0 0 a, cogqmoo@@@@o r->Omho--z t I I I I I I n c 6 liom 0 @O -% CD > r - ' 0 @ I 0) r+ CL CA) r rM 0 -4 U) 0 > rii c E; 0 =r CO CD kLI m co z (." > (D -u 9 IOQ an m Z o !R 9 r, on@ > o .5 C) 0 C z CD N 0 m c :r 0 z 3 3 0 CD CL 0 0 CD :3 CD 3: 0 CD 0 0 M CD :3 % 0 M M CD :3 CL 0 0 CA 77 m (D :3 0 cn 0 CD THE PRESIDENT'S COMMISSION ON HEART DISEASE, CANCER AND STROKE r_ r_ n m - . 0 1) ql I I w a , 6LLL 0 6 1. 9 cm III I CANCER AND STROKE THE PRESIDENTIS COMMISSION ON HEART DISEASE, Iffir REPORT TO Tnt Pj"iESl"D'L"NT A NATIONAL PROGRAM TO CONQUER HEART DISEASE, CANCER AND STROKE Volume I December, 1964 For ale by the Su@ntendent of Doements, U.S. Government Printing Office, Wawngton, D.C.. 20402' Price $1.25 ini"ioll on it D]EAR MR. PRESIDENT: I have the honor to submit the report of the President's Commission on Heart Disease, Cancer and Stroke. The Commission was appointed by you in March 1964, to develop a realistic battle plan leadin- to the ultimate conquest of three diseases-heart disease, cancer and stroke-Which noiv actount for rhore than 70 percent of the deaths in this country. In your initial charge to us, you requested us to recomftiend practical steps to reduce the heavy losses exacted by these diseases through the development of new sc@ientific knowledge and through the delivery to all of our e in every pai-t of this great land of the precious, lif@-avin- medical knowl- peop, 0 edge we now possess, but fail to bring to so many stricken American families. Grateful beyond measure of expression for this Presidential mandate, we Plunged into our assigned task-con@dent that the toll of these three diseases could in fact be sharply reduced now and in the immediate future. During the intervening months, as we sou@ht and received testimony from scores of leaders in medicine and public affairs, our conviction mounted that we could chart a truly national effort-calling upon the full resources of Federal, State and local -overn- ments, the dedicated members of the health professions, and our great v6luntary health organizations-leading to the increased control, and eventual elimination, of heart disease, cancer and stroke as leadin@ causes of disability and death. This report embodies our recommendations for such a united effort by a free and vi@orous people. Our stated -oals are neither impractical nor visionar@ they can be achieved if we so will it. They must be achieved if we are to check the heavy losses these three diseases inflict upon our economy-close to $40 billion each year in lost productivity and lost taxes due to premature disability and death. In the early decades of this Republic, our people tended to view disease as an irrevocable and irreversible visitation from an implacable Fate. Our remark- able progress a-ainst many diseases over the past half century-the life span of the average American has been lengthened by 23 years since 1900-is vivid proof of the reversibility of any disease process. The -reat engineer Charles F. Ketterin- once observed that no disease is tD in incurable; it only seems so because of the i-,norance of man. C) We submit this report, Mr. President, in the deep conviction that its immediate implementation will not only narrow appreciably the spectrum of our i-norance, r but will contribute to the savitia Of thousands upon thousands of American lives now needlessly sacrificed to these three deadly enemies of mankind. Respectfully yours, MICHAEL E. Di HEART I)IS,c-ASF-, CANCER APJD THE PRESID@@MT?S COPIIMISSION 0 Membership of the Commission: Dr. Michael E. DeBakey, Chair- Dr. Howard A. Rusk man. Dr. Paul W. Sanger Dr. Samuel Bellet Gen. David Sarnoff Mr. Barry Bingham Dr. Helen B. Taussig Mr. John Mack Carter Mrs. Harry S Truman Dr. R. Lee Clark Dr. Irving S. Wright Dr. Edward W. Dempsey Dr. Jane C. Wright Dr. Sidney Farber Staff of the Commission: Dr. Marion Fay Dr. Abraham M. Lilienfeld, Staff Mr. Marion B. Folsom Director. Mr. Emerson Foote Mr. Stephen J. Ackerman Gen. Alfred M. Gruenther Dr. Nemat 0. Borhini Dr. Philip Handler Mr. Louis Carrese Mr. Arthur Hanisch Dr. Maureen Henderson Dr. Frank L. Horsfall, Jr. Dr. William L. Kissick Dr. J. Willis Hurst Mr. Lealon E. Martin Dr. Hugh H. Hussey Dr. Bayard Morrison Mrs. Florence Mahoney Mr. Horace G. Ogden Dr. Charles W. Mayo Mr. Marcus Rosenblum Dr. John Stirling Meyer Dr. David Scbottenfeld Mr. James F. Oates Dr. John D. Turner Dr. E. M. Papper Mr. Daniel Zwick HEART DISEASE, CANCER AND STROKE ACKNOWLEDGMETITS In submitting its report the President's Commission wishes to express its profound appreciation for the generous assistance and cooperation offered by professional organizations, voluntary a@encies, and other individuals and groups. A special expression of gratitude is due to Dr. E. Cowles Andrus and all others responsible for the Second National Conference on Cardiovascular Diseases, which was held during the period of the Commission's service, for providin- us with preprints of their proceedings which served as basic scientific documenta- tion for much of our work. We wish also to acknowledge the unstintin.gcooperation of many agencies and branches of the Federal Government, with special thanks to Anthony J. Celebrezze, Secretary of Health, Education, and Welfare; to Surgeon General Luther L. Terry of the Public Health Service; to Dr. James A. Shannon of the National Institutes of Health and to Dr. Aaron W. Cbristensen of the Bureau of State Services (Community Health), for providing staff and support without which the Commission could not have performed its assigned function. Finally, the Commission wishes to express its profound debt of gratitude to the staff members whose work, frequently performed under conditions of extreme pressure, was carried out with uniformly high quality reflectin,@, great credit v both on them as individuals and on the organizations they represent. HEART DISEASE, CANCER AND STROKE 'f"CTII,]E In seeking to develop a national prouram for the immediate reduction and 0 ultimate conquest of heart disease, cancer and stroke, the President's Corn- mission accepted a complex challenge. There was need, first, to document in depth the dimensions of the problem and to assess the Nation's existin@ and potential resources for achieving the stated ao Is. Then it was necessary, based on these asses draft recom- ,, a sments, to iiietidations scaled to the dimensions of the problem and tailored to the limitations of practicality. We quickly recognized apparently conflicting sets of specifications in develop- in- and presenting our pro@ram. The recommendations should be compre- iletisive-in order to advance the attack on all fronts-and yet sufficiently specific to serve as a blueprint for action. Moreover it was essential that the pro-ram be understood and accepted by both the scientists and the policy makin@ repre- .@ritatives of the American people. The present report represents our attempt to meet these specifications. It is presented in two volumes, of which this is the first. Volume I is the summary volume and is intended for wide distribution. It includes the Commission's recommendations for a national proaram to conquer heart disease, cancer and stroke. Volume 11, to be published in a more limited edition, is made up of the full reports of the ei,,ht subcommittees into which the Commission div@ided for a systematic approach to problems confronting it. It also includes additional scientific and technical documentation developed at the Commission's request by other individuals and groups. The first tnvo chapters of Volume I constitute the backdrop against which the Conimission's proposals are to be vieNve4. Chapter One seeks to measure the impact of heart disease, cancer and stroke on the American people-in terms of deaths, disability, and economic costs-and describes current pro@ress in scientific knowledge which offers hope for immediate and future reductions of this toll. Chapter Two discusses the Nation's current state of readiness to com- I)at these three diseases, contrasting the manpower, facilities, and other resources now available with those which are needed to mount a full-scale attack, both in the delivery of medical service and in the discovery of new kno%vled@e. Chapters Three through Seven present the 35 specific recommendations of the Commission. These are grouped under five broad headings, related to specific areas of need for action. Chapter Ei-ht deals directly with legislative and orga- nizational problems which must be resolved if the specific recommendations are to be fully effective. The Commission's suggestions for expenditures needed to carry out the pro- posed programs are tabulated in connection with each specific recommenda- tion. Summary tables, which indicate the total funds recomniended and compare these with existing levels of expenditure, will be found in Appendix A. Considered broadly, the Commission's 35 recommendations are of two general vil types. HEART DISEASE, CANCER AND STROKE ndations which are di- Dories includes those recomme The first of these cate,, Thes constitute the frontal in question. e cifically at the three diseases rected spe assault on problems related to the conquest of heart disease, cancer and stroke. Included in this cateaory are the recommendations comprising the major r> innovative thrust of the report-the establishment of a national network of regional centers, local diagnostic and treatment stations, and medical complexes designed to unite the worlds of scientific research, medical education and medical care. This proposed national network would bring within reach of every physician and every patient, region by region and community by com- munity, the very best in the diagnosis and treatment of heart disease, cancer and stroke. It would, in our judgment, have an immediate impact. It would save many lives and prevent widespread suffering-merely by making medical and scientifiit excellence in heart disease, cancer and stroke readily accessible to those @hose lives depend on it. The national network program is described in detail in Chapter Three of the report. In addition, the direct assault oh the three diseases requires several other ur- gently needed program--. These include the strengthening of statewide lab,ora- tory programs for heart disease control, a national effort directed toward the detection of cervical cancer, the establishment of highly specialized research units for intensive study of specific disease problems, and augmented support of research in heart di---ease, cancer and stroke. But heart disease, cancer and stroke cannot realistically be considered apart from the broad problems of American science and medicine. Therefore the second category of recommendations-no -less essential than the first-is designed to strengthen the total national resource for advancing scientific knowledge and providing medical services. Skilled manpower for the attack on heart disease, cancer and stroke must be drawn from the national reservoir of health manpower-and that national. reser- voirisseriouslyinadequate. Therefore,theCominissionhasreconunendeddirect and forthright governmental support of medical education and other essential training programs. Successful local programs for control of heart disease, cancer and stroke depend upon strong community health resources; therefore, the Conunission has recommended programs to buttress these efforts. Similarly, research on specific disease problems depends upon a variety of supporting resources and mechanisms which are the: 'Subject of separate reconunendations. Scientific knowledge on heart disease, cancer and stroke must be efficiently communicated among scien- tists, to and to the public; thus, a number of recommendations are practitioners, aimed at problems of communication. In sum, if we are to conquer heart disease, cancer and stroke, we must, as a nation, rededicate and redirect our efforts toward this high pqrpose. We must strike boldly at the specific problems po@ by each disease through a nation- wide approach which represents a major innovation in American medicine. vlii At the same time we must strengthen an support our entire health resource upon HEART DISEASE, CANCER AND STROKE which the innovative attack must be based. ConimisOons Repoit, Volume I CONTENTS Page Letter of Transmittal ........................................... Names of Commission Members and Staff ......................... Acknowledgments .............................................. v Perspective .................................................... vii Introduction ................................................... xi PART I Problems, Resources and Needs .................................. 1 Chapter 1. The Dimensions of the Problem .............. I .... 1 Chapter 2. National Resources and National Needs ............ 15 PART 11 Toward the Conquest of Heart Disease, Cancer and Stroke .......... 26 Chapter 3. A National Network for Patient Care, Research and Teaching in Heart Disease, Cancer and Stroke ............... 28 Chapter 4. Application of Medical Knowledge in the Corn- muhity ......... I........... : ........................... 38 ew Knowledge .................. 47 Chapter 5. Development of N Chapter 6. Educition and Training of Health Manpower ....... 53 Chapter 7. Additioiial Facilities and Resources ........... 63 Chapter 8. Recommended Changes in Leg station and Organiza- tion ............................................ ..... 70 APPENDICES A. Summary Tables ............................................ 7,8 B. Members of Commission and Staff ............................ 84 C. History and Operation of the Commission ...................... 87 D. Agencies and Professional Organizations Contacted .............. 92 E. List of Witnesses. . . ................. I ............. 94 F. Bibliography ............................................... 102 G. Acknowledgments ........................................... 114 lx HEART DISEASE, CANCER AND STROKE In his Special Health Message to the Congress in February 1964, President Lyndon B. Johnson made the following announcement: "I am establishing a Commission on Heart Disease, Cancer,and Stroke to recommend steps to reduce the incidence of these diseases through new knowl- edge and more complete utilization of the medical knowledge we already have." Two months later, when the newly formed Commission first convened at the White House, he said: " Unless we do better, two-thirds of all Americans now living will suffer or die from cancer, heart disease or stroke. I expect you to do something about Something can be done about it. Every day men and women are dying who need not die. Every hour families are being plunged into tragedy that need not happen. Wives are widowed, children left motherless-not for lack of scien- tific knowledge, but for lack of the right care at the right time. Every available fact points to the same conclusion-that the toll of heart disease, cancer and stroke can be sharply reduced now, in this nation, in this time. The sweep of scientific progress in the past decade has brought most forms of congenital heart disease within our powers of correction. Advances in sur- gery make it possible to save patients who would have been doomed five years ago; indeed, even one year ago. Rheumatic heart disease now can be virtually eliminated. Many strokes can be foreseen and prevented. Cancer of the cer- vix and uterus can be brought almost to the vanishing point, and chances are greatly improved for cure of cancer in other accessible sites, comprising over 70 percent of all cancer patients. These things can be done now, without further scientific advance. Meanwhile new knowledge of the fundamental processes of life promises great new weapons for the inunediate future. Successful replacement of defective organs comes closer to reality each day. New methods of cancer detection and treatment are in immediate prospect. The way is there. 'All that is lacking is the national will to give our people the full measure of protection against their three most deadly enemies. The Commission is keenly aware that its Report will help to prolong life and ease suffering only if it is followed by vigorous action. Our aim is to kindle a re-dedication of our national health resources and a new awareness on the part of the American people, to the end that heart disease, cancer and stroke may be sharply reduced, increasingly controlled and ultimately conquered as enemies of Man.@ The facts provide abundant proof that the goal is worth the striving. Heart disease, cancer and stroke, taken together, claimed 1.2 million Am@- xi Can lives in 1963-more than 7 out of every 10 deaths in this country. HEART DISEASE, CANCER AND STROKE The 365,000 Americans between the ages of 25 and 64 who died of these diseases in 1962 would have earned wages totaling more than $1.5 billion and paid close to $200 million in Federal income taxes had they lived one more healthy workin,, year. Moreover, this is only the beginning of the economic cost of heart dise@ cancer and stroke; an estimated 14.6 million Americans are suffering from definite heart disease, and another 13 million from suspected heart disease. At the same time, other facts demonstrate that the nation is capable of meeting the challenge. Our nation's resources for health are relatively untapped. The rising tide of biomedical research has already doubled and redoubled our store of knowledge about heart disease, cancer and stroke. Yesterday's hopeless case has become today's miracle cure. We stand on the threshold of still greater breakthroughs in the laboratories and clinical centers of the nation. Yet for every breakthrough, there must be follow-through. Many of our scientific triumphs have been hollow victories for most of the people who could benefit from them. The obstacles in our path are many and formidable. Not the least of these is the harsh fact that modern medical care is too expensive for many of our people. Although our recommendations do not relate directly to this challenge, the Commission recognizes that our society must successfully overcome this obstacle if the promise of modern medicine is to be fulfilled. Each premature death from heart disease, cancer and stroke is a personal tragedy. But each preventable death is a national reproach. Every year, more such preventable deaths are occurring-for the pace of science is bringing more within our reach, but the pace of application allows them to slip through our grasp- We need to match potential with achievement, to fuse the worlds of science and practice. We need to develop and support a creative partnership amonc, all our health resources. This way-which is the way of a democratic republic- is the true path to conquest of heart disease, cancer and stroke. The first line of defense for our people's health is manned by private pre6ti- tioners. The advance in biomedical-research is led by individual investigators. The settings in which these men and women work are our great private, com- munity and State institu-tions-hospitals, universities, scientific institutes. Individual freedom is the cornerstone of t le e structure. Individual initiative is clearly visible also in the work of our great voluntary agencies in the health field. The American Heart Association, the American y and others have pioneered in the support of health research and Cancer Societ in speeding the delivery of the benefits of research to people who need them. Specifically, the funds raised by these organizations are channeled into research, into education of the public and training for the health professions, and into direct service for patients. xii Local and State initiative is demonstrated by rapidly developing public health HEART DISEASE, CANCER AND STROKE programs aimed at control of heart disease, cancer and stroke. State agencies i @ i in particular are in process of accepting greatly increased responsibility for pro- grams combatting these diseases. At the same time, society @, a whole has a heavy stake in the success of this endeavor. It is appropriate and necessary that the Federal government encourage, stimulate and support the upward thrust of national health. Events of the past two decades have proved beyond question that such encouragement and support, far from interfering with personal and scientific freedom, has in fact created the conditions in which such freedom can realize full fruition. The solution to the problems of heart disease, cancer and stroke. can be built only on the foundation of a profound and truly national corn- mitnient to this end, by both public and private resources. The nation's strength derives from the strength of its people. A national investi-nent in the prolonging of productive life for its people pays rich dividefids in national productivity. Good health is good business for the nation. But in a democratic society, there are other motives for action, more com- pelling still. Heart disease, cancer and stroke cut life short; they curtail the enjoyment of liberty; they make futile the pursuit of happiness. One true measure of a titition's greatness is its success in making available to its people the means for protecting and enriching their individual lives. 'Me President's Commission on Heart Disease, Cancer and Stroke bases its ]report on the conviction that the United States will measure up to greatness; that it will choose to continue and accelerate the forward thrust of medical research across new thresholds of discovery; and that it will resolve to make fully available the benefits of scientific knowledge to all those whose life and opportunity for individual fulfillment depend upon them. We do not promise that our program will save a million lives next year. We do not guarantee to all the millions of victi-ms of heart disease, cancer and stroke a new life free from pain and fear. But we believe that many thousands of men and women who might live will die, needlessly, year by year, until the nation makes this new commitment. We believe that many thousands of men and women will suffer and stand idle, needlessly, year by year, until the nation pledges its full resources to their cause. To these men and women we dedicate this Report. xiii HEART DISEASE, CANCER AND STROKE PART hapter One r THE DIMENSIONS OF THE PROBLEM The first of the three 'objectives set for the Commiss,on was to measure the ma-nitude of the impact of heart disease, cancer and stroke on the Ameri- can people. Such measurements have been made by many people, in various ways. The usual product of these assessments is a set of statistical tables. The numbers run into millions, sometimes billions. The columns drift into abstraction-age- Adjusted death rates, man-hours, productivity. These tabulations are valuable and necessary. They are especially valuable when they furnish clues for a more efficient attack on specific aspects of the prob- teni. But they do not measure the true impact of the three great killing diseases on the American people. They do not quantitate grief for more than one million American families every year. They do not express the personal economic hardship that comes in the wake of a fatber's sudden, fatal heart attack. Nowhere in the tables will you find the heartbreak and the long emotional stress that follow a mother's death from cancer. They may count the number of hours of idleness pnforced by chronic Liability, but they do not measure the length of each hour. These represent the true impact of heart disease, cancer and stroke. They thould be read into every statistical paragraph, table and @art in the mate- rial that follows. The Changing Pattern of Sickness and Health lleart disease, cancer and stroke are overwhelmingly the leading causes of death in the United States today. Diseases of the heart and circulatory system- & broad category that includes -strokes-now claim nearly a million lives each year. Cancer takes over a quarter million more. In 1963, these diseases accounted for 71 percent of all deaths in the nation. Compared with them, all,Ithe other enemies of man-the great ranIge of infectious I diseases, accidents, congenital and nutritional disorders-fade into relative in- significance. It has not always been thps. The ascepdanc of the three great killers is I' y a recent development. It is, in fact, a byproduct of brilliant progress in biological science and medical servic@. A few short decades ago, tuberculosis was the greatest single menace to American health. :Pneumonia and influenza took a heavy Itoll each year. Infectious diseases of infancy cut off many lives that had barely begun. For t6 overworked physician of horse-and-buggy days, heart disease and cancer were far down on his list of preoccupations. HEART DISEASE, CANCER AND STROKE We are the beneficiaries of a reat medical ren,oltitioll- "'.st 11' t, 1),@ It greatly tury of scientific medicine has resulted in a swiftly lengthened lifespan, a level of ivell-beina far above tll(', Ili I)CctLitiOlls of our grandfathers' generation. DEATHS FROM HEART DISEASE, CANCER AND STROKE IN 1963 Death from It has also resulted in a heightening of our oivit zisl)ir ivrst)ii@IIIY traaic heart disease or cancer, at a relatively advanced age, ivtls'o ) LI illilia to tolerate what but philosophically acceptable. Today we are no loii-er w was once "the inevitable." Our new intolerance is based on knowledge-that heart ctiticer and ot kill so many people today, and that tolll()rro%v iiiort3 pre- stroke need n this intolerance comes mature deaths ivill be ivithin our poiver to prevent. From is not determination. The magnitude of the problem, as discussed a status quo to be lamented and accepted, but a challeii,r,le to.I)(., filet. la HEART DISEASE Description lillilit)c,,. of coiidi- The term heart disease, as commonly used, includes a Iii tions affecting the heart and circulatory system. It is not LI sil",'Iv disease, but many. The cardiovascular-renal diseases-to use the broadly iii(@llisiN,C technical terms-can be divided into three maj or categories: ilet,vois system; (1) Strokes-damage to the blood vessels affectin@ the c t) (2) Diseases of the heart itself and the blood vessels serving the body, includ- ing rheumatic fever and rheumatic heart disease, arteriosclerosis and de- generative heart disease, functional diseases of the heart, high blood I)res- 2 sure and hypertensive heart disease, and numerous other specific disease HEART DISEASE,CANCER AND STROKE entities; (3) Kidney diseases, including chronic nephritis and renal sclerosis, which are related to the circulatory system and are therefore included in the broad category. Deaths from Heart Disease I in the United States died of the cardiovascular-renal In 1963, 994,747 peop e diseases. Of these deaths, about one-fifth (201,1661) %%-ere caused by strokes. By 7.830), over 70 percent, were caused by heart disease, far the largest share (70 , predominantly arteriosclerotic heart disease includin@ coronary disease (546,'013). Hypertensive heart disease and hypertension accounted for about 7 percent (73,. 791), with the remaining deaths distributed amon@ other disorders of the heart and circulatory system' Heart diseases (and strokes) accounted for more than half (50.1 percent) of all deaths in the United States in 1963. In 1900. these diseases accounted for only about one death in seven. Heart disease is predominantly, but by no means exclusively, a cause of death among older people. About 72 percent of the 707.830 heart disease deaths in 1963 occurred in persons aged 65 and over. There are striking differences in the heart disease rates by sex. Men outnum- ber women as victims by a factor of more than one-third@11,989 to 295,841. This is a relatively new and still incompletely understood phenomenon; until about 1930, the heart disease death rates for men and Nvomen were of about the same magnitude. (1 963-994,747 DIED OF CARDIOVASCULAR-RENAL DISEASES) STROKES 201,166 HEART DISEASE 707,830 HYPERTENSIVE HEART DISEASE AND HYPERTENSION 73,791 PERCENT 10 20 30 40 50 60 70 80 90 100 HEART DISEASE, CANCER AND STROKE the geographic distribution of Interesting and unexplained variations exist in zn cardiovascular disease deaths in the United States. There is higher mortality- for both men and wojneti-in the Eastern and far Western States, with lower mortality in the Central and Mountain re@ions. Death rates appear to be bi@ber in large cities than in smaller towns and rural districts, but these differ- ences do not fully account for the State-by-State and regional variations. More- over, it is believed that persons born in "hi,h mortality" States carry with them a high mortality tendencv even thou-h they may die in a "low mortality" State. DEATHS FROM HEART DISEASE HAWAII mum I omu ul DEATHS PER REGION 19,604 42,237 47,804 55,556 62,487 75,764 93,160 148,079 163,139 Illness and Disability The heart diseases, in addition to their dominance as a cause of death, are the cause of extremely widespread illness and disability in the United States. Studies conducted by the National Health Survey of the U.S. Public Health Service in 1960-62 indicate that an estimated 14.6 million adults suffered from definite heart disease, and nearly as many had suspected heart disease. Of every 100 persons in the population between the ages of 18 and 79, 13 had definite heart disease and 12 more had suspected heart disease. Thus nearly one-fourth of the adult population studied lives in certainty or in jeopardy HEART DISEASE, CANCER AND STROKE of heart disease. The most common condition discovered by the Survey was hypertensive heart disease, with 10.5 million "definite" and 4.7 million "suspect" cases. For coro- nary heart disease, the estimates were 3.1 million "definite" and 2.4 million ggsuspect." In sharp contrast with mortality figures, "definite" heart disease was found to be more frequent in women than in men. Women were more likely to be suffering from hypertensive heart disease, while men were more likely to have coronary heart disease or heart disease of congenital or syphilitic origin. The frequency of heart disease increases sharply with age. Fewer than 2 percent of those aged 18-24 had definite heart disease, while at the other extreme 39 percent of the men and 46 percent of the women aged 75-79 had definite heart disease. Economic Impact The economic cost to the nation of any disease may be measured in terms of its direct costs in diagnosis, treatment, and rehabilitation of patients suffer- ing from the disease and the indirect costs associated with loss of earnings due to disability and premature death. Heart disease, with its enormous death toll and still greater prevalence as a chronic disabling condition, imposes a multibillion dollar burden on the economy each year. Direct expenditures for hospital and nursing home care, physicians' serv- ices, drugs and other medical services for persons with heart disease amounted to $2.6 billion in 1962. About 15 percent of the total days of care in the nation's short-term hospitals are for care of heart disease patients, as are 28 percent of the patient days in skilled nursing homes. One out of ten visits to physicians in private practice are in connection with heart disease. Likewise, the drug bill for cardiovascular patients is estimated at 10 percent of all expenditures for prescriptions. 'Me direct costs are only the beginning. Those who are disabled by heart disease add another burden to the economy, owing to loss of output. Taking into account mei-nbers of the labor force, housewives, and others who were unable to attend to their usual activities, a total of 132 million work days were lost in 1962. These are equivalent to 540,000 man years, which amount to $2.5 billion in terms of 1962 dollars. Other losses result from premature death. As we have seen, approximately a quarter of a million people in the most productive years (25-64) died of heart disease in 1963, slightly more than in the preceding year. Assuming that the deaths occurred evenly over the year, more than 81 billion worth of output was lost in 1962. Had all those who died in 1962 lived just one more year, the economy would have gained $2 billion worth of output. The nation is still paying in lost output for the people who died prematurely of heart disease in the recent past. Of 26 million deaths due to cardiovascular diseases in the period 1900-1961, 5 6 million persons would have survived to 1962 and worked or kept house if this HEART DISEASE, CANCER AND STROKE. major cause of death had been eliminated. The assumption is that the cardio- vascular (including in this instance stroke) death rate became zero while the rates for all other causes remained unchanged. illion. In money terms the loss in output amounted to $24.5 b It may be helpful to compare these losses due to heart disease to the gross national product (the market value of all goods and services produced by the economy). For this purpose the value of output imputed to housewives must be excluded. The sum of direct costs, plus losses of output by members of the labor force due to heart disease, amounted to $22.4 billion, or 4 percent of GNP in 1962. Progress and Prospect The prospects are excellent for reducing the toll of heart disease in the years immediately ahead. Great strides have been made in the past 15 years on the research frontier. Today's challenge is two-fold-to bring these advances not just to the fortunate few but to the many who can benefit from them, and to continue to acquire new lifesaving knowledge. Medical research in the heart disease field has already paid rich dividends on the growing public and private investment in biomedical science. This progress has been documented in depth in the Report of the Second National Conference on Cardiovascular Diseases, based on an intensive review by hundreds of physicians andscientists. Thefollowingareafewofmanyexamples: Advances in surgery in the past ten years have already saved thousands of lives and promise to save many more. Patients suffering from aneurysms ballooning out and thinning of the walls of an artery-were until recently almost certain to die within a year. Now the damaged section of the blood vessel can be removed and replaced with a sub- stitute vessel made of a plastic material. A recent analysis of 1,000 such cases showed more than 90 percent success, even with extensive aneurysms of the aorta near the heart. Similar procedures, with similar prospects of success, can also be employed for replacin@ segments of blood vessels damaged by arteriosclerosis in the many instances in which such damages are localized. Surgery of a highly complex nature is now possible on the heart itself, thanks to the development of artificial machines which can temporarily substitute for the vital functions of the heart and lungs. Valves of the heart which are defec. tive because of congenital heart disease can sometimes be repaired, and valves with acquired damage are also being treated successfully. Research on high blood pressure has brought into being a number of ex- cellent drugs that effectively lower elevated blood pressure levels. This advance has already helped to produce, in the last decade, a significant reduction in the death rates for hypertensive heart disease. These drugs also make it possible for many people who suffer from high blood pressure to return to work and a normal life. 6 There is no question that this gain would not have occurred without effective HEART DISEASE, CANCER AND STROKE research and its application. We have not yet achieved a similar decline in the death rate from atherosclero- sis. especially of the coronary arteries. Coronary heart disease remains the number one cause of death in the nation. But exciting beginnings have been made in this area also, and the prognosis for coronary patients is substantially Wier than it was a decade ago. Electrical devices known as cardiac pacemakers have been developed that can restore a normal rate in a diseased and slowed-down heart. Some of these pacemakers, implanted inside the chest, can maintain a normal heart rate for )'Cars; over 3,000 people who might otherwise be dead are now living with im. planted pacemakers. Arterial embolisms dreaded complication of acute heart attacks-is now greatly reduced in frequency thanks to anticoagulant drugs. Promising work is now underway with clot-d@olvin- dru-s for the treatment of thrombosis. In still another promising area, hard-won progress is being made in the c' ottiremely complex area of transplanting organs-including kidneys, lungs, livem and recently hearts-into man. Perhaps most dramatic of all, research efforts are now being directed toward the development of an artificial heart to replace a diseased heart. Experimental @ have already been tried in man, and an effective model is within the range of possibility by 1970 or even earlier. This challenge-as exciting as any *do" the entire range of science-is enormously complex. It requires the combined excellence of physicians, engineers, experts in the development of syn- dwic materials, and many others. But physicians and engineers alike agree that this is not a dream. The goal is feasible; the problems are not insuperable. Concerted effort on a large scale may weU produce one of the most dramatic breakthroughs in scientific history. Progress in understanding and controlling heart disease has far exceeded I)* fondest hopes of medical men a generation ago. But the challenges are many and formidable. Genuine control awaits further research discovery. @Nteanwhile, substantial reduction of the toU of heart disease awaits a major nationwide effort to apply what is already known. Ik-scripti,Dn CANCER Cancers are uncontrolled new growths which invade and destroy living tissue. They are made up largely of cancerous cells which differ from normal @ in many ways. Cancerous growth of the cells in various tissues occurs throughout the hMOi-tical world. Birds and many species of animals are afflicted with various t" of the disease. Its causes are not fully understood-although knowledge Of factors relating to -its development is growing rapidly. It is now clear that chemical, genetic, viral, environmental, and perhaps other factors cancer occurs in a variety of forms in many different organs of the 7 frequency of cancers in different sites varies relative to race, sex, HEART DISEASE, CANCER AND STROKE. phy, and other factors. It also varies dramatically with the occupation, geogra passage of time. Within a sin@le generation in the United States one form of cancer@arcinoma of the lung in men-has increased strikingly while another- stomach cancer in men-bas declined sharply. Cancer Deaths Cancer is the cause of 16 percent of all deaths in the United States. It is by a wide margin our second greatest killer. In 1962, 278,562 Americans died of cancer; in 1963, the number was 285,362; in 1964, the number will exceed 300,000. These figures stand in sharp contrast to the situation in 1900, when only 3.7 percent of all deaths were attributed to cancer and ivben the disease stood far down on the list of causes of mortality. DEATHS FROM CANCER ALASKA HAWA DEATHS PER REGION 8,175 16,470 18,845 23,743 25,470 32,412 36,866 59,336 64,045 The rise of cancer as a health menace can be charged in large part to the changing age composition of our population. Many more people are surviving the infectious diseases of youth and middle age only to succumb to the diseases of the more advanced years. Yet cancer, like heart disease, is by no means reserved for the aged. In 1963, HEART DISEASE, CANCER AND STROKE 45 percent of cancer deaths were in the age groups under 65. About 9 per- cent-representing 25,629 people-were under 45. And cancer is either the first or the second cause of death in children between I and 14 years. Acute leukemia is the single most common form of cancer in children. When cancer death rates are adjusted for the cbangin,, age composition of the population, it is still evident that cancer is an increasing threat. In 1900, the adjusted death rate was 79.6 per 100,000 people; in 1963, the comparable rate was 126.6. Since 1933 there have been substantial changes in the cancer death rates for men and women. For men, from 1933 to 1963, the cancer death rate has risen from 104.6 to 147.1 per 100,000. For women, it has declined during the same period from 125.9 to 109.8. Thus cancer, which 30 years ago was more of a menace to women than men, has now reversed itself. Cancer of the lung now accounts for 24 percent of all cancer deaths in males, with a total of 36,895 deaths in 1963. Other leading cancer sites in males are the prostate (15,446 deaths), colon (13,932), stomach (11,896) and pancreas (8,944). For women, the leading sites are breast (25,139 deaths), colon (16,684), uterus (14,147), ovary (8,404) and stomach (7,4,04). Thirty years ago, in males, stomach cancer accounted for 27 percent of all cancer deaths and lung cancer for only about 4 perceilt. In females, cancer of the uterus and of the stomach were the two leading sites- in terms of death rates-30 years ago, accounting for 22 and 16 percent of all cancer deaths respectively. Illness and Disability it is estimated that about 830,000 people in the United States will be under treatment for cancer in 1964. This figure includes an estimated 540,000 new cases diagnosed for the first time. On the basis of current trends, about one out of every four people alive in the United States today can be expected to develop cancer at some time during his or her lifetime. Thus, unless cancer illness rates are cut, about 4.8,000,000 people now living will become cancer sufferers. Moreover, about 32 million Americans now alive will die from cancer unless new preventive measures, treatments or curative procedures are developed and widely used, Economic Impact The economic toll associated with cancer also costs billions of dollars annually. Direct costs for diagnosis, treatment, and care of cancer patients amounted to $1.2 billion in 1962. More than half of the direct costs is for hospital care. Approximately 950,000 patients with a primary diagnosis of cancer spent more than 14 million days in short-term hospitals, accounting for 8 percent of the total days of care in the-nation's short-term hospitals. The cost of the services of pby sicians in private practice for cancer patients is $172 million. As in heart disease, these direct costs are only a part of the total economic 9 impact of the disease. HEART DISEASE, CANCER AND STROKE. A total of 54 million work days was lost in 1962 as a result of illness and dis- ability for members of the labor forces, housewives, and others who were unable to attend their usual activities. These days lost are equivalent to 221,000 man years of productivity, or $1 billion in terms of 1962 dollars. Forty-three percent of the persons who died from cancer in 1962 were in their most productive years (25-64). This loss to the economy amounted to more than 100,000 man years, or $430 million. And as in heart disease, the nation is still paying in lost out ut for the people p iybo died prematurely from cancer in previous years. There were 7.6 million such deaths during the period 1900-1961. Of this total 2.2 million persons would have survived to 1962 and worked or kept house if this major cause of death had been eliminated. This loss in output amounted to $8.5 billion in terms of 1962 dollars. To compare the losses due to cancer to the gross national product, the value of output imputed to housewives must again be excluded. The sum of direct costs, Plus losses of output by members of the labor force, amounted to $8 billion, or 1.4 percent of GNP in 1962. Progress and Prospect Today about one cancer patient in three is being saved. A few years ago the ratio was about one in four. This represents a gain in lives of about 45,000 men and women each year. LIVES SAVED FROM CANCER 1 2 3 4 BEFORE TODAY 2 3 GAIN IN LIVES OF 45,000 MEN AND WOMEN Using knowledge now available, this gain can be substantially extended. Just by applying widely what we know, we could now save half of the people who contract cancer: Uterine cancer can be detected at an early and generally curable stage by using 10 a simple, well-establisbed technique; unfortunately, relatively few women seek HEART DISEASE,CANCER AND STROKE and obtain this examination in time. New developments in the early detection of breast cancer hold forth the promise of similar reductions in deaths from this forrii of cancer. Physical examinations using modern diagnostic techniques often lead to early recognition and successful treatment of cancer in many sites. Lung cancer can be sharply reduced by reducing cigarette smoking. Meanwhile medical research is openin@ up new pathways to diagnosis and cure. The search for cancer-controlling drugs has already produced several which have cured cancers in animals. The National Cancer Chemotherapy Program has resulted in the formulation of 165,000 new drugs. These have been tested for possible effect on animal cancers and approximately 100 have been tried in human cancer. About 20 of these drugs have resulted in at least ieniportlry benefit to human cancer patients with marked increase in sur- vival and limiting of disability in patients with lymphoma includin, Hod-,kin's disease, multiple myeloma, chorioepithelioma, melanoma, and certain tumors in children . Radiation treatment and surgery are being improved and refined to minimize side effects and maximize benefit. Since World War II, nuclear medicine and radioactive isotopes have played a vital role in cancer diagnosis and treatment. Detection has been enhanced in cancer of the thyroid, brain, liver, stomach. Specific radioactive isotopes have been used in therapy of can cer of the prostate, thyroid, and bone marrow. The use of Cobalt 60, cesium, linear accelerators, betatrons, electron beam genera- tors and other sources of supervoltage X-ray and gamma ray beams have made possible high energy (megavoltage) therapy in the average metropolitan area. Here, the deterring factor is lack of manpower trained in the use of these methods. With properly trained radiation therapists available, improvement in most of the cure rates would be immediately possible for those patients with lesions suitable for such treatment. In the quest for caticer's cause, biological research is producing important new understanding of the structure and functions of the cell, genetic controls, and the phenomena of resistance or immunity to disease-each of which may have great significance in cancer control. Recent research in virology has shown that the leukemias of several species of animals, which are closely related to human leukemias, are definitely viral in origin. If leukemia in@an proves to be initiated by viruses, preventive vaccines might well be in prospect. Cancer, the number two killer of the Arverican people, is a stubborn and mysterious enemy. But we can make substantial reductions in its toll now, by applyin g broadly what we know. The future is bright with promise of new scientific discoveries and their development to further useful applications. STROKE Description The brain, because of its high energy requirement, demands over one-fifth of all the blood pumped from the heart. If circulation to the brain fails due to disease of the blood vessels, a stroke results. Strokes are often fatal. For those HEART DISEASE, CANCER AND STROKE w ho survive there may be disastrous impairments such as paralysis, loss of speech, and many others. In general, strokes can be divided into three main types: (1) those due to occlusion by thrombosis or clotting of the diseased vessel; (2) those due to occlusion by a fragment of a clot which becomes dislodged from the heart or vessels of the neck and plugs the cerebral vessels; and (3) rupture of a cerebral vessel due to high blood pressure or fault of the sel wall (aneurysm) with hemorrhage into the brain. ves The first two account for the vast majority of cases, Deaths from Stroke As we have previously indicated, strokes account for about one-fifth of the deaths within the broad category of cardiovascular-renal disease. In 1963, al;out 201,000 Americans died of strokes. Thus, if stroke is con- sidered separately, it ranks third as a cause of death in the United States. Its death toll is not far behind that of -cancer,. and more than double that of the fourth-ranking cause, accidents. To a greater extent than heart disease and cancer, stroke is a disease of the aged. About 80'percent (162,755) of the 201,166 stroke deaths occurred in people aged 65 and over. The largest single number (73,388) occurred in the 75-84 age group. However, stroke claimed 38,411 victims under 65-a total that seems small in proportion but is numerically large enough to rank stroke as the No. 5 killer of people in their most productive years, outranked only by heart disease, cancer, accidents, and suicider,. Unlike heart disease and cancer, stroke claims more female than male victims in the United States (106,927 to 94,239). Nonwhite females have the highest death rate from stroke by a substantial margin, but the death rate for white fe- ales is lower than that for nonwhite males. There is a definite pattern of geo- m graphic variation in the United States-the highest stroke death rates occur in the Southeastern States, and the lowest in the Southwestern and Mountain regions. Illness and Disability At least 2 million people now alive in the United Statesbave suffered a stroke. About 8 of every 10 stroke victims survive the acute initial phase of the disease. Most of them live for some years thereafter-usually in a seriously disabled condition. The existence of these hundreds of thousands of surviving stroke victims is a deeply distressing fact of American life. It is made more distressing by the fact that most of it could have been obviated by the timely application of preventive or rehabilitative treatment. The economic burden imposed upon their families and their communities can be estimated. The loss of dignity and the accumulated misery is beyond calculation. Economic Impact Direct expenditures for services and supplies for diagnosis, treatment, and 12 rehabilitation of stroke victims total $440 million per year according to conserva- HEART DISEASE, CANCER AND STROKE tive estimates. DEATHS FROM STROKE DEATHS PER REGION m m m m m 5,731 12,074 16,617 18,599 20,817 21,647 30,057 34,570 41,054 There were 283,000 patients with a primary diagnosis of stroke discharged from the nation's short-term hospitals in 1962. Stroke victims constitute 16 percent of the patients in skilled nursing homes. Although 80 percent of the stroke deaths occurred in people aged 65 and over, the losses in output resulting from disability and premature death are equivalent to 179 million man-hours, or approximately $700 million in 1962 dollars. This, of course, does not take into account losses in output for those who would have survived to 1962 if stroke had been eliminated as a cause of death. Excludin@ these losses from previous years' deaths, the economic costs of strokes to the nation in 1962 is approximately $1.1 billion. Progress and Prospect Stroke has been for many years a tragically neglected disease. The health professions have shown little interest in it; the public has accepted it with resignation. At the root of this neglect are several misconceptions. The most important of these has been the assumption that stroke is simply "a way of dying" after the body has survived all the other ravages of time-as inevitable as death itself. 13 Another has been the oft-quoted half-truth that stroke is "a later life edition of HEART DISEASE, CANCER AND STROKE coronary heart disease'!-a statement now open to more than reasonable doubt. The facts are quite otherwise. Stroke is proving to be neither inevitable nor irremediable. Slowly mountin- interest over the past decade has revealed genuine hope for stroke victims, both present and future. First, many strokes can he foreseen. Three out of four patients with occlusive stroke have symptoms that forewarn of a disabling attack. Some of these warning signs are brief attacks of loss of speech, weakness of limbs, staggering, or loss of consciousness. Clearly, any of these signals may be caused by a variety of other conditions. But a physician, not the patient himself, should make the determination. This determination can be a lifesaver. About three out of four patients with symptoms of stroke experience a discernible narrowing of the blood vessels supplying the brain. This condition can often be corrected by modern surgical techniques. The precise indications for surgical and medical treatment need to be better defined, but the prospect is excellent. Second, intensive modern rehabilitative care can restore as many as 80 percent of stroke survivors to relatively active and productive living. A well-defined and tested program of medical rehabilitation has been developed which, if started early enough and carried through, can make the difference be- tween total dependency and self-sufficiency. A few such programs are underway, but they are reaching pathetically few of the thousands who can benefit from them. Third, promising new avenues for research are opening up in stroke pre- vention and treatment. Among these are epidemiologic studies to define patterns of distribution of stroke; alteration of blood-,clotting mechanisms; control of fat metabolism and hypertension; blood vessel surgery; new drugs to improve circulation to the brain; and experimentation with high pressure oxygen chambers. Stroke claims 200,000 American lives a year. It incapacitates many hun- dreds of thousands. The financial, as well as the human, cost of stroke weighs mmunity, and taxpayers everywhere. It heavily on the patient, his family, his co is imperative that this disease be brought into the mainstream of medical and scientific attention, to develop new knowledge and to apply widely what is alrpadv known. 14 -HEART DISEASE, CANCER AND STROKE PART hapter Two A pH NATIONAL RESOURCES AND NATIONAL NEEDS America need no longer tolerate several hundred thousand unnecessary ,Wthi,tach ),ear from heart disease, cancer and stroke. lly tiringin,ff to all the people the full benefit of what is now known of preven- " tiewtioil, treatment, and cure, we could save, each year, a number of at" equal to the population of a maj or city. nis is the measure of our capability today. As scientific knowledge advances, @frow's romiscisbrighterstill. p Thus the keynote is hope, based on hard scientific fact. TN fact that the death toll can be strikingly reduced is easily documented. To citos few specific examples: t,'otii a few years aao, victims of certain congenital heart defects were ahngst #4" to die in infancy. The few who survived the first year of life lived at most olowthortyearsinaconditionofhelplessness. Today,normal,healthychildren 6" #?owing up toward productive adulthood who would have been hopelessly leforepresentcorrectiveproceduresweredeveloped. IWH very recently, 9 out of every 10 persons who developed the disease its aneurysm were dead within 5 years after the condition was diagnosed. 7 out of 10 who receive the benefit of new surgical procedures are alive wdi at the end of five years. IT'*H the development of the Papanicolaou smear test, cancer of the cervix rarely be diagnosed until too late for successful treatment. Today, there percent survival and cure for those who receive early diagnosis C.Xamples-among many-of the dividends paid by medical research. they also furnish examples of failure to deliver to the people the rch. For babies still die of congenital defects, and patients still ; 14,000 women still die each year of uterine cancer-not be- U-st, but because they have not been reached by scientific medicine. he promise of modern medicine has been unfulfilled. w, to transform hope into reality, is a national decision to invest a O I its vast wealth in the preservation of human life, and to develop new u of Partnership between its public and private resources for health. challenge before the President's Commission has been to determine dimensions of this new partnership. ined the nation's resources-actual and potential-for con- jor offensive against heart disease, cancer and stroke, and have which must be filled and obstacles which must be overcome if that t i6 to be successful. cancer and stroke are by no means the only health problems con- people. The doctors, nurses and others who care for 1 5 these diseases are drawn from the nation's total manpower HEART DISEASE, CANCER AND STROKE pool for medical care. The scientists who investigate research problems related to these diseases are part of the total manpower supply for biomedical research. Thus, in assessing the nation's resources for acquiring more knowledge and making full use of existing knowledge about heart disease, cancer and stroke, we must be concerned with broad national resources for medical service and medical research. RESOURCES FOR HEALTH SERVICE The prevention and control of heart disease, cancer and stroke-the saving of human lives-begins not with the doctor, the hospital or the medical center, but with the individual himself. Be decides to go for a check-up-either before symptoms appear, or at the earliest sign of trouble. Or he decides not to. The decision-often made casually, or not consciously made at all-may add or subtract a decade from his life. Many factors influence his conscious or unconscious decision. One is the state of his knowledge about health matters. Another is his financial condition. An important third is the convenience and accessibility of medical services in his community. Once he enters the medical orbit, his fate is again subject to many whims of chance. If he is wise enough to make his appointment soon enough, and if the physician he chooses is trained and equipped to detect an incipiently dangerous condition and make the proper referral, and if his community is blessed with the special skills and facilities his condition requires, and if he is able and willing to follow through the prescribed course of treatment--in this happy conjunction of circumstances his life will be prolonged, his function unimpaired or restored. Breakage of any link in this chain can nullify the strength of the others. Thus, the delivery of the great potential of modern medicine depends upon many factors. It depends upon an adequate supply of highly skilled manpower.' The physician is the most critical sin-le resource-there must be enough doctors in the community, and their medical knowledge must be Vp to date. Morsover, they must be supported by a wide range of Nvell-trained assistants. It depends upon a variety of health care facilities and services@on- veniently accessible and staffed and equipped to meet the patient's needs. It requires an alert, well-informed citizenry, motivated to take early and decisive action in behalf of their own health and financially able to meet e costs of care. Manpower for Health Service The first hard fact to be faced is that there is not enough health manpower to meet the needs of the American people. There are not enough doctors and not enough supporting people. In broad terms, 3 to 4 million persons are involved in the many aspects of health services through employment in dozens of different occupations and 16 careers. A full-scale attack on heart disease, cancer and stroke will require HEART DISEASE,CANCER AND STROKE expansion of the entire work force in health services. The physician supply is beyond question the most critical single element in manpower for medical service. The physician calls the shots in every individual case. And the national toll of death and disability is only the sum of individual cases. The number of physicians in the United States has approximately doubled lation of the country has increased two and one-half since 1900, while the popu times. In the decade 1950-1960, the physician supply barely kept pace with population growth. Thus, the overall ratio of physicians to population is about the same as it was ten years ago, and slightly lower than at the turn of the century. Meanwhile drastic changes have taken place in the practice of medicine. With the forward sweep of scientific knowledge has come the necessity for specialization. In 1930, only one doctor in six was a specialist. By 1950, the proportion had grown to 36 percent. Today, 61 percent of all physicians in practice consider themselves specialists, and seven out of ten graduating physicians are under- taking specialized training. Specialization has brought great benefits. But these have not been achieved without cost. The number of physicians having "first contact" with patients as personal or family doctors has fallen sharply. How many physicians are needed to serve our future health needs? The most conservative estimate projects a need for 346,000 physicians by 1975. This number is required merely to hold our own in the race against population growth. It fails to take into account increasing demands and expenditures for health service per capita. It fails to provide for any greater effort to deliver the best in modern medicine tothosewhoneedit. Itisastalusquofi-ure. Yet conservative as it is, our current prospects are for meeting that number only through extensive importation of foreign-trained physicians. Currently our hospitals are heavily dependent upon foreign nationals servino, as interns and residents. Clearly the United States should not be a debtor nation in terms of medical manpower. Yet such is the case today. About 7,700 physicians @raduated from the nation's 87 medical and 5 osteopathic schools in 1964. We must be able to graduate an additional 1,000 per year, starting now, to keep pace with popula- tion growth. Present trends, includin@ the 12 to 15 new medical schools in various sta@es of development plus anticipated expansions of existing schools, will yield approximately 9,000 per year by 1975 and fewer than that in the intervening years. The Health Professions Educational Assistance Act, enacted by the Congress in 1963 and funded in 1964, is a step in the right direction., It enables the Public Health Service, for the first time, to provide substantial financial assistance in the construction of new medical schools and the expansion of existin" schools. El But it falls far short of the all-out national effort needed to meet a critical 17 national problem-the shorta,,e of physicians. HEART DISEASE, CANCER AND STROKE t) In the Commission's judgment, a major national effort is required, on a scale never before attempted. to recruit and educate physicians to serve the health needs of the nation. Existing schools must be expanded to full capacity and ne%v schools must be built. Talented young people from every stratum of our society must be attracted to the medical profession in greater numbers. We have great resources to draw upon. In the United States only I medical student in 10 is a ivonian, as compared with 1in 4 in Great Britain and 3 in 4 in the Soviet Union. In the United States- because of the length and excessive cost of medical trainina, a -reat proportion of medical students are drawn from upper-class families-49 percent from fam- ilies with incomes of 810,000 or more per year. Scholarship pro,@)rams-com- parable to those which attract young people to other scientific fields-could greatly broaden our pool of potential physicians for the future. Moreover, the national supply of physicians is by no means the only limiting factor in manpower for the control of heart disease, cancer and stroke. For : the use of the Papanicolaou smear test for detectin@ cancer of the uteruF example r_ can be no more ividespread than the availability of technicians capable of per- forming cytological procedures; the number of laboratory personnel trained in identification of the streptococcal organism which leads to rheumatic fever is ar important factor in the control of rheumatic heart disease; rehabilitation oi stroke patients depends upon an adequate supply of therapists and nurses skil in up-to-date techniques. One of the ironies of our time is the existence of manpower shortages across the entire range of health occupations in a time characterized by manpower surpluses. Finding productive work for the young, the retired, the handicapped, the tech nolo@ically displaced worker is a major challenge of the day. Yet the health disciplines exist as an island of scarcity in a sea of plenty. Each of these groups, whose idleness is a personal and national crisis, is ai- untapped reservoir for health service. To take advanta@e of it, the health profes sions must reexamine and restructure their patterns of work. They must experi ment boldly with new kinds of teamwork between bighl@ skilled and lesser skille( workers, and then work closely with the educational forces of the nation to desig'T training programs to attract and prepare whole new groups of people for servic( to health. Facilities for Health Services A century ago a hospital was a final port of call, a place in which to die People passed its portals with averted eyes. Today's hospital represents a citadel of hopes-some true, some false. It i@ looked upon as a place where daily miracles are performed. In many hospitals the miraculous has become almost routine. But in others, standards of"care ar@ far below what they should be. The years since World War 11 have witnessed a genuine revolution in hospitq 18 care in the United States. Thanks in large measure to the Hospital and Medica i4EART DISEASE,CANCER AND S TROKE Facilities Construction (Hill-Burton) Program of the Public Health Service, th map of the nation's medical facilities has been redrawn. Hill-Burton funds have helped to build more than 7,000 hospitals and other centers for medical service. They have added more than 300,000 hospital beds and over 2,000 other facilities to America's health resources. This has been achieved at a total cost of $6.8 billion. of ivhich slightly less than one-third came from the Federal Government-the remainder coming from local sources. But weak points remain in our hospital armament. There are serious shortages of beds serving many fa-zt-aroiving suburban areas. The older hospitals in the central cities of metropolitan areas are urgently in need of replacement or modernization. These large and once great metropolitan hospitals, many of them associated Nvith universities, should be the centers of excellence, the foundation stones of our entire system of delivering the best in medical care. Instead they have been allowed to deteriorate physically. Many are poorly located in terms of the changing population patterns of the city. In addition t ere is a serious shortage of facilities for the care of chronically ill patients. Today, many beds in general hospitals, equipped to provide maximum service, are being occupied by patients with long-term illness who could be better served, at a fraction of the cost in both monev and professional time, in facilities specially designed to meet their needs. State hospital construction authorities report that a national total of 530,000 additional long-term beds-in chronic disease hospitals and nursing homes-are needed to meet the present demand. With a rapidly expanding aged population, the long-term care require- ments are sure to increase rapidly. Communications for Heal th Service The forward sweep of medical science has brought about a kind of "instant obsolescence" in medical knowledge. Most of the physicians practicing today received their medical education in the 1930's and 1940's. The fact that they are practicing two or three decades later would have been unimportant in earlier, quieter centuries. Today, it poses a critical obstacle to the delivery of up-to-date health care. Therefore, a systematic nationwide program of continuing education for physicians is a categorical imperative of contemporary medicine. Without a large-scale, effective effort, the worlds of science and practice will spiral still further apart. The gap between what is kno%%7n and what is received by patients will be harder and harder to bridge. The imaginative use of new communications media offers the best hope for necessary breakthroughs in continuing education. Closed circuit television, beamed from a medical center into community hospitals at regularly scheduled hours, is one type of experiment that has been carried out successfully in recent years. Open circuit television is suitable for most medical transmission and has been tried durin@ late evening and early morning hours. New types of projectors are becoming available which enable 1 9 the physician to rent and study films in his own office. HEART DISEASE, CANCER AND STROKE All of these approaches are being tested on a small scale in various place around the nation, under a variety of sponsorships. In the Commission's vieik what is needed is a @reatly accelerated and concentrated push for continuing edu cation, with sufficient resources of funds and talent to make a genuine impact. But neither open circuit nor closed circuit television can reach closed circui minds. Alert and informed patients can generate a demand for new knonvled-, where all other motivations fail. This is one of the compelling reasons-th@ other, as we have seen, being the fact that the patient must take the first steps t( save his own life-for greatly increased emphasis on informing the public. The public has an almost insatiable thirst for health information. Yet th public remains remarkably uninformed, or remarkably slow to act, on man- matters which are quite literally "of life and death." Part of the problem mal stem from the sheer profusion of frequently half-true or half-hearted informa tion, reaching the public. The blame for these shortcomings rests not primarily with the mass medi: but with the health professions themselves. Science writing has become a highl developed skill; yet rarely are science writers invited behind the scenes an, truly educated so that they may do an interpretive job. Funds and imagination are rarely made available to apply the awesome power of television and radi to a specific health problem requiring specific public action. At the Federal level, the public information function has traditionally beei viewed darkly. Fears of "self-aggrandizement" and "propaganda" have cause, agencies-notably in the health field-to bury or disguise their appropriation for informing the public. This-in the health field-is both ironic and tra-,ic The Commission believes strongly that public information is a primary healt'i tool; that the Public Health Service has a duty-a major duty-to delive authoritative health information to the people of the United States; that thi function can in fact save many lives in the field of heart disease, cancer an( stroke alone; and that it should he openly recognized and supported on a sea], commensurate with its importance. Coordinated Effort for Health Service Throughout this discussion of resources for medical service, especially a@ related to problems of heart disease, cancer and stroke, we have faced the fac that resources for health are in short supply and that there is no simple, over night solution. Resources for the delivery of medical 'service, community b) community, will never be all that they should be in terms of adequate manpower facilities, and supporting services. Therefore there is an overriding need for coordination of effort. We canno afford duplication of facilities, waste of rare skills on commonplace tasks. The recommendations of the President's Commission dealing with the deliver, of health services to reduce the impact of heart disease, cancer and stroke ar( designed to achieve two goals: to strengthen the nation's health resources botl 20 numerically and qualitatively, and to make the best use of resources we no%, CER AND STROKE have. HEART DISEASE, CAN RESOURCES FOR RESEARCH We are living in a time of brilliant progress and still more brilliant promise in the health sciences. . le matter. The biolo@ist confrontiii- a But biomedical research is not a simp c 0 bacterium is dealin@ with a system immeasurably more complex than is the astronomer confronting a star. When the biologist undertakes the study of a certain man afflicted with a certain disease in a certain environment. the sub- tleties and complexities multiply to%vard infinity. Biomedical science cannot promise that it will understand heart disease and cancer tomorrow. It cannot swear that its @rowing but limited understanding will lead inevitably to means of prevention and cure. But it can point proudly sses. and hopefull), to existin@ clues and leads. to past and present succe 0 But ivithout a major continuing research effort there is no hope of advance, c tion, no cure of those conditions currently beyond our @rasp. Arid no preven I to the extent that the quest is successful. the benefit to humanity, %vhaten,er the cost, will be cheap indeed. The Nature of Research Scientists use the word research to describe a process whereby questions are asked of nature and answers are systematically obtained; the object is the en- richment of man's knowledge; the driving forc e behind it is the curiosity of the investigator. In the biomedical sciences, we are dealing with a spectrum of investigation, ran-in- from fundamental inquiry into the nature of living cells, at the "research Z) 0 extreme, "to clinical care of patients at the "developmental extreme." Inter- mediate steps include laboratory investigation of disease, clinical and epidemio- logical investigation of disease in man, experimentation with drugs and proce- dures, and clinical trials. No band of color in this spectrum is any more "pure" or more "basic" to the solution of disease problems than any other. All are essential, and they are mutually reinforcing, Where in this spectrum of activity are the limiting barriers to proaress against heart disease, cancer and stroke? In the jud-ment of the Commission, they appear to lie chiefly at the ends of z' the spectrum. On the one hand, there is ur@ent need of more fundamental ZD knowled-e of biological processes-the structure and function of organisms, and C) In the nature of disease. On the other. there is a serious la@ in the widespread dissemination throughout medical practice of advances already clinically tested and proved in the great medical centers. The Commission feels stron@ly that pro@ress in understaxidin-, and control of C, tD c) heart disease, cancer and stroke depends to a considerable de-ree on new fuiida- El mental knowledge of the structure and function of livino, organisms in health and C, ZD disease. It urges that every effort be made to support and quicken the pace of 21 research addressed to these problems. HEART DISEASE, CANCER AND STROKE The Conduct and Support of Health Research Medical research today requires specially trained people in specially designed environments. The national pool of qualified investigators and of institutions trictly limited. equipped to undertake significant research programs is s The basic unit of medical research today is a small team, comprising an experi- enced investigator and his immediate associates. Their most frequent habitat is the medical school or graduate school of one of our great universities. A lesser number thrive in a few research-oriented hospitals and research institutes. Thousands of research projects are currently underway. Almost all of them are built around the research team-larger or smaller depending on the scope of the project. Their costs range from $5,000 to $500,000 with perhaps 90 percent of them costing between $15,000 and $100,000 per year. The total annual cost of these thousands of research projects plus the sup- porting services which maintain them has reached approximately $1 billion in the United States. This represents a spectacular expansion in less than two decades; and with rapid expansion has come awkward and patchwork organization. Yet the system works. As we have seen, it has produced remarkable -ains in knowled-,e, many of which have been translated directly into lon@er lives and freedom from pain. The costs of rpedical research are paid from a great variety of sources: university endowments, individual and corporate gifts, foundations, public and voluntary a@encies, State legislatures, and the Federal Government. The Federal share now represents somewhat more than one-half of the total funds spent for medical research. The U.S. Public Health Service, through its National Institutes of Health, is the world's primary supporting agency for medical research. The basic building block of medical research support is the grant-in-aid awarded to an investigator to carry out a specified roject. The process begins p with the submission of a grant application containing a research plan. This is by scientists knowledgeable in the investi@ator's chosen area of study. reviewed C) if it is approved, the investigator is awarded funds to pursue his line of res@earch. This-system has a number of built-in advantages. It permits large-scale use of Federal funds without Federal control. It keeps the initiative with the individual scientist. The investi-ator's plan is judged by a jury capable of rendering competent scientific judgment. The system also has some disadvantages. The support is unstable, year by year; this fact not only creates apprehension on the part of the investigating team, but also tempts the scientist to select the problem promising quick return rather than the long-range project. From the standpoint of the university, the burden of establishing and,main- taining a substantial research enterprise within which scientists may pursue their separate goals is a heavy one-too heavy for most schools already overburdened ith soaring costs related to their teaching programs. 22 For the granting agency-be it governmental or privat@tbe proliferation HEART DISEASE, CANCER AND STROKE of individual grants creates tremendous administrative problems. For the I)OO], the review process is costly in precious time. ert,Tlit-iital mechanisms for support have been developed to fill in tlw r@eircil project grant procedure. Federal funds are available to aid ri., research.facilities, to help support training pro-rams for research ill a relatively few instances, to give support in breadth and t@ Ali it)@tittitioti's research program as a whole. Each of these programs purpose, an(] helps to keep the basic system going. [i) tli,, rc@arch pro,rai-ns of universities and medical schoc)lq, there research institutes dedicated to research on a specific a4 lt,@,,trt disease or cancer. Here, research is more directln- pro- ,in institute are individual scientists ivorkin,, for example, C) uLst -tifg,@rN ; others ivorking on testing drugs which may IoN%-er blood it@ ex.Aittlttiii-, the muscular tissue of the heart, and the like. tenfctx )( rt--.,earch excellence, spearheads of an all-out attack on heart #Start all(] ,itroke, are few in number today. A major recoinmenda- o has to do with the creation of more. lw rt-iiic!iiil)ered that the Commission's endorsement of the center i A not ilill)])' lack of faith in the basic system of individual Lrants. itirlits are complementary. Their products are mutually reinforcing far kesearrh sit@tl) slionvs that about 39,700 professional health workers were en- ttw*ii@Al iiii(i health related research in 1960. This (@orps forms the *h@,h(uturt@iiianpoiverresourcesmustbebuilt. I)ii.@in(, its estimate on projections as to the total medical twtit anticipated in 1970, projects the nation's need for medical %vr ill tile level of 77,000 professional ivorkers at the end of this tl,)ulilt, the 1960 figure. There will, of course, be some normal (4nk% of the present research manpower pool. Taking this into @.@X) professional Nvorkers, fully qualified to enga,,e in medical lwsttltttit investigators, must he recruited and trained by 1970. importer that about one-half of the Ph. 1).'s and two-thirds of the @ile(i addition of 4.5,000 will have to come from the pr @nt 1)@", if the need is to be met. This assui-npt on as ea@,y t.)Ilier nianponver requirements-includint-) those for medical ites of Health of the Public Health Service is the largest ining for medical research manpower. NIH spent about year 1964 for research trainin--a 20-fold iticrea-@ in a The largest share of this expenditure (40 percent) is for I health field. heart Institute support of trainin- totaled $16 million; that of Institute, @@10 million. More than 90 percent of the total 23 is spent for graduate trainin-. HEART DISEASE, CANCER AND STROKE Facilities for Research In addition to its exacting demands for highly skilled manpower, modern health research requires a great number and diversity of special facilities and supportin- resources. At one extreme-the extreme nearest the patient-is the clinical research facil- ity where medical care of human patients is carried on in a research environment. with special laboratories, kitchens, and the like adjoining or directly related to the patient's quarters. Their common purpose is to combine therapy with research: to provide patients with the best in modern care while at the same time studyin@ in minute detail the results of the care provided. At the opposite extreme, in the realm of basic science, is the biomedical research institute which works with highly sophisticated equipment to elucidate the basic properties of the living cell or the chemical synthesis of a hormone. Between these extremes there are many intermediate types of facilities. Therc also exist certain research institutes which corftbine clinical and basic biomedical investigation. And in addition, contemporary research requires supporting re sources, such as highly specialized research units, animal facilities, and manN others. Since 1956 the National Institutes of Health have been supporting the con- struction of health research facilities through a construction grant program. In eight years, 1,129 grants totaling $270 million have been awarded to medical schools, universities, hospitals, and other agencies as the Federal share of research facilities construction whose total value is four times as great. This proaram continues to make a vital contribution, but the need for facili. ties is still outrunning the supply. Communications for Research The information explosion in biomedical science has created a massive com- munications problem. The enormous volume of new knowledge generated and reported each year has overflowed all the normal channels. The traditional main artery of research communications is the scientific journal. Some 1,500 journals related to biomedical science are presently pub- lished in the United States. Another 4,500 are published elsewhere in the world, in many languages. The core resource for managing materials in the biomedical sciences is the medi- cal library system. At the heart of this system is the National Library of Medicine, now a part of the Public Health Service. The NLM publishes Index Medicus, a giant monthly bibliography of medical periodical literature. It operates interlibrary loan services and offers photoduplication of source materials. Its operations have been greatly strengthened in the past year with the activation, in December 1963, of the computer-based Medical Literature Analysis and Retrieval@Systern (MEDLARS)-the largest such information storage and retrieval system yet devised for a published literature. Monthly publication of the Index Medicus 24 occupies only a small portion of MEDLARS capacity. Potentially, it can also HEART DISEASE,CANCER AND STROKE handle 150 recurring specialized bibliographies plus as many as 37,500 individual inquiries for bibliographic search in a given year. The rapid advance of electronic storage and retrieval systems is the brightest ray of hope in the otherwise cloudy picture of communications for research. But electronics cannot solve the problem alone. The present state of most medical libraries in the United States is lamentable- largely because libraries have not received their due share of the greatly increased attention and fundin-, for research. The existing 87 medical school libraries,--which should be the cream of the crop-have collections which fall, in total, 4 million volumes short of a desirable level. They are cramped for space and deficient in manpower. The Commission feels strongly that unless major attention is directed to im- provement of our national medical library base, the continued and accelerated generation of scientific knowledge will become increasingly an exercise in futility. 25 HEART DISEASE, CANCER AND STROKE PART 11 A NATIONAL PROGRAM FOR A NATIONAL GOAL ources for health service and medical ent of the natiOn'S TeS Our assessm research has accentuated needs and shortcoming@for it is these which must be remedied Iif we are to move toward the conquest of heart diseases, cancer and stroke. ine, and the obstacles to progress are formidable. But These needs are genu we can count on many strengths as well. For the delivery of health services we have a strong and dedicated group of physicians, dentists, nurses, and their many professional and technical allies. working in private offices and community hospitals across the nation. Their work, in turn, is supplemented and supported by other agencies and groups. artments of cities, counties and States are rendering a 'Me public health dep growing'number of services to those who suffer from heart disease, cancer and stroke. The great national voluntary agencies-such as the American Heart Associa- tion and the American Cancer Society-perform many services through their local chapters and affiliates and contribute significantly to research'. Indeed, the high level of health now enjoyed by most of the American people has been built by a powerful alliance of public, private and voluntary effort. Yet we as a nation can and must aspire to still higher levels of health To attain them-specifically to control the ravages of heart disease, cancer, an( stroke-we must strengthen our alliance for health in a number of ways. The toll of death and disability caused by heart disease, cancer and strok( is a national problem-a national disaster. Such a challenge demands f national response. It is the conviction of the President's Commission that our government ha,, a profound responsibility, which it is not yet fully discharging, for leadership. stimulation, and support in the protection of the health of the American people The national program envisioned in the detailed recommendations whicl follow is designed to provide the needed stimulation and support without violat ing the basic conditions and freedoms of our existing health partnership. More specifically, our recommendations are based upon the following principles: (1) That the Federal Government shares in the responsibility for assurini that persons suffering from or threatened by heart disease, cancer ant stroke have ready access to the benefits of the best in medical service baser upon the products of scientific research; (2) That the Federal Government has a major responsibility for strengthen 26 ing and broadening the support a/ reseqrch which will generate net, HEART DISEASE, CANCER AND STROKE knowledge essential to the control of heart disease, cancer and stroke (3) That the Federal Government has a major responsibility for direct and diversified support of medical education and other programs desianed to produce the health manpower upon which the control of heart disease, cancer and stroke depends. It is our Conviction that the stronger national role involved in the Commis- sion's recommendations in all three of these area@ervice, research, and teach- in@will enhance and make more productive the efforts of all members of the health partnership. Each public and private resource is indispensable to the achievement of better health for the American people. Finally, and underlying the other principles, we believe: That the nation can well afford and the people will enthusiastically support sub- sta@lly increased expenditures inten4ded to save lives today and produce more lifesaving knowledge for tomorrow. The nation's resources are enormous and rapidly growing. Our Gross Na- tional Product passed $500 billion in 1960 and is spiraling upward toward $1 trillion. 'the projected annual increase in national productivity for the years immediately ahead is about $30 billion. Of this increase, the Federal Government will receive, an annual increment of some $5 to 96 billion per year. Against this gigantic backdrop, expenditures for health cast a small shadow. Disease costs the American people $35 billion per year, but we are investing only about $1 billion of our national funds in medical research. The national program recommended by the Commission calls for a greater investment in the health of the American people than has thus far been made. Every commitment of resources for a given purpose requires decision. It requires assignment of priority. What price, what priority, human life9 (IN BILLIONS) 554.9 1962 500 300 200 100 42.8 0.24 0 GROSS ECONOMIC RESEARCH NATIONAL COSTS COSTS PRODUCT 27 FOR HEART DISEASE, CANCER HEART DISEASE, CANCER AND STROKE AND STROKE PART I hapter Three A NATIONAL NETWORK FOR PATIENT CARE, RESEARCH AND TEACHING IK HEART DISEASE, CANCER AND STROKE The first set of recommendations of the President's Commission would creat@ a national network for patient care, research, and teaching in heart diseasf cancer and stroke. This program is designed to bring together the best in medical care and th best in medical research, region by region across the nation. It would result ir two major benefits: (1) The saving of many human lives and the prevention of widespread dis ability, by making the best in modern medical care readily accessible t( people suffering from or threatened by heart disease, cancer and strok( in their own communities and regions; (2) The rapid development of new knowledge about heart disease, cancer and stroke, by creating a greatly increased number of top-quality centers for the clinical and laboratory investigation of these diseases strategicaUN distributed throughout the country. In addition to these two major thrusts, which strike at the two most critics-- needs in the campaign against the three killer diseases, the proposed national net- work would contribute to the up-grading of all medical services. Each individual component of the network would serve As a teaching and training center, trans- mitting to the medical profession and to the public the latest developments in scientific medicine. The proposed national network is based on the concept that the best patient care is associated with research. It is not envisioned as a totally new and separate pattern of medical service superimposed from above. Rather, it is designed to become a part of the existing fabric of medical services: Existing universities, community hospitals, and research institutes will be the focal points for the cen- ters and stations proposed. In some areas, through the development of medical complexes, individual regional centers and stations will be related to and inte- grated with existing health resources. The system is designed not to duplicate existing resources but to strengthen them. The purpose of the entire system is to assist the doctor in practice in the care of his patient who is suffering from heart disease, cancer or stroke. It will make available to every doctor in the country the newest and most effective diagnostic methods and the most promising methods of treatment. It will, in effect, link every private doctor and every community hospital to a 28 national-and indeed worldwide-network transmitting the newest and best in HEART DISEASE,CANCER AND STROKE health service. And at the same time it win make each doctor a contributor to the worldwide research effort; for his observations will add to the total knowledge accumulated by the stations, centers, and research institutes. The specific recommendations which follow, taken together, represent a major innovation. They constitute a nationwide plan to fuse the worlds of medical research, medical education and patient care. Regional Centers for Heart Disease, Cancer and Stroke Recommendation 1. The Commission recommends the establishment of a national network of Regional Heart Disease, Cancer and Strokg Centers for clinical investigation, teaching and patient care, in universities, hospitals and research institutes and other institutions across the courary. Specifically,-the Commission recommends: A. That 25 such centers for heart disease, 20 for cancer, and 15 for stroke be established over a 5-year period; B. That an Advisory Committee on Regional Centers he established by the Public Health Service to organize, develop, and review plans and projects dealing with the development of regional centers in the three categorical areas; the reconunendations forthcoming from this Committee are to be transmitted to the appropriate National Advisory Council to aid the Council in making its recom- mendations to the Surgeon General regarding applications for regional centers. 29 HEART DISEASE, CANCER AND STROKE C. That the following funds be appropriated to the appropriate units in th( Public Health Service to initiate this program for a 5-year period in the variouE areas: Year Typeof center 1 2 3 4 5 Heart Number of new centers. 10 3 4 4 4 Disease. Funds required* ........ 25. 0 24.5 32. 1 38. 9 45. 7 Number of new centers. 4 4 4 4 4 Cancer. .... Funds required* ........ 50. 0 90. 0 150. 0 150. 0 160. 0 Number of new centers. 5 2 2 3 3 Stroke Funds required* ........ 12. 5 12. 0 16. 0 20. 0 25. 0 'Figures in millions of dollars. Description. Each of the proposed regional centers for heart disease, cancer or stroke would provide a stable organizational framework for clinical and laboratory investigation, teaching, and patient care related to the disease under study. It would be staffed by. specialists from all clinical disciplines and the sciences basic to medicine necessary for a comprehensive attack on problems associated with that disease. These specialists would have at their disposal all necessary diagnostic, treatment, and research equipment and resources@ The center would also provide bed support for the patients under investigation as part of their total care. Such a center would permit the most comprehensive, effective and professional- ized research effort possible. Each regional center must have an allocation of space appropriate to the pro- gram to be mounted, permitting reasonable expansion. To establish such cen- ters, nonmatcbing funds for the construction of new space and/or the'renovation of existing space should be appropriated, in addition to funds for the provision ipment and staff. of necessary equ Centers already exist, particularly in cancer, which can serve as a nucl'e'us for the development of some of these regional centers. Investments in potential 30 sites will be necessary in places where the nucleus for these facilities does not I I 1: I HEART DISEASE, CANCER AND STROKE exist. I i ! I i I1 II i I I The centers would be strongly oriented toward clinical investigation and fundamental research. They would conduct training programs for personnel staffing the diagnostic and treatment stations and would also serve a teaching function for the medical community of the region. Each center will require hospital beds as well as outpatient facilities. It w-fil have areas for specialized care, and research beds related to laboratory facilities for specialized diagnostic studies and new treatments under investiga- tion. In addition it will have operating rooms and other facilities for complex diagnosis and treatment. T'he staff of each center must be large and varied enough to facilitate investigation and treatment in depth, utilizing multiple scientific methods. A Regional Heart Center, for example, might include internists, cardiopulmonary physiologists, cardiologists, peripheral vascular specialists, cardiac and vascular surgeons, biochemists, statisticians, epidemiologists, radiologists, and, in some cases, geneticists. Cancer centers would be staffed in similar depth and diversity incorporating the specialized disciplines necessary for, cancer study. Stroke centers, many of which would be established in conjunction with heart centers so as to make joint use of staff and facilities serving their common needs, would also have specialists in the neurological disciplines. In summary, each Regional Heart, Cancer, or Stroke Center would he estab- lished where possible in conjunction with a major existing medical institution. It would be staffed and equipped to conduct advanced and complex clinical in- vestigation and related research, plus teaching services and high-quality patient care. It would function as a regional resource for these services, interacting with the local diagnostic an d treatment stations and with the other medical resources of the area. A logical, organized program of research, teaching and patient care in a re- gional center can vitalize the interest in the care of the patient, make available the latest techniques and resources in modern therapy and discover new ones for application. By deznonstration and professional education, the patients of a whole area may be benefited. Rehabilitation Center-s. In addition to these specific proposals for the crea- tion of regional centers, the Commission strongly endorses the importance of simi- lar centers in rehabilitation. Five such centers presently exist, supported by grants from the Vocational Rehabilitation Administration. Doubling the number of centers now receiving support and increasing the funding of each center as its program may require would provide vitally needed expansion of rehabilita- tion care, research and training, particularly to meet the needs of patients with heart disease, cancer and stroke. Relation to Clinical Research Center Program. It should he noted that the proposal for categorical regional centers for heart disease, cancer and stroke represents an outgrowth and extension of an already successful program of the 31 National Institutes of Health. The NIH Clinical Research Center Program, HEART DISEASE, CANCER AND STROKE now in its sixth year, has demonstrated on a modest scale the great potential of clinical research units in various parts of the nation. proposal for categorical The Commission considers, hoivever, that its present regional centers constitutes an urgently needed next s-tep in advancing the attack against heart disease, cancer and stroke. The time is ripe for the development of research, training and care facilities that would permit the broadest and most comprehensive attack attainable on the problems of heart disease, cancer and stroke. The Commission recommends, therefore, that the present "Clinical Research Center" program be continued and ame be cban-ed to the Clinical Research Unit pro-ram expanded, and that its n to clarify the relationships betiveen this existing program and the Regional Center program proposed herein. Diagnostic and Treatment Stations t Recommendation 2. The Commission recommends the establishment of a national network of Diagnostic and Treatment Stations in communities across the nation, to bring the highest medical skills in heart disease, cancer and stroke within reach of every citizen. Specifically, 150 such Stations are to be established for heart disease within a 5-year period; 200 for cancer; and 100 for stroke. In addition it is recom- mended that 100 Rehabilitation Units be created in association with many such Stations, to assure th e est in rehabilitative service is rendered to patients receiving diagnosis an treatment. The number of Stations recommended is based on a careful assessment takin- into account the number of existin-, facilities for each disease area, the national need and the feasibility of staffin-, the Stations within a 5-year period. We reco-nize that the su,@ e--ted number of Stations will not, in fact, saturate g theentirecountry. Therestilli@ill emanypatientsbeyondpracticalaccessto these facilities. It is our intention that these will serve as pilot demonstrations 4 stimulating still broader covera@e under local initiative. The Commission recommends that half of the Stations established for each disease area be located in medical centers, and half in community hospitals, to make maximum use of existing skills while assuring that excellence is effectively distributed geographically across the nation. The Commission further reconunends that an Advisory Committee he estab- lished in the Public Health Service to develop a national plan for the establish- ment of these Stations, to re-view applications for grants, and to evaluate the program in the fourth year to determine future needs for further program development. It is recommended that the following appropriations be made to appropriate 32 units in the Public Health Service to initiate this program for a five-year period HEART DISEASE, CANCER AND STROKE in the various areas. Year Type of unit 3 4 5 Heart Number of new units. 30 35 40 45 ...... Disease .... Fundsrequired*.....11.25 18.375 26. 375 35. 25 26. 25 Number of new units. 40 40 40 40 40 Cancer ...... Funds required*.. 15. 0 30. 0 45.0 60. 0 75. 0 Stroke ....... Number of new units. 20 20 30 30 ...... Funds required*..... 7. 5 11. 0 18.25 23. 5 17.5 Rehabilita- Number of new units. 10 20 30 40 ...... tion ....... Funds required 3. 0 7.5 16.5 19.5 15. 0 *rzpwes in @Mons of dollars. Initial construction or renovation and equipment of these Stations should be supported with Federal funds on a non-matching basis. Staffing and operating costs of the Stations should be borne in part by the Federal Government and in part by local resources. It is envisioned that such Stations could become self-supporting within a 10-15 year period. Emphasis should be placed on local resources for the provision of care for medically indigent patients in a diagnostic and treatment unit. Patients other than the medically indigent should pay for services. Description. A typical Heart Station would have the following principal objectives: Immediate and emergency care for patients with acute cardiovascular emergencies. 2. Provision of diagnostic facilities for the screening of patients with cardio- vascular, including peripheral vascular, diseases to determine whether they will require the more highly technical facilities available at the larger medi- cal centers. 3. Outpatient services for patients with cardiovascular and peripheral vascular disease. 4. StiTnulation of interest of medical students and practitioners. S. Training of physicians in the community. . 6. Education of the general public concerning prevention and treatment of 33 heart disease. HEART DISEASE, CANCER AND STROKE e care units for the These Stations will include intensiv emergency care o patients with heart disease. In addition, these Stations would provide limite( laboratory facilities, an outpatient clinic, electrocardiographic and radiologi@ services. Patients requiring advanced diagnosis or treatment would be referrec to the Regional Center equipped to perform it. Each Cancer Station would have similar goals and be equipped and staffe( to provide parallel types of service to patients and to the medical community Each would require provision for cytological and histo-pathological laboratories to effect diagnosis. Team care at each Station would include radiotherapy an( radioactive isotopes, chemotherapy, and the maintenance of a cancer registr- with complete reporting. Each should have access to data processing and coin puter analysis. Each Station should be in close contact with the Regional Cancer Center ii order to obtain directly from these research centers information and training ii newer methods of diagnosis and treatment. The Stations will in turn convey information to other community hospital and physicians and should also serve as part of a network of facilities availabl for collaborative clinical research programs carried out by the large cance research centers. To fulfill its graduate educational function within its own community, eac) diagnostic and treatment station must have resources to provide to the practicing doctors a 24-hour, 7 day-a-week specialist consultation service without charge The diagnostic and treatment unit information service win have access to the in formation services provided by the regional centers, and through these centers t( the total body of knowledge accumulated in a worldwide research effort. The Stroke Stations will include intensive care units for the emergency car of patients with stroke. They should be established so that they may shar@ certain facilities and personnel with Heart Stations. Therefore, it is desirably for the Stroke Stations to be in the same area of the hospital as the Heart Sta tions and to work closely with them, avoiding unnecessary duplication bu supporting each other. ties, physical medicine'@and re These Stations will include laboratory facili habilitation facilities, outpatient clinic and hospital beds, and provision fo eiectroencephalographic, electrocardiographic, neurological, and emergenc, surgical services. evelopment of Medical Complexes D Recommendation 3. The Commission recommends that a broa an@ flexible program of grant support be undertaken to stimulate t e formation 0 m edical complexes whereby university medical schools, hospitals and othe health care and research agencies and institutions work in concert. Specifically, the Commission recommends a major program of institution, grants to university medical schools for the creation of medical complexes whic 34 would involve participation by community hospitals -and other health car HEART DISEASE, CANCER AND STROKE facilities, b some of the regional heart, cancer and stroke centers and station y developed in proximity to each medical center, and by other conununity agencies and institutions. For this purpose, it is recommended that the Public Health Service receive appropriations as follows: First year, $25 million; second year, $37.5 million; third year, $50 million; fourth year, $62.5 million; fifth year, $75 million. It is envisioned that approximately 10 medical centers would receive approval for such grants in the first year of operation, followed by 5 additional centers 'm each of the succeeding years. The average grant for each center would be $2.5 million. Description. The network of Regional Centers and Diagnostic and Treat- ment Stations just described, each oriented toward high-quality services in con- nection with a specific disease, will greatly increase the accessibility of the best in medical practice across the nation. The third recommendation of the Commission is designed to provide a means by which existing medical centers can expand their resources so that they can participate in the development of this national network. The funds would be used by the medical center to transform itself into a medi. cal complex serving a large community, metropolitan area 'or region. Funds could be employed in a variety of ways, such as the increase of staff to provide full-time faculty members for duty at affiliated community hospitals; augmenting staff in other ways to serve the community; setting up necessary administrative mechanisms; and the like. The resultant complex would strengthen the community hospitals by allowing them to draw on the advanced and cosily services available at the center without the need for duplication. The system would provide an ideal base for a continuing education program reaching physicians and other health professionals in the region, and for coor- dinating all community service@including noninstitiitional care through a variety of cooperative and mutually supportive arrangerhents with existing agencies. Development of Additional Centers of Excellence Recommendation 4. The Commission recommends a program of develop- mental grants to medical schools to enable these institutions to improve their total capability for both academic and research programs for the ultimate purpose of creating a greatly increased number of true "centers of excellence" in medical education and research. Specifically, it is recommended that appropriations of $40 million over a 5-year period, beginning with $3 million in the first year, be made to the Public Health Service for a program of nonmatching grants to be used by institutions at their discretion to strengthen various aspects of their academic and research 'Programs. This proposed program parallels an existing program of institutional develop- raent administered by the National Science Foundation and should be carefully 35 coordinated with that agency. Its overall purposes would be: HEART DISEASE, CANCER AND STROKE (1) To raise a number of medical institutions of demonstrated potential to a level of excellence comparable with the few outstanding medical centers of i for the development of medical corn- the nation. This would create new fee for the tendency to channel ever-bigher Plexes, and would also correct in part proportions of available funds to the few outstandin- institutions; (2) To -strengthen the fundamental resources for medical education and medical research and to disperse throughout the country the standards of excel- lence conducive to the most effective preparation of medical manpower required to bring about a substantial reduction in the burden and incidence of heart disease. cancer and stroke. The application for such a grant should be accompanied by a detailed plan indicating the purpose to which the funds would be applied as it relates to the objective of this program. Grants would be reviewed by a peer group of medical educators and distinguished citizens. A National Stroke Program Unit Commission recomme the establishment of c Recommendation 5. The nds National Stroke Program directed by an administrative unit to be creates within the appropriate unit of the Public Health Service to coordinate tlm numerous existing and proposed activities in the field of stroke. This Unit should have a full-time permanent staff with responsibility for development of a comprehensive program of research and training in stroke. Its activities would include administration and coordination of the program- for Regional Stroke Centers and Diagnostic and Treatment Stations alread3 described, plus the Specialized Stroke Research Units recommended in Chapter V of this Report and the training activities related to stroke described in Chapter VI. Its work would be closely coordinated with the work of the voluntary agencies active in the stroke field, such as the National Stroke Program of thE American Heart Association. The National Stroke Pro,-ram should be developed with the advice of thf Joint Council Subcommittee for Cerebrovascular Diseases of the National Ad visory Heart Council and the National Advisory Ne@rological Diseases anc Blindness Council. There are compelling reasons for the establishment of a full-fled,-,,ed and co ordinated National Stroke Pro-ram. The underlying reason is that stroke has been a seriously neglected area ol, study in the past. This neglect has been based largely on the false assumption, that stroke was a hopeless isease and that it was a later-life form of coronary artery disease. Recently there have been substantial advances in knowledge which indicatc that man@perhaps most-strokes are foreseeable and preventable, and that mucl- can be done for stroke victims. Scientific evidence indicates that cerebral throm bosis and hemorrhage may be a different disease process from atherosclerosis 36 and hypertension elsewhere in the body. Moreover, it is clear that the car( HURT DISEASE, CANCER AND STROKE of stroke patients requires special forms of cooperation among such medica specialties as neurology, cardiology, surgery, physical medicine, and rehabilita- tion. The Commission considers the development of a National Stroke Program imperative if we are to achieve the progress of which we are capable against this major killing and disabling disease. To operate this unit, 81 million should be appropriated annually for the first two years with subsequent annual increases until $2 million is reached in the fifth year. 37 HEART DISEASE, CANCER AND STROKE ;II 3 APPLICATION OF MEDICAL KNOWLEDGE IN TH E COMMUNITY t Many individuals, agencies and cups contribute othe health services re gr ceived by heart disease, cancer and stroke patients in American communities State and local health departments, in addition to their traditional and bette@, known responsibilities for the control of conununicable diseases, conduct activ( programs to serve the chronically ill as well. Voluntary agencie@such as the local affiliates of the American Cance, Society and the American Heart Association-assist in many ways. There ar, also the professional organization@the local medical societies and others-an( the various groups providing specific kinds of care such as visiting nurse asso ciations, nursing homes, and the like. Each has a special part to play in the delivery of health services. Manpower and facilities for the delivery of top-quality health care aie in shor supply in virtually every community. Therefore, the efficient use of existing rc sources is imperative. Yet in many conununities the reverse is actually the cast Instead of coordination, there is duplication of services and facilities in som areas, while serious gaps exist in others. There may be several large general hospitals, furnishing more beds for sent care than can possibly be utilized by the communit , while serious shortage y exist in beds for long-term care and programs for those patients who can beE be cared for in their own homes. Several hospitals may possess costly equil ment-such as cobalt devices for cancer care, or heart-lung machines@ach bein,; used only once or twice a week. Teams of highly skilled people required to wor' with this equipment are also standing idle. A beginning response to these problems can be seen in a few of the nation more progressive and active communities. The concept of "areawide pltnning' is being implemented through councils of social agencies, utilization committee,, an community health or patient-care councils. These voluntary organization attempt to achieve coordinated efforts on the part of various independent agencie and individuals concerned with the health and medical needs of the community' citizens. Such endeavors are of the utmost importance if we are to realize our aspira tions for programs that will have maximum iMDacts on heart disease, cance and stroke. Independent and often competing activities of hospitals, healt] departments, and medical practitioners-each working in isolation and oftei at cross purposes-are not in the best interest of the consumers of health service- the health profession, or the nation. 38 The national network proposed in the previous chapter will do much t4 HEART DISEASE, CANCER AND STROKE strengthen and coordinate community services for heart disease, cancer and stroke But much more needs to be done if the full-scale attack on these diseases is to be fully effective. The recommendations in this chapter are designed to assure this success by stimulatin- and supporting community pro@rams and by encouraging the communication of health knowled-e to the practicing physicians and to t e public. Community Planning Grants Recommendation 6. The Commission recommends a special program of incentive grants to communities to stimulate the development of a system for the planning and coordination of health activities. Specifically, it is proposed that there he established within the Community Health Services and Facilities Act Program of the Public Health Service, matching grants to be awarded to community agencies to support and stimulate community wide planning activity. Prerequisites for the receipt of such a grant would be representation from the major educational establishments, the official and volun- tary health services, the major professional societies, and the civic leaders whose participation is essential to the success of any truly effective coordination and planning on a community basis. One of the major factors which inhibits the maximum availability of health services relating to heart disease, cancer and stroke is the lack of coordination of services within communities. Failures in coordination result in services that are uneven in quality and often inaccessible to those who need them most. There- fore, it is imperative that some positive steps be taken to encourage and stimulate community planning and coordination of health services programs on a wide- spread basis. The program proposed would not only do a great deal toward assuring the availability of the best in health services for heart disease, cancer and stroke vic- tims but would also help the communities to participate more effectively in the development of the university medical complex in its area. An appropriation of $1 million annually is recommended to provide the incen- tive to as many communities as possible to undertake such a program of plan- ni g and coordination. n Community Health Research and Demonstration Recommendation 7. The Commission recommends that greatly increased emphasis and support be given to programs of community health research and research training within the Public Health Service, and that the program of demonstration projects under the Community Health Services and Facilities Act of 1961 be freed from existing appropriations ceilings, more adequately funded, and more liberally interpreted. It is vitally important that we find ways of using existing manpower and other resources as efficiently as possible. Indeed we cannot meet the challenge of heart disease, cancer and stroke unless we improve methods for extending accessibility and delivery of health services in. the community. in community health offers one highly promising avenue for efficient 39 HEART DISEASE, CANCER AND STROKE Scientific methods can be applied in the laboratory of the community. pidemiolo-ic research can reveal patterns of disease distribution which in E turn permits a concentrated attack where it will do the most good. Behavioral research, economics research, and research in public health admin- istration all can contribute to effective planning and programing. But corn- munity health research is a very new field. Few people are trained to do the job. A major investment in research training and support of promising research projects in this field can be expected to pay important dividends. Accordingly it is recommended that the present appropriation for this purpose be increased by $5 million for the first year, increasing annually until an increase of $10 million in the fifth year is reached. The Community Health Services and Facilities program, despite the limited number and scope of projects that it has been possible to support, has proved that demonstrations of experimental approaches to the delivery of health care are useful and practical. The Act authorizing this program was designed tc solve the problem of community organization for health service. But it has beer narrowly defined and inadequately funded. Freed from its existing restrictions, this program could make a major con tribution to the attack on heart disease, cancer and stroke. Support of Community Programs Recommendation S. The Commission recommends that appropriate unit of the Public Health Service be given authority and funds for programs o project grants to community agencies, such as public health departments voluntary agencies, and others, and that the Vocational Rehabilitation Admir istration launch a 5-year development program to expand its rehabilitation prc grams for victims of heart disease, cancer and stroke. Specifically, the Commission recommends: A. That the Public Health Service be authorized and funded to initiat@proje( grants to public and other nonprofit organizations for studies, experiments, feas' bility trials, demonstrations, and training in their respective fields of intere, and that a special grants program be initiated by the Public Health Service in t@ field of medical rehabilitation. The project grants envisioned in this recommendation would stimulate Stal and community agencies to deliver expanded and more effective services to p, tients suffering from heart disease, cancer and stroke, thereby speeding the ail placation of scientific knowledge to the people who need it. These categories project grants would provide incentive and encouragement for commufiity prl grams in such areas as the early detection of incipient heart disease, canci and stroke; effective systems of referral for patients; application and trainir 40 in the use of medical rehabilitation techniques for heart, cancer and strol HURT DISUSE, CANCER AND STROKE patients; and the like. The following table indicates the appropriations necessary to initiate the new Public Health Service programs and expand existing ones for a 5-year period. Year Area 1 2 3 4 5 Heart Disease* ..................... 1. 5 3. 0 4.5 6. 0 7. 5 Cancer* ............................ 1. 5 3. 0 4.5 6. 0 7. 5 Stroke* ............................ 1. 5 3. 0 4. 5 6.0 7. 5 Ntedical rehabilitation* ............. 1. 5 3. 0 4.5 6.0 7. 5 'Fjpres in miffions of doUars. B. The program recommended for the Vocational Rehabilitation Administra. tion would include (1) a new system of project grants for State vocational rehabilitation agencies to provide complete rehabilitation services to persons with disabilities resulting from heart disease, cancer and stroke; (2) the con- struction of vocational rehabilitation centers and sheltered workshops; (3) matching fund programs with cities and counties to develop local services; and (4) legislative authority liberalizing the requirements in the existing State- Federal rehabilitation program. The Commission recommends that $25 million be appropriated to the Voca- tional rehabilitation Administration for a 2-year period to achieve this expansion. Statewide Programs for Heart Disease Control Recommendation 9. The Commission recommends that the Public Health Service be given authority and funds to establish and maintain coordinated Statewide laboratory Facilities necessary for heart disease control programs. A total appropriation of $8.5 million over a three-year period is recommended for this purpose-42.5 million for each of the first two years and $3.5 million for the third. The laboratories established through this program should be designed to per. form laboratory services related to heart disease control. These laboratories 41 6ould form a part of a coordinated Statewide program of heart disease control, by a specific unit within the State health department. Such a program, HEART DISEASE, CANCER AND STROKE ordinate the eff orts of the numerous public and voluntar to be successful, must co I and must also collaborat agencies whose work impinges on heart disease contro closely with the private physicians of the State. tory network are several: The objectives of this Statewide labora (1) The grouping of beta-hemolytir, streptococci. Rheumatic fever is potei through prompt identification and immediate tially preventable treatmei with an appropriate antimicrobial agent of patients suffering from betL heniolytic streptococcal infections. Each State should have coordinate laboratory facilities to identify the Group A beta-hemolytic streptoc6ccu organism. Where such facilities exist, they have proved a trerriendou boon to practicing physicians and have facilitated rheumatic fever coy trol programs in that State. (2) The provision of services for the laboratory control of patients receivin anticoa lant agents. A large number of patients in the United Stat( .gu are currently receiving anticoagulant drugs; it is probable that the numb( will grow in the future. The dosage of these drugs must be tailored t each patient individually and the dosage regulated by carrying out al ropriate blood tests at frequent intervals. In many areas of the countr: p this service is carried out by hospitals and rivate laboratories. In othc p areas, however, patients could receive this type of medication if this seri ice was available and convenient. This Statewide laboratory networ would conduct well standardized and controlled tes',s which could bel other laboratories check their methods for acceptable accuracy and als 4 provide laboratory service in areas where it is needed. (3) In conjunction with the Heart Disease Control Program (HDCP) lal>or, tory at the Communicable Disease Center, (CDC), to provide the servic of standardization of chemical laboratory tests to hospital and privat laboratories in the country. The HDCP laboratory at CDC is perforn ing this service for laboratories all over the United States and abroa at the present time. This Statewide network of laboratories could serv as local agents for this valuable program. As such, these local labor-, t nd ories could also perform chemical determinations a . participate i large local and national epidemiologic studies in cardiovascular disease in this sense, these laboratories would act as a valuable resource fo certain research programs of national interest. It must be stressed that the development of such a laboratory network t perform the above services would make it possible to achieve an immediat( specific and measurable impact in reducing death and disability. Each State should, of course, assess its own needs. The Heart Disease Contrc Program of the Public Health Service should have the authority and specifically earmarked funds to assist the States in setting up and operating the neede, facilities. IVational Cervical Cancer Detection Program 42 Recommendation 10. The Commtssion recommends the development of HEART DISEASE, CANCER AND STROKE national program for the early detection of cervical cancer. Ibis program would have two major components: A. A national education program for the general public so that all women are aware of the availability of the cervical cancer screening test. This should be conducted by the Public Health Service in cooperation with the voluntary health agencies, such as the American Cancer Society. B. A cervical cancer detection program directed at those 8 million women aged 25 years-and over who are admitted to hospitals in the United States each year. The Commission feels that such a hospital-centered screening program will be most economical, will reach the.high-risk, low socioeconomic group and offers the greatest potential for rapid public and professional education. it is recommended that $5 million be appropriated to the Public Health Service in the first year and increased by $21/2 million each year for a 3-year period, to provide grants to hospitals participating in this pro-ram. An Advisory Commit- tee should be appointed to help plan the development of this program, to review it after the second year, and to plan for its future development. Total support for cytological examination should be given to hospitals provid- ing care for medically indigent patients, and partial support to hospitals providing care to patients who do not have health insurance or other resources to cover cytological examinations. All other hospitals should include this examination as part of the routine physical examination and the cost of cytology should be included with the cost of other laboratory tests. Ili providing these grants, consideration should be given first to hospitals providing rare for the indigent and-the medically indigent. This national cervical cancer detection program is an intensive effort aimed at a very specific target. Each year many thousands of women die of cancer of the cervix. Most of these deaths are unnecessary, for the disease can be detected easily at a stage in which it is abnost invariably curable. There is no excuse for further delay in launching a major attack that can reduce the death toll from this form of cancer virtually to the vanishin point. Continuing Education of the Health Professions Recommend6tion 11. The Commission recommends that appropriate units of the Public Health Service, and the Vocational Rehabilitation Administration, be provided with lunds and any addi@nal authority that may be neecssary to spearhead a national program for the continuing education of the health Professions. Specifically, the program envisioned has three major elements, as follows: A. The Public Health Service should be provided with funds and additional authority if necessary to stimulate and support, through grants, contracts, or'other means, demonstration projects and experiments directed by universities, medical schools, hospitals, and other appropriate agencies, designed to make scientific knowledge on heart disease, cancer and stroke and other subjects systematically 43 and conveniently available to practicing physicians and other health professionals. HEART DISEASE, CANCER AND STROKE should also include conduct and support of resear( The scope of this program projects desi-ned to develop and experiment with new methods of continua thods of evaluating their actual impact education, use of various media, and me upgrading medical practice. Appropriations of $2 million for the first year, million for the third are recommended. million for the second and $6 egic position i B. The community hospital occupies a particularly strat n carr, ing continuing education programs directly to the practicing physician. To org, h programs a given hos ital should appoint a full-tin nize and carry out suc p Director of Medical Education plus supporting staff. Members of the attendir staff of the hospital should be encouraged to attend courses and take longer add tional training whenever possible. Though, ideally, all community hospitals with 300 or more beds shoul ultimately mount such a program, it is recommended that such units I established and supported in 100 of these hospitals throughout the Unite States on a pilot demonstration basis; if successful, the numb@r of units ca be increased. It is estimated that about $75,000 per year would be neede to carry out a pro@ram of this type in each hospital of this size. A total of $7. million annually would be needed for this program. C. An additional amount of $600,000 per year for 5 years should be appr( priatecl to the Vocational Rehabilitation Administration to provide ,,aonts to ke nd agencies throughout the country r suppoi medical and health institutions a of short-term training courses, seminars, conferences, and workshops in rehc bilitation services for heart disease, cancer and stroke patients., Continuing education is a categorical imperative of contemporary medicin( Without a lar-,e-scale, effectively organized effort, the worlds of science an practice will spiral still farther apart. The gap between what is known an, what is received by patients will be harder and harder to bridge. The greatest sin-,le obstacle to a cohesive program of continuing education fo the medical profession is time. The second is diversity of interest and need,- The third is the fact that continuing education, although it is recognized as critical problem in medicine today, is not the primary responsibility of an- significant segment of our national health resource. Medical schools-the logical locus for the major effort-are correctly pre occupied with undergraduate education first and research second; continuing education, if it receives any attention at all, must settle for what is left of alread, inadequate resources. Similarly, community hospitals could contribute greatli to the continuing education of community physicians, but their first job is to care for the sick. Professional societies have many other responsibilities. The Federal Government clearly has a role to play in helping to forge a national continuing education effort, by assisting all the available resources in giving du( attention to this problem. Public Information on Heart Disease, Cancer and Stroke 44 Recommendation 12. The Commis@n recommends @t the Federal gov- HEART DISEASE, CANCER AND STROKE ernment, primarily through t@ Pub@ Health'Service, recognize that public information is a primary responsibility and a major instrument for the pre- vention and control of disease, and that this activity be encouraged and sup- ported on a scale commensurate with its importance. Application of medical knowledge in such fields as heart disease, cancer and stroke depends on the initiative and cooperation of an informed public. This is true of every step in the process, from prevention and early detection to rehabili- tation@ach of which depends on the active participation of the patient and his family. Specifically, the f 'ollowing projects and programs are recommended: A. The Public Health Service should be authorized, and funds should be ap- propriated, to contract with commercial television producers for the production of twelve 30-minute documentary films each year of the highest quality, on sub- jects related to heart disease, cancer and stroke and such other subjects as are deemed desirable. Each film should be budgeted at or about the level of $150,000 to assure writing and production that will make the films competitive with the best of commercial television, thereby encoura@in,- their use in prime viewin@ hours. This price should include a sufficient number of prints to assure widespread use on local commercial television outlets across the nation. The contract should also provide for the full participation of the producer and his organization in the marketing of the films. The Public Health Service, in conjunction with non-Federal scientists and physicians designated by the Service, should have full control of the content of each film. The film should be available for com- mercial sponsorship within a predetermined ran-e of appropriate product classi- fications. I%e method proposed-which consists essentially of a Federal invest- ment in comniunications talent-would cost about $1.8 mi 'on per year. B. The Public Health Service should be authorized, and funds should be ap- propriated, to the National Medical Audiovisual Center-subsequently described in connection with Recommendation 31-to support through appropriate mech- anisms, such as grants or contracts, the development of effective television pro- graming in the health field on the nation's educational television stations. The sum of $1 million per year is recommended as a beginning figure. Educational television (ETV) program's reach school audiences at all levels fromprimaryschoolthrou-hcollege. InmanycommunitiestheETVpro@ramis viewed widely by the adult intellectual and civic leadership as well. It represents an excellent medium for attracting young people to health careers, for establishing and maintaining desirable health habits, and for stimulating desirable corn- munitywide health activities. In many areas, ETV facilities can also be used for continuing education of health professionals. C. The funds appropriated for the Office of Information and Publications in the Office of the Surgeon General should appear as a budgetary line item. They should be increased by $750,000 per year to finance such addi- tional activities as the development and production of a health yearbook similar In scope and quality to the Agricultural Yearbook; the creation of materials 45 for free public service announcements on heart disease, cancer, stroke and other HEART DISEASE, CANCER AND STROKE edia; and other television, magazines, and other in subjects for use by radio, purposes. ov ded with funds to initiate th( should be pr i D. The Public Health Service Motivation. In addition to spe earch in Health development of a Center for Res directed at the individual decisionmaking process ii cifir behavioral studies of publi d analyze the contents changing patterns of living, the Center woul effectiveness and influence upol paign materials with reference to their cam ion -upon bard behavior, and it would hopefully concentrate particular attent to-reach population groups which reject existing educational campaigns emphe; sizing individual initiative and changes in living patterns. it is estimated the $500,000 per year would be necessary to undertake the support of such a Centel E. The Commission strongly endorses the conclusions and recommendation Committee on Smoking and Health whicl of the Surgeon General's Advisory ous reports, stated that smoking is a seriou in addition to confirming previ programs in tbi hazard to health and indic ted the need for more aggressive a area. ductio of cigarette smokin- offers gr& n It seems apparent that the re possibilities for the prevention of illness, disability, and premature death in tb-' country, with regard to both cancer and cardiovascular disease. Because public information and education are primary instruments for tl attack on this problem, the Commission recomr.,iends that the sum of $10 millio be appropriated to the Public Health Service over a three-year period for a con prehensive national program of education and public information regarding tl hazards of cigarette smoking. The program should be aimed at the education children, adults, physicians and educators with the assistance of State and loc; community agencies. A network of smoking control clinics should be provide to assist those who desire to give up smoking. New and more effective educe tional material should be developed. It is further recommended that the present budget of $500,000 for publ information and education in the Cancer Control Program of the Public Heall Service be increased to $1 million for the first year, SL5 million for the@secon@ and $2 million for the third to permit increased effectiveness in informing tl public about cancer and its prevention and control. 46 AND STROKE HEART DISUSE, CANCER PART I hapter Five THE DEVELOPMENT OF NEW KNOWLEDGE The conquest of heart disease, cancer and stroke requires the continuation and expansion of our highly productive medical research effort in the years ahead. Today's successes in detection, treatment and cure sprang from yesterday's research. But many problems related to these three diseases remain beyond our scientific capability. Of these, a large number appear to be just outside our grasp. We stand on the threshold of further advances. To cross this threshold as soon as possible-to take advantage of the tremen- dous momentum built up by our biomedical research enterprises in the recent past@ertain new elements should be added to our existing scientific resources. In addition, current procedures need to be strengthened or modified to assure ever-increasing productivity of new life-saving knowledge. The national network of regional centers, each primarily oriented toward the solution of a specific disease problem, will generate and verify a tremendous amount of new information on heart disease, cancer and stroke. But there is also the need for a more general research attack on the funda- mental problems of human biology, to which all the sciences basic to medicine can contribute. In addition there is need for highly specialized avenues of f@rch related to heart disease, cancer and stroke. Therefore, other types of research institutions are recommended to supple- nxnt the products of the centers. Moreover, the Commission has examined with great care the overall program of research support provided by the Federal Government. In our view, the diversity of funding devices that has, developed over the years to support bio- R"ical research and training is one of the nation's greatest strengths. Clearly, the variety of available mechanisms offers flexibility of support and provides in- stitutions and investigators with an opportunity, within limits, to develop pro- grams consonant with their needs. Indeed, the Commission recommends that Federal agencies which support biomedical research continue to do so by diverse mftns. At the same time, existing procedures should be strengthened and new @es of support shou Id be developed as these are identified and found to be #Uitable. The Comrnission's recommendations for the development of new knowledge am designed to add further impetus to the powerful forward thrust of biomedi. @rch. Research Institutes i,on 13. The Commission recommends the establishment of rical biomedical research institutes at qualified institutions 47 the country. HEART DISEASE, CANCER AND STROKE The following table indicates the appropriations that need to be made to tl ppropriate unit of the Public Health Service to initiate this program for a fiv a ear period: y Year 1 2 3 4 5 Biomedical Research Institutes: 5 Number of new Institutes ........... 5 0. 0 37. Funds reqiired* ................... 7. 5 f pwes in millions of dollars. nd promise of non categoric The Commission recognizes the importance a biomedical research. Indeed, such research is essential to basic understanding heart disease, cancer and stroke. Clues of great significance, coming fro can be used effectively by research groups investigatin- specif such endeavors, disease problems. For example, through such research, we can hope to attain the more detailt understanding of the living cell which may reveal the nature of the delica change in the balance of cellular activities which manifests itself as cancer. Hop fully, also, there may be an unraveling of the next layer of understanding-tl manner in which highly specialized cells such as those of the brain, kidney, heart perform the specific functions which, uniquely, they contribute to the tot living organism. In parallel we can hope to witness revelation of the manner whereby ti nervous and endocrine systems coordinate and integrate the entire organisi And with such information in hand, incisive understanding of disease, i.e., di turbances of this orderly functioning, may be expected. Such comprehensive biological understanding will, of course, greatly advan@ our hope for control of the wide variety of diseases to which man is heir, includir cancer and cardiovascular diseases which combine to account for about 70 percei of adult American mortality- Thus, the development of a number of university-based biomedical researc institutes, at qualified institutions throughout the country, would strengthen ti national biomedical research effort and add substantially to progress in the fiel( of heart disease, cancer and stroke. Specialized Research Centers Recommendation 14. The Commission recommends the establishment Specialized Research Centers for intensive study of specific aspects,ol hea disease, cancer and stroke to supplement the research and training efloi of the regional centers previously de cribed. Specifically, at least 10 such Centers in heart disease, 10 in cancer, and 48 in stroke should be established in various health and medical research faciliti HEART DISEASE, CANCER AND STROKE throughout the country over a 5-year period. In addition, it is recommended that three Bioengineering Centers and three Rehabilitation Biomedical Enoineering Research Centers be established over a 5-year period in order to take advantage of the potential offered by bioengineer- ing research in heart disease, cancer and stroke. At the same time, there is an urgent need for centers for in-depth research and training in toxicology. It is recommended that serious consideration be given to establishing one such center during the next 3 years, with the understanding that the needs for more centers in this area be reevaluated at the end of 3 years. In order to develop this pro-ram of Specialized Research Centers, nonmatch- in- funds should be appropriated for construction and/or renovation and for the provision of the necessary equipment and staff. The Advisory Conunittee on Centers referred to in connection with Recommendation I would organize, develop, and review plans and projects of these Specialized Research Centers and transmit their recommendations to the appropriate National Advisory Council. The following table indicates the appropriations necessary for the appropriate units in the Public Health Service to initiate this pro-,ram of Specialized Research Centers for a 5-year period in the various areas: Year Type of Center 1 2 3 4 5 Number of new centers .... 2 2 2 2 2 Heart Disease. Funds required* ........... 0.6 1. 2 1. 8 2. 4 3. 0 Cancer ....... Number of new cein 2 2 2 2 2 .Funds required* ... ....... 0.6 1. 2 1. 8 2.4 3. 0 .Stroke ....... Number of new centers ..... 2 2 2 2 2 Funds requited* ........... 0. 6 1. 2 1. 8 2.4 3. 0 )BiGengineer- Nun:Lber of new centers..... 1 1 ing ......... Funds required* ........... 1. 25 1. 6 5 Rehabi Number of new centers.... ......... Funds revke4* ........... 1. 0 1. 5 2.0 1. 5 1. 5 49 in miwoas of &Ilars. HEART DISEASE, CANCER AND STROKE The centers proposed here would bring to-ether the combined talents of multidisciplinary staff for study of special problems related to heart diseae cancer and stroke. For example, in the field of heart disease, centers designed for in-depth reseal and trainin@ might be established in epidemiology, genetics, thrombosis a fibrinolysis, pharmacology (especially for natural products), etc. In cancer, specialized centers of this type might be established in epidemiolo: virology, carcinogenesis, animal cancer, cytopathology, radiobiolo- , clini Cy pharmacolo- immunology, enzymology, radiation therapy, nuclear medicine, t Cy, rD Examples in the stroke field mi-ht be epidemiology, instrumentation for cereb 0 blood floiv and diagnostic tests, experimental cerebrovascular surgerv (especi, in primates known to develop cerebral atherosclerosis), etc. Specialized research and training in bioengineering in the three cate-ori' areas and in rehabilitation offer great potential. Research Project Grants Recommendation 15. The Commission endorses the existing system review of research project grants b study sections and advisory councils at y National Institutes of Health and recommends intensified and e.,rpanded supl of research in heart disease, cancer and stroke. Specifically it recommends: A. That a total of $40 million be appropriated to the National eart nstlt $40 million to the National Cancer Institute, $15 million to the -\ational Ir tute of General Medical Sciences, and $10 million to the National Institutc od over and above curi Neurological Diseases and Blindness in a 3-year peri appropriations to these Institutes for research project grants. hereby funds appropriated B. That NIH be allowed to use a mechanism w special-purpose programs would not lapse if unspent at the end of the fisca y C. That several important areas of research be given special emphasis bec, of the valuable contribution in the past and their high potential for the fut For example, epidemiological studies provide evidence which may lead to identification of factors causin- a specific disease or condition. Of vital importance is the strong support of broad clinical field trials of d, and other methods of treatment. As we have emphasized a number of ti there is a critical lag between the research discovery of a new medication anc' apid evaluation of its effectiveness against a particular form of disease. r must wait too long while individual investigators report their limited finding, technical publications which print articles 12 to 18 months after their submi@ The broad field trials of the efficacy of the Salk vaccine serve as a model ol quick application of an important research finding to the immediate prevei@ of crippling disability and death. We must mount similar clinical trial promising therapies in the fields of heart disease, cancer and stroke. Clii trials of this nature are expensive and require the collaboration of many inF 50 tions, but there is no more effective way of getting to all of our people the HEART DISEASE, CANCER AND STROKE saving and life-enhancing bounty of medical research. D. That $10 million be appropriated to the Vocational Rehabilitation Admin- istration for the first year, with annual increases until $12 million is reached in the third year, for research in rehabilitation of persons with heart disease, cancer and stroke. . The research project grant system, whereby individual scientists receive sup- port for projects which have been reviewed and judged worthy by their peers from other Scientific institutions, is the cornerstone of Federal participation in medical research. It has demonstrated its effectiveness and value over @ period of years. The Commission bases its recommendation for additional funds to support re- search project grants in heart disease, cancer and stroke on three factors: (1) The overriding seriousness of these problems and their impact on American life; (2) the h;ghly favorable prospects for accelerated success in research discovery in these fields, based upon previous developments and work now in progress; and (3) the fact that the American research resource is sufficiently advanced and developed to be capable of using these additional funds wisely and productively. The Commission feels strongly that budgetary increases for r -@rch support should be based, not on arbitrarily applied "percenta,-,e increments" from year to year.bu't rather on actual research needs and capabilities for productive use of funds within each scientific field. Contracting Authority for Research and Development Recommendation 16. The Commission recommends that existing Public Health Service authority to contract for research and development be broad- ened and special funds be earmarked for the use of this mechanism. Specifically, the Public Health Service should be authorized: A. To make advance payments on contracts as a means to assist contractors in initiating new and complex technical operations; B. To pay for the cost of construction involved in and essential to the success- ful accomplishment of the terms and purposes of a contract; C. To commit contractual support for advance periods upward to five years to enable contractors to make substantial investment in facilities and staffs fre- quently required for major contract operations with confidence of adequate recovery of costs and reasonably stable operations. It is further recommended that $45 million over the next 3 years be appropri- ated to the National Heart Institute for contracts for research and development in the field of heart disease. Contracting for 'research and development is an effective mechanism for fi- nancing major projects such as, for example, the development of an artificial heart. As has been noted previously, this project is within the realm of im- mediate feasibility, provided a major scientific development program is mounted on an adequ ate scale. In such an undertaking, very substantial initial invest- ments are required from research institutions and especially from private in- dustry. Existing Public Health Service contracting authority, delegated by the 51 1, General Services Administration, is inadequate in several specific ways for HEART DISEASE, CANCER AND STROKE mmendations woL effective support of such endeavors. The Commission's reco greatly enhance the use of this mechanism and thereby accelerate vitally importa research. General Support for Research Recommendation 17. The Commission recommends that the existing Ge eral Research Support Grants Program of the National Institutes of Health expanded as rapidly as possible to a level of 15 percent of the total NIH search and training budget and that the program be altered to increase eftectiveness. Specifically, the Commission recommends: A sea p That graduate schools engaged in biomedical re rch, su ported grants from NIH, should be permitted to receive grants under the general search support program; and B. That general research support grants should be awarded in two categori- (1) Unrestricted funds to be devoted to research, as at present, and award on a formula basis; and (2) negotiated awards, based on documented appli, tions, to defray the direct and indirect costs of the supporting organization a services provided by each institution to facilitate the conduct of research a which are not ordinarily chargeable as indirect costs. The National Institutes of Health have carried out a program of grants certain institutions for the general support of research for several years. 'I program is designed to assist institutions in achieving balanced research a teacbin@ programs and in meeting rising costs associated with large-scale search programs based on project grants to individual faculty members. is also intended to help institutions in expanding their physical resources f research and initiating pilot research in new areas-two undertakings which E extremely difficult to finance out of general operating funds. The program has been highly successful in its initial phase. The Commissi feels that its continuation, expansion and extension are important to the natioi research effort against heart disease, cancer and stroke. Recommendation 18 t cfeveloF The Commission recommends that the Federbl Governmen standard Government-wide policy for payment of the full costs attributable research grant awards. The Commission is convinced from its studies that the failure to the full costs of research through grant awards is a real deterrent to the furt development of research potential. Because of the great amount of material Congressional and administrative reports on this subject, it is not necessary information in this report. repeat the basic One of the major policies recommended by the CommisEion is that the Fedc Goverranent has the responsibility for continuing and broadening its support research which will generate neiv knowledge essential to the control of he disease, cancer and stroke. Therefore, it is strongly urged that a policy 52 adopted for the payment of the full costs attributable to a research grant un HEART DISEASE. CANCER AND STROKE a standard Government-wide approach. PART I hapter Six EDUCATION AND TRAINING OF HEALTH MANPOWER Many factors combine to increase the demand for additional manpower across the entire range of the health sciences. The expanding population, the rapid growth of its aging component, and other social forces are creating demands for medical care far beyond the present capacity of practicing health profession- als. The swift growth of biomedical science creates parallel demands for increas- ing numbers of highly trained scientists. Moreover, developments in both re- search and the practice of medicine have led to the creation of new technical and supportive discipline@ssential to high-quality work-which are in very short supply. The education of a physician or a research scientist requires many years. is long lead time precludes overnight attainment of manpower goals. But action now is essential if we are not to drop still further behind. Faced with over- whehning needs and inadequate resources, the Commission recommends pro- grams of intensive effort for manpower development. These involve Federal participation-to a degree not previously recognized as desirable, or necessary-in (a) expanding the basic resources and facilities for educating and training health personnel, both professional and sub-professional; (b) providing increased opportunities for education and training to recruit more promising young people into the health occupations; and (c) increasing the effec- tiveness of the highly skilled health manpower now available. Trained manpower devoting its full time and talent to problems of heart disease, cancer and stroke is an absolutely essential element of progress against these diseases. This concentration cannot be achieved entirely or even principally at the ex- pense of the existing total manpower pool, without seriously crippling our national medical effort. The objectives outlined here simply cannot be realized without increased numbers of physicians, dentists and medical scientists. Therefore, the Commission recommends a program of forthright support o medical education. The specific recommendations which follow and those deal- ing with medical school support in Chapter Three are component parts of this fundamental declaration of policy. Expansion of Resources for Preparation of Health Manpower Recommendation 19. The Commission recommends that legislation be sought to permit forthright support of medical education, this program to in- clude formula grants to the health prolessions schools. Immediately, there should be full utilization of the Health Prolessions Educational Assistance Act TheCommissionfurtherrecom- 53 m@s substantially greater and more diversified Federal support of programs HEART DISEASE, CANCER AND STROKE ly of physicians, dentists, and medical scientists designed to increase the supp he Commission recommends: Specifically, t A. That the ceiling on appropriations in the Health Professions Educati( at a several-fold increase in appropriat- Assistance Act be eliminated and th be provided so that adequate facilities will be available to all schools capabl expanding their output of physicians and to offer further Stimulus to ools; development of new scb B. That active consideration be given to a program of Federal support for to achieve the most r creation of 2-year medical schools in existing colleges, could then be pl@ the number of physicians in training who increase in without substantial difficulty for the clinical portion of their training in exis ate teaching staffs. munity hospitals with adequ medical schools or corn as 2,000 additional spaces could be r, It is re liably estimated that as many edical schools if funds were available under the H, available in existing m Educational Assistance Act to facilitate their expansion. Scl Professions ts totaling more than one-half bi have expressed their intent to request gran dollars as compared with an appropriation ceiling of $35 million. Moc these expressions of intent refer to expansion of existing facilities rather construction of new schools. There are comparable demands for expansi( dental and public health schools. In the Commissio@s view it is short'SiE and tragic in the extreme to frustrate the basic intent of the Health Profes Educational Assistance Act by an arbitrary limitation of funds which, in e akes it impossible to utilize to the fullest extent the nation's capacit, m dental education. medical and In addition, it has been estimated that from 2,000 to 3,000 vacancies ex. medical schools for third-year students. The creation of two-year mc er in students would receive the basic SC schools in existing colleges, wh e portion of their training at minimal additional expense, would make it po@ to fill these existing spaces in the shortest possible time and thereby mak quickest impact on the shortage of physicians. Recruitment for the Health Professions Recommendation 20. The Commission recoynmends progrants des to attract young people into the health professions and related discipliner Specifically, the Commission recommends: A. That a program of project grant support for health careers educatio recruitment activities be established, whereby funds would be made availal a matching basis to community agencies or medical institutions, with pref( being given to coordinated community effort, to mount such prograi strengthened health education programs in grade schools and junior high SC to communicate health information and interest children in health careers; science fairs in which leading medical institutions would sponsor and assic Schoch students in developing health interest; community speakers' bureai sources of recruitment literature on health careers; summer employment 54 tunities for young people in laboratories, hospitals, health agencies, etc. HEART DISEASE, CANCER AND STROKE ommended appropriations to the Public Health Service for this purpose wo million the first year, with incremental steps to a level of $10.6 million in the fifth year of the program. B. That central sources be established for information, production of educa- ti6nal materials and audiovisuals, to stimulate and implement this national program of recruitment for the health sciences, both within the Public Health Service and in the headquarters of national professional and voluntary organiza- tions. C. That the Health Professions Educational Assistance Act be amended-to provide for a program of Federal scholarships for talented medical and dental students in need of financial assistance to complete their professional education, with,a matching cost-of-education grant to the professional school accompanying each scholarship. During recent years, the number of college graduates has been increasing, but the proportion of college graduates applying for medical school has de- clined. Among the reasons why medicine as a career has declined in popu. larity are the high cost of medical training; competition from many other StiM- ul@g careers, especially in science; and the comparatively small number of scholarship and training grants available for medical students. A considerable number of fellowships are available for graduate work in the sciences through the National Science Foundation, National Institutes of Health, the Department of Defense, other Goverziment agencies, and private industry. Fellowships are available in other fields under the provisions of the National Defense Education Act. Yet very few fellowships or scholarships have been made available for medical students, except for those being trained specifically for research work. There are a number of constructive measures which can be taken to overcome these obstacles. There should be an expansion of scholarships from Federal, State, and private agencies for students in medical schools, especially for those from lower income families who cannot afford the high cost. The program of Federal scholarships originally proposed for the Health Professions Educational Assistance Act for talented medical and dental students in need of financial assistance would greatly enhance both the quality and quan- tity of applicants for medical education by broadening the base of recruitment to include students coming from families with low or moderate incomes. The matching cost-of-education grants of $1,000 for each scholarship would also be of assistance in meeting the operating deficits of the medical and dental schools. Undergraduate Training in Medical and Dental Schools Recommendation 21. The Commission recommends the continuation and expansion of e@ting grant programs to support undergraduate training in medical schools in heart disease; undergraduate training in medical and dental schools in cancer; and medical undergraduate training in rehabilitation. in addition it recommends the development of an undergraduate training @support program in stroke, administered by the National Institute of Neurologi- 55 cal Disemes and Blindness. HEART DISEASE, CANCER AND STROKE Specifically: raduate training grant appropriations to the Nationa A. The current underg Heart Institute should be continued and increased by about $1.55 million annuall) to permit eligible schools to receive grants of $40,000 per year. B. The undergradute training program in cancer administered by the Nationa Cancer Institute should be broadened to include the development of demonstratior programs in the detection of cancer and care of the cancer patient and expande( so that it is possible to incorporate cancer training in training programs f or intern,, and residents. C. In view of the need' for undergraduate training in --stroke, it is recommendec- that $2 million be appropriated annually to the National Institute of Neurolo-ica@ Diseases and Blindness for the development of an undergraduate training prograrr. in stroke. D. Additional funds should be made available to the Vocational Rehabilitatioi Administration to expand its present program for medical underaraduate trainini in rehabilitation. It is recommended that $9.5 million be appropriated over a five-year perio( starting with $1 million the first year to the National Cancer Institute to provide grants to those medical schools which develop specific educational programs ii these aspects of cancer control. The following is a summary table of recommended appropriations needed to ex pand undergraduate programs in medical and dental schools: Year AREA 1 4 5 Heart D;i'sease* ...................... 1. 55 1. 1. 5' Cancer* ............................ I. o I. 5 2. 5 Stroke* ........... ................. 2. 0 2. 0 2. 0 2. 0 2.0 Rehabilitation* ........... Dental school grants* ........... 56 HURT DISEASF, CANCER AND STROKE 'Figures in millions of dollars. etection of E. In view of the important role played by the dentist in the early d oral cancer and the need for the education of dental students with regard to cancer control, the Commission recommends an increase of $10,000 in the annual under- graduate training grant presently awarded to dental schools by the National Cancer Institute. This will require an additional annual appropriation of $500,000 to the National Cancer Institute. F, In the light of the importance of preventive activities associated with control of heart disease, cancer and stroke greater emphasis should be given to preven- tive medicine in medical school curricula, with special attention to the chronic disease field. Tra -uting for Research Reconunendation 22. The Commission recommends that the national pro. gram of research train' grants be enlarged and expanded at a rate commensu- tng rate u*h @ training capacity of organizations so engaged and the national pool Of young investigators desirous of such training. Specifically, the Commission recomniends: A. That the existing programs of research training grants and fellowships in heart disease, cancer, and the general medical sciences he expanded; The following table sun'un'arizes the recommended appropriations over and above current NIH appropriations to expand the research training programs in heart disease, cancer and stroke: Year AREA 2 3 4 5 NHI-Training grants and fellowships*. 4. 3 5.2 6. 3 7. 5 75 NCI-Training grants and ferowol ps*. 4. 3 5.2 6. 3 NINDB-Tiaining grants and fe - ships ....................... .... 1. 0 1.0 1. 0 1.0 1. 0 ,NIGMS-Training grants and fellow- ships* ............................ 6. 0 9. 25 12. 5 15. 5 18. 5 Training 'm animal care* .............. 0. 5 0.75 1. 0 1. 2 1. 5 57 i. imoin of doUars. HURT DISEASE, CANCER AND STROKE ses and Blindness shoul( B. That the National Institute of Netirological Disea develop a research training grants prograrfi in the field of stroke, and in addition that funds should be made available to the Vocational Rehabilitation Administra tion for training grants in rehabilitation; C. 'Mat the Division of Research Facilities and Resources of NIH be giver the authority and funds to support training programs for specialists in animal car( and medicine. Research is conducted by the minds of trained scientists. It is in the nations interest, therefore, to insure a continuing and expanding supply of biomedica scientists adequately trained to guarantee the quality of health research tomorro-,%- The funding instrument most suitable to the task of assisting the university, o- other research-educational organization,.in roviding such advanced training i@ p the "training grant." This instrument permits local identification of young mer and women with research potential, provides them with appropriate stipend, and, equally important, by diverse means assists the institution to improve th( quality of research training while enlarging its capacity for so doing. This program has resulted in a pronounced upgrading of research traininE during the last 5 years. Its continuation and growth ir, vital to the entire healtl researc enterprise. Indeed, failure at this time to expand such training sup. port must, automatically, limit the magnitude of the entire national health re search program in subsequent years. Universities have developed a variety of mechanisms for enriching the experi. ence of potential physician-investigators. The most formal of these lead to the simultaneous award of the M.D. and Ph. D. degrees. In any case, the student so engaged must devote several additional years to al degree, under- this experience, as well as satisfy the requirements for the medic The following appropriations are reconunended to mount a program in clinical training in heart disease, stroke and rehabilitation. Year AREA 1 2 3 4 5 Heart Disease* ..................... 5. 0 7.0 9. 0 12. 5 15. C Stroke* ............................ 1. o 1. 0 1. 0 1. 0 1. Rehft .................... 1. 0 1. 0 1. 0 1. 0 1. @ilitation 58 HURT DISEASE, CANCER AND STROKE 'F@ft in millions of d.Uais. take several years of residency training, and perhaps serve his obligated military experience before actually embarking on a research career. This is demanding not only of his time but of the financial resources of his family. Withou@t ilddi- donal support, clearly the pool of clinical investigators becomes limited to those whose families possess the financial resources to underwrite this lengthy and expensive program. The Conunission therefore urges that consideration be given to a new national program providing full financial support to those students who aspire to a career of medical research and for whom the institution provides a clearly defined pro- gram which combines medical education with research training. Support of Clinical Training Recommendation 23. The Commission recommends the establishment of clinical fellowships and full-time clinical investigatorships in heart disease and stroke, the expansion of clinical training programs in cancer, and the establish- ment of clinical fellowships in rehabilitation. A. In the heart disease and stroke fields there is urgent need for clinical training for the physicians who are ultimately responsible for carrying the fruits of research to the majority of the American people. And yet, under cur- rent policy guidelines the National Heart Institute and National Institute of Neurological-Diseaws and Blindness can only support training that is research oriented. Greater emphasis must be placed on the training of superior clinical physicians. of clinicians who are capable of precise There is a great need for a larger corps diagnosis and providing the best of treatinent@linicians with minds capable of recognizing and applying new discoveries and clinical observations. To meet this need, authority should be granted and the funds appropriated to the Public Health Service for the establishment of clinical fellowshi- and full-time clinical PS investigatorships in the cardiovascular field. B. To recruit medical graduates into cancer specialties in which there is a marked shortage of personnel, the Commission reconnnends that $500,000 per year be appropriated to the Cancer Control Program in support of residency training in a limited number of specialties essential for progress in cancer con- trol ttnd unlikely to lend themselves to private specialty practice. A supported resident should be required to spend at least one year of his training period in work directly related to cancer and the details of his training program should be specified at the time grant requests are made. In addition, the existing program of Senior Ctinical Traineeships administered by the Cancer Control Program should receive appropriations of $3.5 million to increase the present number of traineeships to the level of 300. It is further recommended that priority should be given to those specialties necessary in can- cer control which have the greatest personnel shortage-for example, radiology, radiotherapy, physical medicine and rehabilitation, preventive medicine, pathci- ogy, anesthesiology, and epidemiology. C. A program of clinical fellowships in rehabilitation will substantially in- 59 @, r crease the number of physicians capable of rendering the best in rehabilitative HEART DISEASE, CANCER AND STROKE care. To this end, the Commission recommends that funds be made available to the Vocational Rehabilitation Administration to initiate such a program. Stabilization ol Academic Positions Recommendation 24. The Commission recommends the establ'ishment of /uU-time career au)ards in universities and other in-s@utiorm, not only for re- search personnel but also for clinical investigators and clinical professor$. The research career awards program of the National Institutes of Health has made a vital contribution by establishing stable positions for career investigators in universities. Through this program leading scientists have been able to plan and pursue lifetime research careers without depending upon year-by-year approval of specific projects. The Commission regrets the fact that a moratorium has been declared on new appointments to this program and urges that support be increased so that the program may be expanded. There is, in addition, a pressing need for the development of stable academic positions to encourage the lifetime pursuit of teaching careers in medicine. Fel- Iowships and career awards parallel to those awarded for research are necessary to support faculty members in clinical investigation and practice. Such faculty members could vitalize and broaden the program of every clinical department and more effectively close the gap between advancing scientific knowledge and application. The recommended program would involve.the establishment of full-time posi- tions in universities and medical schools for clinical investigators or clinical pro- lessors. IIn some instances such professorships might be used to recruit some of our best practitioners from a heavy private practice and enab le them to con- centrate on teaching. Recommended appropriations to implement this program would be at the level of $8 million and progress to $24 million in 5 years. Training of Health Technicians Recommendation 25. The Commission recommends greatly increased effort and investment in the recruitment and training of health technicians and other paramedical personnel whose skills are essential to the control dl heart disease, cancer and stroke. Specifically, the Commission recommends: A. The establishment of a coordinating office within the Department of Health, Education, and Welfare to provide liaison among the agencies supporting educa- tional programs which could be of great ir4portance in training ancillary health manpower, such as the Manpower Development and Training Act of 1962, the Vocational Education Assistance Act of 1963, and the Economic Opportunity Act of 1964. B. A program of stimulation grants administered by the Public Health Service, made available to community and junior colleges for the development of teaching methodology, curriculum, and courses for the training of personnel such as asso- 60 ciate degree nurses, laboratory technicians, and the full range"of'technical per- HEART DISEASE, CANCER AND STROKE sonnel that can support and extend the work of the frontline professionals; appro- priations recommended for this program would be@in at the level of $0.4 million LI and progress to $2 million in the fifth year. C. Increased support of the pro-ram for trainin- medical technicians, includ- ing technologists and other specialists essential to the detection and treatment of cancer, now existin- in the Cancer Control Pro@ram, from its present level of $1.5 C) ents thereafter million per year to $2.5 million in the first year Nvith annual inerem of $1 million. The supply of health manpower to support a full-scale attack on heart disease, cancer and stroke can be recruited and developed only if full use is made of exist- ing programs and authorities, especially those which can recruit into the ancillary health disciplines persons not normally attracted into health pursuits, including the economically disadvantaged, and technologically displaced, the handicapped, and the elder citizens. It is ironic that the health disciplines suffer from chronic shortage at a time when the nation as a whole is experiencing serious problems of manpower surplus. Training of Specialists in Health Communications Recommendation 26. The Commission recommends that the Oflice of In- formation and Publications in the Oflice of the Surgeon General be allocated a specific annual sum of $1 million solely for training specialists in health com- munications. Specifically, the Conunission recommends: A. A grant program to educational in stitutions for the development of pilot training programs in the field of medical communications. Such grants should support the development of a core curriculum, the payment of faculty, and pro- vision of stipends for trainees. A university which has both a medical center and a school of journalism would serve as an excellent setting for these pilot training programs in communications. B. Provision of fellowships for the on-the-job training of a variety of per- sonnel in the gathering and writing of science information materials. Many of these men and women would be trained in the various agencies of the Public Health Service; many would be trained in our medical centers ancl large research institutions throughout the country. In addition we recommend that the Public Health Service conduct and support seminars and other methods designed to give professional science writers the background they need to write accurately, responsibly, and clearly on health subjects. Continuous Assessment of Health Manpower Needs Recommendation 27. The Commission recomraends the establishment in the Bareau of State Services (Community.Health) of the Public Health Service of a health manpower unit, comparable to the research manpower unit of the National Institutes of Health, responsible for continuous assessment of 61 national manpower requirements for health services. HEART DISEASE, CANCER AND STROKE Such unit would have the following responsibilities: (1) To develop baseline information on medical manpower and analyze its meaning; (2) to develop national goals relating to medical manpower and resources; (3) to conduct and support studies and demonstrations related to determining manpower needs, defining specific problems, and recommending improved training and recruit- ment programs to overcome these manpower problems; and (4) to disseminate information on all aspects of health manpower. Appropriations of $0.5 million for the-first year, increasing to 81 million by the fifth year, are recommended. It has been estimated that by 1975 there will be a need for 172,000 additional medical technicians for laboratory work alone. If needs for other types of health technicians were added, the requirement becomes staggering. However, no good estimates of need are available. Studies have been made in recent years of the needs for physicians, dentists, and nurses, but the health technician field has been largely ignored. Therefore, the Commission further suggests that the Surgeon General appoint a group to study the problem of health technician personnel and develop recom- mendations for its solution. 62 HEART DISEASE, CANCER AND STROKE PART I hapter Seven ADDITIONAL FACILITIES AND RESOURCES .Many additional facilities and resources are required to mount the full-,-zcale attack on heart disease, cancer and stroke envisioned by the Commission. The two parallel thrusts of the campai@n-the application of existing knowl- edge through patient care and the development of new knowledge through re- search-@both depend upon supporting services which, like the basic manpower and facilities already discussed, are in short supply. Expanding Patient Care Facilities Recommendation 28.. The Commission wholeheartedly endorses the 1964 ,Amendments to the Hospital and Medical Facilities Construction (HiU-Burion) Act and urges their full implementation. It is further recommended that more funds be made available for the expansion'of long-term care facilities affiliated wtth hospitals. The Hill-Burton program for the construction of hospital and medical facilities, administered by the Public Health Service, has been one of the most remark- able achievements in the history of bringing better health to more people in any part of the world. This program has received widespread recognition and acceptance by the people of the United States and by its Congress. The 1964 Amendments to the Hfll-Burton Act, in addition to extending the life of the program, contain important new provisions which will enable the program to meet these changing challenges more effectively. It provides for- 1. A new grant program for modernization or replacement of public and non- profit hospitals, and other health facilities, giving special consideration to those located in the more densely populated areas where the greatest need exists. 2. A program of project grants to help develop comprehensive regionaL metro- politan area, or other local area plans for health and related facilities. 3. A single category of long-term care facilities, which combines the pre- viously separate grants programs for chronic disease hospitals and nursino" homes, and lifts the annual ceiling from W million to $70 million. 4. The use by States of 2 percent of their allotments (up to $50,000 a year) to assist in the efficient and proper administration of the State plan. The Commission, in endorsing this forward-looking legislation, considers that the continued strengthening of the nation's patient care facilities is an indispen, sable ingredient in the national program against heart disease, cancer and stroke. This need is particularly acute in the area of long-term care facilities to serve the rapidly increasing numbers of patients suffering from the chronic dis- 63 eases and requiring such care. HEART DISEASE, CANCER AND STROKE Strenztheniitg the Federal Hospital Program Recom7nendation 29. The Commission recommends that existing Federal hospital systems administered by the Veterans Administration and the Public Health Service be given authority and funds which will enable them to augment their contribution to research, training and patient care in heart disease, can- cer and stroke. Specifically, the Commission recommen be given increased appropriations to A. That the Veterans Administration carry out research in aging and chronic disease, including heart disease, cancer nds to make research project grants to and stroke; the specific authority and fu affiliated medical schools for collaborative research projects in these fields; and the increased appropriation necessary to further develop its existing program of scientific manpower training. B. The Division of Hospitals of the Public Health Service be appropriated funds necessary for renovation and the development of research space in existing facilities, and for increased research and training activities. With its 168 hospitals, 89 affiliated with medical schools, and 91 outpatient clinics and re-ional offices, the Veterans Administration has the largest system of healthcarefacilitiesintheworld. Inthepastyear6lO,GOOpatientswereadmitted to VA hospitals; 3,695,000 were followed as outpatients. Of the patients ad- mitted, 107,00-0 had cardiovascular disease and 40,000 had cancer, newly diag- nosed in about 30,000. A professional staff of more than 9,000 physicians, psychologists, social workers, and Ph. D. scientists provide a high level of care as well as participate extensively in research, education, and training activities. The VA is carrying on a vigorous program of fundamental and clinical research. Its staff participated in 6,500 research projects in Fiscal Year 1964, with 2,000 of them related to heart disease, cancer, and neurological diseases. Much of this research effort is conducted in association with 78 "-affiliated medical schools. in the area of education and training, nearly 18,000 undergraduate and grad- iiate students in medicine or allied fields received some part of their training in VA facilities in 1963. Among these were 10 percent of the nation's medical residents. The Commission commends this major contribution to the nation's research and training effort and urges that the Veterans' Administration be supported in further developing these vitally important programs. It ur@es also that the smaller but still significant Public Health Service hospital syste@ which has taken promising steps toward an increased research and train- ing program in recent years, be supported in the development of its full potential for research and training as well as patient care. Medical Libraries Recommendation 30. The Commission recommends that the National Library of Medicine be authorized and adequately supported to serve its logical 64 and necessary function as the primary source for strengthening the nation's HEART DISEASE,CANCER AND STROKE medical library system. Specifically, the Commission recommends A. That 82 million per year for a 5-year period be made available to the National Library of Medicine for intramural research and developmental activities to explore new technologies for more efficient management and dissemination of the world's biomedical literature; B. Th at not less than $30 million per year for 5 years be authorized and appropriated to the National Library of Medicine for a program of grants and contracts to su ort improved medical library services in the United States- pp including facilities, resources, training of personnel, secondary publications, and library and communications research; C. That broadly conceived legislation be initiated clearly authorizing the National Library of Medicine to assist medical libraries in the ways recommended herein. Communication of information to scientists and practitioners is critically im- portant to progress in research and application of medical knowledge. Medical libraries are the primary vehicle for accomplishing this communications process. Yet the nation's medical library system is grossly inadequate for the task, due to a serious imbalance of extramural support. For example, in 1964 the Public Health Service appropriations totaled over $1 billion. But less than $1 million accrued directly or indirectly to the extramural support of medical libraries. The National Library of Medicine is the cornerstone of the national medical library network. Through its development of the world's largest collection of the published medical literature and through its sponsorship and operation of the MEDLARS syste m, the largest c(yrnputer-based information storage and retrieval system yet to be devised, the NLM has demonstrated its ability to improve the methodology and efficiency of this medical library network. It is urgent that further steps be taken to enable NLM to improve the efficiency of this network. But to exercise its proper leadership the NLM requires both broadened legis- lative authorities and additional funds for the purposes of strengthening and enlarging its intramural activities, and for the purpose of conducting the type of extramural support program the Commission has in mind. The Commission's recommendations are directed simultaneously to the strengthening of NLM and to the bolsteri ng of the other components of the nation s medical library network. National Medical Audiovisual Center Recoramendation 31., The Commission recommends that the Public Health Service Audiovisual Facility be enlarged in scope and strengthened so that it may become a National Medical Audiovisual Center. To this end we recommend the following specific steps: A. The appropriation of $1.5 million for necessary renovation and expansion of the existing physical plant. B. Appropriation of $1.5 million for the first year, scaled upward to $4 mil- lion for the fifth year, to develop an intramural program at the Audiovisual 65 Center which would include production, experimental use and evaluation of HEART DISEASE,CANCER AND STROKE ucational materials in such areas as radio, televisions motion pictures, pro- ed fields; udiovisual mmed instruction, etc.; research and trainin- programs in a gra international exchange of medical motion pictures; and other purposes. on of an extramural program of grants and fellowships and C. Authorizati t the level of $1.5 million appropriations to support such a program btginning a per year and rising to $8 million at the end of a 5-year period. Such a program would enable the Audiovisual Center to support selectively promising projects in audiovisual communications at medical schools, community hospitals, and other institutions and to assist, through training grants and fellowships, in the development of a national cadre of medical communications specialists. In addition to the program outlined above, the National Medical Audiovisual Center s@ould exert immediate and strong leadership in two communications media of particularly high promise for continuing education of the health professions. These aTe, first, the field of closed circuit television which is already being used sporadically, to a limited extent, by medical schools, hospitals and other health agencies; and second, the use of portable projectors for cartridge-type films which are especially adaptable to private use by physicians in their own offices, at times of their own choosing. We therefore recommend that: (a) an appropriation of 82 million per year, initially, be made to the National Medical Audiovisual Center for the specific purpose of developing, disseminating and evaluating closed circuit television programs on subjects of vital interest to the health professions, and (b) an initial appropriation of $1 million per year be made to the National Medical Audiovisual Center to produce short films for use in cartridge-type projectors, and to promote the widespread use of this promising new educational device by the medical profession. Stallaical Programs Recommendation 32. The Commission recommends improved systems lor the collection, interpretation, and dissemination ol statistics ess'@ntial to the understanding and efficient control Ot heart disease, cancer and stroke. Specifically, the Commission recommends: A. A project grant program to the States administered by the National Center for Health Statistics to finance the salary of competent statisticians and supporting services, designed to improve the quality and timeliness of data collected through death registration; to carry out epidemiological studies using the death record as a point of departure; and to permit intensive analysis of mortality data. The sum of $750,000 should be appropriated to initiate this program,. increased to $1.5 million in the second year and reaching a level of $3.5 'Million by the fifth year. B. Full support of the Public Health Service request for funds to survey hospital discharge records on a sampling basis. 66 C. Stimulation by the Public Health Service of studies of medical practice to AND STROKE determine methods of treatmen HEART DISEASE, CANCER t in everyday use. D. A grant program administered by the National Center for Health Statistics for the training of individuals in health demograp4y, providing both academic graduate training and applied training. The estimated cost of supporting about 70 students in such a program is $500,000 per year. I E. A program to educate physicians and others in the proper methods for cer- tification of cause of death, and a small continuous survey to evaluate the quality of the medical record. F. Appropridtions of $500,000 per year to the Division of Chronic Diseases for the establishment of a National Center of Program Statistics in heart disease, cancer, stroke, and other chronic diseases, to provide to the operating programs essential data on the nature and magnitude of specific disease problems in' com- munities and the present utilization of existing care resources. G. That cancer be made a reportable disease and that' the sum of $1 thilhon per year be made available to the National Cancer Institute to be used in assist- ing States in initiating cancer reporting systems. Assistance should be provided in organizing the reporting system, providing consultation services, purchasing equipment, and providing temporary clerical or other services, in an amount not to exceed $50,000 for any State 4!iring the first year and not to extend beyond 3 years. Priority in establishing cancer reporting systems should be given to States representative of the various regions in the Unit6d States. The Commission, in reviewing existing statistical data on heatt disease, cancer and stroke, recognized certain areas of vital and health statistics that are in ii6ed of development. In our expanded national effort to reduce the toll of heart disease, cancer and stroke, strong statistical programs are necessary to describe the nature of the problems to be dealt with, to pinpoint targets for eff ective action, and to provide indications of progress toward the goals. Animal Resources for Biomedical Research Recommendation 33. The Commission recommends additional appro- priation-s and authority as needed to enable the Division of Research Facil@s and Resources, NIH, to support an improved national program of construction of laboratory animal facilities, to construct specw regional facilities, and to support the training &/ specials in the care of animals needed for biomedical research. Specifically, the Commission recommends: A. That the Division of Research Facilities and Resources be given increased appropriations to implement i national program of construction and improve- ment of integrated institutional animal facilities and resources; B. 'Mat the DRFR be given specific appropriations to construct and operate two or three regional Laboratory Animal Genetic Centers (other than Primate) and two or three regional centers for Research in Laboratory Animal Medicine (other than Primate) C. That thf, capabilities of existing institutions be fully utilized through a 67 program of project grants and contracts; HEART DISEASE, CANCER AND STROKE D. That the DRFR be given the specific legislative authority and appropria- tions necessary to support training programs for veterinarians, husbandrymen, and other animal disease specialists. Appropriation levels recommended for these activities are $10 million for the first year increasing to $20 million by the fifth year. Many striking advances in disease control could not have been achieved without the use of laboratory animals. As research vistas widen, the depend- ence on animal test systems becomes greater. The need is not only for increased number but also for improved quality, both in respect to freedom from disease and to specificity of genetic makeup. The sophisticated research of today demands sensitive instruments which can reproducibly record subtle changes. If the research animal, which represents such a sensitive system, by virtue of disease or variable genetic constitution, reacts inconstantly or unpredictably to experimental situations, time, money, and the experiment are lost. Such occurrences are, in fact, not uncommon. Inade- quate animal housing facilities, often by promoting a high incidence of infection, have frequently accounted for such experimental fai ures. 'I The Commission's recommendations are designed to strengthen our laboratory a.nimal resource in a number of ways to assure that biomedical research in heart disease, cancer and stroke will not be delayed or negated by failures in the supply, nature, and condition of laboratory animals. 4 Clearinghouse for Drug Information Recommendation 34. The Commission endorses current proposals for the establishment of a National Drug information Clearipghouse, in association with the National Library of Medicine, serving and supporting governmental and nongovernmental drug information units. The proposed. clearinghouse would include full information on the chemical structures and biological properties of all known compounds and the derivatives of such chemicals, with regard for their cellular, environmental, and social effects. It would gather information from all reliable sources, including the published liter- ature, conference proceedings, government reports, and other records. Further, the clearinghouse would produce, both for general and specific users, annotaW bibliographies, systematic files of information on drugs in forms suitable for replication, critical reviews, compilations of evaluated data, judgmental responses to individual inquiries, and other appropriate information. Improper use of drugs is today an important cause of avoidable disease. The gaps and wasteful duplication associated with present independent efforts to handle drug information are responsible for much important information failing to reach those who need it most. Therefore, in view of the progressive increase in the consumption of medications and other chemical products, the proposed clear- inghouse will serve an im ortant national need. p International Research and Training Programs 68 Recommendation 35. The Commission endorses the principle t support HEART DISEASE, CANCER AND STROKE of research outside the United States by competent foreign nationals, collabo- rative research involving American and foreign laboratories, training of American scientists in foreign laboratories and of foreign scientists in Ameri- can laboratories are in our national interest, and endorses programs designed to achieve such ends. The Commission suggests the following guidelines: A. Cooperative research projects and programs representing joint efforts of American and foreign investigators should be budgeted from funds appropriated in support of domestic rather than international research. B. Health research and training in those nations wherein there are substantial amounts of Public Law 480 funds should be supported to a maximum extent pos- sible up to the limits of their resources of trained manpower and research facilities. C. Increased opportunities should be made available to foreign graduates to allow them to come to the United States for further training ifi biomedical and clinical research so that such newly acquired knowledge can be applied on their return to their native countries. D. In scientifically and economically more privileged countries where re- search and training activities are good, the following guidelines are recommended: (a) Federal agencies supporting research and research training should con- tinue such activities in all nations in which such opportunities exist; (b) The criteria for judging applications for research grants from such coun- tries should be unusually rigorous with respect to the quality of the project proposed and the competence of the investigator-applicant; (c) The magnitude of ohr health research support program should reflect local opportunities and the needs of agency programs rather than an ar- bitrary fixed fiscal ceiling; (d) Prior to payment of research grants overseas, a representative of the agency concerned, together with our Science Attachi in that nation, should enter into negotiation with appropriate officials of the nation concerned with a view to establishing -the terms and limits of the research support in question. International research offers unparalleled opportunities for advancing our knowledge of heart disease, cancer and stroke for a number of reasons. The United States-has by no means a monopoly on scientific excellence in these fields. Moreover, the contrasting patterns of disease in different cultures may offer important clues to their control. Still further, the interchange of research philosophy and methodology between nations has proved highly produc- tive. T'he Commission therefore urges that international programs he maintained at levels consistent with the mutual interests of the nations and scientists involved. 69 HEART DISEASE, CANCER AND STROKE. PART I hapter Eight 4 RECOMMENDED CHANGES IN LEGISLATION AND ORGANIZATION 0 factors: legislative Federal action in any field depends basically upon tw authority as expressed in laws passed by the Congress, and funds appropriated by the Congress each year to carry out these authorized activities. A third fac- tor important to the effectiveness of Federal programs is the organizational structure of the agencies involved. Many of the recommendations of the Commission, as described in the pre- ceding chapter, can be carried out by the Public Health Service or other agencies operating under their existing authorities. As has been noted in the case of each separate recommendation, many of the programs proposed will require addi- tional appropriations if the attack against heart disease, cancer and stroke is to be advanced at an accelerated pace. Some of the recommended actions, however, cannot be undertaken without chan-es in existing legislative authority or the creation of new authority. There- fore, in this Chapter, recommendations concerning the most important legisla- tive needs are indicated. In addition, it includes a recommendation for reorganization within the Depart- ment of Health, Education, and Welfare which would, in the Commission's view, greatly facilitate and strengthen the full-scale campaign against heart disease, cancer and stroke. 1. LEGISLATIVE RECOMMENDATIONS The first legislative recommendation of the Commission, as set forth below is for a comprehensive amendment and recodification of the Public Health Serv- ice Act. The reasons underlying this recomniendation stem from the fact that the present Act is seriously obsolete. The type of national attack needed to re- duce the toll from heart disease, cancer and stroke cannot be fully mounted until more effective legislative devices are made available. However, recognizing the time required and the difficulty involved in securing the drafting and enactment of a legislative modification of such magnitude,, interim.legislative proposals are recommended for those new or changed au. thorizations so important to the campaign against heart disease, cancer and stroke that they cannot await the omnibus revision. 1. Revision of the Public Health Service Act The last major overall revision or codification of the Public Health Service Act was done 20 years a-,O. 70 In the intervening 20 years, however, there have been tremendous changes in HEART DISEASE, CANCER AND STROKE all areas of the health field. The rapid growth of the biomedical research effort has produced numerous pressing needs for more effective legislative devices. At the same time the growth in importance of the chronic diseases has had a great impact on health programs. The recognized need for comprehensive com- munity health services demands of the Public Health Service a mission and a program of action that far exceed the confines of public health agencies in the past. The response to this changing challengehas thus far taken the form of piece- meal, spasmodic amendments to the basic Act as particular pressures and needs arose. It has become abundantly clear, therefore, that if the program proposed by the President's Commission on Heart Disease, Cancer and Stroke is to be effectively implemented, as well as for many other important reasons, there must be a thoroughgoing and comprehensive revision and recodification of the Public Health Service Act. The matter should be given intensive study by experts in the field, and a legal instrument suitable to the health needs of the nation in these times and for the future should be developed and enact@d. Because studies of legislative change tend to be prolonged and laborious, it is important that a deadline be set for completion of this action. Recommendation It is recommended that the Department of Health, Education, and Welfare establish a task force to develop a comprehensive revision and recodification of the Public Health Service Act by November 1, 1965. 2. Expansion of Resources for Preparation of Health Manpower The Commission recommends that legislation be sought to permit forth- right support of medical education, this program to include formula grants to the health professions schools. Immediately, there should be full utilization of the Health Professions Educational Assistance Act of 1963 and the Nurse Training Act of 1964. The Commission further recommends substantially greater and more diversified Federal support of programs designed to increase the supply of physicians, dentists, and medical scientists. 3. Construction and Operation of Health Research Facilities The need to expedite a direct and immediate research attack upon heart disease, cancer and stroke on a nationwide basis has underscored the importance of flexible authority to construct and operate research facilities to meet the national and regional needs in these areas. The principal deficiency which greatly hampers the efforts of the National Institutes of Health in these fields is that current authorizations are much too low to meet existing requirements. in addition, the rigid ceiling of 50 percent which the Federal Government may now contribute in matching monies to aid in the construction of health research facilities should be lifted to a new maximum of 75 percent-the same ceiling now in force with regard to Federal participation in the construction 71 of mental retardation research facilities. HEART DISEASE, CANCER AND STROKE The present 50 percent ceiling for other than mental retardation research facilities works a most severe hardship on those institutions in less economically favored parts hich cannot compete, in raising matchin- monies, of the country w Z5 with the large, established research complexes. Yet these smaller and financially weaker research institutions are the very ones we must strengthen if we are to achieve a truly broad, regional expansion of our research effort. There is also a lack of nonmatching authority for the construction of research facilities that are national or regional in their scope. Therefore, because of the urgent need to expedite the national research effort on heart disease, cancer and stroke, the followin@ recommendations are made: Recommendations A. There should be an increase in the annual appropriation authorization for health research facility construction from the present $50 million to at $150 million. y the Federal Government should be increased B. The participation b rom 50 to 75 percent. C. New substantive authority should be given to construct, on a nonmatching basis, and to provide for the operation of, by contract or otherwise, research facilities for national regional research purposes. 4. Construction and Operation of Facilities for the Application of the Fruits of Research One of the major recommendations of the Commission is designed to assure that the best that modern medical science can offer for diagnosis and treatment of heart disease, cancer and stroke is accessible in all areas of the nation. The Commission's view is based upon its conviction that the value of the national inv@, estment in research is wasted unless the fruits of research are applied for the benefit of all the people when and where the need exists. For these purposes, a grant pro,,ram is proposed for the establishment of diagnostic and treatment stations in appropriate academic and,community institutions. The operational support for care in such stations would, as in all such institutions, rome from a variety of sources. This proposal does not in any way affect the normal methods of payment for care, such hs direct payment by patients and third-party payments through private insurance, public welfare payments, and other sources. The proposed participation is in the nature of a stimulation grant to help provide the nucleus for operations and help assure that the best quality of service is available for all of the people. Recommendation New substantive authority should be given for initial construction, renova, tion,. equipment, and development of regionally oriented diagnostic and treat- ment stations and to provide necessary incentive through partial operating grant support for a nucleus of highly qualified staff in these stations. 72 5, Authorization for Necessary Transfer of Progra7n Funds within an Institute, I HEART DISEASE, CANCER AND STROKE and for Limited Transfer of Funds between Institutes 4 i Eli - A. It is of paramount importance that the Directors of the various Institutes, with the approval of the Director of the National Insitutes of Health and after fully informing the respective Appropriations Committees of the House and Senate of the reasons for such action, be given the authority to transfer funds from one pro. gram to another within their overall annual Institute appropriation. It is impossible for Institute Directors, who testify before Congress in the spring of one fiscal year, to predict with absolute precision the exact financial requirements of programs to be implemented a year or more in the future. Furthermore, the Institutes frequently receive their initial apportionments 6 months and more after a fiscal year has begun; such delays in allocations obviously force a reassessment of program directions. Over the past few years, the NIH has been subjected to unfair criticism be- cause it has returned sizeable amounts of unspent reserves to the Treasury. If the Institute Directors had flexible authority to reallocate funds after proper con- sultation, they could redirect funds from programs which cannot be initiated be- cause of factors beyond their control to programs in which a sizeable backlog of scientifically app roved applications has built up. B. It is also important that a proviso reinstating the right of the Director of the National Institutes of Health to transfer a limited portion of one Institute budg- et to another be included in future appropriations acts. Such transfer authority should only be exercised when a scientific judgment has been reached that a par- ticular year's appropriation to an Institute cannot be fully and prudently used as determined by each Institute Director and each Institute Advisory Council. Recommendation A. It is recommended that the Institute Directors, after appropriate consulta- tion, be given the authority to transfer funds within their overall annual In- stitute appropriation. B. The previous authority of the Director O/ the Nqfional Institutes of Health to transfer limited funds from one Institute to another should be re- i,nstated. 6. More Effective and Flexible Use of Grants and Contracts for Research and Development The Commission is convinced that the national carppaign against heart disease, cancer and stroke could be accomplished more effectively and expeditiously if more flexible utilization were possible in the use of contracting authority and if there were continuing availability of appropriated funds. In regard to contracts, the Public Health Service currently carries out its ar- rangements under authority delegated from the General Services Administration which has restrictive limitations concerning advanced payment, the inclusion of c and multiple-year a onstruction costs greements. Adequate research contract authority would enable the research program leaders of the Public Health Service to use their best judgment in matching the research support mech@nism to pro. 73 gram needs in the accomplishment of the research mission. HEART DISEASE, CANCER AND STROKE. With regard to the single-year availability of funds, the Corhmission has noted that the Public Health Service is the only Federal organization with a major re- search and development program that does not have multiple-year fund avail- ability which permits the continuing use of funds for this purpose after the end of a fiscal year. For the foregoin- reasons, the following recommendations are made: Recommendations A. The Public Health Service should be given basic authority in research con- tractsto: 1. Commit support for extended periods of time, e.g., up to 5 years and advance payments; 2. Provide for construction when such is essential to the accomplishment of the contract purposes; 3. Contract for clinical and domiciliary care where necessary to achieve research pzi,,poses; 4. Provide for the design and conduct of broad and comprehensive research and development progra-7ns in which the con-tractor has wide latitude for action in achieving a given objective. B. The Public Health Service should be given multiple-year fund availability for research and development activities. 7. Project Grant Authority for Heart Disease Control, Carwer Control, Chronic Disease Programs, and for the National Center for Health Statistics The Public Health Service authority to make project grants in its programs dealing with health application activities in communities is inconsistent. Thus, the Venereal Disease Control and Tuberculosis Control Programs as well as the Neurology and Sensory Disease Control Program have projec@ grant authority. In addition, the Community Health Services and Facilities Act Program also has a limited type of project grant authority. The Commission is particularly concerned with the lack of such authority in the Heart Disease Control, Cancer Control, and Chronic Disease programs. Also, t@ National Center for Health Statistics does not have such authority de- spite the fact that the irliprovement of vital and health statistics at their source is essential to progress in these health program areas. While the inclusion of a general authority for all control programs to make project grants is strongly recommenaed;,fo'r the comprehensive revision of the Public Health Service Act, it is believed urgent that interim authority for pro ect grants be extended to, the programs mentioned in order that the recommendations of the Preside@t's Corn- mission on 14ea'rt Disease, Cancer and Stroke can be implemented more fully withoql delay. Recommendation is recommended that the Heart Disease Control, Cancer Control, and 74 Chronic Disease Programs, and the National Center for Health Statistics be HEART DISEASE, CANCER AND STROKE authorized to make project grants. S. Authoriz@n for a Program for the Support and Stimulation of a National Medical Libraries Netivork It is clear that a major factor inhibiting the reduction of the burden of heart disease, cancer and stroke involves the inadequacy of communications in the field of the medical sciences. Moreover, it is clear,Ias with the problems of health man- power supply, that the correction and improvement needed can only be achieved by attacking the fundamental reasons underlying the deficiencies. One of these fundamental factors involves the inadequacies of the medical li- braries throughout the nation-an(>ther effect of the scientific revolution in which the advancement of knowledge has outstripped the ability to mana-e it. Consequently, in order to facilitate scientific communication, substantive legis- lation is necessary, providing a flexible program of planning, stimulation and support of an improved National Medical Libraries Network to assure all areas and all medical schools, scientists, and practitioners of the benefit of effective access to all medical data and inforrpation. Recommendation A legislative proposal should be developed and enacted providing for the support and stimulation of a National Medical Libraries Network. Particular attention should be given to authorizing reWing to recommendations -of the President's Commission on Heart Disease, Cancer and Stroke concerning the establishment of a network of medical libraries including a limited number of regional libraries; library facility construction; training for medical librarians; and a prog@am of research designed to improve systems and methods of han- dling medical literature. 9. Establishment of Revolving Fund for the National Medical Audiovisual Center One of the important recommendations of the Commission calls for the expansion of the vice Audiovisual Facilit at the Communicable Public Health Ser y Disease Center into a National Medical Audiovisual Center. Particlilar refer- ence in this regard is made to the operational trial of the use of a projector for the in-office continuing education of practicing physicians in which the audio- visual center would be charged with responsibility for the production of a series of films on heart disease, cancer and stroke subjects. In order to carry o@t such a program it is desirable that the audiovisual center have the maximum flexib'ility to permit it to carry out its projects in a most efficient manner. The establish- ment of ;t revolving fund fiscal arrangement, with the accompanying authority to sell or reductions, would greatly facilitate the ability of the center rent its p to carry out these programs. Recommendation It is recommended that authorization for the establish7nent of a revolving fund with I?zy necessary authorities to permit the sale or rental of medical audiovisual productions as appropriate be given to permit the National Medical of the CDC to carry out its junction with maxfmzfm Audiovisual Center efficiency. 75 10. Cq!nprehensive Amendment to the Vocational Rehabilitation Act HEART DISEASE,CANCER AND STROKE Much of what has been said with regard to the need for basic revision of the Public Health Service Act applies to the Vocational Rehabilitation Act. There is a considerable degree of obsolescence in this legislation, and many of the important proposals of the President's Commission on Heart Disease, Cancer and Stroke cannot be implemented with full effectiveness under existing authority. Recommendation It is recommended that the Department of Health, Education, and Welfare establish a task force to develop a comprehensive revision of the Vocational Rehabilitation,4ct by November], 1965. 11. Amendment of the Community Health Services and Facilities Act A number of reconnnendations particularly in the manpower and communica- tions areas could be accomplished through the Community Health Services and Facilities grant pro@ram if it were broadened by the simple deletion of the re- C) striding phrase "outside the hospital particularly for the chronically ill or aged persons," and if its appropriations ceiling were removed. These recommenda- tions include such proposals as a national health careers program; a greatly expanded program of research and demonstration in Community Health Services for the more effective utilization of health manpower; stimulation grants for the development of the capacity of community colleges for training middle-level health technician manpower; support and stimulation of continuation educa- tion programs; incentive grants to stimulate community planning and coordina- tion of health services; and developmental grants to stimulate and assist the uni- versity medical center to extend its resources and competencies to the communities in its area. Recommendation That the Community Health Services and Facilities Act be amended to elim- inate the phrase restricting projects to those pertaining to "outside the hospital particularly for chronically ill or aged persons" and suspension of the appro- rall amendment of the Public Health Service priations ceiling pending ove Act. 11. REORGANIZATION-RECOMMENDATION The specific programs needed to combat heart disease, cancer, and stroke and the legislation necessary to initiate and carry. out this expanded national effort, as recommended by the Conu-nission, relate primarily to the Department of Health, Education, and Welfare. The Commission considered whether the existing ad. ministrative and personnel resources within the Department were adequate for the development of the proposed programs. This study was necessarily limited as to both scope and depth. But it did be. come apparent to the Commission that, in the health area at least, the Department of Health, Education, and Welfare lacked adequate executive depth and functional organization to provide the leadership, support, coordination, and review required by its large and complex programs. Such deficiencies could be obstacles to effec- 76 tive development of the reconunended programs for the control of heart disease, HEART DISEASE, CANCER AND STROKE cancer and stroke. Furthermore, it became apparent to us that the Public Health Service and particularly the National Institutes of Health would be absolutely unable to initiate the sweeping recommendations we endorse in the body of this report unless its personnel force is increased appreciably, and unless present Federal to both retain existin@ personnel and to salary ceilings are raised significantly t) attract new personnel. We are aware of the fact that the National Institutes of Health is still losing some of its top scientists and administrators because its salary scales do not compete with salary scales for comparable positions in medical schools, universities and industry. The major problem seems to be an insufficient number of high-level policy posi- tions to provide effective leadership and coordination of the Department's many programs which are basic to the internal strength,of the nation. The Department has only five such positions: Secretary, Under Secretary, two Assistant Secre- taries, and an Advisory Special Assistant to the Secretary (Health and Medical Affairs). It also has a career Administrative Assistant Secretary and a General Counsel. These people are expected to provide effective leadership of a Department with over 80,000 employees, with about 130 programs (over 40 in health), and with annual expenditures of $6 billion from budget appropriations and about $15 bil- lion from trust funds. Even from a casual study of the situation, and certainly in comparison with other Departments of Government, it seems obvious that strengthening of the Department of Health, Education, and Welfare at the top is greatly needed. Recommendation The Commission recommends that a reorganizatioa of the Department of Health, Education, and Welfare be eflected to provide specific high-level policy, direction and coordination of health programs, with adequate supporting policy positions. 77 HEART DISEASE, CANCER AND STROKE 30 m co C= rc 20 Summary of Appropriations Recommendations Including Those for New Programs and Increases for Existing Programs and Comparison With Estimates of Current Levels of Support Chapter Estimated Year Current Level of NO. Title Support 1 2 3 4 5 (1965) 3 A National Network for Patient Care, Re- search and Teaching in Heart Disease, Cancer and Stroke .................................... 1 153. 25 237. 875 364. 475 421. 4 453. 45 4 Application of Medical Knowledge in the Community ............................ 18. 5 49. 65 61. 65 63. 15 45. 15 53. 15 5 Development of New Knowledge ............ 152. 8 56. 55 83. 107. 9 40. 2 49. 5 6 Education and Training of Health Manpower 37. 7 45. 05 63. 95 78. 15 93. 75 110. 65 7 Additional Facilities & Resources ........... 11. 2 52. 25 56. 00 61. 00 66. 00 72. 50 TOTAL ............................................... 356. 75 503. 175 674. 675 666. 50 739. 25 Includes only pmgrams for -hich ap.6fi@ ppmpri.tions @em--@..dations r. made in this report. Fig.@@. in milli..@ f dolia". 9 n Chapter Three: A National Network for Patient Care, Research and Teaching In Heart Disease, Cancer and Stroke Recommend at on Year No. Title 1 2 3 4 5 I Regional Centers for Heart Disease, Cancer and Stroke .................. 187. 5 126. 5 198.1 208. 9 230. 7 2 Diagnostic and Treatment Stations ................ 36. 75 66.875 106.125 138.25 133.75 3 Development of Medical Complexes .............. 25. 0 37. 5 50. 0 62. 5 75. 0 4 Development of Additional Centers of Excellence .... 3. 0, 6. 0 9. 0 10. 0 12. 0 .5 A National Stroke Program Unit ...... ............ 1. 0 1. 0 I.-25 1. 75 2. 0 Subtotal ................ 153. 25 237. 875 364. 475 421. 4 453. 45 79 1 Figures in millions of dollars. HEART DISEASE, CANCER AND STROKE Chapter Four: Application of Medical Knowledge In the COMmun!tY Year Recommendation 2 3 4 5 No. Title 6 Com munity Planning 11. 0 1. 0 1. 0 1.0 1. 0 Grants @ ................. Community Health Re- 7 and Demonstra- search 6.0 7. 0 8. 0 10. 0 ... 5.0 tion ................. 8 Support of Community Pro- grams .................. i8. 5 24.5 18. 0 24. 0 30. 0 9 Statewide Programs for 5 3.5 ............. 2. 5 2. Heart Disease Control.... 10 National Cervical Cancer 7.5 10.0 ........ Detection Program ....... 5. 0 Continuing Education of 10.1 12.1 14.1 B. 1 8.1 alth Professions ....... He 12 PublicidormationonHeart Disease, Cancer and 9.55 4.05 4.05 7. 55 8. 05 Stroke .................. 49. 65 61.65 63.15 45.15 53.15 Subtotal.' ........ 80 CANCER AND STROKE i Fvm in moons of HEART DISUSE, Chapter Five: The Development of New Knowledge Recommendation Year No. Title 1 2 3 4 5 13 Biomedical Research In- i;titutes ................. 17.5 15. 0 22. 5 30. 0 37. 5 14 Specialized Research Centers .................. 4. 05 6. 7 9.4 10.2 12. 0 15 Research Project Grants .... 35. 0 47. 0 56. 0 ............. 16 Contracting Authority for Research and Develop- ment ................... 10.0 15. 0 20. 0 ............. Subtotal .............. 56. 55 83. 7 107.9 40.2 49. 5 81 F@s in a of dou&m HEART DISEASE, CANCER AND STROKE Chapter Six: Education and Training of Health Manpower Year Recommendation No. Title 4 5 2 3 20 Recruitment for the Health 5. 0 7. 5 10. 6 1. 0 2. 5 Professions .............. 21 Undergraduate Training in Medical and Dental 8. 05 8. 55 8. 55 Schools ................. 7. 05 7. 55 1 32. 7 38. 5 22 Training for Research ...... 16.1 21. 4 27. 23 Support of Clinical Training. 10.0 12.0 14. 0 17. 5 20. 0 24 Stabilization of Academic Positions ................ 8. 0 16.0 18. 0 20. 0 24. 0 25 Training of Health Tech- nicians ................. 1. 4 2.8 4.2 5. 6 7.0 26 Training of Specialists in Health Communications.. 1. 0 1. 0 1.0 1.0 1. 0 27 Continuous Assessment of Health Manpower Needs. 0. 5 0. 7 0. 8 0.9 1.0 110. 65 Subtotal ................ 45. 05 63. 95 78-15 93.75 82 HEART DISEASE, CANCER AND STROKE fda... Chapter Seven: Additional Facilities and Resources Recommendation Year No. Title 1 2 3 4 5 30 Medical Libraries... ...... 1 32. 0 32. 0 32.0 32. 0 32. 0 31 National Medical Audiovis- ual Center .............. 7. 5 8. 0 10. 0 12. 0 15. 0 32 Statii3tical Programs. . . 2. 75 3. 5 4.0 4. 5 5.5 33 Animal Resources for Bio- medical Research ........ 10. 0 12.5 15.0 17. 5 20. 0 Subtotal ................ 52. 25 56. 00 61. 00 66. 00 72.50 83 Ysvms in mffions of doflam HEART DISEASE,CANCER AND STROKE APPENDIX B COMMISSION Chairman rofe--sor and Chairman, Department of Surgery, Dr. illichael E. DeBakey, P Baylor University College of Medicine, Houston, Texas members e School of Medicine, Dr. Samuel Bellet, Professor of Clinical Cardiology, Graduat University of Pennsylvania, Philadelphia, Pennsylvania Barry Bingham, Editor and Publisher, Louisville Courier-journal, Louisville, Kentucky llr. John M. Carter, Editor, McCall's Magazine, New York, New York Dr. R. Lee Clark, Director and Surgeon-in-Chief, The University of Texas M. D. Anderson Hospital and Tumor In@titute, Houston, Texas Dr. Edward W. Dempsey, Former Dean, School of - Medicine, Washington University, St. Louis, Missouri. Resigned on September 28, 1964, to, become Special Assistant to the Secretary (Health and Medical ffairs), U. S. Depart- ment of Health, Education, and Welfare, Washington, D.C. Dr. Sidney Farber, Director of Research, Children's Cancer Research Founda- tion and Professor, Harvard Medical School, Boston, Massac iusetts Dr. Marion S. Fay, Former President and Dean, The Women's Medical College of Pennsylvania, Philadelphia, Pennsylvania Mr. Marion B. Folsom, Director, Eastman Kodak Company, Rochester, New York, and Former Secretary of the U.S. Department of Health, Education, and Wel- fare, Washington, D.C. Mr. Emerson Foote, Former Chairman of the Board, McCann-Erickson, Inc., New York, New York General Alfred M. Gruenther, Immediate Past President, American National Red Cross, Washington, D.C. Dr. Philip Handler, Professor and Chairman, Department of Biochemistry, Duke" University Medical Center, Durham, North Carolina Alr. Arthur 0. Hanisch, President, Stuart Company, Pasadena, California Dr. Frank Horsfall, Jr., President and Director, Sloan-Kettering Institute for Cancer Research, New York, New York Dr. J. Willis Hurst, Professor and Chairman, Department of Internal Medicine, Emory University School of Medicine, Atlanta, Georgia Dr. Hugh H. Hussey, Director, Division of Scientific Activities, American Medi- cal Association, Chicago, Illinois. Resigned as of September 5, 1964, to be- come Special Consultant to the Commission Mrs. Florence Mahoney, Co-Chairman, National Committee Against Mental III- ness, Washington, D.C. 84 Dr. Charles W. Mayo, Emeritus Staff Surgeon, Mayo Clinic, Rochester, Min- HEART DISEASE, CANCER AND STROKE nesota Dr. John S. Meyer, Professor and Chairman, Department of Neurology, Wayne State University College of Medicine, Detroit, Michigan Mr. James F. Oates, Chairman of the Board, Equitable Life Assurance Society, New York, New York Dr. E. M. Papper, Professor and Chairman, Department of Anesthesiology, Col- lege of Physicians and Surgeons, Columbia University, New York, New York Dr. Howard A. Rusk, Professor and Chairman, Department of Physical Medicine and Rehabilitation, New York University Medical Center, New York, New York Dr. Paul W. Sanger, Surgeon, Charlotte, North Carolina General David Sarnoff, Chairman of the Board, Radio Corporation of America, New York, New York Dr. Helen B. Taussig, Emeritus Professor of Pediatrics, Johns Hopkins Uni- versity, Baltimore, Maryland Mrs. Harry S' Truman, Independence, Miss ouri Dr. Irving S. Wright, Professor of Clinical Medicine, Cornell University, Medi- cal College, New York, New York Dr. Jane C. Wright, Adjunct Associate Professor of Research Surgery, New York University School of Medicine, New York, New York STAFF Staff Director Dr. Abraham M. Lilienfeld, Professor and Chairman, Department of Chronic Diseases, Johns Hopkins University Schoolof Hygiene and Public Health, Balti- more, Maryland Executive Secretary Mr. Stephen J. Ackerman, Associate Chief for Planning and Analysis, Bureau of State Services (Community Health), Public Health Service, U.S. Department of Health, Education, and Welfare, Washington, D.C. Sta,# Associate Dr. John D. Turner, Office of the Director, National Heart Institute, Public Health Service, U.S. Department of Health, Education, and Welfare, Bethesda, Maryland. Pl'riter Mr. Horace G. Ogden, Information Officer, Bureau of State Services (Commun. ity Health), Public Health Service, U.S. Department of Health, Education, and Welfare, Washington, D.C. Publ@ Relations Mr. Lealon E. Martin, Information Officer, National Heart Institute, Public Health Service, U.S. Department of Health, Education, and Welfare, Bethesda. 85 Maryland HEART DISEASE, CANCER AND STROKE Staft Assistants Dr. Nemat 0. Borhani, Head, Heart Disease Control Program, Bureau of Chronic Diseases, California Department of Public Health, Berkeley, California Mr. Louis Carrese, Program Planning Officer, Office of the Director, National Cancer Institute, Public Health Service, U.S. Department of Health, Education, and Welf are, Bethesda, Maryland Dr. Maureen Henderson, Associate Professor of Preventive Medicine and Markle Scholar, University of Maryland School of Medicine, Baltimore, Maryland Dr. William L. Kissick, Assistant to the Special Assistant to the Secretary (Health and Medical Affairs), U.S. Department of Health, Education, and Welfare, Washington, D.C. Dr. Bayard Morrison, Clinical Branch, Collaborative Research, National Cancer Institute, Public Health Service, U.S. Department of Health, Education, and Welfare, Bethesda, Maryland Mr. Marcus Rosenblum, Associate Special Assistant to the Surgeon General for Scientific Information, Public Health Service, U.S. Department of Health, Edu- cation, and Welfare, Washington, D.C. Dr. David Sehottenfeld, Associate Director, Admitting and Diagnostic Clinic, Memorial Hospital, New York, New York Mr. Daniel Zwick, Office of the Chief, Bureau of Medical Services, Public Health Service, U.S. Department of Health, Education, and Welfare, Silver Spring, Maryland Consultants Mr. Mike Gorman, Executive Director, National Committee Against Mental Illness, Washington, D.C. Mr. Boisfeuillet Jones, President, Emily and Ernest Woodruff Foundation, Atlanta, Georgia Dr. Morton L. Levin, Professor of Cancer Epidemiology, Roswell Park Memorial Institute, Buffalo, New York Administrative and Clerical Mrs. Frances Carr Mr. Jon Rasmussen Miss Billie Ann Coen Miss Joan Schultz Miss Zi Delk Mrs. Julie Thomas Mrs. Selma Freedman Mrs. Marjorie V. Thompson Mr. George Kreiner Miss Mary Triantis Miss Roberta Laney. Miss Diane Wilkins 86 HURT DISEASECANCER AND STROKE APPENDIX C The Formation of the Commission In his Health Message to Congress early in 1964, President Lyndon B. Johnson stated: "Cancer, heart disease and strokes stubbornly remain the leading causes of death in the United States. They now afflict 15 million Americans-tivo- thirds of all Americans now living will ultimately suffer or die from one of them. "These diseases are not confined to older people. 0 "Approximately half of the cases of cancer are found among persons under 65. 0 "Cancer causes more deaths among children under age-15 than any other disease. 0 "More than half the persons suffering from heart disease are in their most productive years. 0 "Fully a third of all persons with recent strokes or with paralysis due to strokes are under 65. "The Public Health Service is now spending well over a quarter of a billion dollars annually finding ways to combat these diseases. Other organizations, both public and private, also are investing considerable amounts in these efforts. "The flow of new discoveries, new drugs, and new techniques is impressive and hopeful. "Much remains to be learned. But the American people are not receiving the - full benefits of what medical research has already 'accomplished. In part, this is because of shortages of professional health workers and medical facilities. It is also partly due to the public's lack of awareness of recent developments and techniques of prevention and treatment. "I am establishing a Commission on Heart Disease, Cancer and Strokes to recommend steps to reduce the incidence of these diseases through new knowl- edge and more complete utilization of the medical knoivledge we already have. "The Commission will be made up of persons prominent in medicine and pub- lic affairs. I expect it to complete its study by the end of this year and submit reconunendations for action." On March 7. the President announced the names of the members of this Corn- numion and on April 17, 1964, the Commission held its first meeting in the Vimte House. The President addressed the Commission as follows: "Ladies and Gentlemen: On beautiful days like this, the President and school boys have a hard time staying indoors. I think we would set a good example for the Nation, and we would advance the cause that brings us together, if we 87 we would take time for a brisk walk outside this morning. I am a subscriber HEART DISEASE, CANCER AND STROKE brain i,, flabby, you know if your to the view once expressed that if you want to better feel your legs. "Health is something that we treasure in this house where you are gathered throughout our land this morning, and I know it is treasured in every house ealth is the great@t and around the world. It was said several centuries ago7 h ofallpossessions. Apalecobblerisbetterthanasickking. "The work that you have begun today is work in which I have the keenest and on are here to begin mappin- an greatest and the most personal interest. Y attack by this Nation upon the three great killers, the three great cripplers- heart, cancer, and stroke disease. These three account for the majority of deaths and much of the serious disability which strikes our people every year. "I have asked you to undertake these three objectives: First, to measure the full ma-,nitiide of the impact of these diseases upon the Nation; second, to evalu- ate our resources for acquiring new knowledge that we already have; third. to identify the obstacles which stand in the way of advancing knowledge and give us guidelines on overcoming those obstacles. "To this group I do not think I need to tell you how vital this is. Unl ess we do better, two-thirds of all Americans now living will suffer or die from cancer. heart disease, or stroke. I expect you to do something about it. Five million Americans a year are struck down in the prime of life by heart attacks, often fatal. Every two minutes cancer strikes a man or a woman or a child in this country. Every year strokes leave 200,000 Americans dead and another 2 million incapacitated. "I want us to put our great resources-and they are unlimited-to work- to overcome this. We can, and because of the work you will do, I believe we is-M. So let me say this: I know there are some differing viewpoints about the prospects for success in these fields, but from what some of you on this Com- mission have reported to me, and from some other sources that I believe in- I think our goals are in sight. It is well within the range of reasonable expecta- tion that work being done now in regard to controlling growth of cells in the human body will bring decisive victories over heart disease and cancer and strokes. "The point is, we must conquer heart disease, we must conquer cancer. we must conquer strokes. This Nation and the whole world cries out for this %-ic- tory. I am firmly convinced that the accumulated brains and determination of this Commission and of the scientific community of the world will, before the end of this decade, come forward with some answers and cures that we need so very much. When this occur@not 'if,' but 'when,' and I empha--ize 'when'-we will face a new challenge and that will be what to do within our economy to adjust ourselves to a life span and a work span for the average man or woman of 100 years. "Knowing Government as I do, I am sure some President some day will be appointing a commission to study that very great problem, and I would be 88 pleased to be that President. If you do your work well and if you do your work I HEART QISEASE, CANCER AND STROKE with dispatch, maybe I will have that privilege. I "; I "I have often been reminded myself of Shakespeare's line, 'A good heart is worth gold.' I am glad mine is good now and if the doctors and the Secret Service and my guardians in the press will just permit me to get my exercise, I intend to keep it that way. "I want to thank you very much for beginning the work that I think will ulti- mately win the hardest fight that we have ever fought, and I would suspect that just as we look back on Lincoln's proclamation a hundred years a,-,,Ol when he took the chains off the slaves, I would suspect that some day your grandchildren and great, great grandchildren will be looking at this picture made this morn- ing in this beautiful rose garden, all the thorns are inside, and see the leadership of 50 States who are willing to give their talents and their energies and their imaginations, and stay awake at night and ro over an go get a g ass o water and come back and think some more on how to get the results that we know are within our reach. "In my judgment, there is nothing that you will ever do that will keep your name glorified longer, and that will make your descendants prouder than this unselfish task that you have today undertaken to get rid of the causes of heart disease and cancer and stroke in this land and around the world. What can be more satisfying than to feel that you have preserved not a life, but millions of them, for decades. I am here to say to you that while we are interested in the food stamp plan, we are interested in medicare for the aged under social security, we are interested in the civil rights bill that we consider most essential to our leadership in this country and in the world, we are interested in the pay bill that will keep our good civil servants here, we are interested in the immigration bill that will permit families to join each other, and we are interested in the poverty bill that will take our boys out of the pool halls and out of the slums and out of the juvenile delinquency centers of the Nation-we are interested in all those things. "There is nothing that really offers more and greater hope to all humanity and to preserving humanity than the challenge in the task that you have under- taken. You have among you some of the great doctors, some of the great public servants of our time. Somehow, some way, some time, you are going to find the answers, and I hope it will be soon. "Ilank you." Organizatim of the Commis@n The Commission organized itself into the following Subcommittees with the following Chairmen: Heart Disease -Dr. Irving Wright Cancer -Dr. Sidney Farber Stroke -Dr. John Meyer Research -Dr. Philip Handler Manpower -Dr. Edward Dempsey Communications -Mr. Emerson Foote Facilities -Mr. Arthur Hanisch Rehabilitation -Dr. Howard A. Rusk 89 The Chairmen constituted the Executive Committee of the Commission. HEART DISEASE, CANCER AND STROKE Methods ol Operatt'on The Commission established the following methods of operation: 1. The collection of information from agencies, groups, and institutions con- cerned with these diseases through lett ers, staff visits, surveys, etc. 2. The holding of hearings at which expert witnesses from the widest possible range of interests, both public and private, presented their views and dis- cussed the issues involved. 3. The preparation of the report and its recommendations and their submis. sion to the President. Aletter was sent to the professional organizations and voluntary health agen- cies listed in Appendix D, informing them of the appointment of the Commis- sion and indicating that the Commission "would welcome a written statement setting forth the overall views of the organization on the problems pertinent to the mission of the Commission and any suggestions and recommendations. The response to this request was most gratifying and the Commission expresses its appreciation to these organizations for their assistance. In approaching its task, the Facilities Subcommittee considered it desirable to determine the overall need for patient care, research, and educational facilities. As no estimate of National needs was available, the Subcommittee undertook a National survey of medical, dental, osteopathic, public health, and veterinary schools; of research centers; and of community hospitals to obtain information regarding their needs, plans, and problems concerning the construction of new space and the renovation of (>Id. The results of this survey are reported in detail in Volume 2. During November, the Second National Conference on Cardiovascular Diseases was held. Several hundred cardiologists and scientists spent over a year pre- paring a survey of the entire field of cardiovascular diseases for review and discussion at this Conference. All of this material was made available to the Commission, and the Commission would like to express its appreciation to Dr. E. Cowles Andrus, Conference Chairman, and to the Conference.participants for their generous assistance. In view of the need for obtaining information and views on the economic aspects of heart disease, cancer and stroke, the Commission obtained a detailed analysis of the economic costs of these diseases. In addition, Dr. Walter Heller, C airman of the Council of Economic Advisors to the President, called together a group of econornistsforameetingonSeptember3O,l964,todiscussthisarea. Areportof this meeting is presented in Volume 2. The Commission expresses its gratitude to Drs. Heller, Arrow, de Janosi, Hansen, Klarman and Scitovsky for their help. Each of the Subcommittees held hearings to which were invited individual experts, representatives of selected voluntary health agencies and professional organizations and official Federal, State, and local health agencies. The opinions 910 and recommendations of these individuals were obtained, and an official tran- HEART DISEASE, CANCER AND STROKE script was made of each of these meetings. A total of 45 such meetings were held, and more than 166 experts appeared at these hearings, and the Commission is deeply grateful to those who came to these meetings, most of which were held in Washington. More than 7,500 pages of testimony, amounting to many millions of words were obtained. A list of these witnesses appears as Appendix E. Each of the Subcommittees reviewed the testimony, in addition to background material, and prepared a report including recommendations. Each of these reports was then reviewed by the Executive Committee, which held 10 meetings during the term of the Commission. The Commission itself met as a whole 6 times, several of which were two days in length, to review the reports and recom. mendations of each of the Subcommittees and of the Executive Committee. These reports were brought together in a unified fashion to serve as the report of the Commission. 91 HEART DISEASE, CANCER AND STROKE APPENDIX D American Academy of General Practice American Academy of Neurology American Academy of Oral Pathology American Academy of Pediatrics American Academy of Physical Medicine and Rehabilitation American Association of Cancer Research American Association of Dental Schools American Association of Obstetricians and Gynecologists American Cancer Society American College of Cardiology American College of Chest Physicians American College of Obstetricians and GN-necologists American College of Physicians American College of Preventive Medicine American College of Radiology American College of Surgeons American Dental Association American Diabetes Association American Heart Association American Hospital Association American Medical Association American Medical Women's Association American Neurological Association American Nurses' Association American Nursing Home Association American Osteopathic Association American Public Health Association American Society of Clinical Pathologists American Society of Medical Technologists American Society of Neurosurgeons American Thoracic Society Arthritis and Rheumatism Foundation Association of American Medical Colleges Association of Life Insurance Medical Directors Association of Rehabilitation Centers Association of Schools of Public Health Association of State and Territorial Health Officers Association of State Chronic Disease Program Directors Catholic Hospital Association College of American Pathologists' Group Health Association of America 92 Group Life Insurance, Inc. HEART DISEASE, CANCER AND STROKE Health Insurance Council Health Insurance Institute Institute of Life Insurance Inter-Society Cytology Council International Union Against Cancer Leukemia Society Life Insurance Medical Research Fund National Association of Social Workers National Dental Association National Health Council National League for Nursing National Medical Association National Rehabilitation Association National Society for Crippled Children and Adults Public Health Cancer Association Society of Actuaries Society of Public Health Educators U.S. Conference of City Health Officers 93 HEART DISEASE, CANCER AND STROKE APPENDIX E Dr. Frank Adair, Breast Cancer Specialist, and Past President, American Cancer Society, New York, New York Mr. Scott Adams, Deputy Director, National Library of Medicine, Bethesda, Maryland or, National Institute of Child Health and Human Dr. Robert A. Aldrich, Direct Development, National Institutes of Health, Bethesda, Maryland Dr. Otis Anderson, Medical Liaison, American Medical Association, Washington, D.C. Dr. E. Cowles Andrus, Professor Emeritus, Johns Hopkins University School of Medicine, Baltimore, Maryland Mr. Daniel Bailey, Assistant to the Director, National Library of Medicine, Bethesda, Maryland Dr. A B. Baker, Professor and Chairman, Department of Neurology, University of Minnesota Medical School, Minneapolis, Minnesota Dr. Gordon Barrow, Director, Cardiovascular Disease Control Service, Georgia Department of Public Health, Atlanta, Georgia Mr. Carl Berkley, Consultant, RCA Laboratories, Princeton, New Jersey Dr. Robert Bowman, Chief, Laboratory of Technical Development, National Heart Institute, National Institutes of Health, Bethesda, Maryland Dr. David Brand, Chief, Heart Disease Control Branch, Division of Chronic Diseases, Bureau of State Services, Public Health Service, Washington, D.C. Dr. Arnold S. Breakey, Assistant Clinical Professor of Opthalmology, Depart- ment of Opthalmology, New York University School of Medicine, New York, New York. Dr. Lester Breslow, Chief, Division of Preventive Medical Services, California Department of Public Health, Berkeley, California Dr. Ray Brown, Director of Program of Hospital Administration, Duke Univer- sity Medical Center, Durham, North Carolina Dr. Kevin Bunnell, Associate Director, Western Interstate Commission for Higher Education, Boulder, Colorado Dr. Mary 1. Bunting, President, Radcliffe College, Cambridge, Massachusetts, and a Commissioner, U.S. Atomic Energy Commission, Germantown, Mary- land Dr. T. H. Butterworth, Representative, Society of Public Health Educators, Inc., Washington, D.C. Dr. Lee Cady, Associate Professor of Physical Medicine and Rehabilitation, New York University School of Medicine, New York, New York. Dr. John L. Caughey, Jr., Associate Dean, Western Reserve University School' of Medicine, Cleveland, Ohio 94 Dr. Philip Cohen, Chairman, Department of Biochemistry, University of Wis- HEART DISEASE, CANCER AND STROKE consin, Madison, Wisconsin -@ory Disease Service Program, Dr. Clifford Cole, Chief, Neurological and Sen Division of Chronic Diseases, Bureau of State Services, Public Health Serv- ice, Washington, D.C. Dr. Donald A. Covalt, Associate Director, Institute of Physical Medicine and Rehabilitation, New York University Medical Center, New York, New York Dr. Russel W. Cumley, Executive Director, Medical Arts Publishing Founda- tion, Houston, Texas Dr. Emerson Day, Director, Strang Clinic, New York. i\ ew York Dr. George Deaver, Institute of Physical Medicine and Rehabilitation, New York University Medical Center, New York, New York Dr. Bowen C. Dees, Assistant Director (Plannin@). '\ational Science Founda- tion, Washington, D.C. Dr. D. Denny-Brown, James Jackson Putnam Professor of Neurology, Harvard Medical School, Harvard University, Boston, Massachusetts Dr. Harold S. Diehl, Senior Vice President for 'Aledical Research and Medical Affairs, American Cancer Society, New York, New York .Dr. Leonard Diller, Chief, Psychological Section, Institute of Physical Medi- cine and Rehabilitation, New York University Medical Center, New York, New York Dr. James P. Dixon, President, Antioch College, Yellow Springs, Ohio Dr. Patrick Doyle, Deputy Commissioner, Vocational Rehabilitation Adminis- tration, Department of Health, Education, and Welfare, Washington, D.C. Dr. Renato Dulbecco, Salk Institute for Biological Studies, San Diego, California Dr. Charles Dunham, Director, Division of Biology and Medicine, Atomic Energy Commission, Germantown, Maryland Dr. Charles E. Dunlap, Chairman, Department of Pathology, Tulane University School of Medicine, New Orleans, Louisiana Mr. H. P. Dunning, Program Management Officer, Cancer Control Branch, Divi- sion of Chronic Diseases, Bureau of State Services, Public Health Service, Washington, D.C. Dr. Harry Eagle, Albert Einstein College of Medicine, Yeshiva University, New York, New York Dr. Paul Ellwood, Executive Director, Sister Elizabeth Kenny Foundation, Min- neapolis, Minnesota Dr. Kenneth Endicott, Director, National Cancer Institute, National Institutes of Health, Bethesda, Maryland Dr. Lester Evans, Consultant in Education for the Health Professions, University of Illinois Medical Center, Chicago, Illinois Dr. Shirley C. Fisk, Deputy Assistant Secretary of Defense, Health and Medical, Washington, D.C. Dr. Reginald Fitz, Dean, University of New Mexico School of Medicine, Albu- querque, New Mexico Dr. C. Miller Fisher, Assistant Clinical Professor of Neurology, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts 95 Mr. I"Iie Flory, RCA Laboratories, Princeton, New Jersey HEART DISEASE, CANCER AND STROKE Mr. the Advancement of Science Pierre Fraley, Executive Secretary, Council for Writing, Phoenixville, Pennsylvania Dr. Aaron Ganz,. Chief, Research Career Section, Research Fellowships Branch, National Institute of General Medical Sciences, National Institutes of Health, Bethesda, Maryland Dr. Leo J. Gehri-,, Chief, Bureau of Medical Services, Public Health Service, Washington, D.C. ehabilitation Committee, American Medical Asro- Dr. David Gelfand. Member, R ciation, Philadelphia, Pennsylvania Dr. Louis Gerber, Chief, Nursing Homes and Related Facilities Branch, Division of Chronic Diseases, Bureau of State Services, Public Health Service, Wash. ington, D.C. Dr. Menard M. Gertler, Associate Professor of Phy@ical Medicine and Rehabili- tation, Department of Physical Medicine and Rehabilitation, New York Uni- versity Medical Center, New York, New York Dr. Eli Ginzberg. Professor of Economics, Graduate School of Business, Colum- bia University. Neiv York, New York Mr. John S. Gleason, Jr., Administrator of Veterans' Affairs, Veterans Administra- tion, Washington, D.C. Mr. Kermit Gordon, Director, Bureau of the Bud-et, Washington, D.C. Accom- panied by Mr. Sutton and Mr. Loweth Dr. Saxon Graham, Associate Cancer Research Scientist, Roswell Park Memorial Institute, Buffalo, New York Dr. Harald M. Graning, Chief, Division of Hospital and Medical Facilities, Bureau of State Services, Public Health Service, Washington, D.C. Dr. Eugene Guthrie, Chief, Division of Chronic Diseases, Bureau of State Services, Public Health Service, Washington, D.C. Mr. John Hagan, Rehabilitation Consultant assigned to Coordinating Committee on Nation-wide Stroke Programs, American Heart Association, New York, New York Dr. Robert Haggerty, Professor and Chairman, Department of Pediatrics, Uni- versity of Rochester School of Medicine, Rochester, New York Dr. Jack C. Haldeman, President, Hospital Planning Council of Southern New York, New York, New York Dr. Seymour Harris, Littauer Professor of Political Economy, Graduate School of Public Administration, Harvard University, Boston, Massachusetts Miss Inez Haynes, Director, National League for Nursing, New York, New York Dr. Albert Heyman, Professor of Neurology, Duke University School of Medicine, Durham, North Carolina Dr. Herman K. Hellerstein, University Hospital, Cleveland, Ohio Dr. Milton Hoberman, American Board of Physical Medicine and Rehabilitation, New York, New York Dr. Godfrey Hochbaum, Chief, Behavioral Science Section, Division of Commu- 96 nity Health Services, Bureau of State Services, Public Health Service, Wash- HEART DISEASE, CANCER AND STROKE ington, D.C. Dr. Vane Hoge, Assistant Director, American Hospital Association, Washin-ton ZD Service Bureau, Washington, D.C. Dr. A. Hollaender, Oak Rid@e National Laboratory, Oak Rid@e, Tennessee Dr. Donald Hornig, Office of Science and Technology, Executive Office of the President, Washington, D.C. Dr. Warren V. Huber, Chief, Neurology Division, Veterans Administration, Washington, D.C. Dr. Charles Huggins, Ben May Laboratory for Cancer Research, University of Chica@o, Chicago, Illinois Mr. J. Stewart Hunter, Assistant to the Sur-eon General for Information, Public Health Service, Washington, D.C. Dr. George James, Commissioner of Healtfi, Neiv York City Department of Health, New York, New York Dr. Robert S. Jason, Dean, Howard University College of Medicine, Washington, D.C. Mr. BoisfeuiUet Jones, President, Emily and Ernest Woodruff Foundation, Atlanta, Georgia Mr. Tom Jones, Ethicon, Inc., Somerville, Neiv Jersey Dr. Charles Kane, Professor of Neurology, Boston University School of Medicine, Boston, Ma-ssachusetts Dr. Norvin Keefer, Chief Medical Director, The Equitable Life Assurance Society, New York, New York Dr. Jay Hillary Kelley, Office of Science and Technology, Executive Office of the President, Washington, D.C. Dr. F. Ellis Kelsey, Special Assistant to the Surgeon General for Scientific Com- munication, Public Health Service, Washington, D.C. Dr. Charles V. Kidd, Associate Director for International Activities, National Institutes of Health, Bethesda, Maryland Mr. Earl Klein, Chief, Division of Publication, Office of Labor Statistics, Depart- ment of Labor, Washington, D.C. Dr. Ralph Knutti, Director, National Heart Institute, National Institutes of Health, Bethesda, Maryland Dr. Paul Kotin, Associate Director for Field Studies, National Cancer Institute, National Institutes of Health, Bethesda, Maryland Dr. Fredric J. Kottke, Department of Physical Medicine and Rehabilitation, University of Minnesota, Minneapolis, Minnesota Dr. Edward J: Kowalewski, Chairman, Commission on Environmental Medicine, American Academy of General Practice, Kansas City, Missouri Dr. Leonard Lecht, Director, National Goals Project, National Planning Associ- ation, Washington D.C. Dr. Lyndon E. Lee, Jr., Chief, Extra-VA Research Division, Department. of Medi. cine and Surgery, Veterans Administration, Washington, D.C. Dr. Mathew Lee, Department of Physical Medicine and Rehabilitation, New York 97 University School of Medicine, New York, New York HEART DISEASE, CANCER AND STROKE and Dr. Philip Lee, Director, Health Service, Office of Technical Cooperation Research, Agency for International Development, Washington, D.C. Dr. Russell Lee, Director, Palo Alto Medical Clinic, Palo Alto, California Dr. Joseph Leiter, Chief, Cancer Chemotherapy National Service Center, National Cancer Institute, National Institutes of Health, Bethesda, Maryland Dr. Arthur Lesser, Director, Division of Health Services, Children's Bureau, Welfare Administration, Washington, D.C. Dr. Nathaniel Levin, University of Miami School of Medicine, Miami, Florida Dr. Herbert Lichtman, Medical and Research Director, Leukemia Society, Inc., New York, New York Dr. James Lieberman, Chief, Medical Audiovisual Branch, Communicable Disease Center, Bureau of State Services, Public Health Service, Atlanta, Georgia ne, New York. New Dr. Arthur Localio, New York University College of Medici York Dr. Herbert Locksley, Department of Neurosurgery, State University of Iowa College of AIed@icine, Iowa City, Iowa Dr. Irving London, Professor and Chairman, Department of Medicine, Albert Einstein College of Medicine, Yeshiva University, New York, New York Dr. Edward Lowman, Chief of Professional Services, Institute of Physical Medi- cine and Rehabilitation, New York University Medical Center, New York, Neiv York Dr. Champ Lyons, Professor and Chairman, Department of Surgery, University of Alabama School of Medicine, Birmingham, Alabama Dr. Colin M. MacLeod, Office of Science and Technology, Executive Office of t President, Washiii-,ton, D.C. Mr. Rudolph Mallina, Consulting En-,ineer, Hastings New York Dr. Morton Marks, Clinical Neurolo-ist, New York University Medical Center, New York, New York Dr. Jessie Marmorsto'n, Clinical Professor of Medicine, University of Southern CAlifornia School of Medicine, Los An@eles, California Dr. Richard L. Masland, Director, National Institute of Neurological Diseases and Blindness, National Institutes of Health, Bethesda, Maryland Dr. J. F. A. McManus, Department of Pathology, University of Indiana, Bloom- in,,ton, Indiana Dr. Joseph MeNinch, Chief Med-@cal Director, Veterans Administration Central Office, Washington, D.C. Dr. M. Sedgwick Mead, Director, Kaiser Foundation Hospital Rehabilitation Center, Vallejo, California Dr. H. Houston Merritt, Dean, College of Physicians and Surgeons, Columbia University, New York, New York Dr. Thomas Merson, Assistant Director for Commissions, American Associa- tion of Junior Colleges, Washington, D.C. Dr. George E. Miller, Director, Research and Medical Education, University 98 of Illinois College of Medicine, Chicago, Illinois HEART DisEAsE, cANCER AND STROKE Dr. Clark Millikan, Consultant in Neurology, Mayo Clinic, Rochester, Minnesota Dr. George E. Moore, Director, RosNveU Park Memorial Institute, Buffalo, New York Dr. Marc J. Musser, Deputy Chief medical Director, Veterans Administration, Washington, D.C. Dr. Maurice Odoroff, Chief, Program Analysis Branch, Institute of General Medical Sciences, National Institute;,; of Health, Bethesda, Maryland Dr. James O'Leary, Professor and Chairman, Department of Neurology, Washington University, St. Louis, Missouri Dr@ Richard Orr, Director, Institute for Advancement of Medical Communica- tion, Bethesda, Maryland Dr. Irvine Page, Director, Research Division, Cleveland Clinic, Cleveland, Ohio Dr. Oglesby Paul, Professor of Medicine, Northwestern University School of Medicine, Chicago, Illinois Dr. Edmund Pellegrino, Professor and Chairman, Department of Medicine, Uni- versity of Kentucky College of Medicine, Lexington, Kentucky Dr. Paul Q. Peterson, Associate Chief for Operations, Bureau of State Services, Public Health Service, Washington, D.C. Dr. Micceyslaw Pesczynski, Director, Rehabilitation Program Hi-,bland View Hospital, Cleveland, Ohio Dr. Harry T. Phillips, Directoi, Division of Chronic Diseases, ivlassachusetts Departirnent of Public Health, Boston, Alassacbusettt Dr. Leland E. Powers, Associate Director, Association of American Medical Col- leges, Evanston, Illinois Mr. David Prowitt, Producer in Charbe of Science Programs, National Educa- tiona'i Television and Radio Cehtei, New York, New York Dr. Alvin Puth, National Rehabilitation Association, Washington, D.C. Dr. Efraim Racker, The Public Health Research Institute of the City of New York, New York, New York Dr. Herman Rahn, Chairman, Department of Physiology, University of Buffalo, Buffalo, New York lir. I. S. Ravdin, Vice President for Medical Affairs, University of Pennsylvania, Philadelphia, Pennsylvania Dr. Lewis C. Robbins, Chief, Cancer Control Branch, Division of Chronic Diseases, Bureau of Stite Services, Public Health Service, Washington, D.C. Dr. Herbert H. Rosenberg, Chief, Resources Analysis Branch, Office of Program Planning, Office of the Director, National Institutes of Health, Bethesda, Maryland Dr. Allen Russek, Institute of Physical i'vledicine and Rehabilitation, New York University Medical Center, New York, New York Dr. Joseph Sadusk, Medical Director, Bureau of Medicine, Food and Drug Administration, Washington, D.C. Dr. A. L. Saba, Professor of Neurology, State University of Iowa, Ames, Iowa Dr. John J. Sampson, President, American Heart Association, New York, New York 99 Dr. Sidney Scherlis, Cardiologist, Baltimore, Maryland HEART DISEASE, CANCER AND STROKE Dr. Harold W. Schnaper, Chief 9 Research in Internal Medicine@ Veterans' Admin- istration, Washington, D.C. Dr. Robert L. Schoenfeld, Rockefeller Institute, New York, New York on, Director, National Institutes of Health, Bethesda, Maryland Dr. James Shann visor, Intramural Research, National Cancer In- Dr. Murray J. Shear, Special Ad i stitute, National Institutes of Health, Bethesda, Maryland Dr. Cecil Sheps, Professor of Medical and Hospital Administration, Graduate School of Public Health, University of Pittsburgh, Pittsburghl Pennsylvania Dr. John F. Shermani Associate Director for Research Grants and Awards5 Na, tiondl Institutes of Health, Bethesda, Maryland er, Minnesota Dr. Robert Siekert, Section of Neurology, Mayo Clinic, Rochest Dr. Charles Shields, Georgetown University School of Medicine, Washington, D.C. Dr. M. B. Shimkin, Fels Research Institute, Philadelphia, Pennsylvania Col. Robert Shira, MC, USA, Chief of Dental Service, Walter Reed Army Medical Center, Washington, D.C. Dr. Ausiin Smith, President, Pharmaceutical Manufacturers' Association, Wash. ington, D.C. Dr. William Spencer, Texas Institute for Rehabilitation and Research, Baylor University, Houston, Texas Dr. Jeremiah Stamler, Director, Division of Adult Health and Aging, Chicago Board of Health, Chicago, Illinois Dr. Eugene Stead, Chairman, Department of edicine, Duke University Medical Center, Durham, North Carolina Dr. Frederick L. Stone, Director, National Institute of General Medical Sciences, National Institutes of Health, Bethesda, Maryland Mrs. Ethel Mae Strueben, Director, Conference Group on Medical-Surgical Nursing, American Nurses Association, New York, New York Mr. Daniel Sullivan, Representative, Society of Public Health Educators, Inc., Washington, D.C. Miss Mary E. Switzer, Commissioner, Vocational Rehabilitation Administration, Department of Health, Education, and Welfare, Washington, D.C. Dr. Edward Tatum, Rockefeller Institute, New York, New York Dr. A. N. Taylor, Associate Secretary, Department of Medical Education, American Medical Association, Chicago, Illinois . Mr. Eugene J. Taylor, Institute of Physical Medicine and Rehabilitation, New York University Medical Center, New York, New York Dr. Martha Taylor, Chief of Speech Therapy, Institute of Physical Medicine and Rehabilitation, New York University Medical Center, New York, New York Dr. Lewis Thomas, Chairman, Department of Medicine, New York University, New York, New York Dr. James L. Troupin, Director of Professional Education, American Public Health Association, New York, New York 100 Dr. Maurice Visscher, Chairman, Department of Physiology, University of HEART DISUSE, CANCER AND STROKE Minnesota, Minneapolis, Minnesota Dr. T. Phillip Waalkes, Associate Director for Collaborative Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland Dr. George Wakerlin, Medical Director, American Heart Association, New York, New York Mr. John Walden, Information Officer, Division of Chronic Diseases, Bureau of State Services, Public Health Service, Washington, D.C. Dr. Shields Warren, Professor, Cancer Research Institute, Boston, Massachusetts Dr. Stafford Warren, Special Assistant to the President for Mental Retardation, Washington, D.C. Dr. William Wendell, Institute of Physical Iledicine and Rehabilitation, New York University Medical Center, New York. New York Mrs. Margaret West, Assistant Chief, Division of Public Health Methods, Office of the Surgeon General, Public Health Service, Washin@ton, D.C. Dr. Frederick Whitehouse, Director of Rehabilitation, American Heart Associa- tion, New York, New York 4r. L. Holland Whitney, American Telephone and Telegraph Company, New York, New York Dr. Robert W. Wilkins, Professor and Chairman, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts Dr. William Willard, Dean, University of Kentucky Colle-e of Medicine, Lexing- ton, Kentucky Dr. Dael Wolfle, Executive Director, American Association for the Advancement of Science, Washington, D.C. Dr. Paul Zamecnick, Director, John Collins Warren Laboratories of C. P. Hunt- ington Hospital of Harvard University at illassachusetts General Hospital, Bos- ton, Massachusetts Dr. Charles Gordon Zubrod, Director of Intramural Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland Dr. Vladimir Zworykin, RCA Laboratories, Princeton, New Jersey 101 HEART DISEASE, CANCER AND STROKE APPENDIX F Abbey, J. C., et al.: Television in Health Sciences Education: Horne and Hospital Viewing of Continuing Education Broadcasts Under Three Presentation-Response Conditions. Journal of Medical Education 39: 693-703, 1964. Acheson, R. J.: Tle Epidemiology of Acute Rheumatic Fever (to be published) Adam-A, S.: Hospital Libraries: Underde.veloped base for continuing education. Hospitals 38: 52-54, 1964. American Council on Education: American Junior Colleges. 5th edition. Wash- ington, D.C., 1960. American Heart Association: Report of Committee on Standards and Criteria for Pro@rams of Care: Jones criteria (modified) for guidance in diagnosis of 0 rheumaticfever. Circulationl3:617-620,1956. American Heart Association: Report and Recommendations of the Second Na- tional Conference on Rheumatic Fever Prevention, 1963 (in press). American Medical Association: Council on Medical Service: The Hill-Burton Study: A review of the Hospital Survey and Construction Act since 1946. Chicago, Ill., 1958. American Nurses' Association: Facts About Nursing. New York, 1964. Anon., The Availability and Financing of Nursing-Home Care. Blue Cross Re- ports 2: 1-16, 1964. Association of American Medical Colleges: Financial Assistance Available for Graduate Study in Medicine, 7th edition. Evanston, Ill., 1963. Association of American Medical Colleges: A Proposal for a Program of Federal Assistance to Medical Education. Evanston, Ill., 1963. Bailar, J. C., 111, King, H. and Mason, M. J.: Cancer Rates and Risks. PHS Publication No. 1148, U.S. Government Printing Office, Washington, D.C., 1964. Bellet, S.: Arrhythmias: paper prepared for the Subcommittee on Heart Disease of the President's Commission on Heart Disease, Cancer and Stroke. Bellet, S.: Congestive Heart Failure: paper prepared for the Subcommittee on Heart Disease of the President's Commission on Heart Disease, Cancer and Stroke. Bland, E. F., et al.: Cardiac Infections, Bacterial Endocarditis and Pericarditis: papers prepared for the Second National Conference on Cardiovascular Diseases. Washington, D.C., November, 1964. Bloomqu.ist, H.: The Status and Needs of Medical School Libraries in the United,'. States. Journal of Medical Education 38: 145-163, 1963. 102 Breslow' L.: Recognition and Early Treatment of Neoplastic Disease: paper HEART DISEASE, CANCER AND STROKE prepared for Cleveland Health Goals Project. Cleveland, Ohio, 1964. Burch, G. F., et al.: Primary Myocardial Disease: paper prepared for the Second National Conference on Cardiovascular Diseases. Washington, D.C., Novem- ber, 1964. Burchell, H. B., et al.: Pulmonary Vascular Disease and Cor Pumonale: paper prepared for the Second National Conference on Cardiovascular Diseases. Washington, D.C., November, 196,4. Christakis, G., et al.: The Anti-Coronary Club: A Dietary Approach to the Pre- vention of Coronary Heart Disease. A seven-year report, presented at the American Public Health Association annual meeting, New York, October 7, 1964 (unpublished). Commission on Chronic Illness: Chronic Illness in the United States, Care of the Long-Term Patient. Harvard University Press, Cambridge, Mass., 1956. Committee on Appropriations, Subcommittee on Department of Health, Educa- tion and Welfare and Department of Labor: Federal Support of Medical Re- search (Jones Report), U.S. Government Printing Office, Washington, D.C., 1960. Comroe, J. H., Jr., Editor: Research and Medical Education. Report of the Ninth Teaching Institute. Association of American Medical Colle@es, Evanston, Ill.,1962. Crocetti, A. F.: Diagnostic and Surgical Facilities for Congenital Heart Disease in the United States, Johns Hopkins School of Hygiene and Public Health (to be published). De Carlo, L. M., Amster, W. and Here, G. R.: Speech After Laryngectomy. Syra- cuse University Press, Syracuse, N.Y., 1955. desola Price, D. J.: Little Science, Big Science. Columbia University Press, New York, 1963. Dietrick, J. E. and Berson, R. C.: Medical Education at Mid-Century. Associa- tion of American Medical Colleges, Evanston, Ill., 1953. Dryer, B. V,: Lifetime Learning for Physicians: Principles, Practices, Proposals. Journal of Medical Education 37: pt. 11, 1962. Ebbert, A., Jr.: Two-way Radio in Medical Education. Journal of Medical Education 38: 319-328, 1963. Epstein, F. H.: The Epidemiology of Coronary Heart Diseases. A review (to be published). Evans, L. J.: Crisis in Medical Education. University of Michigan Press, Ann Arbor,1964. Ewing, 0. R.: The Nation's Health, a 10-year program: A report to the Presi- dent. Federal Security Agency, Washington, D.C., 1948. Gardner, W. H. and Harris, H. E.: Aides and Devices for Laryngectomees. Archives of Otolaryngology 73: 145-152,1961. Garrett, J. F. and Levine, E. S.: Psychological Practices with the Physically 103 Handicapped. Columbia University Press, New York, 1962. HEART DISEASE, CANCER AND STROKE Gartland, H. J.: Blueprint for a Professional Hospital Library. Hospitals 38 (12) : 58-59, June 16, 1964. Giesler, R. H. and Yast, H. T.: A Survey of Current Hospital Library Resources. Hospitals 38 (12) : 55-57, June 16, 1964. Ginzberg, E.: The Optimistic Tradition and American Youth. Columbia Uni- versity Press, New York, 1962. Gordon, E. E., et al.: Stroke (Community Services) : paper prepared for the Second National Conference on Cardiovascular Diseases. Washington, D.C., November, 1964. Harris, N. E.: Technical Education in the Junior College New Progress for New Jobs. American Association of Junior Colleges, Washington, D.C., 1964. Harris, S. E.: The Economics of American Medicine. Macmillan, New York, 1964. Hartroft, W. S..; Etiology and Pathogenesis of Arteriosclerosis: paper repared p for the Subcommittee on Research of the President's Commission on Heart Disease, Cancer and Stroke. Heintzelmann, F.: Factors in Prophylaxis Behavior in Treating Rheumatic ever: an exploratory study. Journal of Health and Human Behavior 3: 73-81, 1962. Hellerstein, H. K. and Ford, A. B.: Comprehensive Care of the Coronary Patient: a challenge to the physician. Circulation 22: 1166-1178, 1960. Higgins, I. T. T.: The Epidemiology of Congenital Heart Disease (to be pub- lished). Hochbaum, G. M.: Modern Theories of Communication. Children 7: 13-18, 1960. Hochbaum, G. M.: Relating to Health Education. Address to the Joint Meeting of the National Health Council's Committee on Research and Committee on Health Education. New York, December 10, 1959. Hoobler, S.: Hypertension: paper prepared for the Subcommittee on Research of the Presidenes Commission on Heart Disease, Cancer and Stroke. Hughes, T. M.: Guidelines for Aphasia. American Archives of Rehabilitation Therapy 9: 4-10,1961. Institute for Social Research, Survey Research Center: The Impact of Science in the Mars Media; a report on a nationwide survey for the National Association of Science Writers. The University of Michigan, Ann Arbor, 1958. Jones, R. J., Editor: Evolution of the Atherosclerotic Plaque. University of Chicago Press, Chicago, 1963. Joint Commission on Mental Illness and Health: Final Report, Action for Mental Health. Basic Books, Inc., New York, 1961. 104 Katz, L., et al.: Heart Failure: paper prepared for the Second National Con- HEART DISEASE, CANCER AND STROKE ference on Cardiovascular Diseases, Washington, D.C., November, 1964. Keith, J. D., Rowe, R. F. and Vlad, P.: Heart Disease in Infancy and Childhood. Macmillan, New York, 1959. Kidd, C. V.: American Universities and Federal Research. Belknap Press, Cam- bridge, Mass., 1959. Kirklin, J., et al.: Cardiovascular Surgery: papers prepared for the Second National Conference on Cardiovascular Diseases. Washington, D.C., Novem- ber '1964. Klainer, L. J., Gibson, T. C. and White, K. L.. The Epidemiology of Cardiac Failure (to be published). Kottke, F. J.: Prevention of Disability, Social Isolation and Untimely Death: paper prepared for Cleveland Health Goals Project. Cleveland, Ohio, 1964. Ladd, A. C.: Cerebrovascular Disease in an Employed Population. Journal of Chronic Diseases 15:985-990, 1962. Mattison, B. F. and Richman, T. L.: The Case of the Missing Mileposts. Com. munity Health Services, Public Affairs Pamphlet No. 180-s, Public Health Affairs Committee, New York, 1962. Miller, G. E., et al.: Teaebing and Learning in Medical Schools. Harvard Uni- versity Press, Cambridge, Mass., 1961. Millikan, C. H., Siekert, R. G. and Whisnant, J. D., Editors: Cerebral Vas- culardiseases. GrutieandStratton,NewYork,1961. Mohs, M. D.: Service Through Placement in the Junior Colleges. American Asso- ciation of Junior Colleges, Washington, D.C., 1962. Mushkin, S. J., Editor: Economics of Higher Education. U.S. Department of Health, Education and Welfare, Washington, D.C., 1962. Nadas, A. S.: Pediatric Cardiology, 2nd edition. Saunders, Philadelphia, 1963. National Academy of Science@National Research Council, Division of Medical Sciences: Communications Problems in Biomedical Research. Washington, D.C., 1963. National Academy of Sciences, Committee on Science and Public Policy: Federal Support of Basic Research in Institutions of Higher Learning. Washington, D.C., 1964. National Academy of Sciences, Committee on Utilization of Scientific Engin@er- ing Manpower: Toward a Better Utilization of Scientific and Engineering Talent. Washington, D.C., 1964. National Health Council: Health Careers Guidebook. New York, 1955. National Health Education Committee, Inc.: Does Medical Research Pay Off- InLives? InDollars? NewYork,1964. National Heart Institute: Staff Report on Developmental Grants. 1964 (unpublished). HEART DISEASE, CANCER AND STROKE f Neurological Diseases and National Institutes of Health, National Institute 0 lar Study Group. Bethesda, Md., Blindness: Survey Report, Cerebral Vascu 1961. ,, m: Special Report. National Institutes of Health Clinical Research Centers Proara 1963 (unpublished) - National Institutes of Health: Materials on International Research and Training Supported by the National Institutes of Health. Prepared for the Commission by the Office of International Research. Bethesda, iNId., 1964. National League for Nursing Committee on the Que--tionnaire Study of Prac- al Nursing. 1960. New York, 1962 tical Nursing Schools: Education for Practic National Merit Scholarship Corporation: Guide to the National Merit Scholar- ship Program. Evanston, Ill., 1961. Orlans, H.: The Effects of Federal Programs on Hi,-her Education: A study of 36 institutes and colleges. The Brookings Institution. 1963. Osgood, C. and Osgood, M.: Approaches to the Study of Aphasia, a report of an inter-disciplinary conference on aphasia. University of Illinois, Urbana, Ill., 1963. Page, 1. H., et al.: Atherosclerosis: papers prepared for e Second National Conference on Cardiovascular Diseases. Washington, D.C., November, 1964. Pattison, H. A., Editor: The Handicapped and Their Rehabilitation. Thomas, Springfield, Ill., 1957. President's Commission on National Goals: Report. American Assembly, Co- lumbia University, New York, 1960. President's Commission on the Status of Women: American Women. U.S. Gov- ernment Printing Office, Washington, D.C., 1963. President's Council on Aging: Federal Aid for Nursing Homes, Washington, D.C., 1963. President's Science Advisory Committee: Scientific Progress, the Universities, and the Federal Government. U.S. Government Printin-, Office, Washington, D.C., 1960. President's Science Advisory Committee: Meeting Nlanpower Needs in Science and Technology. U.S. Government Printing Office, V'ashington, D.C., 1962. President's Science Advisory Committee: Life Sciences Panel: Some New Tech- nologies and Their Promise for the Life Sciences. U.S. Government Printing Office, Washington, D.C., 1963. PresidenCs Science Advisory Committee: Report. Science, Government and Information: the responsibilities of the technical community and the govern- ment in the transfer of information. U.S. Government Printing Office, Washing- ton, D.C., 1963. 106 Price, D. K.: Government and Science: Their dynamic relation in American HEART DISUSE, CANCER AND STROKE democracy. New York Uni@ersity Press, New York, 1954. Progress Report of the Joint Study of Extracranial Arterial Occlusion, presented at the Fourth Conference on Cerebral Vascular Diseases, Princeton, N.J., Jan- uary, 1964 (in press). Rantz, L. A., et al.: Rheumatic Fever-Collagen Disease: papers prepared for the Second National Conference on Cardiovascular Diseases. Washington, D.C., November, 1964. Rheumatic Fever in Children and Adolescents. Annals of Internal Medicine 60: (Supp. 5) February, 1964. Ritchie, D.: Stroke: A study of recovery. Doubleday, Garden City, N.Y., 1961. Rivlin, A. M.: The Role of the Federal Government in Financing Higher Educa- tion. The Brookings Institution, Washington, D.C., 1961. Rosenstock, I. M.: Public Acceptance of Influenza Vaccination Programs. American Review of Respiratory Diseases 83: 171-174, 1961. Ruhe, C. H. W.: A Survey of the Activities of Medical Schools in the Field of Continuing Medical Education. Journal of Medical Education 38: 820-828 1963. Ruhe, C. H. W.: The American Medical Association's Pro@ram of Accreditation 0 in Continuing Medical Education. Journal of Medical Education 39: 670-678, 1964. Rusk, H. A.: Rehabilitation Medicine, Mosby, St. Loui s, Mo., 1958. Sackett, D. L. and Winkelstein, W.: The Epidemiology of Aortic and Peripheral Atherosclerosis: A selected review (to be published). Sarnoff, D.: The Social Impact of Computers. An address to the American Bankers Association National Automation Conference, New York World's Fair, July, 1964. Schneider J. H.: Survey of Projects Related to the Published Literature Sup- ported by Grants and Contracts From the Public Health Service. National Li- brary of Medicine, Bethesda, Md., January, 1964 (unpublished). Schuman, L. M.: The Epidemiology of Thromboembolic Disorders (to be published). Schweitzer, M. and Gearing, F.: The Epidemiology of Hypertension (to be published). Sheps, C. G., Wolf, G. A., Jr. and Jacobson, C., Editors: Medical Education and Medical Care-Interactions and Prospects. Report to the Eighth Teaching In- stitute, Association of American Medical Colleges. Association of American Medical Colleges, Evanston, Ill., 1961. Sherry, S., et al.: Thromboembolic Disorders: paper prepared for the Second National Conference on Cardiovascular Diseases. Washington, D.C., Novem- ber, 1964. 107 Spring, W. C., Jr. and Honicker, F.: Drug Information for the Biomedical Corn- HEART DISEASE, CANCER AND STROKE U.S. Public Health Service: Report on Nursing Care of the Sick at Home in Se- lected United States Cities. PHS Publication No. 901, U.S. Government Print- ing Office, Washington, D.Ci, 1962. U.S. Public Health Service: Research in Hospital Use: Progress and Problems. A conference report. PHS Publication No. 930-E-1, U.S. Government Printing Office, Washington, D.C., 1962. U.S. Public Health Service: Division of Hospitals: Annual Statistical Summary, Fiscal :Year, 1963. U.S. Government Printing Office, Washington, D.C. 1963. U.S. Public Health Service: Areawide Planning of Facilities for Long-term Treat- ment and Care. Report of the Joint Committee of the American Hospital Associa- tion and Public Health Service. PHS Publication No. 930-B-1, U.S. Govern. ment Printing Office, Washington, D.C., 1963. U.S. Public Health Service: Areawide Planning of Facilities for Rehabilitation Services: Report of the joint Committee of the Public Health Service and the Vocational Rehabilitation Administration. U.S. Government Printing Office, Washin@on, D.C., 1963. U.S. Public Health Service: Division of Chronic Diseases, Cancer Control Branch: Cancer Film Guide: 1963. U.S. Government Printing Office, Washington, D.C., 1963. U.S. Public Health Service: Cancer Services, Facilities and Programs in the United States, 1962. U.S. Government Printing Office, Washington, D.C., 1963. U.S. Public Health Service: Conference on Research in Hospital Use. U.S. Gov- ernment Printing Office, Washington, D.C., 1963. U.S. Public Health Service: Hill-Burton Program: Progress report July 1, 1947- June 30, 1963. U.S. Government Printing Office, Washington, D.C., 1963. U.S. Public Health Service: Hill-Burton Publications: An annotated bibliography. U.S. Government Printing Office, Washington, D.C., 1963. U.S. Public Health Service: Hill-Burton State Plan Data: A national summary as of January 1, 1963. U.S. Government Printing Office, Washington,'D.C., 1963. U.S. Public Health Service: Hospital Emergency Service: Criteria for organiza. tion. PHS Publication No. 930-C-3, U.S. Government Printing Office, Wash- ington, D.C., 1963. U.S. Public Health Service: Hospital-Nursing Home Relationships: Selected refer- enccs annotated. U.S. Government Printing Office, Washington, D.C., 1963. U.S. Public Health Service: Nursing Homes and Ikelated Facilities: Fact book. PHS Publication No. 930-F-4, U.S. Government Printing Office, Washington, D.C., 1963. 110 U.S. Public Health Service: Planning Multiple Disability Rehabilitation Facil- HEART DISEASE, CANCER AND STROKE ities. U.S. Government Printing Office, Washington, D.C., 1963. U.S. Public Health Service: Procedures for Area;vide Health Facility Planning: A guide for planning agencies. U.S. Government Printing Office, Washington, D.C., 1963, U.S. Public Health Service: The Progressive Patient Care Hospital: Estimated bed needs. PHS Publication No. 930-C-2, U.S. Government Printing Office, Washington, D.C., 1963. U.S. Public Health Service: Subcommittee on the Drug Information Clearing House: Science Information Handling, a symposium, conducted by the George Washington University Biological Science Communication Project, June 3-.7, 1963. U.S. Public Health Service: Serving Health Research: The Mission of the Di- vision of Research Facilities and Resources of the National Institutes of Health. U.S. Government Printing Office, Washington, D.C., 1963. U.S. Public Health Service: State and Local S@rveys of Nursing Homes and Re- lated Facilities. Annotations of selected studies. U.S. Government Printing Office, Washington, D.C., 1963. U.S. Public Health Service: Surgeon General's Conference on Health Communi- cations, November 5-8, 1962. U.S. Government Printing Office, Washington, D.C., 1963. U.S. Public Health Service: Survey of Coordinated Home Care Programs. U.S. Government Printing Office, Washington, D.C., 1963. U.S. Public Health Service: The Hospital Electroencephalographic Suite. PHS Publication No. 930-D-13, U.S. Government Printing Office, Washington, D.C., 1963. U.S. Public Health Service: The MEDLARS Story at the National Library of Medicine. U.S. Government Printing Office, Washington, D.C., 1963. U.S. Public Health Service: Heart Disease Control Program: Community Services Developed for Congenital Heart Disease' 1950-65. Prepared for the Second Na- tional Conference on Cardiovascular Diseases, Washington, D.C., November, 1964. U.S. Public Health Service: Directory of Homemaker Services, 1963: Homemaker Agencies in the United States. U.S. Government Printing Office, Washington, D.C., 1964. U.S. Public Health Service: Indian Health Highlights: 1964 edition. 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World Health Organization: Expert Committee on Rheumatic Diseases: Preven-, tion of Rheumatic Fever-Second Report. Technical Report Series No. 126@,' Geneva,1957. 112 World Health Organization: Expert Committee on Cor Pulmonale: Chronic Cor HEART DISUSE, CANCER AND STROKE Pulmonale. Technical Report Series No. 213, Geneva, 1961. World Health Organization: Expert Committee on Arterial Hypertension and Ischaemic Heart Disease: Preventive Aspects, Arterial Hypertension and Is- chaemic Heart Disease. Technical Report Series No. 231, Geneva, 1962. Wright, I. S. and Luckey, E. H., Editors: Cerebral Vascular Diseases. Grune and Stratton, New York, 1955. Wright, 1. S. and Millikan, C. H., Editors: Cerebral Vascular Diseases. Grune and Stratton, New York, 1958. Wright, I. S., et al.: Cerebrovascular Disease: papers prepared for the Second National Conference on Cardiovascular Diseases. Washington, D.C., November, 1964. Wright, I. S.: The Etiology and Pathogenesis of Myocardial Infarction: paper prepared for the Subcommittee on Research of the President's Commission on Heart Disease, Cancer and Stroke. Wright, 1. S.: The Present Status and Future Needs for Anticoagulant Therapy: paper prepared for the Subcomittee on Heart Disease of the President's Com- mission on Heart Disease, Cancer and Stroke. Zilversmit, D. B.: The Metabolism of the Arterial Wall: paper prepared for the Subcommittee on Research of the President's Commission on Heart Disease, Cancer and Stroke. 113 HEART DISEASE, CANCER AND STROKE APPENDIX G The accomplishment of the commission's study and report was made possible by the valuable services of the following: Mrs. Dorothy M. Johnson Mr. Wayne Bara Mrs. Anna Keller Mrs. Frank M. Barry Miss Barbara Lane Mr. G. Stanley Beane Mrs. Mildred K. Lassman Mrs. Charlotte Bloom Miss Marlyn Lebedzinski Mrs. Catherine Bowling Dr. Forrest Linder Mrs. Agnes Brewster Dr. Clem C. Linnenberg, Jr. Miss Lynn Brewster Mr. Erik Lunde Mr. William S. Brooks Mr. Herbert Mathewson Miss Olga Bulka Mrs. Thelma Miller miss Brenda Burkevich Miss Janet Mitchell Mr. Bruce Carson Mr. John A. Mossberg Dr. Helen Chase Miss Dawn Patten Miss Elaine Contee Mrs. Maryland Pennell Mrs. Mary Croop Mrs. Elsie Phillips Mr. Russell Dean Mrs. Martha Phillips Mrs. Mildred Deutsch Miss Helen K. Powers Miss Julie Dickinson Dr. Patrick J. Doyle Mrs. Laverne Ray Mrs. Jacqueline Ellington Mrs. Dorothy Rice -Miss Margaret H. Ferrell Mr. Elmer Riggleman Robb ins Mrs. Marion Fleming Mr. Morton Mr. Harvey Geller Mrs. Virginia Shuler Mr. Irving Goldberg Miss Dolores Shupenka Mrs. Tavia Gordon Miss Barbara Sirnborski Dr. Lee Hansen Mr. Hartman B. Spence Mr. Archie Hardy Miss Bonnie Starner Dr. Arthur L. Harris cia Strelke Mrs. Patri Mr. Wade L. Harry Mrs. Shirley Taylor miss Marjorie T. Hayes Mrs. Vermel Thompson miss Nancy Hedges MissAnnetteTouya Mrs.MarjorieHerbert Mr. Clark L. Tynes Miss Betty Herndon Mr. Samuel B. Webb, Jr. Mr. Calvin Hopewell Dr. Burton Weisbrod Mrs. Eleanor Howell Mrs. Willie Wells Mr. J. Stewart Hunter 114 U.S. GOVFRNMENT PRIN'R[NG OFFICE: 1965 0-75"75 HEART DISUSE, CANCER AND STROKE