is no reason to believe that Maryland's rates of incidence are any greater or any less than the rest of the country. More information is needed as to the real extent of chronic illnesses. Where tests have been utilized for glaucoma and for diabetes, the percentage of incidence in Maryland has been found to be approximately 1% for diabetes and approximately 2% for glaucoma in those populations above thirty-five years of age.

I believe that multiphasic screening programs are feasible and that they urgently need to receive further development. Our plans in Maryland include establishing in county health departments, centers for multiple screening examinations. There are many populations within the State of Maryland who should, and could, be afforded this type of screening. School bus drivers, for instance, those who are medically indigent, other disadvantaged persons by reason of income such as those who are being currently examined under the Office of Economic Opportunity programs, selected persons for certain driving tests; all could be subjected to multiphasic examinations. Several local health departments in Maryland have already begun multiphasic screening. We hope that this program will expand greatly whether or not federal funds become available to help support it.

It is my belief that there should be no age limit established for adult persons to be eligible for multiphasic screening programs. Although it is true that with most chronic illnesses the incidence of a specific chronic illness increases with age, this is not always true and should not be used as the rationale for establishing certain age limits or limiting age groups who should undergo multiphasic examination. Cancer of the cervix uteri, for instance, is not present usually in any great number of women age fifty or over, but the twenty-one to forty-five year age group is the one which should be most carefully screened for cervical cancer. Glaucoma also occurs early in life and mostly below the age of fifty. Fifty percent of all chronic illnesses have made their start before forty-five years of age. It appears to me, therefore, that there should be no age limit established, but that the program of multiphasic screening should be thought of as a health protective program, disease finding, and containing the principle of early correction and treatment if possible for the entire adult population of the United States. There are extensive programs carried on by the Children's Bureau and in most health agencies for children, those under twenty-one years of age. It is my belief that multiphasic screening examinations should encompass the span of adult life between twenty-one and sixty-five and upward for all.

The effect of this program would be to provide centers for multiphasic screening which might be utilized by physicians, by certain groups within a community to avail themselves of these tests. The medical profession has not been enthusiastic about the use of multiphasic screening procedures except for tuberculosis, syphilis, and the more tried and true tests. On the other hand, many physicians do not employ these screening tests in their own offices on patients who routinely come to them for treatment. Many patients are never tested for glaucoma; there are also many others who never receive a Papanicolaou smear for cancer of the cervix; others have never received vision or hearing screening tests other than occasional, very crude approximations. I would suggest that it is important that the practicing physician be involved in multiphasic screening and that, insofar as possible, his office be used as a source of referrals for screening tests. A blood sugar determination is a good example. The test could be taken in the physician's office, sent to a center for analysis, and the result returned to the physician. Ideally, multiphasic screening examination should be connected with a subsequent medical history and physical examination. Those persons who, for example, are coming to the doctor for the first time or coming in for an annual checkup could be routed through the multiple screening examination prior to having a physical examination and medical history by the physician. I believe this type of involvement of the private physician would result in a better acceptance of the principle of multiphasic screening which could be applied as a valuable adjunct to medical practice.

Naturally, any multiphasic screening program should have positive or negative medical results sent only to the private physician of the patient involved. The physician should follow up doing whatever is necessary to make the diagnosis, if one is to be made of a suspected disease. There should be no interference from the agency performing the multiphasic screening tests with this procedure. Only if the physician requests it, should any follow up or assistance be given by a health department or other agency. Complete confidentiality of records is a must in any multiphasic screening program.

Since there is a great shortage of medical manpower existing in this country and since multiphasic screening does not require highly trained technicians to perform most of the tests done, this offers a resource to the medical and public health profession which would possibly strengthen a diminishing manpower situation in the field of health, especially if such screening tests were performed prior to regular visits of patients to the physician's office. Much time could be saved by having these tests done prior to that examination. In addition, those chronic illnesses which are remediable could be detected at any early stage thereby reducing the length and severity of disability and the cost of medical

care.

Multiphasic screening is the most practicable large scale method available for securing early diagnosis and applying preventive medical knowledge to the control of many chronic illnesses and disabilities.

Dr. PEEPLES. One comment Dr. DeBakey made was in relation to the aged.

With respect to multiple-screening procedures I would like to try to impress on you, and I think I wrote Senator Williams several communications about this, that age should not be a factor.

Senator NEUBERGER. Age?

Dr. PEEPLES. Age should not be a factor in the application of multiple-screening tests. Certainly there are a number of diseases which afflict individuals, attack individuals, which Dr. DeBakey indicated in regard to arteriosclerosis and the like at an earlier age than age 50, 40, or 30, and I would urge that if this technique is adopted and applied that it be applied to all adults regardless of age.

There are certainly adequate programs in the country now for the screening of children, the detection of handicapped children of all types. This has been supported by the Children's Bureau, by health departments and interested foundations, groups, all over the country. I feel we have a very comprehensive health program available for children, but such is not the case for adults, and for this reason I would like to emphasize what I feel is a need for including all adults in some type of overall preventive health service.

Senator NEUBERGER. I suppose that we think of it as more for the older population for the reason that we know that just the budgeting and the mechanics of general population screening is beyond us now, and so since many of these ailments compass age 40, which I don't think is old, but that is what we are sort of limited to now just because of the practical problems involved.

Dr. PEEPLES. I realize that this is a problem of budgeting and of funds, and service availability; on the other hand, for, cancer of the cervix, detection beyond age 40 is often too late.

Senator NEUBERGER. Yes.

Dr. PEEPLES. And there are still many, many women in this country who, though this test has been available for the last 25 years, still have not ever had the test. I feel that this type of program should emphasize not only the test itself, but the educational process that this is a protective device where, as Senator Yarborough said, ease of mind is one of the very beneficial effects of screening. A negative examination is worth a great deal to the individual.

Now I would also like to emphasize the fact that a good history is quite important, that this is one screening device that can be utilized and done primarily by the individual. Whereas, we have many diagnostic tests such as some of those mentioned by Dr. DeBakey of arteriography and so on, those tests are very difficult to administer and they

are very difficult to interpret and they are not without some difficulty in interpretation.

A good history, however, can be subjected to computer techniques and such things as a small stroke, which may occur with very little symptomatology, can be detected by a good history with further diagnosis to see where the thrombus or clot originated that caused the small stroke.

I would like to say something about pulmonary disease also. This is a disease which has had the highest rise in mortality in the last decade. I know, Senator Neuberger, that you have been interested in carcinoma of the lung from smoking, cigarette smoking, and I think if anything, emphysema and chronic obstructive lung disease is probably caused even more so by cigarette smoking. This can be detected by pulmonary function tests which are relatively simple and easy to do.

Unfortunately we do not know too much about what to do for the individual once we find him with emphysema, to prevent him from progressing with the disease, other than to stop smoking cigarettes. But nevertheless here is a disease where there needs to be a great deal of not only research, but professional education and certainly a lot of case finding. I feel that if infection can be prevented in this group of people, that much of their disability and ultimate death can be prevented.

I feel that State and local health departments should be involved in multiple screening. We have seen particularly the need for this in Maryland and I believe most other State health agencies have.

As far as chronic illness is concerned, this to me is the only real application of specific preventive measures that can be used in control of chronic disease.

I feel that State and local health departments are and can be helpful in presenting chronic disease programs and preventing chronic disease in the future.

Senator NEUBERGER. Any questions?

Senator WILLIAMS. What is the State of Maryland doing, following your analysis of State and local responsibility? Are you able to gear up a multiphasic screening process?

Dr. PEEPLES. Yes, sir; we have been using, Senator Williams, certain screening procedures for a number of years for TB, the chest X-ray for TB, serology for detection of syphilis, vision and hearing screening, particularly for children, for a number of years.

Senator WILLIAMS. How do you reach them? How do you go about this? What are the mechanics of the operation-bringing people to you or you to the people?

Dr. PEEPLES. We usually go to the people. We are hoping, however, and we have already begun this, to institute certain screening procedures in local health departments where the people might come to

us.

In the case of the several million chest X-rays, we have gone to the people in terms of a mobile unit. I am afraid that we really do not get the population that really needs to be reached if we are going to find TB; finding a clear chest is certainly worthwhile, but if you are looking for TB primarily, you do not necessarily find it by placing your mobile screening unit in a shopping center.

Senator WILLIAMS. You get a concentration of people, but perhaps not that group most likely to be affected?

Dr. PEEPLES. Right.

We have begun in Maryland a program, which will extend statewide, of sending out a kit for the detection of cervical cancer in women. We have tried to get the names and addresses of women, county by county, from 25 to 45 years of age, and these women are mailed a kit and are given instructions as to how to use it. Once they have obtained the specimen from the vagina, with the cervical washings, which is aspirated back into the little container it comes in, the kit is placed in a box and is sent to the laboratory, spun down and the cells examined to see if there is any evidence of cervical cancer.

This has been almost as successful as the Papanicolaou smear and it is one test that is a screening test nonetheless. It can be administered by the woman herself and if any suspicious findings turn up, the woman can then be directed to her physician for "Pap" smear, further investigation and diagnosis. This is being carried on throughout the State.

Senator WILLIAMS. What percentage return do you get on the number of kits mailed out?

Dr. PEEPLES. At the moment we are getting between 55- and 60percent return on these kits. They cost about 25 cents.

Senator NEUBERGER. And in that 60 percent do you find some cancer potential?

Dr. PEEPLES. Suspicious findings in about seven to eight specimens per thousand.

Senator NEUBERGER. Is that test one in which some potential cancer might be overlooked, still is not quite the same as a "Pap" test?

Dr. PEEPLES. It is not thought to be quite as good as a "Pap" test, Papanicolaou's smear. On the other hand, it was used in the Public Health Service clinic that was set up as as demonstration in Memphis, with a similar type of technique. They believed that it was superior to the Papnicolaou smear. On the other hand, realizing the limitation of the individual and probably being able to do this not too well since they only do it once, I would say that it is not as good as a "Pap" smear performed in a physician's office or a clinic. But nonetheless, I think it is an excellent educational technique as well as a good case-finding technique.

Senator WILLIAMS. Would you conclude that it would be far preferable to have centers where people could come in and have a comprehensive screening rather than this sort of one-disease approach?

Dr. PEEPLES. Yes. The type of screening that has been afforded at the Kaiser Foundation in Oakland, San Francisco, is certainly desirable. I believe that this could be done prior to physical examination by a regular physician, or private physician, with these results furnished to him.

This would be of tremendous help, an adjunct to medicine though I believe there is some resistance in the general medical profession toward multiple screening. They feel they have been left out, that it interferes with the practice of medicine.

Senator NEUBERGER. Is that general, though?

Dr. PEEPLES. It is certainly general in our State. They have not responded at all well to general screening examinations.

Senator NEUBERGER. What is it, a sensitivity, a touchiness about moving in on their area?

Dr. PEEPLES. They believe that it could result in interference with their patients and they feel that if this is to be done, they want to direct these things themselves for their own patients.

Senator WILLIAMS. Is this from the medical profession?

Dr. PEEPLES. This is from the medical profession.

Senator WILLIAMS. I would think they would much rather have a patient they can cure than a patient they would have to stand by and bury.

Senator NEUBERGER. It is a little jealousy, I suppose. That is why I keep emphasizing about this, that it is not a physical exam, it is a screening process. You still need the doctor very much.

Dr. PEEPLES. To make the diagnosis.

Senator WILLIAMS. And he will get probably a lot of patients earlier than he would otherwise, and they will be subject to cure and not drastic remedies, be it medicine or surgery.

Dr. PEEPLES. I feel that one avenue that might encourage better participation of the physicians would be for them to form a nonprofit organization in a community and establish their own multiple-screening examinations whereby their patients, prior to coming into their office for physical examination or treatment or what-have-you, would go through this. Screening could follow treatment for an acute illness.

Senator WILLIAMS. We have legislation not before us really, but will be before another committee at some point. I would think the nonprofit group you suggest might qualify under the legislation that we propose, that probably will not be considered this year.

That is a most intelligent approach, I would think. And I think the American Medical Association is the leading professional group of doctors that are being increasingly aware of the partnership role. Do you not think so, Senator Neuberger?

Senator NEUBERGER. I think it has been evident.

Senator WILLIAMS. They have been most cooperative in medicare, I believe.

Senator NEUBERGER. Now, lately.

Senator WILLIAMS. After the fact.

Senator NEUBERGER. Thank you, Dr. Peeples, very much.

I understand Dr. Rappoport is here, so we welcome him to the witness stand.

Dr. Rappoport is from Youngstown, Ohio. He is a member of the board of governors of the College of American Pathologists and is here representing that College of American Pathologists.

STATEMENT OF ARTHUR E. RAPPOPORT, M.D., MEMBER, BOARD OF GOVERNORS, COLLEGE OF AMERICAN PATHOLOGISTS; ACCOMPANIED BY PAUL GEBHARDT, COUNSEL, COLLEGE OF AMERICAN PATHOLOGISTS, CHICAGO, ILL.

Dr. RAPPOPORT. Senator Neuberger, I have with me the counsel of our college, Mr. Paul Gebhardt, and we thank you for the opportunity of appearing here.

As you know we are having our annual meeting here in Washington at this time and Mr. Gebhardt was interested in coming here.