0 0 OPTIONAL FORM t4O, 10 $010-107 MAY 1962 EDITICM GSA G@. REG- NO. 27 UNITED STATES GOVERNMENT Memorandum Dr4 James M. Hunaley ruary 18,-1965 TO Assistant Surgeon General for Operation DATE:Feb FRO ices r @hief, Bureau of Medical Serv SUBJECT: Requested Comments on the Report to the President by the Commission on Heart Disease, Cancer and Stroke The Bureau of Medical Services, through the Division of Hospitals and the Division of Indian Health, would like to participate in the imple- mentation of the Commission's recommendations as they relate to federal beneficiaries. The development or expansion of research, training and care facilities for the Indian beneficiary would provide increased knowledge of the diseases in Indians as well as provide information of benefit to the Nation as a whole. The limited knowledge available As to the prevalence and natural history of these conditions relative to the Indian benefi- ciaries indicate marked differences compared with the general population. Analysis of age specific death rates indicates that the rate of heart disease among American Indians,, age 25-34, is twice the all races rate, and the rate is somewhat higher for ages 35-44 years, but drops sub- stantially for groups over 45. While the age specific death rates from malignant neoplasm is about the same as that for the general population between 25-54, it is substantially lower among older age groups. The Divisions have particular interest in the following recommendations: Recommendation 1 - Regional Centers for Heart Disease, Cancer and Stroke Each of the five major hospitals in the Division of Hospitals, by expanding already existing programs dealing with one or more of the three designated areas, could easily become such a regional center. These hospitals have the advantage of a capsule population representing both the scope in age and the scope in race and sex which would make them peculiarly effective as a teaching population in such a center, Further, with a trained and constantly on-duty commissioned staff and with an excellent medical record 6yste m, research training and demonstration would be extremely effective. Each of these hospitals has the research base in manpower and equipment which could with great ease be expanded to undertake the type of activity proposed in the Comission's recommendation. The single exception lies in the area of stroke where this system does not have a developed program. n-14, TT c on the Pavroll Savinas Plan 2. The Division of Indian Health's larger hospitals at Anchorage, Gallup, and particularly the new Phoenix Medical Center, which will contain a research unit, would be expanded and actively participate in association with a Regional Medical Center. Furthermore) this Division's network of hospitals and health centers could provide a system of case findings, referral, and follow-up in association with the specific programs of the Regional Medical Center. Recommendation 2 - Diagnostic and Treatment Stations The Division of Hospitals feels it hag a part to play in this recommendation within the limits of its responsibility for the federal beneficiaries. Recommendation 3 - Development of Medical Complexes The Division of Hospitals through each of the major five hospitals, could participate in such a medical complex in the treatment of federal benefi- ciaries and in the research effort. Recommendation 7 - Community Health Research and Demonstration The Division of Indian Health's ongoing comprehensive Community Health Program is ideally suited for research in Public Health Administration, and Program Planning and Evaluation. The unique situation of the Division's program of providing direct preventive, curative and rehabili- tative services renders itself to an excellent opportunity for research projects of these types. I Each of the major hospitals in the Division of Hospitals, by cooperating with the Bureau of State Services (Community Health) of the PES could readily serve as demonstration centers and for community health research. Recommendation 10 - National Cervical Canter Detection Program Since 1957 the Division of Indian Health has had a limited program for the early detection of cervical cancer involving the taking of cervical smears., In 1963, 15,000 smears were taken with 20 cases being found and appropriate treatment instituted. The Division of Hospitals has included this examination as part of the routine admission physical examination of its female beneficiaries, and is supporting this recommendation. Recommendation 12 - Public Information on Heart Disease, Cancer and Stroke The Division of Indian Health is interested in having some of this informational material adapted for the use of Indian beneficiaries because of their differences in language and culture. 3- Recommendation 14 - Specialized Research Centers As above,, the Division of Hospitals is interested in cooperating with such centers as this research relates to federal beneficiaries. Recommendatio@l - General Support of Research The Division of Hospitals concurs in this recommendation to further support and expand the intramural research programs, Recommendation 19 -@nsion of Resources for Preparation of Health Manpower The Division of Indian Health desires to see that ways and means are found to provide oDDortunities for education of their beneficiaries in the health professions. Recommendation 20 - Recruitment for the Health Professions The Division of Indian Health is desirous of having its young beneficiaries encouraged and assisted to pursue education in health professions and related disciplines under this program and return to their comunitiese Recommendation PP-- Training for Research The Division of Hospitals feels that it may play a part in this recommen- d,ation in each of the 5 major hospitals, in cooperation with medical centers and affiliated hospitals. I Recommendation 23 - Support of Clinical Training The Division of Hospitals could very actively participate in the training of clinical fellowships,, full-time clinical investigatorships in heart disease and stroke, clinical training in cancer and clinical fellowships in rehabilitation in each of the major five hospitals. Recommendation @ - Training of Health Technicians The Division of Indian Health is interested in recruitment and training of Indian beneficiaries who are economically disadvantaged. This can be done through the expansion of the Licensed Practical Nurse School, establishment of accredited Medical Record Technician School, and certified Laboratory Assistance School within this Division. The Division of Hospitals is interested in expanding the training courses for Medical Technologistsi X-ray Technicians, Medical Record Librarians and in cooperation with affiliated medical centers., to broaden the training of other paramedical personnel. 4. Recomme tion 29 - Strengthening the Federal Hospital Program The Division of Indian Health is interested in augmenting its services to the beneficiaries including rehabilitation for the heart disease.,,cancer) and stroke patients by expanding the hospital program for chronic diseases. The Division of Hospitals, with the support proposed by the Commission, can implement and expand ongoing programs of patient care, research, and training and develop programs in rehabilitation. In the areas of heart disease, dancer and stroke the following material outlines this Division's current programs and undeveloped potentials: I. Current Programs: A. Heart Disease 1. Research In research in heart disease, the Division of Hospitals has research laboratories in four 6f its teaching hospitals concerned with the investigation of heart disease. national Institutes of Health grants and Division of Hospitals awards support the conduct of investigations in these facilities. The following is a sampling of the current list of projects: 1. Physical Training and Hypertension - Staten Island 2. Cooperative Study of Drugs and Coronary Heart Disease (A cooperative study with 5 University Hospitals) - Staten Island 3. Relation of Anaerobic Metabolism to Ventricular Work Seattle 4. Cardiopulmonary Hemodynamics During Acute Heat Stress Staten Island 5. Myocardial Magnesium Metabolism and Cardiac Function San Francisco 6. Measurement of Instantaneous Ventricular Function - Staten Island 7. Retinal Vascular Changes in Hypertension - Staten Island 8. A Study of the Dilated Heart - New Orleans (with Tulane University) In addition, a cooperative study is being conducted in seven of the Division's hospitals concerned with clinical drug trials of antihypertensive agents* Three investigational drugs have been evaluated in the double blind studies over the past two years and a report,on one has been submitted to the scientific literature* Reports on the other two are in varying stages of pending publications The Division of Hospitals supports a study in open heart surgery at the Boston Hospital concerned with hemodilation techniques. This study is also utilized in the training of surgical residents in open heart surgical techniques. Memphis has a small research program in collaboration -with the Heart Disease Control Program of the Division of Chronic Diseases* This study is concerned with the assessment of the efforts on transmission loss due to the pulmonary disease on the surface electrocardiogram and vector cardiogram. 2. Training In the training programs in these hospitals, there is emphasis on cardiovascular disease due to the established research facilities. All health professions in training in these facilities benefit by the presence of these research programs, The Seattle Hospital has an established fellowship for cardiovascular research and the Staten Island Hospital is presently recruiting for an authorized similar position. 3- Services Improved patient services are available due to the presence of the research laboratories and the associated specialty training. The services available to patients are over and above wbat,is usually available in community hospitals. B. Cancer 1. Research In collaboration with the National Cancer Institute, chemotherapy of malignancy programs are being conducted in three teaching hospitals (Baltimore, Boston, and New Orleans). Similar programs are underway through university affiliation at San Francisco and Galveston as a part of the cooperative group program of the Cancer Chemo-Therapy National Service Center of the NCI. These programs concern large scale clinical trials of newer cancer therapeutic agents which are frequently used in association with radiation therapy or surgery. In co @ boration with the Cancer Control Program of the Division of Chronic Diseases (BSS) an Oral Cytology Study is being conducted in all hospitals and major clinics of the division. This program is designed to statistically determine the efficacy of cytologic procedures in the early detection of oral cancer* 6. Demonstration projects in cancer detection initi @ d by the Division of Chronic Diseases (BSS) are now operational in five teaching hospitals of the Division. These projects are concerned chiefly with cytologic procedures for early detection of carcinoma of the cervix in female beneficiaries. 2. Trainina All trainees in these hospitals benefit by the association of the above research programs. The individual trainee receives orientation and emphasis in his training on the early detection of malignancies. At Baltimore and Boston where research laboratories are a part of the chemotherapy programs clinical research fellowships are established. 3. Services Improved patient services are present in the facilities conducting these programs. The latest in cancer diagnosis and treatment is available to Public Health Service beneficiaries. Cancer registries are operational in six of the te @ ing hospitals of the Division. Three hospitals (Baltimore, Boston and San Francisco) are approved by the American College of Surgeons as Cancer Diagnosis and Treatment Centers. Approval is pending for the @ten Island and Seattle hospitals. The preseace of these programs provides more adequate patient care in the diagnosis and treatment of cancer. C. Stroke 1. Research There are no active research projects underway in this area. 2. Training Intern and residency training is enhanced by active Physical Therapy and Occupational Therapy Services in the teaching hospitals of the Division. A great deal of emphasis has alwayB been placed on rehabili- tation of the stroke victim, The Division is embarking on a program of training medical neurologis s in conjunction vith the NINDB; the first internist entered into training outside the service in medical neurology July 1, 1964. Currently underway is an affiliation program with the Departments of Neurology at the University of Washington -with the Seattle Hospital. 7- 3. Services Fairly adequate physical therapy and occupational therapy services are available as a rehabilitation program in the teaching hopsitals. - Other hospitals and outpatient clinics have less adequate physical therapy services and no occupational therapy services. In all the areas (heart disease, cancer, and stroke), the value of early case finding has been demonstrated by a pilot program in preventive medicine in the Boston hospital. This program is designed to institute periodic complete examinations for beneficiaries and has found its greatest potential in the group of retired service officers and their dependents. 11. Undeveloped Potential (Program Deficiencies): A. Heart Disease 1. Research Increased dollar resources are necessary to most fully utilize the investigative potential of diseases in our beneficiary group* For example, the cooperative study on anti-hypertensive drugs has defined a large group of mild to moderate hypertensives that provide a continuing group for further drug evaluation. Competency has been demonstrated in clinical trials and these should be expanded. The same is true of open heart surgical methods; with increased resources further investigation would be possible. 2. Training A great training potential is present. The need is for increased dollar resources to: 1. permit improved laboratory and X-ray facilities for more modern diagnostic methods and 2. to expand fellowship training in medical sub-specialties where research capabilities are available. .3. Services To provide the latest in diagnosis and treatment to our beneficiaries) increased dollar resources are necessary. For example, X-ray equipment in our facilities is generally out-dated and mondern equipment is very important in the diagnosis and treatment of heart disease and stroke. To provide the best in open heart surgery, complete laboratories are essential. For example, the Boston hospital is currently performing heart surgery without a supporting cardiac catheterization laboratory. Other resources needed are funds to provide the modern drugs in the care of our beneficiaries. B. Cancer 1. Research Competency in clinical trials in the chemotherapy of malignancy have been demonstrated. With increased dollar resources this program could be expanded. Clinical trials of these investigational drugs are very important in determining complete methods of tre @ ent of victims of cancer* 2. Training More dollar resources could provide more sub-specialty training to physicians to further develop sub-specialty inservice training. Closely associated with this is the need for improved diagnostic facilities. 3. Services The improvement of the training and research areas and the f)ill develop- ment of potential in these areas would provide more comprehensive services to our beneficiaries. Roentgen therapy continuesto be an important part of cancer therapy. Our equipment badly needs updating and much additional equipment is needed. C; Stroke 1. Research In order to encourage research in this area, more competence is needed in rehabilitation. There is a need for trained physiatrists and neurologists to institute clinical investigation in this area. The Division has potential for good investigation into rehabilitation problems of stroke victims. 2. Training There is a need for increased resources to train physiatrists and neurologists to provide adequate training programs for residents and interns. 3- Services The increased resources of trained manpower and diagnostic treatment facilities and research would provide the latest of diagnostic treatment and rehabilitative services to victims of stroke. 9. t@78neral: The autnority and resources to estab-@sh preventive medicine clinics in facilities of the Division of 'f7,o@,-Lcals for the early diagnosis of heart disease and cancer -vTould -rrovide better training for physicians in these areas a-"-d produce iml)rovea, service to beneficiaries. Recor@nendation @P - Statis-'U-i-cal Pro ra:z-- I- T'ne Division of Hos-ri-@--i-s is -vTill@-Ln- to -rartiti-oate in the collection and dissemination oL@ health statistics as 'uhey apply to ',he three disease categories. Reco-iirnendation 34 - 'Clearinghouse for Dru@@- information The Division Hospitals is actively I,-,z-,i-tici-nating in reporting adverse reactions to dru--s and disseminating '@n@'s information to the hospitals W3'.thin the Division, therefore, welcomes this recommendation, 4 and -would actively participate -in such a clearinghouse. Reco.L@-ende,t-'-Ic,n --search and Training Proorams ,@5 - International R CD The Division of Hos@it--ls could assists in the 'U-"aihing of ,foreign physicians in t7ne clinical research activities o-F' the Division.