nosis of symptoms as they arise in the future. Third, the recording of such observations on a periodic basis would make it possible to identify the beginning of small pathological changes in the individual and lead to early diagnosis and preventive management.

Let's consider some of the possible uses of the data in a little more detail. When data indicates the probability of disease, the physician would more than likely want to perform a physical examination and appropriate laboratory procedures to arrive at a final diagnosis. In this way, the individual with a detected, previously unknown disease condition would promptly be moved into a system of care and guidance leading to a lessing of impact from his disease.

With respect to the data providing background information on the health of a given patient, the intrinsic value is more long-range than immediate. Accurate interpretation of any laboratory determination that may be made on an individual is often aided greatly by the results of a similar determination made previously. Classic examples are the chest X-ray with a suspicious shadow or the electrocardiogram with non-specific changes. A record of previous determinations that can be checked for comparison purposes is a resource of enormous value.

Moreover, when procedures are done periodically, the physician can observe changes taking place over a period of time. For example, he is able to observe a gradually increasing blood sugar level or increases in intraocular pressure. These may be most important leads in following the development of diseases. Indeed it may well be true that such changes as these may be the very earliest manifestations of incipient pathological processes.

By taking these three items in perspective, both individually and collectively, the practicing physician cannot help but be in an immeasurably stronger position to deal with the health of his patient. And no one can deny the thesis that the more a physician knows about his patient, the better guidance and care he can give the patient. To my knowledge, there is no other mechanism than the automated laboratory which in an economical and rapid fashion can assemble such information.

To demonstrate the application of this approach within the community, the Gerontology Branch of the Division of Chronic Diseases has plans underway for the creation of four model Adult Health Maintenance Centers which will utilize the automated equipment and computer techniques for health testing developed at Kaiser Permanente. Because of financial limitations, these will not be fullscale demonstrations, but will contain many of the essential features; the extent to which these programs can be expanded and new approaches investigated will depend on the future availability of funds.

The critical problem to be resolved in these activities is not whether the "technology" or "machinery" for such services is feasible the Kaiser Permanente program and others have demonstrated and are demonstrating this-but the main effort will be to determine how such a program can be most effectively integrated into a community's complex medical care structure.

In each program, emphasis is given to the development of techniques and methods to be employed in motivating and recruiting participants for the health appraisal service, as well as other behavioral and educational factors.

A second major area of concern is the development of appropriate followup techniques and counseling and referral methodology to assure the fact that significant findings are brought under appropriate medical care. Since the crux

of health maintenance in this program is the early detection of suspected disease and effective management or treatment of the condition by a physician, regardless of the setting in which he practices, this assurance of effective follow-up is a most vital component of the total program.

An underlying concept which should be made clear here, and which we have stressed throughout the development of our projects, is that health assessment as rendered in a health protection center is not proposed as a substitute for traditional periodic physical examinations or any other traditional medical care or preventive health service; rather it is proposed as a new entity in the complex of health services-an entity which is not presently available.

It differs from a traditional physical examination in that the health assessment involves only limited physician participation and consists of a broad series of health status evaluative measurements which do not necessarily result in a definitive diagnosis.

It also differs from the usual multiple disease detection activity. Historically, multiple disease detection programs have used prescribed criteria for each labora

tory test to determine whether a person is likely to have or not have a specific disease process. The health assessment involves not only such tests and criteria, but also through the use of automated equipment and computers makes feasible the collection from each participant of a broad scope of physiologic measurements and pertinent psychological and sociological information which will be of greater assistance in ascertaining the presence or absence of a number of disease processes. The health assessment, therefore, provides the physician with more complete, meaningful information which will be utilized as a step toward final diagnosis. The comprehensiveness of information derived in the health assessment process should be far more revealing of health status than any preventive program promoted heretofore.

Hopefully, the new technology employed in these demonstrations will conserve medical manpower and will provide physicians with a valuable tool in diagnosis and management. Equally important is the fact that this kind of an approach will provide disease detection services for a vast segment of the population that would never seek, or could never afford, or could not otherwise obtain such a comprehensive health assessment by any other mechanism.

We are confident that these four modest demonstrations will provide us with many answers, and will identify many problem areas to be resolved in our efforts to develop effective health maintenance programs for the adult and aging population.

Senator NEUBERGER. Thank you for those very kind words, too, Dr. Chinn. We appreciate it. I think all of us feel that we have certainly learned a lot, and I know I have. It has opened up entirely new vistas.

I really believe that you have given such a wonderful summary of our 3 days of hearings that it behooves me to leave it at this point, because you pulled it together so well, with some of your comments. One question might be: Do you have some followup plans built into these projects that we have been discussing?

Dr. CHINN. Well, nothing more than the fact that two of them are just getting underway, and the other two are in a final stage of negotiation. We hope that by this time next year, perhaps we will have some information from them.

Senator NEUBERGER. Good. We will we interested. Thank you, Dr. Chinn.

As these hearings end, several immediate conclusions occur to me. One is that the hearings could not have come at a better time. For one thing, it is obvious that Congress should soon give increasing attention to nagging and worrisome deficiencies in present medical services.

After all, we were told at this hearing that we pay out roughly $57 billion a year for direct and indirect costs of death, disability, and illness caused by chronic disease. This is well more than half of all such costs for all diseases.

What can we do to decrease such costs? The hearings have given substantial evidence that both medical men and the general public still think primarily in terms of dealing with the damage caused by disease, rather than prevention of disease.

And yet, we have it on authority from witnesses at these hearings that prevention of disease will yield far greater returns than treatment ever will or can.

We were further told that we already have vast experience and sophistication in the use of mass screening for disease, even though quite often such screening is sporadic or limited to specific diseases.

And finally, we were told that our technology is quite capable-here and now-of providing efficient, accurate, and convenient screening to large numbers of our citizens. It is true that improvements can be made, but it is believed that widespread screening will accelerate those improvements.

It is quite clear, therefore, that Congress has an obligation to make multiphasic screening a fundamental consideration in future actions for improvement of our health resources. That is my own individual view at this moment; this subcommittee will issue a report giving a more detailed analysis and definitive recommendations.

Once again, I would like to thank our many distinguished witnesses for giving us their time and their thinking. They have performed an important service to Congress and the Nation.

The committee meeting is adjourned.

(Whereupon, at 3:20 p.m., the hearing was adjourned.)

APPENDIX

The subcommittee in its investigation and preparation for the hearings held on September 20-22, 1966, corresponded with many people and organizations interested in the health of our Nation. Letters received by the subcommittee are included in the appendix.

A. MEDICAL SCHOOLS AND COLLEGES

The following form letter was mailed to the deans of many medical schools and colleges:

DEAR

U.S. SENATE,

SPECIAL COMMITTEE ON AGING,
August 23, 1966.

The Subcommittee on Health of the Elderly of the U.S. Senate Special Committee on Aging is beginning a study of modern health screening methods intended to detect and thus help prevent chronic illness.

I would like to have your viewpoints on the subject.

As has been found with limited screening programs to identify such diseases as glaucoma, diabetes, tuberculosis, et cetera, the subcommittee believes that substantial benefits would result from more comprehensive screening programs reaching greater numbers of people.

One example is the multiphasic screening program conducted for members of the Kaiser Foundation in California. Participants receive a battery of tests within two and a half hours, with the help of latest equipment and computer evaluation of data. Final diagnosis is made by a physician after he studies all records.

We are also interested in the mobile health testing effort in Washington, D.C., and will give attention to automated or semiautomated device systems that may be capable of speeding large-scale screening. Our hearings-now scheduled for September 20, 21, and 22—will not deal with any single legislative proposal or any one method of health screening. We want to receive objective, informed, and widespread opinion on the cost of chronic disease today and the potential helpfulness of screening to prevent such affliction. The advent of medicare adds a weighty argument for greater emphasis on prevention. We will be especially interested in responses to the following:

1. Is there a place for multiphasic health screening in health care in our country? Are there any particular problems that may be anticipated in the acceptance of multiphasic screening programs by the public or by the medical profession?

2. Have any members of the faculty or staff of your college partici pated in the organization or operation of a multiphasic health screening program?

307