the level of care will probably fall back to what occurred in 1963 when preliminary data was gathered prior to their inception. At that time

37% of the patients were under current medical supervision. In tuberculosis, if a patient is not under supervision he is by definition out in the community spreading the disease. Therefore, 63% of patients were not being controlled and were spreading the disease. In 1971 the study was repeated. At that time 98% of patients were under current supervision. The national average for 1970, patients under current supervision, is 73%. With the closing of the combined clinics the 6,500 complicated patients would necessarily be referred to other inadequate facilities or would have to be cared for as inpatients at a cost of $127 each per day. I must repeat myself in that most of the progress we have made in tuberculosis control in New York City is due entirely to the concept of providing comprehensive care to the tuberculosis patient in the context of his tuberculosis, which makes him a captive of the medical care system for the duration of his treatment. This is the charge given to the combined chest clinics and this is what would be lost if these clinics were closed. Briefly, other difficulties that we would have to encounter would be the inability to train young community oriented physicians, nurses and community people in considering tuberculosis in the mainstream of medicine. 109 project paid employees would have to be terminated of which 71 represent minority groups, many of whom are former tuberculosis patients themselves. We have found that individuals from the community can relate as no professional can to the patient concerning his problem,and our extremely low lapse rate reflects this clearly.

Appended to the report is the new case data with rates for 1969, 1970 and 1971. As can be seen the case decrease for 1969-70 does not occur in 1971. Brooklyn and Queens show a marked rise in new active cases. Clearly this is not the time to decrease support.

5. Q. What will be the priority given for tuberculosis programs in New York State when federal funding is stopped?

A. The State of New York has indicated to us that they are very concerned about the tuberculosis control program. They have recently assured us that the 314 (d) formula money earmarked by them for tuberculosis control in New York City will not be decreased in fiscal year 1972. However, they too are in a bind when it comes to other programs and as in my answer to question (1) above, and in my prepared testimony, it has been shown that the state cannot support additional outlays for tuberculosis control in New York City because of their own other priorities on the use of this money, much as they would like to. Authorizing specific earmarked

tuberculosis project funds obviate the use of such money for other priorities many of which are likely to be short term and political as opposed to good public health practice.

6. Q. For fiscal year 1973, the Department of Health, Education and Welfare has requested $14 million for vaccination assistance, $10 million of which is for rubella, and $4 million for all other immunizations. Could you comment on this appropriation request? Will it meet the need for the coming year in the prevention and control of communicable diseases?

A. 14 million dollars for vaccination assistance will certainly be a welcome boost to the efforts of the immunization program. Immunizable disease is clearly one category of disease that fits into the description of entities that the Communicable Disease Amendments seek to eradicate. From a public health standpoint, however, immunizable disease eradication is entirely different than eradication of tuberculosis and venereal disease. With immunizable disease one contact between the health worker and the exposed individual is all that is required.

In venereal disease, highly specialized conferencing of the patient with contact follow-up is necessary. With tuberculosis, contact follow-up is also necessary, but 2 years of treatment of an asymptomatic individual which is required to take the patient out of the pool of those who remain a public health danger is an entirely different problem.

When a new active case of tuberculosis is found, the patient must be interviewed, and his contacts and associates brought in for surveillance. After undergoing diagnostic tests the patient is placed on chemotherapy, usually as an outpatient. The only indication for hospitalization in New York City's program is illness of the patient and since patients become symptom free in a short term those that are hospitalized are then discharged to outpatient follow-up. What sets tuberculosis apart from the other diseases mentioned in S. 3442 is that tuberculosis requires an asymptomatic patient to take medication and be followed at monthly intervals for 2 years in order to render him cured. If this doesn't occur he is a danger to his community as well as himself.

It is for this reason that I feel very strongly that tuberculosis cannot be considered just another communicable disease, but a unique communicable disease that must be mentioned by name in legislation and that everything that can be done must be done to assure that there are appropriations

provided to go along with authorizations to be passed.

I cannot understand why the Department of HEW can request a clearly categorical sum for vaccination assistance while callously ignoring other categories of communicable disease that will not be affected by vaccination assistance and that clearly remain major public health problems.

78-669 - 72 - 12

Bureau of Tuberculosis Control

Bureau of Health Statistics and Analysis

JK/16 4/13/72

1969, 1970 and 1971 rates are based on 1970 Census of Population.

Department of Health

Health Services Administration

The City of New York

Senator HUGHES. The Chair now calls Dr. William Schaffner of the Department of Medicine of Vanderbilt University School of Medicine, who is representing the Action Committee for Childhood Immunization.

STATEMENT OF WILLIAM SCHAFFNER, M.D., DEPARTMENT OF MEDICINE, VANDERBILT UNIVERSITY SCHOOL OF MEDICINE, AND ACTION COMMITTEE FOR CHILDHOOD IMMUNIZATIONS

Dr. SCHAFFNER. Mr. Chairman, I apologize for not having a manuscript of my prepared testimony. It is brief.

I represent the Action Committee for Childhood Immunizations. It is a newly formed nonprofit group of physicians around the country who are sufficiently concerned with the immunization problem that we have gathered together with almost no funds to try to do something about it.

Let me point out that vaccines are available that can protect every child in this country against well-known crippling and killing diseases such as measles, polio, diphtheria, and tetanus; and that cost-benefit studies demonstrate that the gains from immunization procedures are among the greatest to be achieved from any existing public health practice.

If you eliminate the disease, you completely eliminate the need for the diagnostic, therapeutic and rehabilitative structures attendant on that disease.

I would submit that we are not now effectively or comprehensively protecting American children with available vaccines. What we think is needed is national recognition of the situation in a long term Federal commitment to a coordinated plan for the control of these diseases.

You ought to know, lastly, that research is underway which will result in the availability of several new vaccines within the next decade. But we have been unable to effectively use the vaccines we now have. We need to quickly set up a more effective vaccine distribution system, or the failure of the new vaccines is preordained.

Immunization activities have in the past decade been subject to eratic funding, and fads in funding. It has almost been the "disease of the year" approach. In the middle 1950's we were interested in polio. In the middle 1960's when I was in the Public Health Service we were terribly interested in measles. With the advent of rubella vaccine, measles funding diminished, and attention was directed to the administration of the rubella vaccine.

Local and State health departments responded with a distribution of effort dependent upon how these vaccine funds were distributed. I think what we need is a stable, long term commitment to the entire package of immunization of children. Let me give you some quick examples, and then I will stop for your questions.

Measles is our most recent and most dramatic example of immunization failure. This is a disease that we ought to protect children against. One out of every thousand gets encephalitis, and one out of every 10,000 dies. It disrupts schools, and is costly in terms of physicians and other health personnel manpower.

Measles is resurgent today, despite the fact that in the mid 1960's we were talking about the eradication of this disease. Last year there were some 75,000 cases in all economic groups all over this country.