Today I would like to add only one additional point concerning the screening for risk of degenerative heart disease: Since more than half of the American people are potential risks for death from cardiovascular disease, these individuals, as well as practically all others, are in definite need of those simple but nearly universally neglected health measures which are apt to prevent the fatal, and often prematurely fatal, outcome. Thus, sophisticated cardiac screening would be of particular practical value only under two specific conditions: (1) Relatively advanced and recognizable indications of an urgent and immediate need of energetic preventive measures, such as a gradually progressing intensive exercise regime, drastic diet adjustments, and complete abstinence from smoking. (All of these rules being in principle equally desirable for everyone else.) (2) Presence of pathological conditions which would require complete or partial or temporary exclusion from the above-mentioned, relatively drastic health rules, if (except nonsmoking) potentially detrimental because of incompatability with the subject's specific pathological condition (e.g., congestive heart failure, malnutrition, etc.). Thanking you again for the privilege of having been consulted, I Senator MAURINE B. NEUBERGER, Washington, D.C. DEAR SENATOR NEUBERGER: Thank you very much for the opportunity to comment on the general subject of modern health screening methods, a matter which I understand is to be studied by the Subcommittee on Health of the Elderly of the U.S. Senate Special Committee on Aging. May I say at the outset that I have long had an interest in the matter of health screening and periodic checkups and have very mixed feelings about them. First of all, I have very litttle question indeed that within the forseeable future we will have developed a large number of very sensitive predictive biochemical and physiological analytical techniques which will enable us to predict disease before actual symptoms occur, in fact, I suspect we will be able to predict disease successfully in the offspring by performing certain biochemical analyses on parents. It is true that many such tests will also be performed automatically, inexpensively and rapidly and that the results of these tests will be correlated by computer, and their implications provided to the physician for subsequent study and use. It is my hope that when the truly predictive tests become available it will be possible actually to prevent the occurrence of certain types of diseases before any symptoms develop. I should like, however, to emphasize that we are not yet at that point. There are some tests which can be performed which do demonstrate early disease and, of course, are therefore very helpful. But these are relatively small in number and many of them are not truly predictive of disease, but rather indicate early disease. There are many conflicting points of view concerning the value of periodic checkups, very strong positions being held by proponents and opponents on the basis of very little good scientific evidence. It is my personal suspicion that at the present stage of the art we are moving rapidly from a point where it would be difficult to justify extensive physical and laboratory checkups on every person in the United States, because the cost would far outweigh the benefits, to a point where the application of specific biochemical and physiological tests to mass population, if done in a selected way, will be useful in preventing disease. I am enclosing a copy of the latest volume of the Archives of Environmental Health which contains an excellent article by Dr. G. S. Siegel of the USPHS entitled "An American DilemmaThe Periodic Health Examination." In addition I would recommend two of the very brief editorials which are indicated in red on the front page. I believe the article expresses the concern of many of us very well. I am concerned that we as a nation not proceed to support large scale screening efforts until we have adequate scientific evidence that such efforts are indeed useful and economically feasible. I should like to also reaffirm my position that ultimately they will be so. I am not certain whether or not they are appropriate at the moment. Therefore I should like to urge support of research in the development of new diagnostic techniques of new predictive tests, and of means of automating existing tests. I would also like to urge support of large scale population studies which could determine the suitability of such testing procedures and of the long-term benefits provided by such procedures. It is all very well to diagnose disease early, but analyses must also be made of the benefits provided to the individual in whom disease is recognized. In other words, it is often not possible to do much for people suffering from certain disease even though the disease is recognized. Research into the types of developments listed above might well become an appropriate part of the regional medical programs concept which is now being implemented through the National Institutes of Health. Needless to say, even if a multiphasic health screening program is put into effect in many areas in the country it will not necessarily be accepted by the public or by the community of physicians. There may be a reluctance to participate in such a program because of the implied impersonal approach. The private physician will continue to be concerned that large screening programs not be used to channel his patients into other systems of medical care. In summary I am pleased indeed that the Subcommittee on Health is considering this very important area and focusing attention upon it. I suspect that the committee's interest will stimulate interest throughout the country and will precipitate a more thorough evaluation of such screening methods than has been available heretofore. I would urge the committee very seriously to consider recommending financial sup port for study and research in multiphasic screening methods and that it also consider the possibility of advocating support of pilot studies which might be applied on a relatively wide scale, and which might determine the effectiveness of these programs and their acceptibility by the general public and by physicians. I feel that our scientific and sociological knowledge in this field is not yet at a level that it would be wise to recommend support of multiphasic screening programs on a nationwide basis. Sincerely yours, JOHN R. HOGNESS, M.D., Dean. Hon. MAURINE B. NEUBERGER, VANDERBILT UNIVERSITY, Nashville, Tenn., September 20, 1966. Chairman, Subcommittee on Health of the Elderly, DEAR SENATOR NEUBERGER: I asked Dr. Frank Blood, director of the central laboratories, to prepare a statement in answer to your letter. The enclosed is his reply and I wholeheartedly concur. Sincerely yours, RANDOLPH BATSON, M.D., STATEMENT FROM DR. FRANK BLOOD, DIRECTOR, CLINICAL LABORATORIES During the past 10 years there has been a phenomenal development in the methodology and instrumentation used by the various disciplines which make up the clinical laboratory organization in hospitals and clinics. The greatest advances have been made in the areas where quantitative determinations are performed such as the biochemical laboratories. Analytical procedures which utilize spectroscopy, flame photometry, electrometry, coulometry, electrophoresis, chromatography, atomic absorption spectra, polarography, and so forth are no longer relegated to the research laboratory but are available for clinical laboratory use. Equipment and techniques now available make it feasible to perform large numbers of analyses rapidly and accurately. Since the newer analyzers decrease personnel requirements, the cost per determination is low enough to make health screening programs economically feasible. This has been demonstrated in a number of hospitals that have already introduced routine inpatient screening techniques with phenomenal success. In one study nearly as many abnormalities were uncovered by the screening process as were detected by the conventional diagnostic procedures. Ideally the screening program should not be restricted to the elderly but should be available to all adults since early diagnosis and treatment of disease is often important. Acceptance of such techniques by the younger physician is usually not a problem but the older practitioner may not be as receptive to this approach. However, evidence of the success that can be realized is perhaps best shown by the annual physician's health evaluation laboratory which is available at the AMA meeting each year. Data processing of laboratory results makes screening programs even more valuable. Programing can be such that preliminary diagnoses are available with a minimum of participation by the physician. Needless to say, the final treatment and the manner in which the patient is handled must be a function of the medical doctor. Before screening programs can be effective, trained personnel must be available to operate the new instruments but of equal importance is the need for persons to maintain and repair the equipment. Automated equipment required for screening programs is complicated and effective preventive maintenance is a necessity. Individuals at Vanderbilt who have a special knowledge and interest in this type of program are Dr. Frank R. Blood, director of clinical laboratories, and professor of biochemistry, associate professor of pathology, and Dr. Guilford G. Rudolph, director of blood chemistry laboratory and associate professor of biochemistry. WASHINGTON UNIVERSITY, SCHOOL OF MEDICINE, OFFICE OF THE DEAN, St. Louis, Mo., September 6, 1966. Senator MAURINE NEUBERGER, Chairman, Subcommittee on Health of the Elderly, U.S. Senate, Washington, D.C. DEAR SENATOR NEUBERGER: Thank you for your letter of August 24. I would agree that the people of the United States will demand, and should receive, better health care in the future. As you know, this will require more medical and paramedical manpower than we now have. May I answer your questions as they are numbered. ap 1. Yes; there is a place for multiphasic health screening in health care in our country. You ask, however, if there are problems in such a program. Yes; there are several. First, many physicians find it dull work to employ routine screening procedures in persons who pear to be healthy. Thus, there may be a problem to some degree in acceptance by the medical profession. Second, adults in this country have not accepted routine health appraisal for themselves when available as well as they have the "well-baby" care routinely provided for their children by specialists in pediatrics. The two previous problems can be surmounted in time. Third, however, health screening programs may be harmful to certain people in some instances. Any physician with much clinical experience knows this. Cardiac cripples have been created by the finding of electrocardiographic abnormalities in persons previously enjoying good health. The state of our present knowledge is not sufficiently advanced to make prognostic statements based upon many of these abnormalities, but neither do we know for sure which have no sig nificance (and should be withheld from the patient). I pick but one example. There are many instances, of course, in which health appraisals serve to prevent illness or disability. 2 and 4. Yes. Our department of preventive medicine conducted, for several years, annual health appraisals for the executives of certain corporations. Dr. Robert Shank, professor of preventive medicine, organized this program. I hope these comments are helpful. M. KENTON KING, M.D., Dean. WAYNE STATE UNIVERSITY, Detroit, Mich., September 19, 1966. Hon. MAURINE B. NEUBERGER, SCHOOL OF MEDICINE, Chairman, Subcommittee on Health of the Elderly, DEAR SENATOR NEUBERGER: Dean Ernest Gardner has referred me your questionnaire on the detection of illness in our elderly citizens. There has been a good deal of thought on the problem in Detroit, but the majority of our plans are still on the drawing boards. No large-scale screening clinics now exist which are specifically designed for the elderly person. The two largest outpatient facilities in the city are in the Detroit General (Receiving) Hospital and in the Henry Ford Hospital. Both of these organizations provide comprehensive medical examinations on request, but these remain a part of the general medical clinics and neither seeks out nor caters the elderly citizen. Costs vary from full pay (Henry Ford) to a variable sliding scale based on income (Detroit General). A large number of the patients at both hospitals are 60 or more years of age. The Wayne State University presently has no hospital or clinics of its own, but utilizes a number of the voluntary and public institutions within the city for training. One of the voluntary teaching units, Harper Hospital, has established the Rand Geriatric Health Evaluation Clinic which gives complete examinations to citizens over age 60 for a total cost of $15, including as many X-ray and other examinations as are necessary. Utilization of this relatively new clinic by the community, however, has not been large. The Detroit total action against poverty programs, supported in part by the Office for Economic Opportunity, have recently established six neighborhood community health centers; these also have not been heavily utilized by our senior citizens. The programs for the aged poor have been increasing their impetus, however, and there is now operating a community action program to locate and provide health and other social services for the older age group. Two significant programs for the future are being designed for our elderly citizens. Wayne State University is constructing a $2 million Luella Hannan Gerontology Center within the new Detroit Medical Center. Its purpose will be to provide demonstration housing and social programs (including health care) for the elderly, and to carry out |