We estimated that the annual costs to the Nation in heart disease, cancer, and stroke areas alone was well over $30 billion, and I think this is a conservative estimate.

Senator NEUBERGER. What is that based on? The loss of time

Dr. DEBAKEY. Yes; it is based upon both the direct costs of supporting the disabled individuals in hospitals or elsewhere, and the loss of output by members of the labor force due to these diseases.

I think it is also important to realize that these diseases that we are talking about affect a fairly large segment of the people under 50, so we are finding more and more arteriosclerosis, which was at one time thought to be a disease of the elderly, affects a high proportion of people under 65. I would say, for example, that at least one-fourth of patients with heart disease occurs in this group. Thus, among those struck down by these diseases, about one-fourth are in the most active period of their lives.

Senator NEUBERGER. I know since your report on heart disease, cancer, and stroke I find myself-and I hope this is not a new routine tendency-reading the obituaries and when anybody dies, to be interested in the age. We have the terrible example of the Moyers boy at 39. It is shocking to me to find people younger than I am dying of heart disease. And I presume that is why it all adds up to why it is the greatest killer, I guess, now.

Dr. DEBAKEY. Yes, and you see, Senator, we are going to see more of this in my opinion, because we are finding means of prolonging people's lives by reducing their chances of dying from infectious diseases, such as pneumonia, smallpox, and diptheria. We are screening out these causes of death and people are becoming increasingly subject to diseases we used to regard as chronic degenerative diseases, such as heart disease and emphysema.

Senator NEUBERGER. That is the other thing I watch for, if it gives the cause of death, heart disease, lung disease, emphysema. I watch it. Young people really, in their 40's or 50's, who are dying. They seem to be needless deaths.

Dr. DEBAKEY. What is even worse, Senator, the tremendous amount of disability they produce. The patients not only cannot work, they have to be taken care of, and this is a tremendous burden, particularly in the increase in cost of medical care. I think this is a very important area and I want to urge you to take a very aggressive approach to this problem.

Senator NEUBERGER. Something you said I would like to ask about. I am interested to know that you think there is some value in screening, I am sure for a lot of other things other than your specialty, that it is not just an exercise in going through an area, but the thing you said that particularly I am pleased to hear is that you hope, through research, that we can select out the type of patient and therefore detect a potential stroke. Did you say that?

Dr. DEBAKEY. Yes, I did, and we have reason to believe that this can be done and what is needed, of course, is to obtain more information, by research, on ways and means of doing this.

We are engaged in many centers in a collection of data to develop certain patterns in which the criteria and the characterization of these conditions can be developed in what we might call a profile, where they can be selected out, even on a computer basis. I have also indi

cated a more precise way of screening in which the diseased arteries can actually be visualized.

We are just beginning to develop arteriographic visualization of the whole body, where the entire vascular system of the body is visualized in a precise way.

Senator NEUBERGER. When you are speaking of arteriography

Dr. DEBAKEY. It consists essentially of an injection of dye that shows up on an X-ray like a map. It maps out the arteries of the whole body from the very small arteries to the very large ones. It may be considered as an arterial map and can pinpoint the site of the disease quite precisely.

Even if we collect this data without developing it on some computerized method of screening, it may not be effectively applied. We have the necessary knowledge but not the technology to do it.

What we need to do is improve the technology on a widespread basis. Then we will have in addition to methods of characterizing these diseases, a more precise way of visualizing them and this could offer tremendous opportunities of detection that we do not have today.

Senator NEUBERGER. Your speaking of the technology that is lacking reminds me that a doctor at Harvard Medical School told me recently they are working in conjunction with some of the people at MIT. I said what I thought of MIT's engineering and that sort of thing, and he said, yes, but we are doing that in medicine. It came to the point whether either Harvard was going to have to build an engineering laboratory or MIT a department of medicine. So, the two have come so closely together.

Dr. DEBAKEY. That is quite true, Senator. It is true of our center and a number of other centers in this country. As a matter of fact, you might say engineering is so essential to a good medical center that it is impossible to do without it.

Senator NEUBERGER. Senator Yarborough, do you have any questions?

Senator YARBOROUGH. Dr. DeBakey, if it is not intruding too much in the field of your private practice, if it is I am certain you will tell me so, would you mind giving us a rough estimate in the thousands of about how many heart patients you estimate you have treated in the course of your practice in one way or another? I do not mean limited to surgery, through medicine, prescribing?

Dr. DEBAKEY. Well, Senator, I think it must be close to 15,000.
Senator NEUBERGER. 15,000?

Dr. DEBAKEY. Yes.

Senator YARBOROUGH. Now if we had had these tests, do you think that they would have had any effect on the number of cases-if we had tests several years earlier in the field of preventive medicine to anticipate trouble?

Dr. DEBAKEY. Oh, yes, Senator. I am convinced that if we had had the knowledge and the tests to detect many early stages of disease, a large number of illnesses could have been avoided. No doubt about it, in my mind.

Senator YARBOROUGH. You have spoken about one expression you used I believe a moment ago, which was the yield in terms of detection is relatively low in these tests. In other words, most of the people tested are found to be within their limits for age and so forth normal, you say normal, not

Dr. DEBAKEY. You see, Senator, this is because the methods of detection in screening are too gross to pick up many of these problems in a sufficiently early stage to be effective, and, of course, as you know, a typical story is told about the man who goes to the doctor for an examination and is told he is doing fine, and he walks out of the door and drops dead.

This has happened. It simply means that many of the tests we do now are not sufficiently refined to screen out some of the things at an early enough stage. This is why we have to do more in the way of developing better techniques of detection, too.

Senator YARBOROUGH. The fact the map test you described, taking the dye and getting a picture of the entire circulatory system, would detect certain abnormal conditions that are not shown.

Dr. DEBAKEY. Exactly, before any symptoms or before the individual feels or knows anything is wrong or before any signs are shown. This is what I mean by more precise detection, and this is possible. This is something we already have demonstrated as feasible.

As I say, we have the knowledge about it. It is just that we do not have the technology to do it in a simplified manner on a widespread basis, but we will if we get more active support.

Senator YARBOROUGH. An artery swelled out beyond its normal size you can detect that on this map system?

Dr. DEBAKEY. Right.

Senator YARBOROUGH. Would that be detected on any other methods of detecting?

Dr. DEBAKEY. We may not be able to detect that by any other method. In fact, one of the most ancient of diseases is called aneurysm. This is a ballooning out of the artery. This was described several thousand years ago and has been known throughout medical history as a dangerous disease, one for which there was no cure until recently, when we did develop ways and means to remove it and replace it with an arterial substitute.

The danger of this lies in the fact that it ruptures very often without any previous signs and a person bleeds to death internally before anything can be done. We know it may have been present for even several years before it ruptures, but it may give no sign of its presence.

Senator YARBOROUGH. Do you think that is what cost us the loss here of one of the ablest men to serve in this body, Senator Estes Kefauver, one of the ablest men, I think, in the Government?

Dr. DEBAKEY. This is one of the most tragic examples of this disease. Senator YARBOROUGH. I think of another benefit here, Dr. DeBakey, you say that in most of these cases nothing would be found that called for medical attention. Would not the ease of mind in those people be one of the valuable byproducts of these tests, particularly old people beginning to worry about their health. If the tests show that they are in perfectly normal condition for their age bracket, this is valuable. Dr. DEBAKEY. You are quite right, Senator. I have seen this in my own personal experience with many patients who come back to me after we have operated upon them, for example, for some of these conditions, and we do these kinds of tests on them, in this way, for arteriosclerosis, and this gives us a precise way to reassure them that their arteries are in good condition. And there is nothing more reassuring to a patient than to know that.

Senator YARBOROUGH. And it adds to their productive capacity? Dr. DEBAKEY. Absolutely. I have had many of them go back to work after they have retired, return and resume full activity.

Senator YARBOROUGH. Thank you for this very valuable contribu

tion.

Senator Neuberger?

Senator NEUBERGER. I have one more question. I cannot let you go without referring to the success of the artificial heart. If there were some early detection in those cases, would you have been able to still forestall the heart difficulty or not? Or is that pathologically impossible?

Dr. DEBAKEY. Well, no, not at all, Senator. For example, we know certain forms of heart diseases due, say, to rheumatic fever, and this is a condition we could prevent if we could do it on a mass detection basis and methods for doing this are available. If we could also treat these people at an early stage, we would prevent most rheumatic heart disease. We could prevent it today.

Senator NEUBERGER. So we have a real goal to work for then?

Dr. DEBAKEY. You certainly have, and I want to assure you we are grateful for what you are doing in this regard and you certainly can count on our support.

Senator NEUBERGER. Thank you very much.

Did you have a question, Senator Williams?

Senator WILLIAMS. I just had the honor of having Dr. DeBakey on a television program, so I have asked you all the questions I should ask you today.

Senator NEUBERGER. All right. Thank you and we will go on to the next witness.

Is Dr. Rappoport here?

. (No response).

Senator NEUBERGER. If Dr. Rappoport is not here, then we will move on to the next witness, who is Dr. William Peeples?

Dr. Peeples is the commissioner of health for the State of Maryland and we are glad to have you here, Dr. Peeples, to add to our knowledge.

STATEMENT OF WILLIAM J. PEEPLES, M.D., COMMISSIONER, MARYLAND DEPARTMENT OF HEALTH

Dr. PEEPLES. Thank you, Senator Neuberger, Senator Williams. I have submitted a statement to you and would just like to make a few comments in addition to those that Dr. DeBakey has so aptly presented.

Senator NEUBERGER. We would be glad to accept your entire statement for the record. If you would like to abridge it or comment on it in any way you want to, that will be fine. But it will appear as presented.

(The statement referred to follows:)

PREPARED STATEMENT OF WILLIAM J. PEEPLES, M.D., M.P.H., COMMISSIONER, DEPARTMENT OF HEALTH, STATE OF MARYLAND

I am Dr. William J. Peeples, Commissioner of Health for the State of Maryland, 301 W. Preston Street, Baltimore, Maryland, 21201.

Screening tests are procedures which sort out those persons who may have abnormalities from those who probably have none. Multiple screening is the

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simultaneous use of two or more screening tests. Its major aim is the early detection and subsequent treatment of disease found. Screening programs were first developed as case finding tools in the control of syphilis and/or tuberculosis. Techniques and tests are now available which make it possible to screen for many diseases. The term multiple or multiphasic screening refers to the use of some of these tests when an individual is screened for more than one disease at a single visit.

The fact that any given test, technique or procedure is available as an aid in the diagnosis of a particular disease does not automatically qualify this test for use as a screening tool or device. The primary purpose of screening is not diagnostic. It is directed at selected populations of apparently well individuals. It is a selective elimination to find those people who should undergo diagnostic procedures. A screening procedure must be reasonably capable of selecting from a large population those persons most likely to have the disease for which the procedure is used. Such individuals, many of whom are unaware of any illness, are then referred to their physicians for definitive diagnosis. This enables the person with suspicious screening findings to obtain maximum benefits from early diagnosis and treatment. Studies have shown that screening tests have brought many people with asymptomatic but significant disease, especially chronic diseases, to medical attention.

We are still using in Maryland the 70 mm. chest X-ray to detect tuberculosis and certain cardiovascular and pulmonary diseases, and we are using various serologic tests to detect the presence of undiagnosed syphilis. The State Health Department is also using an especially prepared kit where women can obtain satisfactory material themselves to detect the presence of cervical cancer. This is being done on a state-wide basis at the present time. Women thirty to fortyfive years of age are sent one of the kits. The kit is used as directions indicate, and are returned to the laboratory for examination. Results of the test are sent to the woman's physician and in the case of positive findings, further examination is required for diagnosis.

Vision and hearing screening have been used in Maryland, especially among children, for many years in the school health programs throughout the State. Screening has been taking place on a routine basis for years in many Maryland schools for preschool children and in day care centers and Project Head Start, for a condition known as amblyopia ex anopsia, which is a particular eye affliction leading to blindness affecting children of preschool age. This is an effective screening test, one which can readily detect the condition and lead to its correction if found early. Vision screening and hearing screening are also, of course, carried out in the schools for the school aged child.

Other screening tests have been utilized on a sporadic basis in Maryland— those for glaucoma, the detection of diabetes, obesity, anemia, hypertension and other such conditions.

Although we do not know the complete extent of chronic illnesses which affects populations of various ages within the State of Maryland, we do have certain information regarding mortality among certain age groups from various chronic illnesses. Maryland, for instance, is in the highest quintile for the United States in adjusted death rates per 100,000 population for major cardiovascular diseases affecting both white males and white females for 1959 through 1961. This is also true for arteriosclerotic heart disease in white females. However, in white males the death rate is in the next to the highest quintile. Maryland also falls within the next to the lowest quintile for adjusted death rates for cerebrovascular diseases in white males and in white females. With hypertensive heart disease, both white males and females in Maryland are in the highest quintile for the United States. With rheumatic fever and other forms of heart disease, Maryland falls into next to the lowest quintile for the United States.

There is no evidence that cancer incidence in Maryland is any different from other areas of the United States, especially for the types of cancer which can be readily detected by screening methods. At the present time these types of cancer which are amenable to techniques leading to early diagnosis are the cervix uteri, the breast, oral cavity, and possibly the urinary bladder. Skin cancer, of course, is usually readily visible and only must be looked at and biopsied in order to make a diagnosis of cancer of the skin.

With regard to other forms of chronic illness, we have little information as to the true extent of these forms of illness. However, in populations which have been surveyed for glaucoma, diabetes, tuberculosis and other conditions, there