More than 4 cases of previously unknown diabetes per 1,000 screened were diagnosed by the private physicians in followup of these surveys. In glaucoma detection, the physician tests for pressure in the eyeball-and this does take a physician because it is delicate business. The testing instrument is called a tonometer. It measures pressure much the same as weighing something upside down. If the pressure is found to be abnormal, then an ophthalmologist checks the vision. If glaucoma is found, medication may be prescribed. A public health nurse may help teach the patient the proper use of the medication.

Glaucoma screening survey, Ottawa County, May 1959

Again, the results are the important thing. There were 20 suspects per 1,000 persons screened in this one project. There was no particular difference between the number of cases found in men and women. But there were four times as many cases found among persons over the age of 60 than among those under 60 years of age.

REHABILITATION

Now, then, we shift to the Saginaw chronic disease unit-a comfortable place-not plush but comfortable-where the patients' rooms have television sets, and there are fixtures such as hand railings along the corridors, so the patients can help themselves along with a little security.

There is a patients' dining room where they get together to eat, and an all-purpose room. Here the unit is equipped with devices such as a trapeze suspended from the top of the bed and the patient with good arm muscles can use the trapeze to get to the wheelchair, and then sail along and bid goodbye to that bed. This is one of the first steps in helping folks get along and do as much for themselves as possible. As you go through the unit, you see a variety of patients: One lady is blind. She was in a home for the aged and broke her hip. She was brought into the chronic disease facility bed fast. She has been able to get up. She is now learning to put her shoe on with a long-handled shoehorn. The determination in their faces and hands tells a story.

One fellow is exercising his arm muscles and his wrist muscles in the occupational therapy room. He is a person 79 years old with arteriosclerosis. Again the determination to come back. Another lady is on a tilt-table. This is tilted into a horizontal position and she is learning to use her legs once again-to gradually strengthen them.

This lady is learning to walk using parallel bars. The belt around her waist is attached to the overhead track in case she stumbles. She is 53. She came in with her right side paralyzed and was bedfast. Now she is walking toward the wheelchair, and she hopes her next step will be toward home.

Here is a 64-year-old man with diabetes who lost his left leg below the knee. He is learning one of the most difficult things that one can do with crutches-to walk upstairs.

This is a 71-year-old victim of a stroke learning to go down the stairs. In addition to the difficulty with her arm and with her leg, she has difficulty in talking-aphasia, it is called.

Here is a speech therapist with the very patience of Job, himself teaching things by means of association, the use of a picture of a telephone in this case, and the reward when the patient says: "How are you?"

Here is a 22-year-old person paralyzed as the result of an accident, completing the 12th grade with the help of a visiting teacher.

This woman is 60 years old. She came in bedfast because of a heart condition, and now is progressing and making stuffed animals to earn a little extra money on the side.

This man, 72 years old, came in bedfast with a heart condition. He is now taking some interest in woodwork and learning to use plastics. In another corner of the occupational therapy room we see some folks in a group. They have the opportunity to work together and yet the expression on their faces shows concentration in their own individual work.

Saginaw County Hospital chronic disease unit, Sept. 3, 1958, to Sept. 1, 1959

This is a summary: There were 112 persons admitted to the unit in the year ending September 1, 1959. At the time of admission 48 of the patients were judged by physicians to have rehabilitation potential, and 42 more had some doubtful rehabilitation potential.

SAGINAW COUNTY HOSPITAL CHRONIC DISEASE UNIT

(Sept. 3, 1958, to Sept. 1, 1959)

Patients discharged: improved, 37; unimproved, 6; total, 43.

The discharges in that same period of time, the first year of operation: 37 improved; 6 not improved, and most of the persons of the 37 that were improved were discharged to their own homes.

Here is a lady who was discharged to her own home. She is making the grade. She is talking with the public health nurse, again financed with Federal funds, who helps form the bridge between the hospital program and the local health department home care programs. Here this 80-year-old is doing the things she likes to do in her own kitchen, and here, coming down the front steps. She says,

"My friends say that I am stubborn and maybe that's so, but I just want to get on by myself, and I am.”

RECOMMENDATIONS

To sum this up, Senator McNamara, we make four specific recommendations for the consideration of your committee.

First, we would recommend that local health services be strengthened. A great deal depends upon local government, and local government will not shirk its responsibility, but more State and more Federal participation is necessary if we are to develop some of these services.

The second point-and most important of all-we strongly recommend that you give preventive medicine the first priority. Now the problems of those who are already aged are manifold, indeed, and yet if we are to build for the future we must remember that the child today who does not get poliomyelitis vaccine may well show up as the cripple of 1999. Communities need more help for these preventive health services.

Our third recommendation would be that we get more realistic about payment of care in nursing homes by government and find some way for government to carry its fair share. Cheap service is not good, and cheap service is often not economical either.

Fourth, we would recommend that there be further broad-scale exploration of public testing programs, and we would intensify the partnership of public health, private medicine, hospitals, nursing homes and home nursing, as well as the public chronic disease hospital. It may seem a long way between what we are doing and what needs to be done, Senator McNamara and Mr. Ford, but it isn't nearly as far to go as it is from the earth to the moon; it is not nearly as expensive to travel; it is just as exciting and, in our opinion, it is much more rewarding.

We appreciate your consideration in giving us a little more than the usual time, and I will be happy to do my best to answer any questions.

DEVELOPMENT OF SAGINAW CHRONIC DISEASE UNIT

Senator MCNAMARA. Doctor, we don't have any questions. Your testimony is excellent and very dramatic and the slides are very worth while. Tell us about this operation in Saginaw. This facility that does seem to be doing miracles, really. Is that supported largely by local funds?

Dr. HEUSTIS. It is supported entirely by local funds. The only other than local funds they get at all would be the categorical Federal grant programs, where they may get a small amount of Federal money, but the primary source of funds to build it and maintain it is local.

Senator MCNAMARA. Thank you. I expect it would qualify for Hill-Burton funds, would it not?

Dr. HEUSTIS. They didn't qualify for Hill-Burton funds. They built the building, as you can see, and they have a 50-bed hospital for

43350-60-pt. 6

$158,000, and they have some things that would not meet Hill-Burton specifications.

Senator MCNAMARA. How old is it?

Dr. HEUSTIS. It was built in 1958-started in operation in the fall of 1958.

PERIODIC HEALTH EXAMINATIONS

Senator MCNAMARA. You indicated it would be of great help if people could get to their doctors earlier and have an opportunity for early discovery of cancer and related things. Isn't the cost of people going for this examination that you mentioned rather prohibitive

now?

Dr. HEUSTIS. I have no

Senator MCNAMARA. Do you have any figures on that?

Dr. HEUSTIS. I have no figures on that. The care or the payment of physicians is not in the hands of the health department. This is handled by the crippled children's commission and by the social welfare department. They might have some figures on that, sir.

Senator MCNAMARA. You know we have had some of the representatives of the medical profession before our committee, and they highly recommend physical examinations.

Dr. HEUSTIS. Don't use the word physical examination. Use the better word, periodic health appraisal. Let me amplify it.

Senator MCNAMARA. I think you need to because they mean the same thing to me.

Dr. HEUSTIS. There is a whale of a difference. In a physical examination you go in and take off your clothes-and if anyone wants to know my test of a physical examination it is in direct proportion to the clothing they have to take off-but there is more to a health appraisal than that. There is a very careful history and this does not come within the connotation of the physical examination. What has the person been doing? If he has been out on the farm pitching hay for 70 years, he can do a few more things than if he has been sitting in an office chair for 70 years or if he has had certain industrial exposure. So, there is a very careful history covering their experience together with the things they would like to do or feel called upon to do. These are all extremely important in giving the best advice for their health. Senator MCNAMARA. I certainly agree with you, and I am sure nobody could disagree with that statement. However, if we have approximately 16 million Americans who are over 65, and as you have very dramatically indicated, there are many problems below the 65 year age, too, we just don't have enough doctors. You mentioned that, in passing, in your statement. How would you go about examining 16 million Americans to any degree-when I used the term "physical examination," I think it would indicate even less of an examination than your phrasing. It presents a tremendous problem.

Dr. HEUSTIS. Yes, but one of the things that could be done right away with the expenditure of very little money and with the present medical manpower is this process of screening. It could be done with the cooperation of the private physicians and local health departments agreeing upon a battery of from six to a dozen different tests, most of which could be done by nonmedical persons, but under medical supervision and with medical criteria. These tests would be reason

ably simple to give. They could be evaluated by physicians. Those persons found to have a possible abnormality could then be referred to their physician for diagnosis and treatment. We could at least weed out those with the greatest need to consult their physicians.

Senator MCNAMARA. I think perhaps this recommendation is about as sound as any we have had in all of our testimony.

Dr. HEUSTIS. It makes sense to us.

Senator MCNAMARA. But even the semiskilled, these technicians who do the job, isn't there a tremendous shortage of those?

Dr. HEUSTIS. There is a shortage of all personnel, but we can find enough people to do work of this type.

Senator MCNAMARA. If we have the will to do it.

Dr. HEUSTIS. If we have the will to do it, that's right. This is based upon mutual trust and mutual cooperation between Government and private enterprise.

Senator MCNAMARA. This we need to develop, as you well know. You are the fellow right in the middle between Government and the professions we are talking about.

Dr. HEUSTIS. It is a very enjoyable spot.

Senator MCNAMARA. I think on both sides there is a need for recognizing the problem, from both sides. I am sure you are the pivot man on this problem. Can you estimate the savings in both lives, and particularly money, yielded by the screening and preventing of major illnesses? Would there be a tremendous economic saving, as well as saving of lives as you have mentioned?

SAVINGS THROUGH SCREENING

Dr. HEUSTIS. This, of course, is tremendously true. We get into pretty fantastic figures. I have no statistics available here but those who know how much it costs to take care of a dependent blind person would give you some idea. I have often thought it is much more economical to spend $15 a day-this is about the cost of care in a chronic disease facility-for 4 or 5 or 6 months than it is to spend $3.50 per day for the rest of a person's life. To me, this makes sense, and I would not give you the impression that everybody who is bedfast may be put back to work either, but our figures show approximately 15 percent of persons now bedfast in Michigan nursing homes have rehabilitation potential, at least up to a state of self-care.

NURSING HOMES: LICENSING AND ENFORCEMENT

Senator MCNAMARA. Doctor, do you have any authority in the field of nursing homes as to their license operation?

Dr. HEUSTIS. We license them, yes.

Senator MCNAMARA. Have you had occasion to close any of them, or many rather, in the State of Michigan?

Dr. HEUSTIS. One hundred twenty-five homes-I think the figure is correct-have been voluntarily closed over the past 3 years. I think that was the figure I had. Yes, sir, 125 homes closed, changed locations or reduced bed capacity. Of the 125, if my memory serves me correctly, 75 were closed. This was done without going to court. We have had some administrative hearings. We have had excellent cooperation from the Michigan Nursing Home Association. Their offi