aids, expensive medications, dentures, proper shoes, and necessary medical care. Those people whose economic security is assured have little difficulty in obtaining these items, but there are large numbers who are living on small incomes and are unable to purchase these very necessary adjuncts to comfortable living. Many of these persons cannot qualify for old-age assistance and therefore, must obtain medical care from the county departments of social welfare. Whether such care is obtainable depends upon varying standards of each county department, in spite of the fact that the State contributes a minimum of 30 percent of the cost of such medical care (other than hospitalization). Therefore, it is recommended that the State law be amended to provide that the State social welfare commission have the power to establish minimum statewide standards for all assistance programs where the State contributes to the cost of such programs.

20. Migrant workers

Thousands of migrant agricultural workers come to Michigan every year, many accompanied by families which include large numbers of children. These migrant workers are necessary for our agricultural economy, and there is every indication that they will be needed in growing numbers. For many reasons, these families suffer from many health problems and nutritional deficiencies. It has not always been easy to reach these families to help them raise their health standards and to bring them the health services that would benefit them. In recent years, however, our State health department, and local health units, with the cooperation of growers and farm organizations and interested community groups, have been successful in improving health conditions among migrant families in some parts of the State. The time is appropriate, we believe, to look into the health conditions of these families and to plan necessary services in a practical and effective way.

We, therefore, recommend:

(a) One or two demonstration projects be set up in selected counties under the direction of local health departments to determine the kinds of health problems that migrant families have and to plan and develop basic health services for them.

These projects would be carried out in cooperation with growers and with other official and voluntary agencies and, if possible, in areas where special educational projects for migrant families are being carried out.

(b) Financing of the projects would come from the State health department, through an appropriation from the Michigan Legislature for this purpose.

21. Postsanatorium care for patients

Tuberculosis is Michigan's leading communicable disease. Despite lifesaving gains, far too many Michigan men, women, and children have their lives endangered, interrupted, and handicapped by this disease. Most patients leaving Michigan's 21 public-supported sanatoriums continue treatment at home. As a rule, 12 to 18 months of such carefully supervised treatment follows discharge from the hospital. This prolonged treatment is focused on prevention of relapse. In the past, as many as 3 of every 10 tuberculosis patients who were discharged from the hospital later returned, their disease again active. Besides the loss to the patient, his family, and community, relapse means the expensive course of isolation and treatment is repeated. Specialists treating tuberculosis are convinced that continuing medication and close observation for the patient after sanatorium discharge improves the patient's chance to stay well, protecting the investment of many thousands of tax dollars already made in his treatment. To assure effective followup and supervision, State assistance is needed in financing approved postsanatorium home care. It is recommended that State financial assistance should be given to the counties in providing post sanatorium care for tuberculosis patients who are at home with the approval of the local health officer.

V. STRENGTHENING VOLUNTARY PROGRAMS

22. Expanding our voluntary health insurance programs

Voluntary health insurance has made remarkable strides in the past decade in Michigan. Enrollment in the nonprofit plans (Michigan Hospital Service and Michigan Medical Service) and in the private insurance plans includes over 80 percent of the State's population for some type of health insurance coverage. The most widely held type of protection is for hospital care, with protection for surgical care also very extensive but held by a smaller proportion. Pro

tection against comprehensive care, including physicians' services in the home and office, and diagnostic and laboratory services for ambulatory patients, while increasing in recent years, are held by only a small proportion of the population. The efforts of Michigan Blue Cross and Michigan Blue Shield to provide more comprehensive benefits are commendable. Other attempts to provide more complete protection are being undertaken and it is hoped that out of this experience more complete health insurance benefits will be made more widely available. Groups in the population which are least well protected are the rural population, particularly Michigan's migrant workers, persons over 65 years of age, employees of small firms, and low-income groups. In addition, some public em

ployees are not yet covered under existing health insurance arrangements. In recognition of the fact that the segments of the population now uncovered constitute, in the main, high cost groups, we support and endorse the principle of communitywide rating for health costs which has been adhered to by the voluntary nonprofit plans, and urged continued adherence to this principle to encourage the widest possible participation in health insurance.

Voluntary health insurance enables people to meet the burdensome costs of medical care and to have access to early diagnosis and necessary treatment. In the interests of preventing unnecessary disability and the consequences of untreated illness, as well as keeping tax expenditures for medical care from increasing, we believe in the widest possible participation in health insurance. A start in meeting this objective would be the inclusion of two groups among whom health insurance is not now widely prevalent-public employees and migrant workers.

(a) A number of States and political subdivisions have arrangements under which the political unit, as an employer, contributes on behalf of the public employee for protection under voluntary health insurance. New York State, Massachusetts, New York City, and Philadelphia have such programs. The executive branch of the Federal Government has recommended such a plan for Federal employees. Many private employers contribute toward the voluntary health insurance protection of employees and their families.

We recommend that the State of Michigan, as an employer, contribute on behalf of its employees toward comprehensive medical care insurance.

(b) Although some migratory agricultural workers and their families have health insurance coverage, the great majority do not. When these migratory workers or their families become ill, they become a responsibility of local welfare and health agencies. We believe that the employer of agricultural labor and the Michigan Blue Cross Blue Shield plans should work out a cooperative arrangement by which insurance coverage is provided for migratory workers and their families. The State and local health agencies should cooperate to the extent necessary to make such coverage administratively feasible.

(c) We recommend that appropriate arrangements be established for periodic review of the experience of other States in the medical care field so that Michigan will continue to lead in the progressive improvement of medical care programs for the entire population. Among such experience which should be studied is the California plan of hospital insurance for employees covered under that State's temporary disability insurance program.

23. Voluntary health agencies

There are a number of voluntary health agencies providing important health services in some parts of the State. We especially urge increased financial support for the health agencies in the various local Community Chests. We urge these agencies to make every effort to develop services in those counties which do not have such services.

PROGRAM GOALS, DIVISION OF TUBERCULOSIS AND ADULT HEALTH, MICHIGAN DEPARTMENT OF HEALTH

PART 1-CASEFINDING

I. TUBERCULOSIS

1

1. Chest X-ray screening: The chest X-ray survey facilities of the division shall continue to serve local health departments and unorganized counties within these policies:

1 State owned and operated equipment includes five mobile units (mobile combination unit, 70 mm./14 x 17) and one stationary combined unit 70 mm./14 x 17 (Retake Center, Old City Hall, Detroit).

(a) First priority will be given to those counties whose tuberculosis problem index is in the upper and third quartile.

(b) The local survey sponsor(s) must be capable of providing the services associated with survey organization, promotion, and followup.

Approximately 25 surveys will be completed in the period with a coverage of 300,000 adults.

2. Tuberculin testing: (a) It is intended that all local health departments and unorganized counties shall have some form of systematic tuberculin screening of their school-age children. For purpose of uniformity, it will be suggested that all departments will test grades 1, 5, and 10. By the close of fiscal 1959-60, 71 of the 83 counties will have established tuberculin surveys as part of their control problem. A goal of 300,000 students tested is proposed for 1960-61 (200,000 in 1959-60).

(b) The applicability of the intradermal testing of your adults has been demonstrated in district 7, the copper country, Genesee County and Michigan colleges. The plan to expand this method to adults will limit the application to captive groups to insure complete followup.

(c) There shall be continued demonstration of the use of nonmedical personnel as tuberculin testing teams for mass surveys. The division's tuberculin testing team will limit its services to the training of local teams.

(d) The division will promote increased use of intradermal testing by the practicing physician, private clinic, and hospital.

(e) Systematic tuberculin surveys in local health jurisdictions will provide data, useful to:

(1) Determine the rate of infection within a selected sample, and from this provide an additional criterion for determining the status of tuberculosis control in the area.

(2) Tuberculin reactor rates with other morbidity data, will help identify areas or population segments which will require intensified casefinding, utilizing mass X-ray and field investigation.

3. A constant goal in TB casefinding is to increase local activity in terms of of private physician referral, hospital admission X-ray, preemployment and periodic physical examinations in industry, preservice examination of welfare applicants, examinations of patients and staff in nursing homes and homes for the aged (reference to regulation).

4. Efforts will be continued to achieve a closer working relationship with health agencies providing separate mass casefinding services, particularly in: Jackson, Ingham, Genesee, Kent, and Berrien Counties. The goal here is to promote maximum utilization of State-owned and operated casefinding facilities to supplement local resources to expand and refine local programs.

5. The success of mass screening is largely dependent upon efficient and complete followup examination of all suspects and their contacts. Local health departments will be encouraged and assisted in expanding this phase of public health field nursing, supplemented by specially trained field investigators. One primary objective in mass surveys is to find new active cases of tuberculosis.

6. The emphasis on selective X-raying adds further the need to develop new educational techniques to motivate voluntary participation by those segments of society where the tuberculosis problem is believed to be greater (slum areas, males over 45 years; young housewives).

7. There shall be an increasing emphasis upon chest X-ray screening for nontuberculous abnormalities, particularly pulmonary neoplasm and cardiovascular disease. The cancer and heart sections of this report have additional information on this goal.

8. Dual reading of all State-sponsored survey X-rays will be established as an integral part of X-ray interpretation and reporting. This goal is in accord with the department policy on the control of the hazards of X-ray radiation through maximum utilization of single X-ray exposures.

II. CHRONIC DISEASE

1. Chest X-ray: (a) Mass surveys: Mass survey X-rays and those originating in clinics and hospitals, are a primary means of detecting pulmonary neoplasm

The tuberculosis problem index is based upon the following data for the years 1954-57; (a) population estimates: (b) newly reported active cases; (c) current active cases; (d) deaths. These are combined to make up an index ranging from the low of 24 (Roscommon County) to a high of 480 (Alger County). All but Chippewa County (third quartile) in the Upper Peninsula are in the top or fourth quartile; Leelanau, Charlevoix, Arenac, Lake, Jackson, Wayne, and Monroe Counties are also in the fourth quartile.

in the asymptomatic stage, and abnormalities in the size and shape of the cardiac silhouette. The chest X-ray survey plan described earlier (I-1), will include a greater emphasis upon early detection of lung cancer and heart disease. A second major goal is to insure complete followup examination of these suspects comparable to that achieved in tuberculosis.3

(b) Dual reading: Additional evidence to support dual reading (item 1-5), of this report, is found in the study quoted below: **

2. Combined surveys: Selective serologic testing and diabetes screening with chest X-ray: the combination of testing to detect chest pathology, syphilis' and diabetes will be expanded to those health jurisdictions having the interest, local support, and capacity to do the complete job, particularly followup. The goal is 4 surveys, 25,000 persons, annually.

3. Multiple screening: The goal here is to have this type of mass screening, reestablished to the extent that 20.000 adults will be examined during fiscal 1960-61. This will be carried out in a series of casefinding surveys working primarily with captive groups, but including a few communitywide surveys. Major emphasis will again be made on the need for adequate and accessible facilities for diagnosis and therapy in the followup phases of multiple screening. This is important both in terms of acceptable medical practice and to provide added measures of the validity and reliability of screening tests.

4. Cervical screening: Four projects are proposed to be carried out annually, involving cytologic examination of specimens from 12,000 women. A committee of pathologists who have participated in surveys cosponsored by the department, have recommended that these be carried out as single demonstration projects; primarily in rural health jurisdictions; the minimum age remain at 25 years; that the personal physician be encouraged to examine all accessible sites in the initial process; every survey shall be preceded by a comprehensive educational program for physican and laity.

5. Sputum cytology: Through a special project with the Upper Peninsula Cytology Laboratory, Menominee, Mich., a study of lung cancer detection by X-ray and sputum cytology will be continued. It is intended to collect sputum specimens for cytologic examination from 3,000 suspect pulmonary neoplasm cases reported from statewide mass X-ray surveys, annually (1959-60 and 196067). The specimens will be collected in the followup phase of the initial screening, either by the personal physician or local health department.

Charles R. Williams, M.D., James Lofstrom, M.D. "Lung Cancer Detected by Mass X-ray Survey"-The Journal of the Michigan State Medical Society, April 1959, pp. 568571.

The Michigan Department of Health sponsored this study of 464 patients suspected of having a lung cancer by the routine survey photofluorogram. These persons were from 754, 475-screening X-rays taken in Detroit. Wayne County, Highland Park, Hamtramck, Oakland County, Macomb County from 1955-58. Their conclusions are pertinent to the expansion of chest X-ray surveys:

"1. Bronchogenic carcinoma in the curative stage can probably best be detected by routine survey of selected groups.

"2. Delay in establishing diagnosis and in initiating treatment was observed in analysis of this survey ***. It is unfortunate but true that considerable delays have also been observed in hospitals doing routine chest examinations. We believe a more diligent followup of tumor suspects would result if a specific individual in each health department, institution, or industry conducting chest surveys would be responsible for maintaining records and coordinating subsequent efforts of the health department and/or private physician involved.

"3. We feel that these suggestions, if carried out, plus an increase in cooperation between public agencies and private physicians would result in the saving of lives."

Brodeur, Baker, Enterline "Abnormalities Seen on Chest Photofluorograms and Diagnosable Heart Disease," the American Journal of Roentgenology, Radium Therapy and Nuclear Medicine, vol. 78. No. 2. August 1957, report these conclusions:

"On the average, cardiovascular abnormalities have been noted in one-half of 1 percent of these films (ranging from 0.1 to 1.0 percent) and, where followup has been done, these have produced between 1 and 2 confirmed cases of heart disease per 1.000 examinations, of which 60 to 80 percent were previously known. If all abnormalities of the heart and great vessels seen on the films were considered as indication for recall for followup, it is estimated that chest photofluograms could detect 53 percent of the heart disease existing in our population.

"With proper selection of reading criteria, chest photofluorography compares favorably with other screening devices for heart disease.

The reservoir of untreated and inadequately treated syphilis remains high in the State 5 percent reactor rate; 35-45 percent requiring treatment. leading causes of death in Michigan in 1957. Diabetes ranks 6th in the 10

Combination surveys have been demonstrated in Dickinson-Iron, Chippewa-Luce-Mackinac, Montmorency, Gladwin, Arenac, and Saginaw Counties from 1955 to 1958.

7 Multiple screening is differentiated from combined surveys through the introduction of a battery of standardized tests, with the operations evaluated on the basis of the total battery; in the combined survey, each test is usually evaluated independently.

6. Diabetes screening: In addition to screening in combination with other testing, separate diabetes detection projects will be planned with local health departments and medical groups. The goal of 35,000 adults (including the number to be covered in combined surveys) is established for 1960-61.

The Wilkerson-Heftman blood-sugar screening test, with the clinitron, will be used in these operations.

The Diabetes Committee of the Michigan State Medical Society has endorsed public health-sponsored diabetes screening projects. (Report of committee. March 1959).

7. Serologic survey testing: The scope of this testing needs to be extended to meet the explosive growth of population, largely by immigration to the industrial areas of Detroit, Saginaw Bay, and the Benton Harbor-Muskegon regions. Cluster testing, already demonstrated, will be a major part of this expansion. Studies of relationship of mental illness and institutional care to venereal disease provide support to this emphasis. The importance of early casefinding, followup, diagnosis and treatment for syphilis is dramatized by these facts taken from the records of State mental hospitals: During the fiscal year 1957-58 of 5,689 admissions 0.90 percent were admissions with psychoses due to syphilis; of the total resident population of 21,911, 5.31 percent are residents with psychoses due to syphilis. The cost to taxpayers of Michigan during fiscal 1957-58 to maintain 1,164 mental patients with psychoses due to syphilis in institutions was $1,933,113.

8. Glaucoma screening: With the primary goal to educate the physicians and laity, demonstration projects will be continued in 1960-61. It is planned to screen 4,000 to 6,000 adults in a series of surveys. (Surveys proposed for 195960 will reach an estimated 1,500 to 2,000 adults).

III. CASEFINDING, GENERAL GOALS

1. Screening tests are an essential device for early casefinding-to be undertaken in the physician's office, hospitals, public and private clinics, or health centers, industrial health services and in schools. Their contribution to primary prevention, while less direct, can be measured in terms of the public response to health education activities involved in the organization and promotion of mass surveys.

2. With the gradual progress toward tuberculosis maintenance control, emphasizing full utilization of local casefinding facilities, State owned and operated equipment will be used even more directly to examine those segments of the population where the incidence of tuberculosis and other chest pathology is known to be greatest, 30 to 40 years and over. It has been estimated that the State's population will reach 7,926,000 by 1960.0 Approximately 34 percent will be 40 years and over (2,725,000+); nearly 50 percent will be 30 years and over (3,950,000+). The size of these age groups shows clearly that even full use of State and local X-ray (private and public) equipment, will not begin to meet the need. The output of the State X-ray operations averages 300,000 per year; all other facilities are probably reaching 1 million or less annually.

3. Periodic health examinations: Infant and child health programs have clearly demonstrated the value of complete periodic health examinations in primary and secondary prevention of disease. Public health casefinding surveys, when full attention is given to services for followup in diagnosis and treatment, provide an important supplement to the thorough periodic physical examination, which has these functional characteristics: Medical and personal history; physical examinations (testing), laboratory testing; and health counseling. 4. Epidemiology in chronic disease: The value of epidemiological methods in the public health control of communicable diseases is well documented. The

8"Conclusions and Recommendations on Prevention of Chronic Illness" Commission on Chronic Illness; Chronic Illness Newsletter, vol. 7, April 1956.

Tuberculosis maintenance control: those basic tuberculosis control activities designed to hold or further reduce an area to a relatively low incidence rate. A low incidence area is an area in which the tuberculosis death rate, incidence rate (new active cases), and tuberculin reaction rate will be in the lowest statistical quartile for a period of more than 1 year. Such areas are then eligible for maintenance control activities. Basic maintenance control activities in such areas include contact investigation, tuberculin testing in school children (and in adults when feasible), hospital admission X-rays, and those diagnostic activities performed by practicing physicians for examination of their own patients.

10 Thaden, J. F., "Population of Michigan by Counties, 1959, and Projections to 1970."