In Alberta, Canada, they had a 16 percent drop in the past year, due to a concentrated attack. I think the problem is associated with insufficient prenatal checkups, and, on that basis, improper prenatal care. Possibly also, on insufficient premature care, and on lack of finances. Many of these patients are admitted to the hospital, delivered and sent home either the same day or a day or two later and not provided with the proper care. It is a complex problem to answer in simple terms as to why we rate only 10th among the leading countries, but I am sure that it could be improved. This would, again, be something that an Institute like this could consider. The CHAIRMAN. Is most of the problem, you think, centered in the field of prematurity? Dr. BURKE. In terms of the rising mortality rate? The CHAIRMAN. Yes. Dr. BURKE. I think that is an important reason, but I do not think it is the only one. The CHAIRMAN. Do you think there are other factors other than prematurity? Dr. BURKE. I am sure that there are, Mr. Chairman. 1 think that infections account for some, but I think that probably, if one were to single out a single cause, it is lack of prenatal care. The CHAIRMAN. Do you know of any study that shows that problem by States or by regions? Dr. BURKE. I believe there are such data, but I do not have them at my fingertips. The CHAIRMAN. I believe that is all I have. Mr. O'BRIEN. Just one question, Doctor. Is there not a rather serious area of nutritional neglect between the time the child gets out of the highchair, formulas and what not, and goes to school? Is there not a tendency on the part of a great many people today that, once the child can handle a hamburger, that seems to be his diet. because it is easier to prepare? Is that a serious area? Dr. BURKE. Yes, I think that probably the two most neglected areas, in terms of nutrition in childhood, are the two growth periods where growth is so rapid: between birth and 2 years, and then in the adolescent period. Between 2 and 5, the period that you refer to, at least it would be my estimation that there is less worry in that group than there is in the other. I think that we do run into some intimate problems in raising children at this age: namely, that the mother is used to having seen child eat large amounts of food at 12 to 14 months, and then, when suddenly they do not eat very much at all, they become quite concerned. But, for the most part, this is in response to the decreased needs of the child, so that our concern basically would be with the two rapid growth periods. We have our own adventurers in pediatrics, those who have given hamburgers and fried eggs to children in the first month of life, and many of them survived it. It is perfectly true that many normal children can survive the hamburger diet and even the early age period. But I think that these are largely adventuresome people who are challenging physiologic reserves which, for the most part, on the average, would not stand it. Mr. O'BRIEN. Thank you. The CHAIRMAN. The gentleman from Florida? Dr. BURKE. Thank you, Mr. Chairman. The CHAIRMAN. Our next witness is Dr. Louis Hellman, professor and chairman of the Department of Obstetrics and Gynecology, State University of New York, and director of obstetrics and gynecology, Kings County Hospital, Brooklyn, N.Y., and representing the Society for Gynecologic Investigation. He is accompanied by: Dr. Nicholson J. Eastman, professor emeritus of obstetrics, Johns Hopkins University School of Medicine, and president of the American College of Obstetricians and Gynecologists, Baltimore, Md.; Dr. M. Edward Davis, professor and chairman of the Department of Obstetrics and Gynecology, the University of Chicago School of Medicine, and chief of the Chicago Lying-In Hospital; Dr. Duncan E. Reid, professor of obstetrics, and chairman of the Department of Obstetrics and Gynecology, Harvard Medical School; chief of staff, Boston Lying-In Hospital; and Fellow of the American Gynecological Society; Dr. Howard C. Taylor, Jr., editor of the American Journal of Obstetrics and Gynecology, chairman of the Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University; and Dr. R. Gordon Douglas, professor of obstetrics and gynecology, Cornell University Medical College; obstetrician and gynecologist in chief to the New York Hospital, New York; and president of the American Association of Obstetricians and Gynecologists. Dr. HELLMAN. I would like to have Dr. Eastman lead off, if you do not mind, sir. STATEMENT OF NICHOLSON J. EASTMAN, M.D., PROFESSOR EMERITUS OF OBSTETRICS, JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE AND PRESIDENT OF THE AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS, BALTIMORE, MD. Dr. EASTMAN. Mr. Chairman and gentlemen, my name is Nicholson J. Eastman. I am president of the American College of Obstetricians and Gynecologists, past president of the American Academy for Cerebral Palsy, and served for 25 years as professor of obstetrics at Johns Hopkins University School of Medicine. As president of the American College of Obstetricians and Gynecologists and on behalf of our 7,000 fellows, we should like to express our opposition to H.R. 8398 which provides for the establishment of an Institute of Child Health and Human Development. We are fully cognizant of the value and high intent of this bill, but we feel strongly that its objectives are not adequately set forth in the bill as it is now phrased. I refer to the fact that the most important period of human development and the most important factors bearing on child health, namely, the 9 months of prenatal life and the process of childbirth, are not even mentioned either directly or by implication. Few people realize the huge number of human lives that represent potential American citizens that are lost in the course of pregnancy and childbirth. If you take all causes of death at all ages-cancer, heart disease, vascular disease, all causes of death at all ages-10 percent of those occur in babies in close association with the birth or reproductive process-about 175,000 deaths a year in these infants. Of the 113,000 babies that died in the first week of life in 1958, over 60 percent were the result of premature birth. This is the major problem in obstetrics, and because the cause of premature birth is not known in more than half the cases, and to explore the factors which cause the uterus to start into labor and bring forth these tiny immature babies, that is one of the goals that we think should loom large in this proposed Institute. It sometimes happens as the result of fortuitous factors that these aberrations, these abnormalities in pregnancy and childbirth, may not kill the baby, but they maim the baby. Ninety percent of cases of cerebral palsy, of which there are from a quarter to a half million in the United States, about 90 percent over 90 percent are the result of something, some unfavorable environmental factor between conception and delivery, and here is another area that needs exploration. Here is another area that is obstetrical in nature and must occupy a major portion of our consideration, if child health is to be studied in broad perspective. With your leave, I should like to read one sentence from a telegram that President Kennedy very graciously sent me on the occasion of our last annual meeting, which very succinctly sets forth the importance of obstetrics in this overall endeavor: Healthy lives depend_first of all on safe and healthy childbirth. We feel, accordingly, that if this Institute is to serve the high ends for which it isWe feel if this Institute is to serve the ends to which it is intended more attention should be given to obstetrical factors as they bear on child health than is written into the bill at present. Therefore, and to this end, we respectfully beg that the following changes be made in the wording of the bill: 1. The name of the Institute should be changed to read "Institute of Maternal and Child Health and Human Development." 2. Page 2, line 8, the words "maternal health" should be inserted just before "child health" so that the entire line reads “and training relating to maternal health, child health, and human development." Page 2, line 10, the word "mothers" should be inserted before the word "children" so that that line will read "Problems and requirements of mothers, children, and aged persons" and so forth. On page 2, line 12, a comma should be placed after the word "development" followed by this insert "including prenatal development and maternal factors pertinent thereto," so that the entire line will read "development, including prenatal development and maternal factors pertinent thereto." Thank you very much. The CHAIRMAN. Thank you, Dr. Eastman. It is the opinion of the Chair that you have certainly made a very wonderful contribution to the work of our committee. You have raised, I think, a very interesting question and certainly one that I can assure you will have the consideration of this subcommittee when we begin our deliberations on this bill. It does seem to me that it is a very difficult thing to separate the mother from the child in any research. I don't mean to be facetious, but I say this: that if you put motherhood in this bill, it will have a very strong chance for passage as far as the Congress is concerned. I do appreciate your contribution and I think perhaps we should have one of the other gentlemen who plans to make a prepared statement to make it now so that we can direct our questions to the entire panel. I believe Dr. Hellman has a statement. Dr. HELLMAN. Mr. Chairman, I would like to have Dr. Taylor make his prepared statement next if you don't mind. STATEMENT OF HOWARD C. TAYLOR, JR., M.D., EDITOR OF THE AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY, CHAIRMAN OF THE DEPARTMENT OF OBSTETRICS AND GYNECOLOGY, COLLEGE OF PHYSICIANS AND SURGEONS, COLUMBIA UNIVERSITY Dr. TAYLOR. Mr. Chairman, I am going to try to be brief because I think we are in danger of treating you to a certain amount of repetition. Dr. Eastman has spoken very well for us and I believe has enunciated the opinion of the entire group, and I will condense my statement although I have a typed statement for you. In repeating, to some extent, what Dr. Eastman has said, it is our view that a very large percentage of the handicaps that a child, and eventually an adult, must go through life with, are already present at the moment of its birth, because of heredity, because of some adverse environment while developing in the mother's uterus or because of some accident of birth itself. This is the field of obstetrics. We have been aware for some time of the need for scientific development of this field. The American Gynecological Society 6 years ago appointed a committee to study the problem of recruiting scientific talent for the development of obstetrics and its sister branch, gynecology. After 5 or 6 years of work, the committee of the American Gynecological Society completed the report, which was published a week ago. I bring this report-five copies submitted-as witness to the fact that obstetrics and gynecology has been conscious of the need of some agency which could help it to produce the necessary personnel to carry on the research which we already envisage. When the idea of the Institute appeared and when we first heard of it, we hailed this as an important step in furthering the solution of this need of scientific personnel that we had already envisaged. From the moment we heard of it we were enthusiastic and in general we come here backing the idea of an Institute in this general field. At the same time, we have felt a degree of disappointment in that no reference in the proposed title of the Institute is made to the enormous contribution which the mother makes, or to the part to be played by the obstetrician who takes complete care of the mother, and until the baby is born, the baby itself. 81475-62- 8 No recognition in the proposed title of the Institute is being made to this tremendously important phase. We feel that study of the mother and of her child are inseparable. My branch of medicine, obstetrics, will be distinctly disappointed if its aspirations cannot be furthered by the public recognition of its position in this field in the title which will be applied to the Institute. The CHAIRMAN. Thank you, Dr. Taylor. I think without objection we would like for your formal statement to be filed for the record and we would also appreciate it if we might have the report in the files of the committee, and the Chair would like to indicate that we will submit these proposed amendments to the Department of Health, Education, and Welfare for their comments so that we will have before the subcommittee their feeling about these amendments. (The complete prepared statement of Dr. Taylor is as follows:) STATEMENT OF HOWARD C. TAYLOR, JR., M.D., EDITOR OF THE AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY, CHAIRMAN OF THE DEPARTMENT OF OBSTETRICS AND GYNECOLOGY, COLLEGE OF PHYSICIANS AND SURGEONS, COLUMBIA UNIVERSITY The objective of the proposed Institute of Child Health and Human Development, if I understand it correctly, is to turn attention to the handicaps of early life, their prevention, early detection, and treatment in order to balance somewhat the current emphasis on the ailments common in the later years. The importance of the concept seems nearly self-evident. The work of such an Institute would surely be directed toward sources of human suffering as great as those of any already established Institute. When one examines the field of work of the proposed Institute more closely it is evident that many, perhaps the majority, of the errors in human development, stem from mishaps occurring at or before birth. These include the hereditary defects foreordained from the moment of fertilization, anomalies due to an unfavorable environment while the fetus is still in its mother's womb, and to the results of accidents affecting the baby during the processes of birth and the first few moments of life. The period of life in which these hazards occur is that which falls under the observation and medical supervision of the obstetrician. Hence it seems that an essential for scientific progress in this field is the training of a group of research oriented obstetricians. The support of a training program for this purpose would, I assume, be a major objective of the proposed Institute. It is this aspect that I wish to speak of in particular. The need for more scientifically trained obstetricians and gynecologists has for some years been evident to the teachers of this branch of medicine and has been the object of a study and report, sponsored by the American Gynecological Society and supported by the Josiah Macy, Jr., Foundation. The completed report entitled "The Recruitment of Talent for a Medical Specialty" (that of obstetrics and gynecology) became available in book form last week. A copy is here for your inspection. As the editor of this report, I can tell you something of the problem to be met. There are now some 80 medical schools in the country and it is generally assumed that perhaps 20 more are needed, making a round hundred which must be staffed. A department of obstetrics and gynecology of average size can hardly be effective with less than 5 faculty members making a total of 500 as the basic force needed for teaching and clinical investigation in the field. There can certainly be no more than a hundred academic full-time members of departments of obstetrics and gynecology in the country at present. Obstetrics and gynecology has not tended to attract the research minded medical student and for fairly obvious reasons. The specialty has for years been primarily concerned with the establishment, standardization, and enforcement of the clinical roles that would reduce the loss of mothers' lives. This objective has been to a large extent attained by the steady, conscientious, repetitive clinical work of the obstetrician. Our specialty has not on the other hand been aware enough of the complex problems of physiology and chemistry that now present themselves and must be solved if the events of pregnancy are to be related to the future development |