Senator KENNEDY. I want to welcome the Administration witnesses, Dr. DuVal, Assistant Secretary for Health and Scientific Affairs, accompanied by John S. Zapp, Deputy Assistant Secretary for Legislation, Mr. Robert J. Laur, Deputy Administrator for Prevention and Consumer Services of the Health Services and Mental Health Administration, and Dr. David J. Sencer, Director of the Center for Disease Control, Health Services and Mental Health Administration. STATEMENT OF DR. MERLIN K. DUVAL, ASSISTANT SECRETARY FOR HEALTH AND SCIENTIFIC AFFAIRS, HEW; ACCOMPANIED BY JOHN S. ZAPP, D.D.S., DEPUTY ASSISTANT SECRETARY FOR LEGISLATION (HEALTH), HEW; ROBERT J. LAUR, PH. D., DEPUTY ADMINISTRATOR FOR PREVENTION AND CONSUMER SERVICES, HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION, HEW; AND DAVID J. SENCER, M.D., DIRECTOR, CENTER FOR DISEASE CONTROL, HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION, HEW

Dr. DUVAL. Thank you, Mr. Chairman. This is Dr. Laur's first appearance before your committee and we are pleased to have him with us this morning.

I am glad to be here today as the Department of Health, Education, and Welfare witness on a subject of great concern to both of us, the prevention and control of communicable diseases. We share with you a great optimism for the potential of preventive medicine in reversing the present risky and expensive crisis intervention mode of practice to a more dependable health surveillance and maintenance approach. Nowhere is this more evident than in our combined attention to the control of communicable disease.

In fact, new developed vaccines, drugs, and improved methodologies make it possible to project realistically not just the cure but the eradication of many historical communicable disease "plagues". Just within the past year we have seen our strategy for the control of smallpox, one of the most dreaded infectious diseases, reach full cycle.

Our concern had been to keep immunization levels high and to maintain vigilance at our borders to assure against importation of the disease from countries where it was still endemic. As a result of the World Health Organization's worldwide smallpox eradication program, of which the United States Department of State and the Department of Health, Education, and Welfare were active participants, the global situation has changed dramatically.

Worldwide eradication is now being realistically predicted; therefore, the threat of importation has been dramatically reduced. As a result, we are now able to recommend the discontinuance of routine smallpox vaccination for the Nation as a whole.

We must, Mr. Chairman, remain free to evaluate and reevaluate objectively the status of diseases, levels of protection, and current state of scientific and technological development, if we are to continue to provide leadership in improving the health protection of the people of this country, and by necessary implications of the world.

You expect this of us, and it is our willing responsibility; yet the constraints of fear, misconception and prior knowledge must be ac

cepted. New facts and redefined methodologies require both improved communications and usable statutory authorities.

When, as in the case of smallpox, we need to redirect our approach and, for example, make known the reduced risk of infection vis-a-vis the potential for reactions to inoculation, we need to be able to accomplish this task under available authorities as well as to be able to respond to the impact this redirection makes upon State and local

resources.

Our preference for flexible and logically consolidated grant authorities for these kinds of situations has been often stated in the past. We opposed the Communicable Disease Amendments of 1970 on this basis and remain opposed to the establishment of narrow categorical grant

programs.

S. 3442 would extend the 1970 Communicable Disease Amendments by providing in section 317 of the Public Health Service Act an appropriations ceiling of $90 million for fiscal year 1973 and each of the next 4 fiscal years. Aside from minor changes in wording, the only other substantive change provided in the bill is the addition of a new subsection, 317 (h), authorizing the appropriation of up to $5 million for each of the next fiscal years (5) for the purpose of supporting grants or contracts with public and private nonprofit agencies to carry out public awareness programs.

Beyond the problems of redirecting at State and local levels categorical emphasis established by legislation, as I have discussed, the addition of the subsection authorizing a public awareness, or health education program would create further redundancy and complexity in our legislative authorities in the health field.

Similar international and publication distribution authority can be found and is now being utilized under section 301 of the PHS Act, as well as sections 311, 314, and 315.

In addition, the committee is considering S. 3187-"National Venereal Disease Prevention and Control Act"-which would authorize during fiscal years 1973 through 1975 a multiphase venereal disease control program. For each fiscal year there would be authorized an appropriation ceiling of $70 million which would be used as follows: $15 million for project grants to public or private nonprofit organizations to carry out research, demonstrations, or training for the prevention or control of venereal disease; $25 million for formula grants to States for venereal disease diagnostic and treatment services; and $30 million for project grants to States for carrying out venereal disease prevention and control programs.

Again, let me emphasize that the Public Health Service Act now contains authority for these kinds of programs. In section 301 there is ample authority for research and demonstrations and in section 314 there is formula grant and project grant authority which would serve the same purposes as provided for in S. 3187.

Present authorities, as cited, I think offer ample support for the support of ongoing activities in these activities in which we are all so vitally interested. The record of what has been achieved in response to the Nation's most urgent communicable disease prevention and control needs can, I think, be best illustrated by reviewing in a number of critical areas the changes in disease incidence reported to the Center for Disease Control by State health departments.

POLIO

In 1962 when the Vaccination Assistance Act was passed, the original section 317 of the Public Health Service Act, we found that poliomyelitis had once again become "infantile paralysis". After the early successes with the Salk vaccine, a new reservoir of unprotected children was built up as large numbers of the newborn added each year to the population went unvaccinated.

At that time, too, a new oral polio vaccine was being developed which would permit not only simpler, less painful administration but also more effective, longer lasting protection. The Vaccination Assistance Act was designed to take advantage of this development and at the same time to ride the coattails of the new vaccine and to attempt to raise the levels of protection against diphtheria, whooping cough, and

tetanus.

The following is a comparison of the number of cases of polio at the beginning and end of the decade.

Number of cases of paralytic polio:

1962

1971

910

12

Looking back over the 10 years period, we find that we have a better immunized population and that protection has resulted in a dramatic drop in the number of cases of paralytic polio. Admittedly, the situation is not as simple as the figures would imply.

For in the past few years, immunization levels have slipped off creating concern that localized outbreaks might occur. However, when it was found that there were pockets of nonimmunized children, it was possible to respond rapidly to this need by reprograming funds under 314(e) and that had become available because of reductions in the price of rubella vaccines.

This was accomplished under the authority of section 314 (e) without any legislative revisions.

MEASLES

In 1963 a measles vaccine became available; however, it did not enjoy widespread use. Acceptance of the vaccine was hampered by its high cost and by the fact that the public had learned to accept measles as a mild childhood disease that was simply a part of growing up.

As a nation, we were not fully aware of the drastic side effects that could accompany disease-death, disability, and mental retardation. To correct the situation, the Vaccination Assistance Act was extended and amended to include the support of a measles vaccination program-this was the Community Health Service Extension Amendment of 1965.

Under this authority, a nationwide measles control program was undertaken. The success that was achieved in the few short years under that program is reflected in a comparison of reported measles cases in 1962 and 1971 (it should be kept in mind that 10 years ago measles was grossly underreported):

Number of cases reported:

1962

1971

481, 530

75, 007

Since measles is a very highly infectious communicable disease, a slight fall off in immunization levels unfortunately resulted in a sharp rise in the number of cases of measles, which is not reflected in the above data. As was the case with polio, the administration met this problem by directing funds available under section 314(e).

RUBELLA

Rubella, or German measles, was another childhood disease which we had no means of preventing and whose apparent mildness marked serious, heartbreaking, consequences, not to the person with the disease but rather to the unborn children.

Pregnant women who contracted rubella during the first trimester of their pregnancy can and do run the terible risk of having a child born with severe congenital malformations or mental retardation. In the fall of 1968 when it became apparent that there was a good chance that a rubella vaccine would be licensed for use in the United States, the Department began work on the development of a rubella control program.

As a result of this program planning, a supplemental appropriation request for fiscal year 1969 had been submitted to Congress before the new vaccines had been licensed. Funds for this activity were requested and provided under the broad authority of section 314(e). The administration and Congress responded so quickly to this opportunity that programs were underway in the summer of 1969.

This rapid mobilization of Federal, State, and local resources had, at first, strained the production capabilities of the health industrya temporary situation which was quickly resolved. Since the rubella vaccine was licensed only in May, 1969-a period of time which can be counted in terms of months-more than 31 million children have been immunized against rubella.

Having reached about 70 percent of the prepubertal school children, we are now concentrating on immunizing preschoolers. This is an achievement of which we can all be very proud. And, I am convinced that when the program is completed we will have witnessed one of the Nation's biggest successes in modern day preventive healthand it will have been done without special legislation.

TUBERCULOSIS

It was in fiscal year 1962, under point-of-order authority contained in the appropriation act, that special project grants for tuberculosis control were first authorized. This also marked the beginning of the Department's efforts to modernize tuberculosis control activities across the Nation.

More specifically, the Department was striving to: (1) Achieve more widespread use of the drug isoniazid for both treatment and prevention of tuberculosis; and (2) change the concept of tuberculosis care from one of long-term hospitalization to an approach that combined a shorter hospital stay with outpatient treatment, and (3) generally improve the management of tuberculosis cases.

Under the circumstances, the number of reported cases fell from 1962 from 53,315 to 37,137 in 1970.

The results of the program are, however, more significant than the number of cases indicated. As a result of the prevention of new