PARTICIPANTS

Dr. Lorand Johnson, professor of ophthalmology, Western Reserve University School of Medicine

Miss Kathern F. Gruber, assistant director, American Foundation for the Blind, Inc.

Dr. Franklin M. Foote, executive director, National Society for the Prevention of Blindness

Miss Mildred Weisenfeld, executive director, National Council to Combat Blindness

Mr. Hulan Walker, National Council to Combat Blindness, Inc.

Dr. Pearce Bailey, director, National Institute of Neurological Diseases and Blindness

The CHAIRMAN. I understand the discussion leader today will be Dr. Lorand Johnson, University Hospital, Cleveland, Ohio. It has been our custom as you doubtless know, Dr. Johnson, to handle our meetings rather informally. Will you please, therefore, begin by introducing the members of your panel and giving us some of the history and background of each.

STATEMENT OF DR. LORAND JOHNSON, PROFESSOR OF OPHTHALMOLOGY, WESTERN RESERVE UNIVERSITY SCHOOL OF MEDICINE

Dr. JOHNSON. I am Dr. L. V. Johnson, professor of ophthalmology, Western Reserve University School of Medicine.

I will say in opening that I never enjoyed such a nice presentation as we have just witnessed from the neurological group. I regret very much that we cannot present for you a disease-by-disease discussion of the various entities in blindness. I wish that we might have among us someone to describe cataracts, to describe glaucoma, to describe retrolental fibroplasia, and these other diseases.

The best we can do, certainly in the time we have left, is to make a general discussion of the matter of blindness and hope that the disease entities may somehow be included in your minds, even though not in our discussion.

In opening the discussion on the problem of blindness there are a few items that I might like to present to you.

It is estimated that there are more than 600,000 blind and partially sighted in this country. Less than $400,000 was spent by our Federal Government through the Institute of Neurological Diseases and Blindness for research in the prevention of blindness during the year of 1952-less than 57 cents per person in this category.

If the 1 million persons who are blinded in 1 eye are included, we observe that the Institute of Neurological Diseases and Blindness had available for research less than 3 cents per person with limited vision. If each person with limited vision were to write to you Congressmen requesting adequate research support, the postage alone would equal the present appropriation for research to prevent blindness.

Concurrently, an estimated $150 million was spent for the inadequate care and rehabilitation of the blind. A mere statement from their oculist entitled these people to an extra $600 income-tax exemption, a potential $360 million of top-bracket taxable income.

It is impossible to estimate the amount of taxable income which would have been earned by these unfortunate blind had they sufficient visual acuity to be employable.

Assuming only the income provided by the minimum-wage law, another $500 raillion worth of taxable income would be lost.

Not all blindness can be prevented by research. Accidents are a very important cause of blindness in this country. The Industrial Commission of Ohio alone spent $5.5 million for the settlement of eye claims out of an annual expenditure of $20 million for all industrial claims.

The inadequacy of proper facilities for the care of injured eyes is obvious from these figures, and it is certain that the industrially injured are on the average far better treated than are average citizens who have less opportunity for medical direction.

There are 3,069 counties in the United States, and there are but 3,400 oculists certified for practice by the American Board of Opthalmology. This board of certification has been in existence for 20 years, and a large number of these certified oculists are now dead or retired from practice. With definitely less than one oculist per county, it is obvious that a sufficient number of trained men are not available for clinic practice.

Prior to the establishment of the Institute of Neurological Diseases and Blindness there were but half a dozen laboratories in established eye institutions and medical school departments where any continuous research of a basic nature was being conducted. So scanty were these facilities that even early meager assistance from the Institute for Neurological Diseases and Blindness soon nearly supplied the intellectual and laboratory research potential of these institutions.

In general, moneys for increased personnel have been limited but available. Money for increased laboratory construction and the development of new laboratories has not been possible.

Provisions for training new laboratory personnel, as well as personnel in clinical research, are recently announced, but it has been mentioned that space requirements are essentially saturated as compared to the preresearch era. The intramural activities of the Institute will no doubt aid in this development. However, one cannot exclude the enormous potential for training, consultation, and direction which must be obtained from the complete facilities of all of our medical schools and hospital clinical services. Deserving eye-research laboratories in close proximity to a medical-school faculty must be provided with money to develop and expand.

Furthermore, clinical ophthalmologists must be in close contact with any sizable research laboratory. Selected clinical patients may be aggregated into Bethesda but the intramural clinical facilities can never equal the combined patential of all of the clinical facilities of the Nation's medical centers.

There must be a greatly increased number of capable medical students who choose the broad field of ophthalmology for their career. There are obvious reasons why so few medical students even know of the potential opportunity in the field of blinding eye diseases.

The traineeship program of the National Institute for Neurological Diseases and Blindness should be made effective by provision of sufficient money to allow the activation of a reasonable percentage of applications submitted. This is not now possible with the funds available.

Institutions providing basic training in ophthalmology should be given financial aid for extension of their instruction, especially in the category of providing laboratory space and equipment for instruction in ophthalmic basic sciences.

Adequate funds for the activation of current provisions for institutional graduate medical training grants should be immediately provided, including provision for salaried instructors who can extend the teaching facilities of medical centers into the various State hospitals and county hospitals for the chronically ill. The enormous facilities of the various city hospitals for the indigent should be developed for better teaching centers.

Laboratories in an ophthalmic training center serve a dual purpose. Not only is there developed a wealth of fundamental data of common value to all working in the field of ophthalmic research, but there is further the decided advantage that this local personnel may teach and motivate in the training program.

Assuming from the foregoing testimony that an adequate number may be properly motivated to the necessity for service in the field of blinding eye disease, there remains still one most important aspect for training. Notwithstanding recent emphasis, most hospitals still adhere to the policy of utilization of interns in relationship to hospital needs rather than to the policy of training doctors in proportion to community needs. As an example, in the year of 1900 when most childbirths occurred in the home, hospitals were unable to train a sufficient number of good obstetricians to meet the community need. Fifty years later, with most mothers demanding the safety and convenience of a hospital, residents in obstetrics are still chosen with regard to 24hour hospital needs, rather than to community requirements. The facilities for hospitalization for such specialties as ophthalmology, neurology, and neurosurgery are, in most teaching centers, so limited that relatively little activity is present to motivate medical students into these appendages to the main body of medicine. Most major hospitals at training centers allocate beds for staff requirements rather than for training for community need and as a result specialty-training facilities are diluted among so many community hospitals as to make none outstanding for training purposes.

The "leper and the blind" have traditionally been cited for special compassion, and yet only the leper has attracted Federal interest in the realm of medical institutional construction. A special case should be provided through Hill-Burton building assistance, for the creation of eye institutes for diagnostic and therapeutic care, as well as surgical rehabilitation for the blind. May I cite as an example, that the entire State of Ohio has no ophthalmic institute. Nearest specialized facilities are at Chicago or Philadelphia or in the near future at Toronto, Canada. It is beyond the capacity of a medical school to provide such facilities for an entire community, and it is traditional that medical centers provide only sufficient facilities for meager student-teaching purposes and not for adequate resident training or for prevention or rehabilitation.

Notwithstanding the remarkable achievement of the understanding of yellow fever of far greater economic and humanitarian significance to this country, has been the prevention and treatment of ophthalmia neonatorum (sore eyes of newborn babies). Equally im

portant is the prevention of total blindness by tabetic optic atrophy (dead optic nerve from syphilis). Therapeutic cortisone now does, to a large extent, prevent blindness from inflammatory diseases of the cornea and from iritis. Does basic research pay dividends?

A more recent result of research in the blinding eye diseases is the elimination of blindness caused by trachoma and the consequent ability to close the "Indian schools," since the isolation of these racially susceptible carriers of trachoma was no longer necessary. Recently reported research, and the clinical activity by the Institute of Neurological Diseases and Blindness, provides early optimism that the combination of experimental (animal) research and a nationwide statistical survey, may now allow the prevention of retrolental fibroplasia. This new disease of premature babies has, during its short life span of 10 years (from the first identified baby to the present probable understanding of its cause and prevention), blinded probably 4,000 babies. The estimated cost for the inadequate care and education of the blind baby is $100,000 during its lifetime, an estimated public future obligation of $400 million incurred during a brief 10-year duration. Successful research at a cost of 10 cents per blind baby. A research cost of 10 cents to prevent an expenditure of $100,000. Does clinical research pay dividends?

I am optimistic that with adequate finances and facilities, many causes of blindness such as diabetic retinopathy-the tragic blindness that looms as the certain future for every diabetic if they live sufficiently long-will, through basic research, be understood and prevented. Better diabetic care is already prolonging the life expectancy. Legislative unfamiliarity with the program needs, or adherence to a previous budget base, are the two major obstacles to the reduction of the incidence of blindness, and both obstacles spell lack of dollars. The very capable staff of the Institute of Neurological Diseases and Blindness know how to administer efficiently all appropriated funds and have excellent information sources concerning the institutions most deserving and most certain to obtain results from this financial support.

We trust there will be aroused an economy-minded electorate who will demand that money be spent for research, training, and improved clinical facilities to replace the tremendous economic loss to this Nation through preventable blinding eye disease. Funds must be made available not only for training additional personnel but for new specialized laboratory facilities, ophthalmic institutes for clinical research, for the diagnostic and therapeutic custody of potential blinding eye-disease patients, and for surgical rehabilitation as well. The meager $400,000 for research for the prevention of blindness in 1952 was a shameful achievement after 175 years of government "for the people." A sum of $20 million would be more realistic to combat the challenge of blindness. Thank you.

The CHAIRMAN. Are there any further questions, gentlemen?
Who will be your first witness, Doctor?

Dr. JOHNSON. Our first witness will be Miss Kathern F. Gruber, assistant director, American Foundation for the Blind, Inc. Miss Gruber.

STATEMENT OF MISS KATHERN F. GRUBER, ASSISTANT DIRECTOR, AMERICAN FOUNDATION FOR THE BLIND, INC.

Miss GRUBER. Mr. Chairman and members of the committee, I am Miss Kathern F. Gruber, assistant director, American Foundation for the Blind, Inc., and I have brought with me some material to place in the record when I have completed my presentation.

The American Foundation for the Blind, a national, private research and consulting agency in the field of blindness, comes before this cominittee to submit a statement dealing primarily with two subject matter areas in which the committee has expressed definite interest:

The estimated prevalence of blindness in the United States. The estimated economic burden placed upon the Nation because some of its citizens happen to be blind.

The actual number of blind persons in the United States is the subject of perennial questions since there is no detailed census which provides that information. The United States Census Bureau for many decades attempted to include an enumeration of the blind in its regular decennial census of the population. It developed, however, that no matter how great the care taken, the figures reported never seemed accurate or reliable. The difficulty of applying a definition of blindness uniformly and the unwillingness of some families to admit the presence of a blind family member were two of the major reasons that the reporting tended to be seriously incomplete.

The census authorities themselves recognized these weaknesses and, as a result, no census of the blind was taken in the general population census of 1940 nor in any later census. In lieu of this, the American Foundation for the Blind and the National Society for the Prevention of Blindness have, since 1929, jointly sponsored a committee on statistics of the blind whose purpose it is to study the problems of statistics of blindness and to make recommendations for the improvement of such statistical data.

The work of this committee, under the able chairmanship of Dr. Ralph G. Hurlin, of the Russell Sage Foundation, has resulted in the release of a number of surveys and estimates concerning the prevalence of blindness in the United States, with each new estimate always showing an upward revision of figures. The most recent published report is that of July 1, 1952, complete copies of which are being given to each member of this committee. That report indicates that as of July 1, 1952, there were 308,000 blind persons in the United States.

However, applying the same statistical formula used by Dr. Hurlin in that report to the United States Census Report issued on July 1, 1953, it is estimated that there were 314,000 blind persons in the United States on July 1 of this year.

It should be understood, at the outset, that in these reports, a blind person is one whose loss of vision brings him within the following definition of blindness which is most frequently used by Federal and State governmental bodies:

Central visual acuity of 20/200 or less in the better eye, with correcting glasses; or central visual acuity of more than 20/200, if there is a field defect in which the peripheral field has contracted to such an extent that the widest diameter of visual field subtends an angular distance no greater than 20n degrees.