patient's environment, such as family, work, religion, and community adjustment. When need be, help is called for from the proper disciplines and agencies so that the patient may better be served. Using this type of procedure as a guide, organized medicine is being urged to and is studying the needs of the oldster in the fields of work, home, retirement, housing, recreation, etc.

The doctor realizes from his experience that the stigmata and diseases usu. ally associated with aging are due to the impact of stress and environment. This, like, the infectious diseases and infant mortality, can be attacked and defeated.

And finally the doctor realizes that aging is a growing process and he expects the senior citizen to present certain admirable accomplishments, dignity and rank. He is expected to keep pace in dress, manner and thinking. In turn, for his past contributions and his present status his community should recognize anew that the right of citizenship be not abridged because of age.

Dr. SWARTZ. What I have to say now is probably in the way of explanation of many of the items that appear in the paper.

UNRECOGNIZED CHANGES IN AMERICAN MEDICAL PROFILE

Many doctors and the nonmedical group by and large do not realize that there has been such a great change in the profile of American medicine. When most of us went to medical school there were three divisions of medicine, largely: Pediatrics, which dealt with the diseases of children; adult medicine, which dealt with adult diseases, and which included, by and large, pneumonia; and geriatric medicine, which dealt with diseases of old folks. We categorized people in these three groups, by and large, but recently we have come to find out that many of the contagious diseases of children appear in the older age groups. Poliomyelitis, for example, has been known to kill people past 50 years of age. Also we have found that many of the diseases which are associated with aging process in most people's minds are found in great numbers among the young folks.

In the 1954 death statistics for the United States, 98 children below the age of 5 were listed as having died of arteriosclerotic heart disease and coronary disease. This diagnosis appears in every 5-year segment from then on.

So we have come to realize that medicine is not segregated, as we had originally thought, into diseases of the aged and diseases of children, but that most of our problems are pretty much the same irrespective of the age of the individual.

AMA INTEREST IN THE AGED

The American Medical Association has been very interested in the diseases and problems, so called, of the aged, for a number of years, and exemplified this interest in about 1949, when the Commission for the Study of Prime Diseases was inaugurated.

In 1955, they established a Committee on Geriatrics. Geriatrics was the study of the diseases of the aged, and at the very first meeting of this committee they realized that there were no diseases that were characteristic of the aged group. Therefore, they wanted to know exactly what their role was going to be in this particular problem, and they decided that as a committee they were interested in the older individual, they were interested in the first group who were sick, the second group who were frail and fragile, and who might become sick, and then the great group who were well oldsters, who by the utilization of our known precepts of preventive medicine, might be able to live longer in better health and take care of their own problems.

So this committee went back to the American Medical Association, after they changed their name to the Committee on Aging. Since that time, we have found, just as the private practitioner finds in his own office when he handles a sick patient, that many of the facets of discase are concerned with the man's relation to his environment, to his wife, to his family, to his job, to his community, to his neighborhood. So the physician has had to, in this modern change of profile type of medicine, become interested in labor and management, in community activities, in the church, and in the neighborhoods and the family. In order to practice medicine as a family physician, these things have become quite important.

POSITIVE HEALTH PROGRAM FOR THE AGED

The Committee on Aging of the American Medical Association, as is outlined in this paper, came out with a positive health program which consists primarily of the following:

(1) A realistic attitude toward aging by all people, not only the aged themselves; (2) promotion of a health maintenance program and a wider use of restorative and rehabilitation services; (3) an extension of effective methods of financing health care of persons over 65; (4) an expansion of skilled personal training programs and improvement in medical and related facilities for the older people; (5) amplification of medical and socioeconomic research in problems of aging; and (6) cooperation in community programs for senior citizens.

Our major contribution I think has been in the line of a positive health program. This, of course, has to do with, very briefly, the treatment of the oldster who is ill. This takes us into a terrifically large field where we expect to provide for the patient all the modern treatment that is necessary, and also in facilities that are tailored to meet the particular needs.

In the statement that Professor Cohen has made about the care of the cost of hospital care in the future, we have some considered remedies for this, I think. In the modern construction of hospitals we are trying to tailor the construction just as you do a machine plant in the automobile industry, to a functional character, rather than just sort of hotellike accommodations.

We feel that by this type of a building we can give the patient as he comes in the intense care he needs and then gradually, as he gets better, he can be moved to a chronic department or a rehabilitation center, or to a nursing home, and still receive all the medical care he needs but at less expense.

In this positive health program we would hope we would be able to modify the course of that one chart that you have.

Senator MCNAMARA. Like schoolbuildings, your hospitals are generally in fairly good residential areas and you have to take this into consideration. You do want to be good neighbors and maintain a high standard?

Dr. SWARTZ. That is true but it is well to point out that the architects of the Nation are becoming cognizant of this, and the fact that hospitals have been built and are being built at a cost of anywhere from $4,000 to $25,000 per bed indicates that there is a great deal of unrest in this area, and it will finally probably settle down to a little more normal situation.

Senator MCNAMARA. That is very interesting and very noteworthy at this point.

Dr. SWARTZ. The emphasis is we are trying to make, too, on the well oldster is for periodic health appraisals for the detection of disease, for the prevention of disease, and also in the absence of disease, a phase of medicine which has not been emphasized too much before this, and that is health guidance, increasing mental and physical activity.

Dr. Osler, a number of years ago, said to a number of young doctors, "the best protection against senility is a well-worn medical library.' This is not only true of the doctor; it would be true of everyone else. It could also include the well-worn golf shoes and the fishing material that men use for recreation.

SAFETY PROBLEMS

There is another facet of this whole problem that has just come up recently, which has to do with safety. It is primarily concerned with the oldster and his automobile. This brings up the relation to automobile insurance companies, which are now refusing to write insurance for people past a certain age. That brings up the licensing of individuals to drive automobiles. When we have discussed this with traffic managers it has also brought up the fact that a great number of people who are in middle age or oldsters have never had a course of training in driving. This also brings up the possibility of a modified type of training course for older individuals when certain deficiencies occur, such as a delayed reaction time and things of that sort.

This is a field that also needs a great deal of study, which has just begun, as far as I know.

CHANGING CONCEPTS OF "AGING"

There is one other facet I would like to inject. That is that even though we are all talking about aging, there is no one, as far as I know, who knows what aging is. It was thought in years gone by to be characterized by the tottery gait, the shaky hand, the spindly shank, the thick glasses, the bald head, the gray hair, the forgetfulness. These were the stigmata of aging, so-called. In fact everybody in this room is conscious of the fact that in the early days most of the oldsters actually, by years, were 45 or 50. Since that time we find great numbers of people who are 60, 65, and 70 who are living well, doing a creditable job, and are in comparatively good health. So we are commencing to change our opinion of the aging process.

I think this is extremely important, because if all of the stigmata of aging are the results of the impact of time on an individual, then there is nothing that we can do about it, immediately speaking. But if they are due to some other factors, then we can make corrections in this area and even improve the life expectancy and the health of the older group.

This has been proven. This is not an idle dream. People who have participated in graded activities most of their life, in the older years are much better off physically, and it has been reported by a reliable authority that this has the possibility of improving the life span by 6 or 8 years.

At this point from a medical standpoint, we would like to say that we do not know what aging really is, what is the impact of time on the individual. We do know that a lot of the things that have been attributed to aging are probably due to the impact of tension, stress, environment, and previous disease. If this is true, then we can make great inroads, as we have in the past against infectious disease. If may use one of Professor Cohen's charts which has to do with the life expectancy in the United States, actually since 1900, to 1956, we have made very little impression upon what you can expect after age 65. We have not improved the life span a great deal. Our properly beautiful picture of increased longevity has been due to the fact that we have improved the chances of the youngster to become an oldster. In the State of Michigan in 1900, one-third of the people under 15 died before they got to the age of 15. In 1957, this has been reduced to one-tenth.

If we can do this in the area of infectious diseases, infant mortality and maternity care, then we can now concentrate our efforts on the area. of chronic diseases, which is what we are trying to do.

I would like to conclude my remarks by a quotation from "Public Health Looks at Michigan's People Past 45," which was written by Dr. A. E. Heustis, who is the State health commissioner. The opening sentence says:

Today, health prospects for persons in the middle and later years are bright. The job is to bring the gap between what is found in the laboratory and what is used by the individual, his family and his community.

Thank you, sir.

Senator MCNAMARA. Thank you, Doctor. Your testimony is very interesting and I am sure will be very helpful to the U.S. Senate.

The next witness we are very happy to have with us today is Dr. Maurice Linden, director of the division of mental health, Department of Public Health, Philadelphia, a member of the Committee on Aging of the American Psychiatric Association.

Doctor, we are very happy to have you here. You may proceed in your own manner.

Dr. LINDEN. Thank you, Senator McNamara.

STATEMENT OF DR. MAURICE LINDEN, DIRECTOR, DIVISION OF MENTAL HEALTH, DEPARTMENT OF PUBLIC HEALTH, PHILADELPHIA, AND MEMBER OF THE COMMITTEE ON AGING, AMERICAN PSYCHIATRIC ASSOCIATION

Dr. LINDEN. I should like to request, Senator, that my full statement, properly edited, be inserted in the record. I do not intend to give the bulk of the material, but just to speak a bit off the cuff about some of the material.

Senator MCNAMARA. If you will see the reporter has a copy, we will insert your complete statement in the record.

(Dr. Linden's prepared statement follows:)

A poem by the Greek Poet Theognis of Megara seems to be appropriate in introducing an aspect of the philosophy of mutual help. Theognis spoke to a disciple as follows:

"Learn, Cyrnus, learn to bear an easy mind;

Accommodate your humor to mankind
And human nature;

Take it as you find

A mixture of ingredients good and bad—
Such are we all, the best that can be had.
The best are found defective and the rest
For common use are equal to the best.
Suppose it had been otherwise decreed;

How could the business of the world proceed?"

There is a considerable appeal in a passive and fatalistic philosophy that accepts human nature as it presents itself. Perhaps it is the role of philosophers and scholars who merely record the parade of reality to be uninvolved observers. How we envy the position of these secure watchers who note man's social evolution and move with its fortunes, but who utilize their insights merely to describe man-not to change him.

From my point of view such an attitude toward mankind is a comforting isolationism, a luxury of which there can be no partaking by those who would relieve man's suffering, correct his mistakes, and plan for him a better future. The student of human behavior and the worker devoted to reducing human misery can hardly be unaffected by the awesome statistical picture of aging today in our culture.

Were the worker in the professional therapeutic disciplines still unaffected by exposure alone to the cold majesty of numerical figures, certainly his curiosity and interest in aging are aroused at least by a desire to reduce the daily pressure upon his service program occasioned by throngs of hapless oldsters and their distraught families seeking solutions to problems of living and human relationship.

Let us spend a few moments upon a consideration of a sampling of statistics applied to the aging. We shall thus determine with some accuracy the extent to which we have no right not to be concerned.

There are today about 151⁄2 million persons 65 years of age and over in the United States. They represent an increase of over 400 percent in their numbers since the turn of the century, a period during which the total population increased some 130 percent. About a quarter of a million older people are treated in mental institutions annually. Nearly a half million live in nursing homes and homes for the aged.

INDEPENDENCE OF AGED

Those of us who are responsible for public programing to meet the needs of the aged find two areas of public misinformation that require correction. The first of these has reference to the current hue and cry that had been raised about the problem of the aged. It is significant that the public be acquainted with the fact that in the neighborhood of 70 percent of persons in the age range 65 and over get along fairly well, are not true public charges, and manage their lives with reasonable independence and adequacy.

We

In regard to the above, some recent statistics command earnest attention. learn that 13 out of 18 people now 40 will live beyond age 65. Only 1 out of 13 is financially independent at age 65. At the present time, Americans are reaching retirement age at the rate of 3,300 a day. Only 7 percent of all people over 65 have incomes of over $5,000. About three-fourths of Americans over 65 have no income or receive less than $1,000 a year.

MENTAL HEALTH PROBLEMS

It has been estimated that approximately 10 percent of the older group of citizens at any one time have mental problems of sufficient severity to be considered appropriate for institutional care. The reason that the emotional problems of older people have reached public attention is found not in the percentage showing psychological illness, but rather in the absolute numbers of such individuals for whom public facilities must often be found.

Let us be conservative in our estimate and let us assume that only 5 percent of the total group suffer from such mental aberrations as to warrant institutionalization. If such people were actually hospitalized in psychiatric beds, they would occupy all the institutional space available for all diagnostic entities of

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