However, in order to get to the disease, venereal disease, in order to get a girl who is pregnant in early enough to do something about it, one has to, I think, go along with the idea that an individual type of private relationship with a youngster can be introduced, and a physician need not involve the family.

I feel though in overall venereal disease control one can work out a sensitive enough system for confidential reporting-and, as a matter of fact, this has worked out in some of the free clinics with youngsters that involve an informal confidential reporting system wherein youngsters are encouraged to say where they probably got the gonorrheaand where a sensitive investigator does look into who the contacts were, and tries to get to them, to try to lead them to treatment.

I think there are true advantages that were mentioned earlier of reporting venereal disease for the purposes mentioned, but what may be needed is a much more sensitive approach, much more confidential approach, to handling the problem.

You know a lot of us, I am sure a lot of parents, a lot of physicians, are rather judgmental about the finding of venereal disease. That attitude can be detected by individuals, and by youngsters particularly, and I think we have to begin to look at this as a health problem, which is indeed a part of a social problem, but it is a health problem, in trying to set up mechanisms for handling it more sensitively. In other words, I think we need reporting. I think we should do it in a more sensitive way.

Senator HUGHES. Dr. Parrott, I might just ask you. Previous witnesses testified to the fact there was no violation of the law involved in this, and no penalties.

Dr. PARROTT. If it was not reported? With failure to report?

Senator HUGHES. With failure to report, but on the matter of enforcing laws, I believe every State in the Union prohibits commission of the sex act outside of wedlock, regardless of age. It must be about the most violated law in America today, unless it is the laws against smoking marihuana.

I am wondering about this. I know in my own State from my experience as Governor that we do have a few people in prison serving sentences as a result of breaking some of these laws, but you have to prosecute both parties; you just cannot prosecute one or the other; it has to be both parties involved.

I suppose the only purpose of this question is: Do you believe we should rid ourselves of all of these extraneous laws that are obviously unenforceable, and which have not been enforced in most States for years?

Dr. PARROTT. Let me comment. The feeling of many individual physicians about communicable disease reporting-and perhaps if my comment is correct it could lead to an approach which would allow us to adhere to the law as it was intended-I think physicians often feel that the requirement to report certain communicable diseases is just a law, and little is done about it, and it becomes cumbersome, and they do not necessarily fully understand it.

The way many physicians have been brought up over the last 20 or 30 years, they have thought that the lectures on epidemiology of venereal disease and control as given by medical school or public health people have been among the driest, the least understandable,

the least important in their interpretation of the various kinds of principles that have been taught.

They have not seen a real followup on a lot of communicable disease reporting.

I think if communicable disease reporting, including VD reporting, can be made simpler, a hot line type of thing, less cumbersome in terms of writing things out, the follow up made more sensitive, then the real value of it, which I do not think could be disputed, could take place. It may be there would not be so many "law breakers" as there apparently are among physicians.

Senator HUGHES. A few weeks ago I had an opportunity to talk to a man and wife team of physicians, and the wife particularly was directing her energies at educational programs on university campuses in the State of California.

The problem she was running into was that in an educational forum no one would come forth but there were many contacts in the informal atmosphere afterward. Then within a day or two or week afterward she receives requests by phone for advice or examinations.

Do you have any specific recommendations we might consider as a committee to improve education and public information so that this problem can be brought out into the open?

We obviously have an epidemic widely out of proportion to our capabilities of meeting it.

Dr. PARROTT. With regard to the group of diseases for which there are currently vaccines, I think the public information largely needs to be directed to inner city groups, and it is going to require very special attention.

This is a problem that has not been dealt with successfully in the instance of other aspects of health care, so that very intense efforts are going to be necessary by sensitive people, hopefully by people coming from the immediate community.

As a public information and education matter, and with particular regard to venereal disease I think we have to open the minds of parents, and PTA's there are PTA's in this country who do not think we ought to teach the principles of sex and the potential consequences of disease in the course of sex.

On the other hand, there are examples of very progressive programs in certain PTA's. There are other "crash" programs. There will be one in this city, as I understand it, in the fall, a crash porgram in which I believe it will be possible to call attention to the problem of venereal disease, with an invitation in multiple places-clinics, physicians' offices, whatever-to come and be examined, to be examined for possibility of venereal disease.

I think we need more crash programs. I think we need a long term program of sex and health education, as I implied before, not just for children but for all of our families.

Senator HUGHES. Dr. Parrott, I take it you feel our educational systems are not meeting the challenge of explaining VD and the risks

at all.

Dr. PARROTT. Collectively, as families, churches, and school systems, we apparently are not. I do not think it should be put all on the school system by any means.

Senator HUGHES. No, but we are failing in getting that sort of approach across.

Dr. PARROTT. Yes.

Senator HUGHES. Dr. Parrott, thank you very much for your testimony and your willingness to be here.

Our next witness is Dr. Leo Reichman, tuberculosis control officer of the New York City Department of Health.

Dr. Reichman, we welcome you to the subcommittee.

STATEMENT OF LEE B. REICHMAN, M.D..; MPH DIRECTOR, BUREAU OF TUBERCULOSIS, NEW YORK CITY DEPARTMENT OF HEALTH

Dr. REICHMAN. On January 16, 1972, an editorial appeared in the New York Times. I found it quite disturbing and would like to share some of my thoughts about it with you today.

The editorial was basically a salute to the 50th anniversary of the discovery of insulin. To quote the editorial:

This historic achievement has relevance for medical problems now under intensive discussion. The present tendency is to put into the foreground "practical" questions of the organization and delivery of health care while minimizing basic research in the medical and related sciences.

The final paragraph of the editorial reads:

Today the unsolved problems of coronary heart disease, neurological illness and other ailments require similar basic discoveries before cures can be found. The insulin story is a useful reminder that too great concentration on the "practical" approach to medical problems with a consequent downgrading of research can be self-defeating.

How, you might ask, does this editorial concern the legislation under consideration, which is communicable disease, specifically, for me, tuberculosis. Tuberculosis as you probably know, is a totally curable disease. Of the top 20 causes of death in the United States, it is the only one that is completely understood. We know its pathogenisis, we know how it is transmitted, we know how to prevent the infected from coming down with the disease. We know all these things, that is, no "basic discoveries," to use the wording of the editorial, are required "before cures can be found." Yet in 1970, tuberculosis killed 5,560 Americans and newly affected 37,137. Of these, 386 deaths and 2,590 new active cases were New Yorkers. Dr. DuVal pointed out that the rates have come down gratifyingly, but I must point out in nonwhites in the USA the rate was up 2 percent in the period 1969–70. 1969-70.

In other words, this disease in which no more basic research is needed, is still a grave, health, economic, and social problem. Another statistic which I feel brings home the point is that the new active case rate for central Harlem in 1970, although gratifyingly down 50 percent since 1960, was higher than the rate for New York City as a whole was in 1942-135.9 percent per 100,000 population to 130 per 100,000 population.

The preceding remarks, I feel, provide us with compelling evidence that, the editorial notwithstanding, "practical" questions of health care delivery are still a paramount problem in medical practice. Tuberculosis rates, I feel, are a prism through which the glaring deficiencies in the organization and delivery of health care can be viewed.

With this as an introduction, let us look at the tuberculosis problem in New York and what we have done with your aid, but what still must be done.

Tuberculosis occurs among the people of all ethnic backgrounds. Since 1945 marked changes have occurred in the ethnic makeup of New York City. An ethnic analysis of tuberculosis patients compared to the makeup of the city itself reflects this. In 1945, whites represented 90 percent of the population and accounted for 70 percent of the new active tuberculosis cases reported. Nonwhties and Puerto Ricans represented 10 percent of the total population and accounted for 30 percent of the new active cases of tuberculosis. On the other hand, in 1970 whites made up 67 percent of the population and accounted for only 32 percent of the new active cases, while nonwhites and Puerto Ricans represented 33 percent of the population and accounted for 68 percent of the new cases.

Thus we can answer the question who gets tuberculosis by saying that although tuberculosis declined among all ethnic groups, the minority groups in whom dissemination of health care is still a great problem, were most affected.

Where are the new patients? The new active tuberculosis case rate for New York City in 1970 was 32.8 per 100,000 population. This is the average for the city's 30 health districts. The individual district rates range from central Harlem's 135.9 per 100,000 population, to Flushing's 7.2 per 100,000. Only eight of the 30 health districts, with a total of 1,348 new active cases account for 52 percent of the new active cases reported in the entire city.

Underscoring these figures is the fact that the city's rate is twice. the national rate of 18.3 per 100,000 and three times the upstate New York rate of 11.9 per 100,000.

To further emphasize where the new patients are: the rate in central Harlem is seven times the national rate and 11 times the upstate rate. One more representation which most effectively shows us where the new cases are, is this comparison of the per capita homicide rate for each district, compared with the geographical distribution of tuberculosis cases. It can be seen that they are almost identical in distribution.

Most of our cases are reported from hospital and department of health chest clinics. Only 4 percent of the new active cases were reported by private physicians. This reflects again the health care delivery pattern in our city as far as the average tuberculosis patient is concerned. TB patients, almost by definition do not have access to private health care delivery.

In 1963, the Surgeon General appointed a task force to study the status of tuberculosis control in the country. This report completed in December 1963 contained recommendations for a 10-year plan to raise the level of nationwide tuberculosis control services through greater Federal participation, by means of increased formula and project grants to the States. New York City, acknowledged as having the greatest tuberculosis problem, was a charter recipient of this support. I would like to review for a moment what was done in New York City with the substantial personnel, funds, and flexibility, provided by the Federal tuberculosis project.

The tuberculosis project, which is under the control of the director of the bureau of tuberculosis, provides support in the form of managerial

Senator HUGHES. No, but we are failing in getting that sort of approach across.

Dr. PARROTT. Yes.

Senator HUGHES. Dr. Parrott, thank you very much for your testimony and your willingness to be here.

Our next witness is Dr. Leo Reichman, tuberculosis control officer of the New York City Department of Health.

Dr. Reichman, we welcome you to the subcommittee.

STATEMENT OF LEE B. REICHMAN, M.D..; MPH DIRECTOR, BUREAU OF TUBERCULOSIS, NEW YORK CITY DEPARTMENT OF HEALTH

Dr. REICHMAN. On January 16, 1972, an editorial appeared in the New York Times. I found it quite disturbing and would like to share some of my thoughts about it with you today.

The editorial was basically a salute to the 50th anniversary of the discovery of insulin. To quote the editorial:

This historic achievement has relevance for medical problems now under intensive discussion. The present tendency is to put into the foreground “practical" questions of the organization and delivery of health care while minimizing basic research in the medical and related sciences.

The final paragraph of the editorial reads:

Today the unsolved problems of coronary heart disease, neurological illness and other ailments require similar basic discoveries before cures can be found. The insulin story is a useful reminder that too great concentration on the "practical" approach to medical problems with a consequent downgrading of research can be self-defeating.

How, you might ask, does this editorial concern the legislation under consideration, which is communicable disease, specifically, for me, tuberculosis. Tuberculosis as you probably know, is a totally curable disease. Of the top 20 causes of death in the United States, it is the only one that is completely understood. We know its pathogenisis, we know how it is transmitted, we know how to prevent the infected from coming down with the disease. We know all these things, that is, no "basic discoveries," to use the wording of the editorial, are required "before cures can be found." Yet in 1970, tuberculosis killed 5,560 Americans and newly affected 37,137. Of these, 386 deaths and 2,590 new active cases were New Yorkers. Dr. DuVal pointed out that the rates have come down gratifyingly, but I must point out in nonwhites in the USA the rate was up 2 percent in the period 1969–70. 1969-70.

In other words, this disease in which no more basic research is needed, is still a grave, health, economic, and social problem. Another statistic which I feel brings home the point is that the new active case rate for central Harlem in 1970, although gratifyingly down 50 percent since 1960, was higher than the rate for New York City as a whole was in 1942-135.9 percent per 100,000 population to 130 per 100,000 population.

The preceding remarks, I feel, provide us with compelling evidence that, the editorial notwithstanding, "practical" questions of health care delivery are still a paramount problem in medical practice. Tuberculosis rates, I feel, are a prism through which the glaring deficiencies in the organization and delivery of health care can be viewed.