of health systems agencies and State agencies responsible for health planning and resources development. The program is designed to improve the quality and delivery of health services throughout the Nation, while at the same time containing the cost of providing health services and preventing unnecessary duplication of health resources. The program is designed to improve health care for the total population, not for a particular group such as the aged. Nevertheless, to the extent that the planning agencies improve the effectiveness and efficiency of the health care system, the elderly will be major beneficiaries. This is particularly so in terms of improved accessibility to health manpower and facilities, and in terms of moderating the excessive costs of health care. To date, 201 health systems agencies have been designated, as well as 50 State health planning and development agencies. The health systems agencies will be responsible for preparing and implementing plans designed to improve the health of residents in their areas, for providing technical assistance to organizations seeking to implement the plans, and for reviewing applications for Federal funds for health programs within the service area. The State health planning and development agencies will work to integrate the health plans of the local agencies into a State health plan, administering the facilities construction program, and implementing the certificate-of-need programs. In 1977, a particular focus will be on the health systems agencies as they develop their health systems plans and annual implementation plans. These plans will be addressing the health needs of the population of the health service area and to that extent will be considering the problems of the aged. These plans, to the extent that they provide for a priority for the aged, have a capacity to be addressed through the area health services development fund, which should be available late in 1977. 4. NATIONAL CENTER FOR HEALTH STATISTICS The National Center for Health Statistics has as its mission the identification of problems and trends of health status of the general population through the collection and dissemination of quantifiable data. As part of its mandate to collect data on health indicators that affect the total population, the National Center has compiled data on health issues applicable to the elderly. Acting as a statistical resource base for the other components of PHS, NCHS has conducted surveys which measure the health and nutritional status of persons aged 60–74; the health status and utilization of health facilities by persons aged 65 and over, and the characteristics of residents of nursing homes. These data are presented in the Vital and Health Statistics series reports published by the Health Resources Administration. Data relevant to the activities of the elderly obtained by various data collection mechanisms of NCHS are as follows: National Mortality Statistics examines death by various causes. The statistics are broken down by age, sex, race, State, counties, and places with more than 10,000 inhabitants. Health and nutrition examination survey provides data related to the health and nutritional status of the population collected through actual examination of a sample of the Nation's noninstitutionalized population. The survey supplies data for evaluation of nutritional status through analysis of dietary intake and food frequency interrelated with physical examination, medical history and biochemical assessment data. The survey was specifically designed to examine population groups at high risk of poor nutrition, i.e., preschool children, the aged, the disadvantaged and women of childbearing age. The age group of the sample is from 6 months to 74 years. Health interview survey conducted on an ongoing basis identifies health characteristics and the utilization of health services by individuals in the noninstitutionalized population. Variables examined include: age, sex, color, ethnicity, material status, and socioeconomic status. Hospital discharge survey conducted on an ongoing basis compiles data on discharges, diagnoses and surgical operations or procedures of populations in short-stay hospitals in the United States. Age, sex, race, and marital status are examined. National ambulatory medical care survey collects data on an ongoing basis on the diagnosis, treatments or services and the dispositions of patients for ambulatory medical care visits in the United States. The sample population covers noninstitutionalized individuals and office based physicians in the United States. Variables used in this study are: age, sex, color of patient, and physician characteristics. National nursing home survey conducted every 3 years examines the characteristics of nursing homes, their expenses, services and staff, and the health and demographic characteristics of their residents. Diagnoses, conditions, functional status, age, sex, color, ethnicity, marital status, and source of payment are resident variables utilized in the survey. Data from the 1973-74 survey have been published and the next survey is scheduled for mid-1977. In addition to these data collection activities, the National Center for Health Statistics is sponsoring a technical consultant panel for the purpose of developing a minimum basic data set for long-term health care. When developed, the data set will be collected on a regular basis to show up broad variations and trends in factors related to long-term health care. 5. BUREAU OF HEALTH MANPOWER The Bureau of Health Manpower strives to expand the force of primary care practitioners and improve the distribution of health personnel. The Bureau's activities do not focus primarily on elevating the health concerns of the aged, but they affect this segment of the population. On July 29, 1975, the Nurse Training Act of 1975 (Public Law 94-63) was enacted, revising and extending the nurse training authorities under title VII of the Public Health Service Act until June 30, 1978. It includes new authority for nurse practitioner programs with emphasis on training to meet the particular problems of geriatric and nursing home patients as well as training to provide primary health care in homes, ambulatory facilities, long-term care facilities and other health care institutions. Primary care training is supported through grants to hospitals to train residents in family practice. At the undergraduate level, primary care preceptorships are assisted through special project awards. A Graduate Medical Education National Advisory Committee (GMENAC) was established to advise the HEW Secretary on physician specialty distribution in relation to graduate medical education opportunities. Public Health Service scholarships are awarded to students of medicine, osteopathy and dentistry who are willing to serve in health manpower shortage areas. To increase the output of medical and dental services, particularly in shortage areas, the training of physicians and dental extenders is supported. Eleven area health education centers, designed to link health manpower training with community service needs, are supported in various parts of the country. Priority is given to clinical training of medical and other health professions students in hospitals and ambulatory care settings in medically underserved areas. The health professions educational assistance program was substantially revised and extended on October 12, 1976, with the enactment of the Health Professions Educational Assistance Act of 1976 (Public Law 94-484). The new law puts added emphasis on alleviating the problems of specialty and geographic distribution of health personnel. Special consideration is given to assistance programs for students willing to participate in shortage related activities. In addition, there is special project authority for training in the diagnosis, treatment, and prevention of the diseases and related medical and behavioral problems of the aged. B. NATIONAL INSTITUTES OF HEALTH NATIONAL INSTITUTE ON AGING The vast increase in the absolute number and relative proportion of older people is the most startling demographic characteristic of the twentieth century. Individuals over 65 comprised 3 percent of the population in 1900, nearly 10 percent by 1972, and will comprise a projected 17 to 20 percent of the population in 2020. In only 45 years, one out of every five Americans will be over 65. This explosion in numbers will have social, economic, and personal consequences if plans are not made well in advance. Congress demonstrated great wisdom and foresight in establishing the National Institute on Aging. The research conducted and supported by the NIA will help improve the quality of life, enhance service delivery, and contain costs. The major commitment of time and effort necessary to unravel the mysterious process of aging is rightfully undertaken now, before the post-World War II "baby boom" reaches age 65, if we are to prevent unnecessary suffering and hardship. Time and money invested in research today will pave the way for more efficient services at less cost in the future. Fundamental to all good health care and social services is research-biomedical, behavioral, and social research. Yet often, criticism of our health care system frequently extends to a questioning of the value of continuing research. This questioning is more than antiintellectual; it is part of a real national anxiety to commit public resources toward immediate social ends, instead of making a long-term investment to acquire useful information. The demand for some justification in economic terms of the return on research is a fair one, but one that is not always easy to satisfy. How, for example, can savings of suffering brought about by the development of a new drug be quantified? We no longer rely on leeches and the purge to protect us from periodic outbreaks of plagues. Both the practice of medicine and our health care system are still based a good deal on trial and error; without research they would not progress. The ultimate purpose of research is the same as social welfare: to improve the well being of man. In the case of research, this is done by promoting a greater understanding of the nature of life. At the most basic level, we gather knowledge about the functioning of life-giving systems and about the processes of growth, development, and decline. Combining and developing this basic information leads to ways of understanding, preventing, and curing disease and disability. Our lives are influenced every day by mass social actions such as the fluoridation of water, mandatory sanitation, and pollution control practices, all of which have resulted from information gotten in basic laboratory studies. Individuals also participate directly in the application of research to health when they change life styles by improving eating habits or stopping smoking. Perhaps one of the biggest problems we face is the enormous educational proc. ess which needs to take place in this country before we can eradicate negative attitudes toward aging These attitudes carry over into our medical schools and research institutions. Unbelievably, there is minimal teaching of geriatric medicine in U.S. medical schools. There is no greater need for research than in the field of aging. The creation of the National Institute on Aging by the Congress 2 years ago is indicative of Federal recognition of this need. THE RESEARCH PLAN Recognizing the necessity for an orderly approach to the various aspects of aging in America, the Research on Aging Act directed the Secretary of DHEW to develop a plan for research on aging. The Secretary designated NIA as the lead organization in the preparation of the research plan. NIA, working in conjunction with the National Advisory Council on Aging, has now completed its recommendations to the Secretary. The Secretary has in turn transmitted this plan to Congress. Any well-conceived research plan must necessarily deal with specifics. But research on aging is particularly vulnerable to fragmented approaches. The plan, therefore, is conceived as a holistic approach to discovery of information about aging. In the course of developing this plan, the NIA was able to begin defining its mandate in more specific terms. Its mission extends the study of aging beyond decline, loss and decrement, to an examination of the normal processes of development that contribute to the quality of life in later years. By investigating the wide variety of factors that constitute and affect the aging process, the NIA hopes to be able to translate the accumulated knowledge into ways of preventing, modifying, or reversing these factors. The ultimate goal of the Institute is to improve the quality of life, and extend the healthy, productive middle years of life. In some cases, we can move ahead fairly rapidly, with applicable returns on our research investment possible within 5 years; for other issues, their very complexity demands a longer, more sustained effort, although significant improvement in our understanding is possible within several years. The Institute is divided into intramural and extramural programs. At its intramural research facility in Baltimore (commonly known as The Gerontology Research Center), the Institute conducts studies ranging from investigations of the tiny molecular building blocks of life to the broad age-related changes that occur over long periods of time, such as the decline in the body's ability to resist disease. A longitudinal study of aging uses a sample of 650 men to examine the effects of aging on metabolism, organ function, hormone biochemistry, psychology, and genetics. Plans are now being made to include women in the longitudinal study. Grant- and contract-supported research covers a wide variety of areas, such as cellular aging, endocrine changes with age, immunologic aging, the pharmacology of aging, the use of experimental animals in aging research, cognitive changes with age, and societal aspects of aging. Extramural research (supported by grants to universities and medical centers) is administered by the Adult Development and Aging Branch. The extramural program is evaluating the need for the development of centers for aging research. These centers would permit a multidisciplinary approach to the study of aging, ranging from biology to geriatric medicine and behavorial studies. The need for tangible and immediate improvement in the quality of life for the aged has shifted research away from its exclusive disease orientation, with its study of the sick and institutionalized, to a broader inquiry into normal physiological changes occurring with age, the behavioral constitution of the aged, and the social, cultural, and economic environment in which the elderly live. To identify issues amenable to research or requiring additional effort, the National Advisory Council on Aging sought the advice of the research community. In so doing, it identified the following: Biomedical issues amenable to a short-term effort include: 1. The decline in immunological competence with aging, and its implications. 2. Variations in the process of aging, life expectancies, and the patterns of disease among the aged of different ethnic, racial, and cultural groups, as well as between the sexes. 3. The interaction of aging and its accompanying diseases with such external factors as nutrition, physical fitness, and response to medicines. 4. Collaborative studies with other Institutes of the NIH and with other DHEW agencies of diseases more common to the aged, including diabetes, myelitis, senile dementia (organic brain syndrome), atheroscelerosis, and osteoporosis. 5. The effective diagnosis and management of the reversible forms of senility. Long-term studies needed in the biomedical area are: 1. The criteria for healthy and successful aging. 2. The mutually interacting influences of aging and disease. 3. The influence of cultural background on successful aging. 5. Prosthetic technology as an aid to the maintenance of an independent life. Short-term investigations in the behavioral and social areas include: 1. The social costs. system costs. and socioeconomic impact of an increased population of the old on communities, public and private services, and the old themselves. 2. The advantages and disadvantages of flexible retirement policies to society as a whole and to the aged in particular. 3. Occupational and social roles for older people. 4. Adjustments to crises in the life cycle. 5. The impact of income-maintenance programs. Long-range projects that merit study are: 1. Relationships among family structure and support, lifestyles, and patterns of aging. 2. Middle age as a transition to old age. 3. Personality changes during life, from young adult to very old age. 4. Improvement and maintenance of memory. 5. The meaning and impact of the new age structure on American society. Many issues in the area of human service and delivery were also identified for the use of the Department of Health, Education, and Welfare and are improving the quality of services to the aged. ADVANCES IN AGING RESEARCH At the same time that identification of research directions was being conducted, the NIA was actively engaged in organizing, staffing, and performing research. One of the Institute's most valuable and productive endeavors is the Baltimore longitudinal study, conducted at the NIA's Gerontology Research Center (GRC). The study is specifically designed to collect medical data on a number of individuals over a long peroiod of time and see how these data change with age. The Baltimore longitudinal study was began in 1958, before the formation of the NIA. Every 18 months, approximately 650 men, ranging in age from 20 to 96 years, come to GRC and undergo 21⁄2 days of extensive examinations that include clinical, biochemical, and psychological tests. NIA sponsored 52 projects in its intramural research program in addition to the Baltimore longitudinal study last fiscal year, and expects to increase its program significantly in fiscal year 1978. Those activities produced many advances, including the following findings: -Older men generally handle alcohol as well as younger men physiologically, but there are differences in metabolism. The same amount of alcohol, for example, produces a higher peak blood alcohol level in older men, a finding which is consistent with a reduced body mass and total body water content known to occur with aging. Physiologically, older men appear less intoxicated than their younger counterparts, but testing showed that their memory and decisionmaking ability was impaired more than in younger subjects. Since alcohol has greater psychological effects on the old and they perceive those effects to a lesser degree, the drug is potentially more risky for older men than for younger ones. -Older hearts tend to have thicker walls and fill slower than younger hearts, but the changes apparently have little to do with function. Both under stress and at rest, old hearts are just as good as young hearts, all other factors being equal. -Cells from older donors grown in tissue culture have larger volumes than similarly cultured cells from younger men, but they tend to reproduce themselves much more slowly and they don't live nearly as long as younger cells. On the basis of these and other findings, investigators conclude that there is probably a highly regulated mechanism inside cells which is responsible for aging at the cellular level. It is clear that the NIA will have to excite the interest and then support many more investigators if it is to carry out satisfactorily the mission that Congress has given it. The question, of course, is where these investigators will come from. There are several possible sources. Investigators in other fields may shift to aging research. Newly trained scientists may take postdoctoral training that launches them in research on aging. Predoctoral students can conduct their research in an area of their discipline that bears on aging processes or the problems of the aged. NIA plans to recruit scientists from all these sources. FUTURE PLANS Fundamental Biology of Aging Studies of the aging process at a fundamental level are essential if the National Institute on Aging is to responsibly address public expectations of an improved quality of life throughout the lifespan. The basic mechanisms of the aging process are still unknown. Any attempt to ameliorate age-correlated health problems, such as are seen in the organic brain syndrome and osteoporosis, may ultimately depend upon knowledge of the aging process at the molecular and cellular levels. Furthermore, knowledge achieved at this basic level must then be integrated with knowledge of more complex biological systems within the organism. Current theories, hypotheses, and concepts within the field of biological gerontology are inadequate to justify a highly directed research program on the mechanisms of aging. In order to insure growth in the field, we must stimulate new ideas among competent researchers. Although most experimental work must be conducted on laboratory organisms, studies should be conducted on humans or human materials wherever possible, or on animal model systems which approximate human aging phenomena if humans cannot be used. A great deal would be gained by comparing the characteristics and bases of the aging process in selected organisms throughout the animal |