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of clinical research will, of course, continue to receive full attention but it must be increasingly supported and revitalized by probing and sophisticated research into fundamental biological processes, on the one hand, and by meticulous and comprehensive observations of normal human behavior, on the other.

Dr. SHANNON. Yes, sir.

I would like to make one general statement now, and then submit for the record more specific information. I am convinced that the enlightened attitude of the Congress toward the productive use of new medical knowledge over the past 15 years is largely, if not completely, responsible for placing the United States in the forefront of all modern nations in the growth of medical knowledge and its application to the health of our people.

Whereas two decades ago we looked to other lands for the primary training of our scientists, they now look to us. Quite apart from the practical benefits to our citizenry, of our increased stature in this field, the prestige that comes to this country as the result of its outstanding work in the medical sciences is very substantial. This has become increasingly evident to me, as I have visited other countries. This, I would say, is an indirect benefit, sir, but not one that should be overlooked.

Mr. ROGERS of Florida. Thank you.

If you could submit that for the record, it would be helpful. Just two quick questions.

I think it would be helpful in connection with the consideration of this Center on the Aging, as well as the Center on Child Health, if you could give us the implementation and experience of the Kerr-Mills bill, which was passed by the Congress to help approach this problem of the aged.

If you could, give us that.

(The information requested may be found in the files of the subcommittee.)

Then I notice that you wanted to make a change in the law on page 12, for giving authority to the Surgeon General to make project grants for research training, as well as for research. Is this consistent with the authority throughout?

Dr. SHANNON. Yes, sir. This is consistent with current practice and really regularizes something that has been in operation for some 15 years.

Mr. ROGERS of Florida. And then I notice you wanted to relieve the Council of grant review functions.

Dr. SHANNON. We want to relieve the National Advisory Health Council of some of the grant review functions, because it is overloaded and cannot do all the things that the statutes require it to do. Mr. ROGERS of Florida. Would that go to another council? Dr. SHANNON. This would go to another council; yes, sir. Mr. ROGERS of Florida. I see. Not just to one individual?

Dr. SHANNON. No, sir.

Mr. JONES. More important, Mr. Rogers, it would enable the Surgeon General to use highly specialized advisory committees that already exist, which by statute now cannot so be used.

Mr. ROGERS of Florida. Thank you very much.

Thank you, Mr. Chairman.

The CHAIRMAN. The subcommittee will stand in recess until 2 o'clock and at that time our witness will be Dr. Robert Cooke. (The following information was submitted by HEW:)

BACKGROUND DATA ON SELECTED HEALTH PROBLEMS OF CHILDREN (Prepared by Center for Research in Child Health, Division of General Medical Sciences, National Institutes of Health)

CHILD POPULATION 1

Our child population has more than doubled since the turn of the century. Children under 21-over 75 million of them at the time of the last census-now make up more than two-fifths of the total population. Paradoxically, our population is growing both younger and older at the expense of those in the middle years. By 1980, it is estimated that the number of young people under 21 and older persons past 65 will be about half again as large as in 1960.

Other demographic changes affect children, such as the continuing urbanization and suburbanization of families, the mobility of the American population, the trend toward earlier marriage, the increase in the number of children involved in divorces, the increase in the proportion of the dependent population and the corresponding relative decline in the productive ages, and the personal, national, and international tensions under which we live. These all have an actual or potential effect on the physical or emotional health of children. Much more research is needed to determine their implications on child health so as to minimize their bad effects and take advantage of their benefits.

PREMATURITY

The number of births has reached record highs in recent years, with over 4 million births each year since 1954.2 In 1960, more than 44 million births were registered. Beginning about 1965, more young women will reach child-bearing age each year, because of the increase in births immediately after World War II.1 But every 13th birth is immature. This means that about 330,000 babies a year are subject to higher than average mortality risks.

Prematurity is the largest single cause of neonatal deaths, accounting for more than three-fifths of all deaths under 4 weeks of age.2

Nearly 9 out of 10 deaths in the neonatal period occur in the first week of life. The majority of these infants who fail to survive are born to mothers whose pregnancies do not run to normal term. In many cases the reason for the premature termination of pregnancy is unknown.

INFANT MORTALITY

The long-term decreasing trend in infant mortality has been slowing up since about 1950. Although the provisional 1960 infant mortality rate of 25.7 per 1,000 live births was the lowest recorded in this country, there are still about 110,000 babies dying each year.? Data for 1959 for a group of representative countries indicate that the United States was outstripped by Australia, New Zealand, Czechoslovakia, Denmark, Finland, Iceland, Netherlands, Norway, Sweden, Switzerland, and the United Kingdom."

Early infancy is the most hazardous period. Almost three-fourths of the infant deaths now occur within the first 4 weeks, nearly two-thirds are within the first week, and close to four-fifths take place in the first day.8

Deaths during the neonatal period have decreased much less rapidly than later infant deaths. This is due in part to the sharp reduction in mortality from influenza and pneumonia, gastrointestinal diseases, and other communicable diseases. About two-thirds of all infant deaths now are from prenatal and nata[ causes. The death rates for babies less than 3 days old have changed very little in the past two decades.10 Adequate knowledge to prevent many of these early deaths is not yet available.

1 Data in first paragraph derived from: Health, Education, and Welfare Trends, 1961 ed., U.S. Department of Health, Education, and Welfare, Office of the Secretary, pp. 3, 35. Vital Statistics of the United States, 1959, U.S. Department of HEW, PHS, NOVS, sec. 3, Natality Statistics, p. 3-15.

News release dated Dec. 19, 1961, HEW-S4.

Same as footnote 1, pp. 3-12.

Children and Youth, C. B. Publication No. 363, chart 13.

Current Status of Infant Mortality in the United States, U.S. Department of HEW, PHS, NCHS, NVSD. Mimeographed. (This statement was prepared for the use of the Surgeon General in testimony.) 7 Monthly Vital Statistics Report, U.S. Department of HEW, PHS, NOVS, vol. 9, No. 13, p. 15. Vital Statistics of the United States, 1959, sec. 6, Mortality Statistics, U.S. Department of HEW, PHS, NOVS, pp. 6-30, T. 6-P.

Children, November-December 1960, "Current Trends in Infant Mortality," Alice D. Chenoweth, M.D., and Eleanor P. Hunt, Ph. D., p. 214. p. 35.

10 Children in a Changing World, WHCCY,

PREGNANCY WASTAGE

Deaths before, during, and just after birth were reported at about 150,000 in 1959, including fetal deaths occurring at gestations of 20 weeks or more, and neonatal deaths under 4 weeks.11 Since under-reporting is common in the area of fetal deaths, the true figure would probably be considerably higher. More voer, it has been estimated that "at least 3 out of every 10 known conceptions never get beyond the first trimester. Since very early embryonic losses commonly go unnoticed, the true wastage before birth may well be 70 percent of all conceptions."12 Taking the 150,000 figure as a conservative measure of perinatal mortality, it ranks only after heart disease, cancer, and vascular lesions affecting the central nervous system in number of deaths.13 Stepped-up research in this area is needed not only to discover how to prevent fetal and neonatal losses, but also to find ways of assuring that as many babies as possible are born physically and psychologically adequate, without the developmental defects which are now too often found among infants and children.

CHILDHOOD MORTALITY

Using mortality as a criterion, childhood past the first year of life is the most healthful period in the lifespan. Provisional 1960 death rates per 1,000 population for the age groups 1 to 4 years, 5 to 14, and 15 to 24 were 0.1, 0.6, and 0.1 respectively compared with the overall death rate of 9.5.14

However, it is of interest to note that two categories associated with infancy or childhood, congenital malformations, and certain diseases of early infancy, are among the 10 leading causes of death for the population as a whole.15

Accidents and cancer are among the five leading causes of death in all age groups from 1 to 24 years. Congenital malformations and influenza and pneumonia show up in the five leading causes in the 1 to 4 and 5 to 14 age groups, and diseases of the heart in the 5 to 14 and 15 to 24 age groups. Among the 15 to 24 year olds, homicide and suicide rank as the third and fourth causes of death respectively.16

CHILDHOOD MORBIDITY

Although medical science has gone far in the reduction of specific diseases, acute illnesses are still a major problem of childhood. Children are the principal victims of communicable diseases. In the year July 1959-June 1960, there was an average of 3.6 episodes of acute illnesses per child under 5, 2.5 per child 5 to 14, and 1.9 per person 15 to 24 years of age.17 Respiratory conditions occurred most frequently, followed by infectious and parasitic diseases and digestive system conditions.17

Although the chronic diseases affect persons in the middle and older age groups primarily, they can also be a serious problem for some preschool and schoolage children. One in every six children under 17 years of age has one or more chronic conditions.18 More than half a million of these children are limited in major activity because of these conditions.18

During the year July 1959-June 1960, young people under 25 averaged 10 to 12 days per person of restricted activity because of illness or injury; more than two-fifths were days on which the affected person was confined to bed.19

Illness and injury take a large toll in the form of lost time from the education of our youth, causing an average school loss of 5.3 days for every child between 6 and 16 years of age.2

20

11 "Vital Statistics of the United States," 1959 U.S. Department of Health, Education, and Welfare, PHS, NOVS, Sec. "Fetal Mortality Statistics," p. 4-1. Íbid., sec. 11, "General Natality and Mortality,' p. 95, T. 25.

12 The Nation's Children," vol. 2, "Development and Education," WHCCY. "Growth and Development," by Stanley M. Garn, chairman of the physical growth department of the Fels Research Institute and associate professor of anthropology at Antioch College. p. 25.

13"Vital Statistics-Special Reports," National Summaries, vol. 54, No. 2, U.S. Department of Health, Education, and Welfare, PHS, NOVS, "Leading Causes of Death," pp. 48-50, T. 1.

14 Monthly Vital Statistics Report, vol. 9, No. 13, U.S. Department of Health, Education, and Welfare, PHS, NOVS, p. 7, T. C.

15Vital Statistics-Special Reports," National Summaries, vol. 54, No. 2, U.S. Department of Health, Education, and Welfare, PHS, NOVS, pp. 48-50, T. 1.

16 Ibid., pp. 52-54, T. 2.

17 "Health, Education, and Welfare Trends," 1961 edition, Department of Health, Education, and Welfare, Office of the Secretary, p. 14.

18 "Health Statistics from the U.S. National Health Survey," Series B, No. 31, pp. 5, 11, U.S. Department of Health, Education, and Welfare, PHS.

19 Same as 1, p. 20.

20 Same as 1, p. 21.

Children under 15 were hospitalized at about the rate of 50 hospitalizations per 1,000 persons per year in the fiscal year 1958, with an average stay of approximately 51⁄2 days.21

CONGENITAL MALFORMATIONS

With almost 22,000 deaths in 1959, congenital malformations were the ninth cause of death in the population as a whole.22 More than 7 out of 10 of these deaths occurred in infancy; another 17 percent were in the 1 to 19 age group.23 Almost half of all deaths from congenital malformations were due to congenital malformations of the circulatory system, representing mostly congenital heart disease.23 From 30,000 to 50,000 children are born each year with congenital heart disease.24 In terms of incidence, however, orthopedic malformations are highest.25

We have some knowledge of causes of congenital malformations-prenatal virus infections of mothers, vitamin deficiencies, and radiation can be injurious to the fetus. Increased knowledge that might make prevention more widely

possible is an important need.

MENTAL RETARDATION

Mental retardation is one of our most serious problems in terms of size, cost, and impact on the affected person and his family. Over 111⁄2 million children 26 and almost 4 million adults 27 are mentally retarded. Unless more is learned about the prevention of the numerous conditions which can result in mental retardation, there will be another million victims by 1970.27 There is a wide range in degrees of mental retardation from somewhat subnormal to totally dependent. The great majority are "educable," most of the rest are "trainable," and only a small proportion is "totally dependent." 28

29

Approximately 3 percent of the mentally retarded are in institutions.2 Mental retardation accounts for some $250 million annually in public institutional costs.30 "The mentally retarded are heavily represented among persons who qualify for child's benefits based on disability. Among the 20,000 persons of 18 and older who qualified for childhood disability benefits in 1957, the first year in which payments were made, mental deficiency was the primary diagnosis in 45 percent of the cases. In addition, 22 percent had cerebral spastic infantile paralysis with mental deficiency." 31 Thus, mental deficiency was a factor in two-thirds of the cases.

Complete information on mentally retarded persons receiving help under public assistance programs is not available. "However, a study made of 'Characteristics of Recipients of Aid to the Partially and Totally Disabled' in 1951 showed that mental deficiency was the major cause of disability for persons under 35 (20.3 percent of all received APTA in this age group). For those 35 to 54, it was the major cause of disability in 8.3 percent; and for those 55 and over, 2.8 percent." 32 An estimated 200,000 children were patients at psychiatric clinics in 1955.33 Among child patients on the rolls of reporting clinics in 1956 whose services were

31 "Health Statistics from the U.S. National Health Survey," Series C-1, "Children and Youth," U.S. Department of Health, Education, and Welfare, PHS, pp. 27-28. 24 "Vital Statistics-Special Reports," National Summaries, vol. 54, No. 2, U.S. Department of Health, Education, and Welfare, PHS, NOVS, "Leading Causes of Death," p. 50, T. 1.

23 Vital Statistics of the United States," 1959, vol. II, U.S. Department of Health, Education, and Welfare, PHS, NOVS, p. 96, T. 71.

14 "Information Sheets on Children and Youth," prepared for the 1960 WHCCY, Forum XVI, workgroups 165-168, p. 1.

25 New Medical Materia," November 1959, p. 17 (source given, the National Foundation). "Pediatrics," vol. 14, pp. 505-522, 1954, "The Incidence of Congenital Malformations: A Study of 5,964 Pregnancies," by Rustin McIntosh, M.D., et al., T. XI.

26 "Growth of Children's Bureau Services to the Mentally Retarded and Plans for the Future," by Mrs. Oettinger, Chief, Children's Bureau. Presented before the Northeast Regional Conference of the American Association on Mental Deficiency, Newport, R.I., Oct. 19, 1960. Mimeographed.

27 "Health Services for Mentally Retarded Children," U.S. Department of Health, Education, and Welfare, Social Security Administration, Children's Bureau, 1961, p. 12.

25 The Child Who Is Mentally Retarded," Children's Bureau Folder No. 43, 1956, U.S. Department of Health, Education, and Welfare, Social Security Administration, Children's Bureau, pp. 10-11.

20 "Basic Considerations in Mental Retardation: A Preliminary Report," Group for the Advancement of Psychiatry, Rept. No. 43, p. 15.

30 Information Sheets on Children and Youth," prepared for the 1960 WHCCY, forum XV, work groups 155-156, p. 2.

31 Mental Retardation-Programs and Services of the U.S. Department of Health, Education, and Welfare, Fiscal Year 1960," U.S. Department of Health, Education, and Welfare, Office of the Secretary, June 1959, p. 26.

32 Ibid., p. 30.

33 "Public Health Reports," vol. 74, No. 11, November 1959, Health, Education, and Welfare, Public Health Service, "First National Report on Patients of Mental Health Clinics," Anita K. Bahn and Vivian B. Norman, p. 945.

terminated, almost one-fifth of those diagnosed were classified as mentally deficient.34

Preventive measures are now available for only a very small fraction of conditions causing mental retardation. Research is gradually decreasing the large segment of mentally retarded persons of unknown etiology. Recent discoveries on the importance of organic causes such as inborn errors of metabolism are bringing into new prominence such professional groups as the biochemists, geneticists, and embryologists in mental retardation research.35 This is a field where the collaboration of many disciplines is needed to bring about more effective knowledge.

Of utmost importance to research progress in mental retardation is the availability of enough qualified persons, but there is an acute shortage of scientists prepared for such investigation.36

HANDICAPPING CONDITIONS

Many of the physical, mental, and emotional problems in our population have their start in childhood. Research leading to their prevention or control would have a tremendous impact on the health of the country.

There are no complete or exact data on the numbers of children with various types of handicaps, but approximate estimates are available for some conditions. The National Health Survey found that there were over 2 million impairments among children under 14 and 13⁄44 million among youths of 15 to 24 years of age. Over 300,000 young people under 25 were reported as blind or with other serious visual defects, almost 600,000 as deaf or having serious trouble with hearing, and more than 700,000 with speech impairments. Over 1,800,000 were found with orthopedic impairments, including paralysis, amputations, and other types of orthopedic defects.37 These figures probably understate the problem, since they do not include the institutionalized population, and may otherwise be subject to underreporting.

Close to 100,000 children have cleft palate or harelip. Some 30,000 to 50,000 children a year are born with congenital heart disease.38

The number of mentally retarded children is over 11⁄2 million.39 About 1 out of every 600 or 700 babies is mongoloid.40

Without further progress in research and prevention, the numbers of handicapped children will increase from year to year, partly because of the increase in the child population and partly because medical advances are keeping some children alive who otherwise would have died."1

Projections of available data suggest that by 1970 there will be nearly one-half million children under 21 with handicaps resulting from cerebral palsy, and nearly as many with epilepsy. The number of children with some degree of mental retardation may be as high as 24 million.42

ARMED FORCES REJECTEES 43

A substantial number of babies come into the world with handicaps resulting from prenatal and natal causes for many of which we do not yet have adequate knowledge for prevention. Still other children accumulate physical or emotional problems during childhood and adolescence. By the time these children reach young manhood, many of them do not qualify for service in the Armed Forces. The extent of rejection for military service is a reflection of the state of physical fitness of our youth.

The actual number of young people who are examined and found physically or emotionally not qualified for military service obviously varies greatly from year to year, depending in part on the need for manpower and the criteria in effect for

34 Ibid., p. 947.

35 Same as footnote 27, above, pp. 15-16.

36 Same as footnote 31, above, p. 13.

37 Health Statistics From the U.S. National Health Survey," series C-1, pp. 14-15, U.S. Department of Health, Education, and Welfare, Public Health Service.

38 "Information Sheets on Children and Youth," prepared for the WHCCY, forum XVI, workgroups 165-168, p. 1.

39 Growth of Children's Bureau Services to the Mentally Retarded and Plans for the Future," by Mrs. Oettinger, Chief, Children's Bureau, presented before the Northeast Regional Conference of the American Association on Mental Deficiency, Newport, R.I., Oct. 19, 1960. Mimeographed.

40 "The Mongoloid Baby," Children's Bureau Folder No. 50, 1960, p. 3.

41 "Exceptional Children: A Positive Appraisal," by Mrs. Katherine Brownell Oettinger, Chief, Children's Bureau, p. 3. Address before the Pennsylvania Federation, Council for Exceptional Children, Bedford, Pa., Oct. 13, 1961.

42 Ibid., p. 3.

43 "Health Services for Armed Service Rejectees," to be published in Follow-Up Reporter, NCCY.

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