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.  U.S.  Gov-
         ernment Printing Office, Washington, D.C., 1964.
         U.S. Public Health  Service:  Representative  Construction  Costs  of  Hill-Burton
         Hospitals and Related Health Facilities. U.S. Government  Printing  Office,  Wash-
         ington, D.C., 1964.
         U.S. Public Health  Service:  Science  and  Technical  Information  Activities  of
         the National Institutes of Health, Fiscal  Year  1963.  U.S.  Government  Printing
         Office, Washington, D.C., 1964.                                                    HEART DISEASE, CANCER AND STROKE









                                             U.S. Public Health Service: Smoking and Health.  Report  of  the  Advisory  Corn-
                                             rnittee to the Surgeon General of the Public Health Service, PHS Publication  No.
                                                                                                                1
                                             1103, U.S. Government Printing Office, Washington, D.C., .1964.
                                             U.S. Public Health Service:  Up  and  Around.  PHS  Publication  No.  1120.  U.S.
                                             Government Printing Office, Washington, D.C., 1964.
                                             U.S.  Senate:  Committee  on  Government  Operations:   Documentation,   Indexing
                                             and Retrieval of Scientific Information: a study of Federal and non-Federal  sci-
                                             ence information processing and retrieval programs. 86th  Congress,  2d  session.
                                             Senate  Document  113.  U.S.  Government  Printing  Office,   Washington,   D.C.,
                                             1960.
                                             Ullman,  M.:  Behavioral  Changes  in  Patients   Following   Strokes.   American
                                             Lecture Series No. 474, Thomas, Springfield, Ill., 1962.
                                             United Kingdom and United  States:  The  Evolution  of  Rheumatic  Heart  Disease
                                             in Children. Five-year report of a cooperative clinical trial of ACTH,  cortisone
                                             and aspirin.  Circulation 22:503-515, 1960.
                                             Vocational Rehabilitation  Administration:  Guidelines  for  Provision  of  Voca.
                                             tional Rehabilitation Services to Individuals with Cancer.  Rehabilitation  Serv-
                                             ices Series No. 64-6. U.S. Government Printing Office,  Washington,  D.C.,  1963.
                                             Vosburgh, B. L. and Rozendaal, H. M.: The Cancer  Patient  in  Industry.  Journal
                                             of Occupational Medicine 2:4.32-434,1960.
                                             Warren, S. L.: Proposal: The National  Library  of  Science  System  and  Network
                                             for the Published Scientific Literature (unpublished).
                                             White, P. D., Rusk, H. A., Lee, P. R. and Williams,  B.:  Rehabilitation  of  the
                                             Cardiovascular Patient. Blakiston, New York, 1958.
                                             Whitehouse, F. A., Editor: Living a Useful  and  Meaningful  Life  After  Stroke.
                                             Journal of Rehabilitation 29:45-47, 1963.
                                             Whittemore, R., et al.: Community Service Aspects of Rheumatic  Fever  and  Rheu-
                                             matic Heart Disease:  paper  prepared  for  the  Second  National  Conference  on
                                             Cardiovascular Diseases.  Washington, D.C., November, 1964.
                                             Wilkins, R. W., et al.: Hypertension: papers prepared  for  the  Second  National
                                             Conference  on  Cardiovascular  Diseases.  Washington,  D.C.,   November,   1964.
                                             Wolfle, D.: Science and Public Policy. University  of  Nebraska  Press,  Lincoln,
                                             Nebr., 1959.
                                             World Health  Organization:  Report.  Study  Group  of  Atherosclerosis  and  Is-
                                             chaemic Heart Disease.  Technical Report Series No. 117, Geneva, 1957.
                                             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