ing the devastating effects of chronic diseases, and hopefully we will be able to meet the demands when new resources are made available. If resources are not made available and the problem enlarges as our population ages, as we have seen over the past several decades, will we be faced with an economy that will depend upon the ability of a chronically diseased population to produce the labor force required to sustain it? In discussing multiphasic screening we must also keep in focus the impact of the positive screenee on an already overburdened physician. With screening, we will have people consulting with physicians who previously never consulted with a doctor except for some acute or terminating illness. Hopefully, the solution as outlined in earlier recommendations of the President's Commission on Heart Disease, Cancer and Stroke, will lie in training enough paramedical and medical personnel to care for these new patients and also provide new centers of medical excellence for the application of these skills. In spite of the demand for a physician's time, many of the problems we experienced in coordinating our multiphasic screening programs, in Michigan with the medical profession, no longer exist. This is reflected in the development of close working relationships with the various professional medical groups in the state. As an example, we participate with voluntary health organizations in the screening of members of the Michigan State Medical Society at their annual meeting. Further evidence of the rising interest and awareness of the medical profession is their continued support and participation in the multiphasic screening program conducted at the annual meeting of the American Medical Association with their most recent program in Chicago in June of this year. Programs like this, and the cooperative one we have in Michigan, can further bridge the gap between public health and private medicine. In any cooperative effort there is no substitute for understanding and close communication. After being properly involved and informed, it is believed that physicians will recognize that screening can be an important part of medical management. While screening will not relieve, but rather will add to their work load, it will alter the type of patient they see. In my opinion, the time has come for us to prevent sickness rather than spending all of our time in patching up those who are already sick or disabled. The greatest thing that could be done for the older population is to find, treat and counsel those in the great middle years when they are incubating the diseases which will later cause them to require prolonged care and hospitalization. Mr. BIGGS. We will now hear from Dr. Borhani. STATEMENT OF DR. NEMAT 0. BORHANI, SECRETARY-TREASURER, ASSOCIATION OF STATE AND TERRITORIAL CHRONIC DISEASE PROGRAM DIRECTORS; CHIEF, BUREAU OF CHRONIC DISEASES, CALIFORNIA STATE DEPARTMENT OF PUBLIC HEALTH, BERKELEY Dr. BORHANI. First of all, if I may, I would like to reiterate what Dr. Cowan mentioned and request that the summary document that I prepared and submitted to you last week be inserted in the record. We did send a telegram to all States and territories, and the response received was summarized into that document, which represents the entire picture of this program in the United States. Thank you. (The document referred to follows:) SUMMARY OF HEALTH SCREENING PROGRAMS IN SELECTED STATES 1 Arkansas PROGRAM 1 1. Chest clinics for tuberculosis in some counties; diabetes screening in a few counties; plans to start cervical cytology in a few counties. 1 Replies received as of September 8, 1966. Four other states also replied but did not describe any screening programs. Colorado 1. Planning a regional medical program on heart-cancer-stroke, if grant approved. 2. Had a diabetes screening program which lapsed with withdrawal of USPHS personnel. 3. Presently some screening for tuberculosis and respiratory diseases, and for cervix cancer in six areas of state. 4. Some community diabetes screening by Diabetes Association. 5. A few (4-6) glaucoma screening clinics per year by Society for prevention of Blindness with State Department of Public Health's assistance. Connecticut 1. Screening for tuberculosis, diabetes, glaucoma and visual defects and for visual and hearing defects in school-age populations. Florida 1. Four permanent glaucoma screening centers screened 86,800 persons and identified 1,360 that were diagnosed as glaucoma (rate of 15.1 per 1,000 examined). 2. Recently screened 10,174 Aid to Dependent Children recipients for cervix cancer by Pap smear; 205 confirmed as cervical cancer by biopsy for yield of 19 cases per 1,000 examined. County Health Departments are continuing this program. 3. Have long had screening programs for tuberculosis and venereal disease. In tuberculosis screening, program also finds 1 in 800 suspicious for lung tumor and 1 in 300 suspicious of cardiac pathology. Georgia 1. Combined testing for syphilis and tuberculosis was started in 1942. In 1949, anthropometry and diabetes tests and cardiological review of X-rays were added. The program was discontinued after several years due to lack of funds and inadequate follow-up. Now have separate screening program for syphilis, tuberculosis, diabetes, arthritis, pulmonary and cardiovascular diseases. Plan to start cervical cytology program for medically indigent females. Have specially trained health educator-administrator men assigned to work with local screening programs and promote public acceptance. Hawaii 1. Screening for diabetes, glaucoma, tuberculosis. 2. Two instances of multiple screening exams, one among plantation employees and one in an isolated, predominantly Hawaiian neighborhood. Illinois 1. Screening for diabetes, glaucoma, rheumatic fever, cervical cytology tuberculosis. 2. Health activities below age 60 include pre-school and school exams, pre and postnatal exams and multiphasic screening examinations in housing particularly in metropolitan areas. Indiana 1. Fluoroscopic surveys for tuberculosis. Massachusetts 1. Trial program in 1952 demonstrated potential of multipha. examinations for disclosing unsuspecte Mississippi 1. Screening for diabetes; re glaucoma, visual acuity, diabete Missouri 1. Did a multiple screening: 5,000 persons. Physicians dic and patients frequently did no 2. St. Louis City Health! study at a housing proje e. No program no 09-803:0 Montana 1. No programs except a few small ones such as heart sounds screening in children. Nevada 1. Screening for tuberculosis and an annual glaucoma screening. No support for multiphasic screening examinations or other screening programs. New Hampshire 1. Screening for pulmonary diseases, diabetes and glaucoma. New Jersey 1. Screening for diabetes, syphilis, tuberculosis. New Mexico 1. Some programs in oral cytology, venereal disease, tuberculosis and cervical cancer screening. 2. Conducted a diabetic screening program in 1959-1960. 3. Conducted a multiphasic screening examination in June 1966 for 268 women at an agricultural extension service course. Tests were height, weight, blood pressure, urine sugar, urine protein, blood sugar. 4. An Adult Health Maintenance Program is being developed for a low income rural area of four counties. Will include nutritional and medical history, laboratory tests, and limited physical examination with physician referral and follow-up planned. New York 1. State employees in Albany area receive battery of screening tests, primarily for cardiovascular and respiratory disease. Screened 6,000 in past year. Plan to expand group and offer repeat exams at three-year intervals. Plan to add further tests. 2. A Well Aging Conference by Erie County Health Department in Buffalo has been in operation as demonstration past three years. Expect it to be absorbed in the department on continuing basis. 3. New York City Health Department operates continuing screening programs in glaucoma and diabetes. 4. Numerous glaucoma and diabetes programs throughout State, some continuous, some periodic. North Carolina 1. Screening for diabetes, cancer and heart, and other chronic diseases on a limited basis. North Dakota 1. Screening for glaucoma and cervical cancer. 2. Conducted one multiphasic screening examination at Fort Berthold Indian Reservation in 1958. Oklahoma 1. Has operated a mobile multiphasic screening trailer since 1960. Tests are height, weight, blood pressure, oblique lead EKG, vital capacity, hematocrit, blood sugar and cervical cytology. By the end of 1965, 295,379 people had been screened and 21 percent had been referred to their physicians for further examination. Pennsylvania 1. Screening for diabetes, glaucoma and tuberculosis routinely. Special screenings for anthro-silicosis and similar conditions. Tennessee 1. Screening for diabetes, tuberculosis, oral cytology, P.K.U., heart disease. Also multiphasic screening examinations for eligible patients in Family Planning Clinics. Multiphasic screening examinations in Shelby County. Texas 1. State has been involved in selective screening programs involving tuberculosis, diabetes and cancer. Some glaucoma screening conducted by voluntary agencies. 2. Houston City Health Department is developing a multiphasic screening program to become operational soon. Utah 1. Screening for diabetes, tuberculosis, glaucoma. Cervical 2. Screening of pre-school children for amblyopia and other visual defects. 3. A cervical cytology screening was done between 1962 and 1965. cancer was diagnosed in 16 of 4,498 women. 4. The U.S. Public Health Service Occupational Health Field Station examines and screens past and present uranium miners by sputum sample for lung cancer. Lung cancer has developed in 54 men. 5. State Health Department is cooperating with the Salt Lake County Medical Society in developing a screening program for the Kennecott Copper Corporation. It may be modeled somewhat after the Kaiser program in California. 6. Now being planned are development of a Chronic Disease Screening Program for faculty of the University of Utah, a multiphasic screening program for about 300 persons age 62 and over who will be living in a housing development, a screening program for elderly Navajo Indians, and screening programs in Senior Citizens Centers in principal cities and in some industries. Virginia 1. Limited multiphasic screening examinations for migrant workers by mobile trailer; hope to use in other parts of state after migrant season ends. 2. Screening for tuberculosis, diabetes, syphilis. Washington 1. Various screening programs are conducted in the state. SUMMARY OF OPINIONS AND RECOMMENDATIONS OF STATE CHRONIC 2 1. There was almost unanimous agreement that there is a need for the development of multiphasic screening programs. Only one State Chronic Disease Director expressed the opinion that national legislation is neither necessary nor desirable for such a program. 2. Almost all replies stressed one or more of the following points regarding proposed legislation and development of multiphasic screening programs: a. The legislation should clearly name state and local health departments as the responsible agencies. There was much objection to the regional concept. It was suggested that funds be channeled through the usual machinery of Federal aid to States, and State plus Federal aid to local health departments. b. Funds must be adequate to provide for a total program of: 1. lay and medical education to promote acceptance and utilization of multiphasic screening, 2. development and application of the best screening procedures, 3. comprehensive follow-up of individuals with positive findings, and 4. development of adequate resources for diagnosis and treatment. c. Any legislation should be highly flexible so programs can be developed at the local level and tailored to the health needs of the population and medical resources available. For example, multiphasic screening programs in largely rural areas probably need to be organized quite differently from those in urban areas. d. Funds should not be earmarked for any one type of screening or chronic condition. e. No age limits should be imposed for eligibility for multiphasic screening, although specific tests used vary according to age. f. Provision must be made for the evaluation of any multiphasic screening program. One State Chronic Disease Director suggests Federal legislation with an adequate appropriation to encourage development of a nationwide network of multiphasic screening examination programs aimed at defining the productivity of varying approaches under differing field conditions. 3. A number of states reported improved physician cooperation in recent years; however, several states reported difficulty in getting the medical community to accept and cooperate with screening programs. Attention must be given to early solicitation of physician cooperation in the program, with em * Includes replies received as of September 8, 1966. phasis on the concept that the purpose of screening is to bring patients to their family physician early in the development of the disease process. 4. It was emphasized that the purpose of multiphasic screening examinations must be made clear to the public, particularly that these are screening programs. not diagnostic clinics, and that a visit to their personal physician is essential for completion of the examination. 5. Several states emphasized the shortage of medical and related personnel essential to carry out screening programs and follow-up to insure that treatment is given where indicated. Dr. BORHANI. Now, with that, my responsibility of representing the Association of Chronic Disease Program Directors is finished: however, I do have another task, if I may be permitted to proceed. that is to represent the State of California Department of Public Health. As you recall, Dr. Lester Breslow, director of the department, was invited, but unfortunately could not attend this hearing because of other pressures of work back home. It is a pleasure for me, and an honor, to appear before this committee, and to represent the California State Department of Public Health. First, I would like to mention that last night I had the privilege of being instructed by the Governor of the State of California, the Honorable Edmund G. Brown, who sent a telegram through Dr. Lester Breslow. He asked me to present his views to the committee. I would like to request that the Governor's message to the chairman be entered in the record. Mr. BIGGS. This may be done. Dr. BORHANI. The Governor's message reads: DEAR SENATOR NEUBERGER: AS Governor of the State of California, I wish to add to this hearing my earnest endorsement for the establishment of a health screening program. I am well aware that chronic diseases account for three-fourths of the deaths which occur each year in California. I know, too, that these diseases strike down thousands of Californians who might otherwise continue normal and productive lives for many years. Such deaths not only bring untimely and needless tragedy to thousands of families, but they also do harm to our productivity and to our economy. You will be interested to know that I have proposed that multiple screening examinations be made available to one million people of my State that are in our Medical (Title XIX of the Public Law 89-97) program, and that another one million residents be reached through a joint State-Federal program. I congratulate you upon your interest in this extremely important phase of public health. I hope that the Congress will support you in the development and realization of such a vital program. This is the end of the Governor's message to the chairman of the committee. I also, if I may, would like to introduce in the record a letter which was sent directly to the chairman of the committee by Dr. Lester Breslow, director of the California Department of Public Health; I trust that you have received that letter. "If not, I have a copy I can furnish for the record. Dr. Breslow did send me a copy of his letter, which arrived last night in his letter he indicates again his regret at being unable to appear before this distinguished committee, and very clearly points out our position in regard to the subject under discussion. I have also submitted, as you know, a document which summarizes our activities in the State of California on multiphasic screening ex |