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Forrest Brown, M.D., chief of the Community Health Service in the Oklahoma State Department of Health, gave this estimate of reaction to screening programs in that State:

From the beginning, we were concerned about the acceptance of this screening program by the medical profession. We realized that, without the understanding and participation of the medical profession, it would be impossible to attain our goal; that is, patient care in the earliest possible stage of the disease condition. Admittedly, two county medical societies in Oklahoma have declined to invite this program into their county. It is also true that, in some counties where it has been accepted, some physicians have accepted it on a doubting note-You say this is how it will work, but I won't believe it until I see it." To date, with possibly 1,000 physicians in Oklahoma having had contact with this screening program, we have not received a single objection. In fact, once the program was conducted, the physicians were usually generous in their praise of the program (H 250).

Finding 8

The concept of early detection of chronic disease utilizing multiphasic health screening techniques was endorsed by each witness appearing before the subcommittee and almost all persons with whom the committee corresponded. However, some problems and reservations were pointed out.

Every witness and a great majority of those persons corresponding with the subcommittee endorsed the concept of the utilization of multiphasic health screening for early detection of chronic disease. A number of persons did, however, express some reservations or point up problems for consideration by the subcommittee. This report reflects the subcommittee's consideration of the major reservations and problems posed.

INCREASED DEMANDS ON MEDICAL PERSONNEL

This topic was discussed in part in our discussion of finding 7. It should be pointed out that the long-range goal of an early detection program is to detect disease at the earliest possible stage in its development. It is reasonable to assume that if disease is discovered at an early stage and proper corrective measures are taken then, the need for treatment of its resulting illness or disability will be curtailed. It may, therefore, be anticipated on a long-range basis that in many instances the treatment of a particular patient afflicted with chronic disease may be less time consuming than heretofore.

Careful analysis should be given to the role of physicians, engineers, chemists, biologists, sociologists, and other personnel concerned with health in the formulation of early detection programs. It should be kept in mind that one of the expected benefits of multiphasic health screening is the assumption by nonphysicians and nonmedical personnel of much of the data collection responsibility that is now being undertaken by the practicing physician. We specifically have reference to the collection of so-called quantitative data or "objective measurements" as opposed to the exercise of the physicians' judgment in diagnosis.

FRAGMENTATION OF HEALTH CARE

It is the opinion of the subcommittee that this caveat deserves careful consideration in the formulation of multiphasic health screen

be

ing programs. Multiphasic health screening programs can designed and will be most effective when they become an integral part of the health care and medical practice of our Nation.

INSUFFICIENCY OF EVIDENCE OF BENEFITS TO BE DERIVED
FROM A MULTIPHASIC SCREENING PROGRAM

Several persons expressed this reservation. This reservation was discussed and effectively rebutted by Dr. James in his testimony before the subcommittee.

To the charge that final research proof is lacking that detection tests actually do lead to a saving of lives, we have a simple reply. The existing scientific data proving the value of the control of risk factors and early treatment after the use of a detection test are every bit as good as the data upon which we base the application of many well-established clinical measures after chronic disease strikes.

The patient with a coronary occlusion is put to bed, given oxygen, heart stimulants, and possible anticoagulants. The research proof for the validity of any of these measures is quite inadequate. Second, early detection allows us to work with a clinically well patient, offering the hope for keeping him so, instead of fighting an incapacitating illness requiring extensive rehabilitation at much social and financial cost. Third, we cannot condone the principle of the value of ignorance. Even were we impotent to be of assistance, the knowledge of the existence of early disease or risk factors must be considered as an observation of high relevance to the possibility of eventual control. Here is an area over which we must throw more light, where more research must be done-denial of its existence, failure to recognize its presence firmly closes the door to hope for its exploration. As indicated above, our record in the control of chronic disease limited to the clinical approach is not so good that we can afford to ignore the opportunity for fresh approaches (H 20).

PHYSICIANS WILL BE INUNDATED WITH INFORMATION

The data collection and handling aspects of a large-scale multiphasic screening program could become a problem. However, the subcommittee has been assured by competent witnesses that the presentation of data from the screening program to the physician could be handled competently and effectively. It is reasonable to anticipate that modern computer technology will be adequate to handle the information collected.

THE SPECTER OF DEPERSONALIZATION

A number of persons offered the opinion that multiphasic health screening would be unpalatable to screenees and thus create a hesitancy on the part of the public to submit themselves for screening. The evidence received by the subcommittee indicates that experience with multiphasic screening programs supports a contrary view. Leonard A. Stevens, a prominent medical writer, testified before the subcommittee concerning his experience in the Permanente Health Screening Center.

I have been invited to come here, as you know, to comment on my feelings about it-whether it was an impersonal experience, whether it had qualities of the assembly line, or what.

I have to admit that when I first heard about the center, I didn't know much about it, and some of the terms that go with it-"automated," "computerized," "multitest," and so forth-stirred some rather interesting images.

But actually, in the experience itself, I don't think it is emphasized enough that you are really dealing with people. And these people give you the tests.

You

are not connected into machines any more than you ever would be in a physical examination. They use equipment, and it is equipment that almost anyone may have experienced if he has had a number of physical examinations.

The computer is something that the typical patient going through the center never sees, and I don't think he is even aware that the data is being processed as it is taken from him.

The people giving the examinations do a commendable job. They are obviously selected for their personality, for being able to deal nicely with people. I remember in particular a lady giving the tonometer tests for glaucoma. She was very willing to discuss what she was doing. She would not discuss anything in a diagnostic sense; I don't mean that. But people are interested in this center and in the equipment, and it makes a difference if those administering the tests are willing to talk to you.

I think this was revealed, in that, after my going through the center, the following day I interviewed a number of the patients to talk about some of the things that you have been asking about. And I found nobody who considered this an impersonal experience. In fact, I don't think they had ever thought about it. They were more concerned that this was a very reassuring experience (H 223).

Dr. Warner V. Slack described the patient reaction to computerbased medical history.

And I should say that the patient reaction to this program has been quite gratifying. They have all enjoyed it, practically all have enjoyed it, found it interesting and have not in any way been threatened by being interfaced with a computer. As a matter of fact, the churning tapes and the flashing lights, I think, have added to it (H 93). .

INCONVENIENCE TO THE PATIENT

A very significant problem is concerned with the location of health screening centers. The subcommittee has received various suggestions for the locations of screening centers. These suggestions include hospitals, medical centers, medical schools, mobile units, separate screening facilities, places of employment, and group practice clinics. It is of utmost importance that the screening facilities be located so that prospective screenees may have convenient and ready access to the facility. Dr. George James stated:

The solution of this problem lies more in our ability to engineer the technique to the normal habits of our population rather than in massive programs of health education. The straddling of crowded city streets with tuberculosis X-ray trailers has proved far more effective * * * than health education and an appointment system (H 20).

ADEQUATE FOLLOWUP PROGRAMS

Without exception, witnesses warned that a screening program, in and of itself, is of no benefit in preventing chronic disease or alleviating its affects. It was emphasized time and again that upon the detection of an abnormality, there must be a followup program to insure that the abnormality is brought to the attention of a physician for diagnosis and appropriate treatment. It is, therefore, of utmost importance that the screening program be designed as an integral part of medical care. A question remains: How may screening programs be most effectively integrated into the mainstream of medical practice?

Finding 9

Multiphasic health screening offers the possibility of converting “an ounce of prevention" from a proverb into an avenue of health for the Nation. Adequate planning, appropriate Government assistance, and the involvement of the medical profession will be necessary.

It is quite apparent to the subcommittee that large-scale screening programs will be fruitless and perhaps harmful if regarded merely as a limited, temporary or trivial appendage to the existing health service

structure.

Screening should be regarded, in Dean Beattie's words, "as a basic community health serivice." Screening cannot stand alone as a separate process but must become part of the national way of life.

President Johnson has ordered a study intended to improve delivery of health services throughout the Nation, and he has asked for a separate study of medical manpower problems. The subcommittee believes that these studies are timely and essential, and it also believes that programs for multiphasic screening will have a basic place in improved delivery of health services of the future.

Such progress in multiphasic screening cannot be expected, however, unless adequate attention is given to: need for Federal incentives in establishment of screening programs, need for adequate followup work after screening, and the need for referral of findings to physicians and for general cooperation from the medical community.

FEDERAL INCENTIVES

Throughout the hearings, many references were made to grants made by the U.S. Public Health Service for development of screening equipment and techniques. The need for such assistance was discussed in the following exchange:

Senator NEUBERGER. As we progress in these hearings I take greater and greater pride in the work of our Public Health Service. We have had wonderful testimony from people, both State public health and Federal Public Health Service. And I think that the case of detecting disease would be 50 years behind if we didn't have this wonderful help through the Public Health Service.

Dr. COLLEN. I would like to agree with this and point out that although much of the research in the past has been directed to symptomatic, therapeutic and restorative medicine, only now, because of the advent of automated equipment and computers, is epidemiological research in chronic disease involving large numbers possible.

The costs of such programs cannot be borne by private groups, only by the Government.

Senator NEUBERGER. We had one machine here yesterday-$17,000. And when private groups say, "Let us do the screening" or "We are leary of this," I always think if we depended on the private groups to the extent you just said, we would make no progress. It seems to me that we have got to have cooperation here between private medicine and Public Health medicine and research engineers, and so on, or we wouldn't get anywhere (H 222).

EVOKING PUBLIC RESPONSE

Dean James and other witnesses said that public apathy could well be a problem. Dr. James, former New York City health commissioner, added:

One overriding difficulty in detection programs has been the lack of patient interest. Even in sophisticated New York City where an active health depart

ment is engaged in the widespread development of detection programs, the following data are highly revealing:

Each year, the New York Health Department clinics detected only one-fortieth of the estimated existing but unknown cases of carinoma of the cervix, onefiftieth of the unknown cases of diabetes, one two hundredths of the unknown cases of glaucoma, and one-half of the unrecognized cases of infectious tuberculosis, where they have one of the largest and most comprehensive programs (H 20).

Dr. James, however, also observed that the solution of this problem "lies more in our ability to engineer the technique to the normal habits of our population rather than in massive programs of health education." He gave as an example the tuberculosis X-ray trailer, which "has proved far more effective in producing high chest X-ray yields than health education and appointment system."

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The subcommittee also heard descriptions of widely varying campaigns to encourage widespread participation in screening programs. In Washington, D.C., for example, visits by a mobile health screening unit is preceded by visits from two community health workers who organize the neighborhood for optimum scheduling of appointments. For a hospital-based project now about to begin in a low-income area in Brooklyn, program directors plan the following approach: In our program, we first identified the characteristics of the community by analysis of demographic data and consultation with experts familiar with this population. Educational approaches, specifically tailored for each major group,

are being formulated.

We have approached the several broad-based action groups in the community with suggestions that each form a strong health committee, and that each of these send representatives to a joint committee representing the community to meet with our department on a regularly scheduled basis at the hospital. These organizations represent the most effective propaganda mechanism for achieving communitywide coverage through its membership and influence.

Our community health educator, who is a respected member of the community, will work with the health committees of these organizations, and guide and coordinate the activity of our community health aids. These aids will be selected from the community, and trained to be our representatives and educators in specific assigned geographical areas. The aids will work with the blockworkers of these organizations.

Hopefully, this kind of community involvement will recruit registrants for the periodic health examinations. In the process, good health concepts will be disseminated, and eventually have an impact on a significant portion of this population, and once the individual becomes involved in this project, we have the opportunity to bring him into the mainstream of medical care, and keep him there (H 267).

In Jefferson County, Fla,. a rural county with a population of approximately 10,000 people, a screening program is located in and operated by the county health department. It has achieved full acceptance by the general population and physicians.

Mr. Martin Sobel, director, city of Hope industrial health screening planning program, told the subcommittee of the city of Hope's plan to institute screening programs in an industrial setting. In association with unions, the city of Hope plans to take multiunit mobile clinics directly into factory parking lots and upon adjacent streets. They project a cost of a penny or a penny and a quarter an hour for the program, which would be included in the labor-management contract package.

Dr. Lester M. Petrie, director, branch of preventable diseases, Georgia Department of Health, urged the subcommittee to aim at the labor force with screening programs. He suggested the establishment of health screening centers by business, industry, occupational,

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