There are no diseases strictly characteristic of the aging process. Our interest includes the sick oldsters, the frail or fragile oldster who without good attention would become sick, and the well oldster who if guided by a positive health program should be able to solve most of his own problems.

Doctors have agreed that there really were no diseases characteristic of the older age group. Poliomyelitis and other diseases usually thought of as appearing only in childhood were occurring in those past middle life. Also, the socalled degenerative diseases of men, such as arteriosclerosis, hypertension, and nephritis, originally thought of as being part and parcel of the aging process, are being recognized in the younger age groups. Hardening of the arteries and coronary diseases are supposed to be characteristically a malady of middle or old age, but in 1954 arteriosclerotic heart disease, including coronary, killed 98 children under 5, and is found in every age bracket thereafter.

It was therefore decided that the AMA Committee on Aging's interest and activity as a physician's committee should be:

1. The sick oldster;

2. The frail or fragile oldster who, without good attention, would become sick; and

3. The well oldster, who, if guided by a positive health program, should be able to solve most of his own problems.

The oldster and his environment must be understood if a solution is to be found.

We approach the total national problem in the same way a doctor tackles a single situation in his own office. The solution of many of the individual illnesses requires some knowledge and ability to deal with all the problems of the 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 usually 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.

The CHAIRMAN. Dr. Larson, you had some material appended to your statement.

Dr. LARSON. Yes.

The CHAIRMAN. Without objection, that will be included in the record at the conclusion of your remarks.

Dr. Larson, and Dr. Swartz, we thank you both for bringing to this committee this discussion of the views of the American Medical Association on H.R. 4700.

I well recall, Dr. Larson, you appeared before the committee last year to which you referred in your statement.

Are there any questions of these gentlemen?

Mr. Forand.

Mr. FORAND. Dr. Larson, so do I recall your appearance last year and the fine discussion that we had. I think you are just about as sincere as I am.

I profess to be very sincere. There are many, many questions that I would like to ask, many points I would like to raise, but I realize that time is limited, therefore, I shall have to pass up some of them. However, I have here a copy of the AMA News, which was issued this week. You recognize that sheet, I am sure.

Dr. LARSON. Yes.

Mr. FORAND. I notice in there an article headed "public relations for M.D.'s," in fact, I will read the first part of it:

Many a physician, fearful he will be accused of unethical advertising practices, often is reluctant to appear on a radio or television program or to allow his name or photo to be used in connection with a newspaper story.

Then it works down to the point where it says if he is in doubt that the code points out that the doctor should engage in these activities. where it is considered for the good and welfare of all concerned.

It points out if they are in doubt they should check with the local medical society.

The reason I bring up this point is that a couple of days ago, a very good friend of mine, a doctor, informed me that something was being done that was not in writing, but that the word had been passed around from headquarters of the AMA to the secretaries of the several State societies, to pass the word around to doctors, in an inferential way, telling them that if they should testify in favor of the Forand bill they might be violating the ethics of the profession and subject themselves to sanctions.

Now, I expect I am going to get an answer to the effect that that is not true. However, again this morning I got the same information coming from a Midwest State that that is being done.

Now, do you know anything about that?

Dr. LARSON. No, sir; I know nothing about that.

Mr. FORAND. Would you tell this committee that a doctor is free to express himself for or against this, or any other piece of legislation without violating the ethics of the profession, and without being subject to sanction?

Dr. LARSON. Yes, sir.

Mr. FORAND. That is possible?

Dr. LARSON. Yes, sir.

Mr. FORAND. I am glad to hear you say that. I ask that for the record so that all doctors will know that they can express themselves for or against, because whether they are for my bill or opposed to my bill, that I do not care, but I want them to have freedom of expression.

Dr. LARSON. Mr. Forand, I would like to say this: that so far as the American Medical Association is concerned, there is nothing we could do to jeopardize the standing of any physician, to criticize him in any way. Now, that would be up entirely to the local medical society. They are independent and we have no control over them.

But any inference that this has come from the American Medical Association, I think, is completely unwarranted because I know nothing like that that has been said and I think I would know about it if it were.

Mr. FORAND. I am glad to have you say that because I do not think that it should be done and I would not expect a respectable organization such as yours to indulge in it, but the fact that it came to me from two different sources in the last 3 or 4 days has led me to believe that there is something behind it.

Now, it may not be done officially by the organization, it may be done by some individual. However, I did want to clear this point because I believe in freedom.

Dr. LARSON. That is right.

Mr. FORAND. I believe that the people have a right to say what they want to say even though I may not agree with what they say.

Now, I know that other means have been used to intimidate not just doctors, but also Members of Congress. In fact, you are perhaps conversant with the questionnaire that emanated from the AMA just before the election campaign last year.

Now, I am going to read the 15 questions that were in this questionnaire which went out to leading physicians in every congressional district in the country. I am going to leave to you and to others an opportunity to think for themselves whether this was intimidation or an attempt to intimidate or not.

Mr. CURTIS. Mr. Chairman, a point of order. Is the committee going into the subject of lobbying tactics or the issue of the health of the aged?

If you are going into lobbying tactics, that is one thing. If you are going into something else, which I thought we were, let us confine ourselves to that.

Mr. FORAND. This is not lobbying. It is electioneering.
Mr. CURTIS. Whatever you call it.

The CHAIRMAN. The gentleman has made a point of order. Of course, we will stay within the rules in asking questions and the Chair feels that Mr. Forand has the right to interrogate the witness, just as is true of any other member of the committee, with respect to any matter that might come within the overall and general study that the committee is making of this problem.

Mr. Forand.

Mr. FORAND. This questionnaire reads as follows:

1. Who is the person or persons in each ward or county in the congressional district who is most influential with the Congress?

List the names, addresses, and business or profession of each.

2. Who is the physician who knows and can work with each of the above? 3. Who are the four or five men in the Congressman's district who really influence him? List their names, addresses, and business or profession.

4. Who are the principal contributors to his campaign?

5. What contacts does the medical profession have with officers or leaders of such organizations as the Blue Cross-Blue Shield, dentists, hospital boards, or directors, chambers of commerce, farm bureau and grange? Who are the doctors who can talk to these leaders?

6. Who is the Congressman's personal physician at home and in Washington? 7. What contacts does the medical profession have or who knows the Congressman's top secretariat on his Washington staff?

8. What are the Congressman's hobbies, his favorite charities, boards or organizations, church?

9. What papers in the district supported him in his last campaign? What is their present attitude toward him.

10. What contact does the medical profession have with any or all of these newspapers, either directly with the editors or through other influential citizens or advertisers?

11. How big a factor is labor in the district?

12. Do any of the labor organizations deviate from the national labor organizations and for what reason.

13. How big a factor are old folks in his district?

14. What contact has organized medicine or individual physicians with the Congressman?

15. What is his general attitude?

Are you familiar with this questionnaire?

Dr. LARSON. Yes, I have seen it.

Mr. FORAND. What was the purpose of it?

Dr. LARSON. The purpose was to find out the feeling of the Congressmen and to be able to give to him in the most effective way the position of the American Medical Association through his own physician, through the local organizations of physicians.

I see nothing wrong in that. There was no intention to intimidate. I think every Congressman, unless I am badly mistaken, is very glad to know what his constituents think about legislation, whether physicians, farmers, or businessmen, or laborers or who they are. Mr. FORAND. How about the question regarding campaign contributions?

Dr. LARSON. Campaign contributions?

Mr. FORAND. Yes.

Dr. LARSON. That is entirely a personal affair, a personal affair so far as the physician is concerned. Nobody is going to tell me who I am going to contribute money to.

Mr. FORAND. Well, it is very interesting to read that list. If there is not an indirect inference contained in there, I am misreading it.

Now, I have a lot of respect for doctors. I have some of my own relatives who are doctors and who are just as bitterly opposed to this bill as you and your organization are.

That does not disturb me in the least because I am still working for one purpose and that is a solution of the big problem.

Dr. LARSON. We are, also, Mr. Forand, and I think, as I said a year ago, I believe I used the word "catalyst," that you could consider yourself a catalyst in this whole problem of care of the aged. You are the one who dramatized this problem before the American public through this bill and I congratulate you on that. I thank you for your expression of sincerity on my part.

I want to assure you that I consider that you are sincere, also.

Mr. FORAND. I want you to understand, Doctor, that when I say you, I do not mean anything personal. I am referring to you as a representative of your organization.

Dr. LARSON. Thank you.

Mr. FORAND. On page 8, I do not recall whether it was you or Dr. Swartz, who made a statement relative to the estimate of cost of $2 billion as the cost of this program.

Secretary Flemming told this committee in his report, and also before the committee here, that the cost would be approximately a billion dollars for the first year.

Dr. LARSON. This is $1 billion, something like that, was his estimate. But this figure of $2 billion is based primarily on the estimate of the health insurance association.

Now, I am not qualified to go into those statistics and I understand that Mr. Faulkner is supposed to testify sometime this week and I would imagine that he will go into that subject rather carefully. Mr. FORAND. Thank you.

Now, do you agree with the American Hospital Association that it is conceivable that the use of the social security mechanism might eventually be necessary in the handling of this problem?

Dr. LARSON. No, we don't. The position, as I understand it, of the American Hospital Association, is that they are opposed to the Forand bill, they recognize it may be necessary to have some form of Federal intervention if you want to call it that.

Now we are convinced in our own minds that given time this probably can be solved on a voluntary basis.

We agree it is going to take time, but we think the progress to date has been good and that we can solve this on a voluntary basis.

Mr. FORAND. But you have no idea how long that will take?
Dr. LARSON. No, sir. I don't think anyone has.

Mr. FORAND. Because we have already spent years studying. We have the statistics, and talks about it, but we have yet to reach a successful point.

Dr. LARSON. I realize that.

Mr. FORAND. Is your object of a voluntary basis, prepayment plan through the use of nonprofit organizations, something like Secretary Flemming suggested the other day?

Dr. LARSON. I heard that he had suggested that. I was not here.

I think that is a very interesting subject. We would certainly want to study that very carefully. I could not give you any opinion offhand on it.

Mr. FORAND. I wish you would let the committee know if you reach a conclusion on that.

Dr. LARSON. We will do so.

Mr. FORAND. Does your organization consider this H.R. 4700 to be unethical insofar as your profession is concerned?

Dr. LARSON. Unethical?

Mr. FORAND. Yes.

Dr. LARSON. No.

Mr. FORAND. I gather from your statement you consider nurses an indispensable element in the health posture of our Nation. Can you tell me why the American Nurses Association was not invited to participate in the joint council for the health care of the aged?

Dr. LARSON. Well, the four organizations that formed the joint council were considered to be the major purveyors of the service.

Now, someone had to start it. Since the organization has started there has been considerable discussion as to the advisability of admitting other organizations such as the American Nurses Association, the AFL-CIO, and other organizations that have expressed an interest. I think the board of directors, of which our organization only has 3 out of the 12 on the joint council, is giving very serious consideration to that.

Mr. FORAND. Now, I understand from the activities of this so-called joint council that that is a front for the AMA to kill H.R. 4700.

Dr. LARSON. I do not believe that is true, Mr. Forand. I think that this is a sincere endeavor on the part of the four organizations to study this problem, find out the extent of the problem, to assess what we already have and to see whether or not something cannot be done on a voluntary basis to solve the problems of the aged.

Mr. FORAND. It seems peculiar because I understand that the American Nursing Association is favoring this bill, the labor groups are favoring this bill, and neither one of them was permitted to participate as active participants in the joint council's activities.

Dr. LARSON. It seems to me, if you are referring to labor, they are the recipients of that service. This organization, so far at least, is composed of the purveyors of service.