably broadened the effectiveness of modern screening programs.

Automated Chemical Analysis of Blood

Dr. Ralph Thiers, director of the clinical chemistry laboratory at Duke University Medical Center, described progress made in automated chemical analysis of blood-a basic process in any screening examination. He said that Dr. Leonard Skeggs developed continuous flow analytical procedures:

*** One tremendous bonus of the continuous flow analytical system is that one can split the stream. And this is where the toughest nut of all, in laboratory medicine, namely, clinical chemistry, got cracked. Because when the stream could be split, you could do a sugar analysis on one of the tributaries by treating by one technique, but you can treat another tributary by a different technique, and do an analysis for urea, for example. And you can treat a third tributary by a third technique (H 122).

Dr. Thier demonstrated an automated blood chemistry analysis instrument before the subcommittee in the hearing room and said: The instrument shown here today splits the stream 12 ways. And in one sample of blood serum about the size of a teaspoonful, it does 12 determinations simultaneously.

This has meant a tremendous amount to clinical chemistry and in the long run to multiphasic screening. As shown in the next chart, it has taken the output of one technical person which in 1955 was between 10 and 100 determinations per hours (these blobs indicate how rough the data are), and raised it rapidly. In 1960 it was up to between 100 and 200. Today one technician can turn out 300 to 500 numbers per hour. And it doesn't take a crystal ball to see that in another 5 years or a decade these machines will be turning out a thousand or 2,000 numbers per hour (H 122.) [Emphasis added.]

To keep data thus gathered manageable, said Dr. Thiers, new model computers can be of assistance. One such device "takes the blood sample as soon as it comes out of the patient's arm and maintains that identity automatically until the results are printed up." Dr. Thiers also foresaw dramatic decreases in the costs of blood chemistry findings as soon as "the tremendous firepower of these instruments" is put to work more extensively.

The manufacturer of the 12-channel AutoAnalyzer demonstrated by Professor Thiers furnished data to the subcommittee showing that the per sample cost for all 12 determinations could be as low as $1.71, or about $0.14 per test.

The subcommittee also witnessed demonstrations of other new instruments.

Medical History Taking by Computer

Dr. Warner V. Slack, assistant professor of medicine and computer sciences at the University of Wisconsin School of Medicine described problems with regard to the medical history as it is traditionally taken:

In the first place, it is very time-consuming *** and incomplete or inadequate histories are often the result of time limitations beyond the physician's control. And as a corollary to this, the medical history process is very expensive * * *. Furthermore, the use of data collected from the medical history is rendered very difficult by the methods used to record these data.

First of all, the traditional illegibility of the physician's handwriting is a major problem, and furthermore, the lack of standardization of these records makes retrieval of this information for patient care and clinical research difficult and often impossible (H 90-91).

Dr. Slack demonstrated a small digital computer programed to take histories with the help of a cathode ray screen, which looks very much like a television screen. Questions flashed on the screen are answered by a patient who records his answers by pressing a numbered key on a keyboard in front of the computer.

Dr. Slack said:

Now, upon completion of this computer-based history, a print-out is generated by means of a teletype machine and the print-out is in a traditional form with the exception that it is legible. Our aim is to provide this to the physician for use in patient care. He will have this complete summary available to him prior to his initial interview with the patient. At the same time, all of the patient's responses have been entered directly into the computer and stored on magnetic tape where they can be used, both for care of this patient in the future and also for purposes of clinical research (H 93).

Dr. Slack added that the cost of the computer on a lease basis is about $600 a month, "*** which is the price of one expensive laboratory technician."

Computer analysis of electrocardiograms and spirograms

Telephone transmittal and teletype responses were used in a demonstration showing that analysis of spirograms (to measure vital capacity and thus help detect potential respiratory abnormalities) and electrocardiograms could be accomplished miles away at a data center within a matter of seconds.

Dr. Cesar A. Caceres, Instrumentation Activities Chief for the Heart Disease Control Branch in the Public Health Service said electrocardiogram findings could be provided within 15 seconds after the signal is received at the distant computer center by telephone wire, or, as he expressed it:

*** long before the physicians at the emergency room have been able to obtain the services of a specialist (H 103).

Spirometric analysis, he added, now would take a physician or trained technician about 20 minutes while utilization of the computer again cuts the time to seconds.

He commented:

In this day when we know that emphysema, a disabling lung disease, is highly prevalent, and we know that smoking is a major cause, we can say with certainty that insufficient numbers of people are being tested for their pulmonary problems. This is so because the spirometric testing requires some degree of additional training for the physician. It also now requires an investment of physician time that might be excessive in view of the numbers of people that require testing, and in view of the large amount of computation time needed to do the analysis by manual methods.