Senator NEUBERGER. We will move right on to you, Dr. Cheraskin. Dr. CHERASKIN. I, too, have prepared a statement which has been submitted. In the interest of expedition, and with the hope that this will allow more time for questions, I shall simply summarize, if I may, that report.

PREPARED STATEMENT BY EMANUEL CHERASKIN, M.D., D.M.D., ON THE PREDICTIVE MEDICINE PROGRAM, HOLLYWOOD, CALIF., SPONSORED BY THE RETAIL CLERKS LOCAL 770 AND FOOD, DRUG AND GENERAL SALES EMPLOYERS BENEFIT FUNDS Gentlemen: It is my understanding that the agenda for these hearings included an initial session relegated to philosophies of health and disease, a second period devoted to advances in automated instrumentation, and these hours, assigned to a discussion of existing multiphasic screening projects. I have been asked to outline the Predictive Medicine Program sponsored by the Retail Clerks Local 770 and Food, Drug and General Sales Employers Benefit Funds.

There are unquestionably many denominators common to all of the present projects. In the interest of expedition, I shall confine my remarks to how the Predictive Medicine Program differs from other current plans. In general terms, its singularity stems from its: (1) philosophy, (2) mode of operation, and (3) quality control.

PHILOSOPHY OF THE PROGRAM

Much has been written about the nature of health and disease. Very likely, some of this material has been recited during these hearings. The thesis which dominates the Predictive Medicine Program has been described by many but most eloquently by Doctor Jacques M. May of the American Geographical Society when he wrote:

"It is as though I had on a table three dolls, one of glass, another of celluloid, and a third of steel, and I chose to hit the three dolls with a hammer, using equal strength. The first doll would break, the second would scar and the third would emit a pleasant sound."

This lyrical and no less scientific pronouncement underlines the point that whether man remains healthy or succumbs to disease depends largely upon his metabolic machinery which, for want of a better word, may be termed host resistance and susceptibility. Simply, whether man develops tuberculosis, to select one example, is not just a question of inhaling a particular microbe. If the latter were the case, then all of us should be suffering with this malady because all of us have been exposed to the microbial challenge. The big question is why some individuals can withstand the bacterial invasion. Or, apropos to Doctor May's statement, why is the metabolic fabric of steel in one person and glass in another? Herein lay the first of the unique features of the Predictive Medicine Program for it is most concerned with the ingredients which influence host resistance and susceptibility.

To enlarge upon this hypothesis, man may be likened to a sphere built from a series of concentric layers. The outer lamella, the obviously visible one, bares the clearcut ravages of disease (e.g. the atrophic arm and the cancerous canker). This mantle over the sphere is the purview of present-day curative medicine. Its dramatic successes are a matter of record. The need for these committee proceedings is proof of its shortcomings. Beneath the peripheral rim is a second, less visible, layer. This is the zone of man's performance. For, in fact, before there is obvious evidence of disease, particularly the common killing and crippling chronic syndromes (which is in fact the principal issue), there is a disturbance in productivity. This can take many and diverse forms from difficultto-measure fatigue to quantitatable expressions such as absenteeism. But even more important is the central core of the sphere. Here it is that disease first begins. It is here that biochemical testing is most meaningful. Therefore, it is quite comprehensible that the Predictive Medicine Program is largely concerned with the central core which signals impending trouble in advance of reflections in the outer lamellae.

MODE OF OPERATION

The operation of the Predictive Medicine Program has much in common with other multitesting systems. It departs from other programs in two major areas: (1) the type of parameters studied, and (2) the criteria for health.

We are mindful, in the Predictive Medicine Program, that the term diet is inflammatory and the subject of nutrition highly controversial. It would indeed be a serious mistake to regard diet and nutrition as a panacea. On the other hand, it is no less in error to ignore diet and nutrition as is the case in other multiple testing projects. Doctor Willard A. Krehl of the University Hospitals in Iowa City, Iowa, puts the subject into proper perspective with the following statement:

"Greater realization is needed in medicine and in public health that good nutrition along with good hygiene are the best weapons avaliable in the prevention of disease. If one were bold enough to make a prediction, it would be that the most important measure [italics added] that could be taken to prevent the development of many chronic diseases would be the provision of consistently good individual nutrition, supervised by physicians with a strong assistance from the housewife, from conception to the grave."

For these and other reasons too cumbersome to enlarge upon here, the Predictive Medicine Program recognizes the place of nutrition by the inclusion of dietary analysis, biochemical testing and, as we shall see later, health education measures. Mention was made earlier that performance (residing in the middle layer of the sphere) suffers before there is overt evidence of disease in the periphery. The developing Predictive Medicine Program recognizes this fact and has programmed into it available records of absenteeism, sick leave, disability benefits, and other reflections of productivity. Hence, in a fourth way, the Predictive Medicine Program differs in that it has the capacity to relate the outer rim (classical expressions of disease) to performance (housed in the middle) to the central core (wherein resides the predictive biochemical data).

All of the existing multiple testing programs employ biochemical tools. However, the interpretation is no more meaningful than the criteria which have been set to delineate health from disease. Practically all health standards are based upon averages and so-called standard deviations of presumably healthy persons. The common statistical tools utilize 95 per cent of the tested population. In other words, the presumption prevails that an individual is healthy if his profile agrees with 95 per cent of the tested population. The illogic of this approach is amply demonstrated by the fact that 95 per cent of the population suffers with dental caries and pyorrhea which cannot be regarded as desirable! There is increasing concern, in recent times, with criteria for health and disease. Doctor Leo P. Krall of the Joslin Clinic in Boston employs a fascinating analogy to underscore the need for a fresh approach:

"The detection of diabetes can be compared to fishing with a small mesh net that increases the catch of fish but also seines some nonfish or the wrong variety of fish, as opposed to using a larger mesh which would be more specific for the size and type of fish sought but bring a smaller yield."

The point in his story extends far beyond diabetes and fish. I presume that these hearings are concerned with learning the best methods of eliminating disease and maintaining health. This could be likened to the task of removing all of the fish from a lake. If one employs a coarse mesh, then all of the big fish will be caught. This is not unlike identifying the major diseases in their classical and obvious forms at the periphery of the sphere. But sooner or later, the little fish will grow to become big fish. Repeated dredging with the coarse mesh net will never accomplish the prime mission of removing all of the fish. And so in man, the mildly ill will eventually become obviously ill. The solution to the lake problem is to employ a fine mesh net which will trap all of the fish and even the eggs! Hence, what is needed is more sensitive tools (and for this we call upon the measurement scientists) and more restricted health standards. It is here that the Predictive Medicine Program is different in that it employs more rigid health criteria so that disease can be anticipated rather than identified.

QUALITY CONTROL

The Predictive Medicine Program is structured so that the eligible membership will be provided with an initial multiphasic screening evaluation. By this technique, three groups of individuals will be identified including: (1) the obviously ill, (2) the optimally well, and (3) the large gray area of incipient, marginal, subclinical sickness. The participants will then be offered the opportunity of sharing in the programmed series of health education lectures, film clips, motion pictures, literature, and demonstrations. As far as we can determine, there is no other multiphasic screening program which incorporates an organized health education plan.

More importantly, after the health education series is concluded, the participants will be reevaluated in the multiple testing system. If the health education series is fruitful, there should be measurable beneficial changes observed in the clinical (outer layer), performance (middle rim), and biochemical (inner zone) areas. Hence, we regard this unique opportunity to evaluate our suc cesses and failures as a form of quality evaluation which is a distinct departure from existing programs.

The Board of Trustees of the Retail Clerks Local 770 and Food, Drug and General Sales Employers Benefit Funds cordially invites the members of this committee to visit the Predictive Medicine Program and observe first-hand its philosophy, modus operandi, and quality evaluation. Finally, I should like to applaud personally the Board of Trustees for their comprehension of this health concept and their courage and conviction in charting its course. It is indeed a great honor to be invited into their family for this voyage which, I believe, will open new and profitable vistas in the health sciences.

Dr. CHERASKIN. Obviously, as a multiphasic screening program, we have much in common with others. And this has been discussed many times during these hearings. Again, in the interest of moving along quickly, I should like to point out its differences. Basically, there are five major differences. There are others, and we would be pleased to discuss those, if you wish, later.

These five major departures can be grouped into three categories. First, our philosophy is at variance with most of the existing multiphasic screening programs.

Secondly, our mode of operation has built into it some very sharp departures.

And, lastly, there is a quality control, or quality evaluation which I think makes our program somewhat singular.

Perhaps the best way of describing the philosophy of the program is to illustrate it with, I trust, not an oversimplified illustration. Man may be likened to a sphere, made up of a series of layers. The outer layer is what one sees; the very obvious, the ravages of disease. This is the purview of curative medicine, and I need not go beyond that, I trust.

If one peels off that layer, there is less obvious lamella which may be described as one's performance. I believe it is a well-established fact that before one falls apart, in terms of the typical measures of disease, performance diminishes. One becomes forgetful, and tired, and inefficient and sleepless. We shall have some additional remarks to make concerning performance.

And lastly, to fill the picture, there is a core to this sphere, a chemical core. It is in this area where matters go wrong first. Our program is predicated on the principle that if we must deny something, we shall deny the outer layers, and do something about the inner core; namely, the metabolic machinery. This, for practical purposes, is measured by biochemical instrumentation, and this is where we join forces with measurement scientists.

The man who probably best and most eloquently described our philosophy is Dr. Jacques M. May, right here in Washington with the American Geographical Society, when he once wrote very, very beautifully—

I have three dolls; one made of glass, one of celluloid, and one of steel, and I choose to hit them with a hammer with equal strength. The first breaks, the second scars, and the third emits a pleasant sound.

Our whole concept is based on why is it, two people can breathe the same germ, like a tubercle bacillus, and one individual-somehow