disability limitation, rehabilitation, and readjustment of the individual and his environment in a way which will permit him maximum of self-sufficiency, dignity, and social usefulness (H 19-21).

Thus, chronic disease is not necessarily an advanced or terminal state of illness. It is a process that may affect individuals throughout many years of their lives while advancing through several stages of development.

WHO IS AFFECTED BY CHRONIC DISEASE?

Mrs. Dorothy Rice, medical economist, Acting Chief of the Special Studies Branch of the Division of Health Insurance Benefit Studies, Office of Research and Statistics, Social Security Administration, stated that almost one-half of our population is directly affected by chronic disease. This is demonstrated by the following table:

Number and percent of persons with one or more chronic conditions, by sex and age, July 1964-June 1965

Source: U.S. Department of Health, Education, and Welfare, Public Health Service, "Current Estimates From the Health Interview Survey, United States, July 1964-June 1965," Public Health Service Publication No. 100, series 10, No. 25.

SUMMARY

In this report and in all subcommittee research for the report, multiphasic screening has been regarded as the providing of two or more easily given and readily summarized tests to determine whether screenees have presymptomatic defects or abnormalities which may indicate the presence of a chronic disease. Findings from such tests are to be transmitted to physicians for diagnosis when defects or abnormalities appear.

It is also assumed that multiphasic screening will make use of technological improvements already in use and others which, according to witnesses at the hearing, may soon be ready for everyday use.

ᏢᎪᎡᎢ 2

FINDINGS

Finding 1

Approximately 87,300,000 people in the United States suffer from at least 1 chronic condition-if the present trends continue, chronic disease will become an even greater problem

A concise summary of the extent of major chronic disease was given in a Department of Health, Education, and Welfare study discussed at the hearing. Its major conclusions:

Chronic diseases affect almost half of our total population and more than 7 out of 10 persons aged 45 years and over.

An estimated 87.3 million persons, or 46.3 percent of the civilian noninstitutional population, reported 1 or more chronic conditions for the 12-month period ending June 1965.

Of the 87.3 million persons with 1 or more chronic conditions, 22.6 million, or more than one-fourth, report some degree of of activity limitation.

A total of 14.6 million adults have definite heart disease, and another 13 million have suspected heart disease.

About 13 million Americans report they suffer from some form of arthritis.

There are 2 million known diabetics in this country.

Approximately 1.2 million persons have some visual impairment which results in a limitation of activity.

More than a half million new cancer cases are diagnosed each year.

The vast majority of the 1.5 million persons in institutions are there because of some chronic disability.

More than 70 percent of deaths are now due to three chronic illnesses-heart disease, cancer, and stroke.

CAUSES AND OUTLOOK

Dr. Austin B. Chinn, Chief of the Gerontology Branch in the Division of Chronic Diseases of the U.S. Public Health Service, described the high prevalence of illness and disability resulting from chronic diseases as one of the most difficult health problems we face today. He also gave the reasons for increases in chronic disease:

These include more effective control of acute infectious diseases through sanitation, immunization, and powerful therapeutic agents; increased urbanization with close and often inadequate living conditions leading to physical, mental, and social stresses; the relatively high prevalence of both overnutrition and undernutrition-but particularly overnutrition; and a significant increase in the number and proportion of older persons in the population (H 301).

As the population of older persons increases, said Dr. Chinn, there will be a corresponding increase in the need for institutional beds, along

with the need for more doctors, nurses, dentists, and technical experts. He asked the subcommittee to consider these facts:

Currently, approximately 5 percent of persons over 65 are occupying institutional beds. In 1985, estimates indicate that the aged population will increase to 25 million persons. Based on the existing rate, we would need to have by that time an additional 350,000 institutional beds to take care of just this segment of the population (H 301). [Emphasis added.]

Dr. George James, dean, Mount Sinai School of Medicine, and formerly commissioner of health for the city of New York, states that:

The key to our present handling of chronic disease revolves around the institution. It is doubtful whether we can afford to continue to build institutions fast enough to meet the growing problem of chronic disease among our aging population. I am reminded that by the year 1970 it is estimated we will have over 10,000 people in New York City over the age of 85, which is more than we have nursing home beds available for them, if they all have to be put there, and there are large numbers of people over 65 that will also need institutional care unless we can do something about it (H 18).

Projections were made for California by a public health official who foresees dramatic potential in organized programs of health screening.

For instance, we found out that in California, if the annual death rate expected in California during the early 1970's, based on 1950 and 1960 trends-if we calculate the death rates for various diseases, like lung cancer, we should expect, in the 1970's, in California, according to our population, 7,500 deaths from lung cancer-if the trend of the 1950's continues in the 1960's.

We believe that 3,750 of these deaths, again by projection of our know-how and programs, can be definitely prevented, by just developing a good, wholesome public health program of early detection, and control programs against one factor, stopping cigarette smoking.

Taking, for instance, the breast cancer: The projections we make for the 1970's is 2,700 deaths. By applied public health programs, we believe we can definitely eliminate 600 of these deaths (H 197).

Finding 2

Chronic disease costs our economy an estimated $57,800,000,000

annually

Mrs. Dorothy Rice, medical economist for the Social Security Administration, gave conclusions from an exhaustive study, "Estimating the Cost of Illness," published in August 1966. She described the elaborate methodology used to make specific dollars and cents estimates of disease costs, and gave the following major conclusions on costs in 1963, the year for which her data were collected:

Expenditures for medical care and the treatment of chronic conditions amounted to more than $12 billion in 1963, or 53 percent of the total personal health care expenditures distributed among the various diseases.

Indirect costs of chronic disease amounted to $15.1 billion. This estimate is based on factors including losses in income (a total of 244 million days was lost from work in 1963 due to chronic conditions), institutional costs, and loss in taxes that would have been paid.

Economic cost of mortality caused by chronic diseases was estimated at more than $30 billion. Giving the rationale for such estimates, Mrs. Rice said:

If an individual who died this year had not succumbed, he would have continued to be productive for a number of years ***. For mortality, the estimated cost or value to society of deaths in a particular year is the

product of the number of deaths in that year and the expected value of these individuals' future earnings after sex and age have been taken into account. This method of derivation must consider life expectancy for different age and sex groups, the changing pattern of earnings at successive ages, varying labor force participation rates, imputed value of housewives' services, and the appropriate discount rate to convert a stream of costs or benefits into its present worth (H 71-72).

The economic toll associated with illness, disability, and death in 1963 due to chronic disease, therefore, amounted to $57.8 billion, or far more than half of the $98.5 billion total national direct and indirect cost of all illness.

Mrs. Rice recognized that:

*** there are additional losses that should be considered, including pain, suffering, and grief associated with disability and death. which the economist cannot attach dollar values (H 76).

Finding 3

These are intangible to

Chronic disease is the cause of tragic losses to society and human potential

Walter Beattie, dean of the School of Social Work at Syracuse University, described "the tragic social consequences" wrought by chronic diseases.

"To the individual,"

Said Dean Beattie

"far too often long-term illness results in the loss of self-mastery and an increased emphasis on dependency-physical, psychological, emotional, economic, and social-in a society which places a high value on independence."

Often, said Dean Beattie, chronic disease leads to "depersonalization of the individual when he becomes institutionalized."

He added:

When man thus becomes isolated from his fellow man, he loses that which makes him a human being. [Emphasis added.] All men must belong to a social group. As a society, our approach to aging and long-term illness is that of dehumanizing and depersonalizing the very essence of the human being.

To the community and society, the social significance of chronic disease must be that of the loss of our basic human resources. Our goal should be to conserve such resources and to enhance their contributions to the society (H 25).

EFFECT ON MANPOWER RESOURCES

Dean Beattie pointed out that dependency causes additional strain on our already limited manpower resources. He added:

I am sure all of you are aware of the great scarcity of professional and technical manpower in the helping professions, including those concerned with medical care and social service. By 1975 it is estimated that one-half of our population will be either under 18, or 65 years and over. We must take appropriate steps to assure that these, the higher consumers of health and social services, will have appropriate health, welfare, and educational resources available to them (H 25).

THE FIVE-GENERATION FAMILY

Dean Beattie also saw "many implications in regard to health and social service goals" in the emergence of the five-generation family as more and more older persons live a fuller life span:

The tensions and strains developing among each of our generations as to their reciprocal roles and responsibilities to one another is evident. Today's 40-year

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old is too often concerned with his responsibilities toward his 60- or 70-year-old parent who, in turn, is facing retirement and who is also concerned about his 85- to 90-year-old parent. At the same time, the 40-year-old may be anxious about his 20-year-old child who is getting married or indeed having a first child. The prevalence of chronic disease and tensions of long-term illness of those in such families too often results in social breakdowns which could indeed be prevented through the application of medical and-I would like to underscore this-social knowledge at all stages of the life span (H 26).

EFFECT ON INDIVIDUALS

His Eminence Cardinal Ritter, of the Ritter Institute in St. Louis, Mo., submitted a statement saying that "chronic illness, which virtually incapacitates people completely and permanently" is one of the great challenges confronting the Nation today:

For some the statistics on the mounting tide of chronic illness and its damaging effects may seem distant or academic in nature only. If, however, one could go behind the statistics to the individual or individuals affected-one would then be better able to measure its damaging effects by seeing it engulf the individual or family in pain or despair or death-by seeing it sap the foundation of family life and community life in all parts of the country (H 31).

While the subcommittee made no attempt to elicit specific examples of the effect of chronic disease upon those afflicted and their families, Dr. Leo Gitman, Chief, Gerontology Section, Brookdale Hospital Center, Brooklyn, N.Y., in describing a program in the beginning stage at the Brookdale Hospital Center, lucidly portrayed the effects of chronic disease:

The statistics I have quoted, being aggregate entities, fail to convey the consequences in terms of people-individual people. It is in the microcosm of clinical practice that they become meaningful.

The 60-year-old man, a diabetic, with gangrene of a foot, who refuses to permit amputation despite his constant pain, drags his wife, his children, and their families all into his own orbit of despondency, bickering, and emotional turmoil. Or again, the 55-year-old widow crippled by arthritis, living with an unmarried daughter, who is living her life out in quiet desperation. The 75-year-old man who prided himself on the fact that he had never seen a physician, until a chronic sore on his face began enlarging, and now is a hideous, foul-smelling disfigurement. We can go on, literally ad nauseam (H 270).

Finding 4

The heavy economic and social costs of chronic disease are preventable to some degree

Heavy costs of chronic disease were, in the opinion of many knowledgeable witnesses, preventable to some degree.

Dr. Carruth J. Wagner, Chief of the Bureau of Medical Services for the U.S. Public Health Service, gave these examples:

Studies have been made in various disease categories to determine the extent of undiagnosed conditions which exist today. Here are a few of the important facts:

Use of the Papanicolaou smear to detect cancer of the cervix would prevent thousands of deaths. In fact, it is predicted that if all cervical cancers could be discovered in this way before they become invasive, cancer of this site would be 100-percent curable. Yet the fact remains that more than 8,000 women die each year of cancer of the cervix.

Glaucoma, a serious eye disease causing 14 percent of all blindness occurring among adults, can be identified in its early stages by a relatively simple screening measure utilizing the tonometer. Yet, the fact is that there are approximately 1,300,000 cases of glaucoma among the population over age 40.