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THE PRESIDENT'S COMMISSION ON HEART DISEASE, CANCER AND STROKE REPORT TO THE PRESIDENT A NATIONAL PROGRAM TO CONQUER HEART DISEASE, CANCER AND STROKE Velwme ! Decemberr 1964

DEAR ~II. ~RESInENT; 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 realislic battle plan leading to the ultimate cm~quest of three diseases--heart disease. cancer and stroke--which naw account for more than 70 percent of the deaths in this country. In your initial charge to us. you requesled us to recommend practical steps to reduce the heavy losses exacted by these diseases through the d~velopn~enl of Jww scientific ht~owiedge ~r~d tbrough the ddi~'er), to all of t>ur people in every part of this great land of Ihe precious, lifesaving medical knowl. edge we now possess, but fall to bring to so many stricken American families. Grateful beyond measure of expression for this Presidential maudale, we pl~ged i~to ~utr assigne3 task ran/ide~l thai the toll of these three dtseases could in fact be sharply reduced i~ow and irt the immediale future. During the intervening months, as we sought and received leslhnorty from scores of leaders in mezlicine and public affairs, our conviction mounted that we could chart a truly ¢~atlotJal cfg~rt ealllng upon the full [¢sonrces of Federal, State and local govern- ments, the dedicated members of the health professions, attd our great rolutltary health organizations--leading to the increased control, and eventual elimination. ~,1 heart disease, cancer and slroke as leading cause~ of disability and death. This report ernhudies our recommendations for such a united efforl by a free and vigorous people. Our stated goals arc neither imprattieal nor ~isionary - they can be achieved if t~e so will it. The~ must he achieved if we are to check the h~'avy losses these three diseases iu{lict upon o.r economy--close It> S30 higbu~ each year in lost pr~dnelivity and lost taxes due t~ prelnatule dlsabilit~ and death. In the early decades of this Republic. our people tended Io view disease as an irrew,cahle and irreversible vlsitatian from at~ implacable Fate. Our remark- able progress against many diseases o~er the past half ecntury--lhe llfe span of the aterage American has heen lengthened hy 23 years since 1900--is vitid proof of the reversibility of ar~y dlsea~e proee~. The great engineer Charles F. Ketteting ettce observed that no dlsease is ineu table ; it on ly seeuls so be¢allse of Ihe ignorance of man. We submit this report• Mr, President. b~ the deep eouvi¢lion that its immediate implementation will lint only narrow appreeiablf the spectrum of our ignorance. but will c~mttlhute to the saving of thousands upon thousands ul American lives now needlessly sacrificed to these three deadly enemies of mankind. Respectfully )'ours,

THE )RE$1DENT'S ~0MMISSION ON HEART ~ISEASE. .~ANCER ~ND 5TRORE Membership o] the Commission : Dr. Michael E. DeBakey, Chair. tileR. Dr. Samuel Belier Mr. Barry Bingham Mr. John Mack Carter Dr. R. Lee Clark Dr. Edward W. Dempsey Dr, Sidney Father Dr. Marion Fay Mr. Marion B. Folsom Mr. Emerson Foole Cen. Alfred M, Gtuenther I)r. Philip Handler Mr. Arthur Ilanisch Dr. Frank L. Ho~fall, Jr. Dr. J. Willis Hurst Dr. ltugh II, Huasey Mrs. Florence Mahoney Dr. Charles W. Mayo Dr. John Stirling Meyer Mr* James F, Oates Dr. E. M. Pepper Dr. ttoward A. Rusk Dr. Paul W. Sanger Gen. David Sarnoff Dr. Helen B. Ta ussig Mrs. Harry S Truman Dr. Irving S. Wright Dr, Jane C. Wright Sta~ oj the Commission: I)r. Abraham M. Lilienfeld* St@ Director. Mr. Stephen J. Aekerman Dr. Nemat O. Borhani Mr. Louis Carrese ])r. Maureen Henderson Dr. William L. Kissick Mr. LeMon E. Martin Dr. Bayard Morrison Mr, Horace G. Ogden Mr. Marcus Rosenhlum I)r. David Scilo!tenfeld Dr. John D. Turner Mr. Daniel Zwick V HEART OISEASE, CANCER AND STROKE

;IGI(I BWLEBGIVlENTS In submkting its zeport the President's Commission wishes tc~ express its prnfunnd appreciation for tile generous assislance and cooperation offeled by professional organlzatlons, voluntaly agencles, a~d other individuats and groups. A special expression of gratitude is due Io Dr, E. Cowles Audru$ and all others responsible fur the Second National Conference on Cardiovascular I)iscases, ~hlch was held riming the period of the Commission's ~rvice, for pruviding us with preprints of their proceedings t~hich served as basic scientific doeumenta- lieu for much of our work. We wish also to acknowledge the uustit~ting coopezation of many agencies and branches of the Federal Golernment. wilh special thanks to Anthony J. Celehrezze, Secretary f~f Health, Education, and Welfare; to Surgeou General Luliler L. Terry of Ihe Public lieahh Servile: to Dr, James A. Shamlon of the National Institutes of Hcagh and to l)r, Aaron W. Chrlstensen of Ihe Bureau of Stale Services (Community f|nalth), for ploxldlng staff and support without which the Commi~slon could not have performed its assigned function. Finally. the Cotrtmis.~ion wishes to express its grofotlnd debt of gratitude to the stall memhels whose work. frequently performed under conditions of extreme pressure. ~as carried out t~ith uniformly high quagty reflecting great ezedlt both on them as individuals and on the organizatluns they represent. vii HEART DISEASE, CANCER AND STROKE

PERSPF, u,I/E In ~eeklng to develop a national piogram for the immediate reduction and u]tlmate conquest of heart disease, cancer and stroke, the l)resident+s Com- mission accepted a complex cllallenge. Tbere was need, flrsl, to document in depth the dlmer~slons of the problenr and to assess the Na ion sex s "ng a d potential resources for aelfie~ing the ~tated goals. Then il was necessary, based on these as~esstneuts, to draft reconl- mendatltms sealed to the dimensions of tile pt oblera and tailol ed to the [finltatlons of practicality. We quickly recognized apparently conflicting sets of specifications in develop. ing and presenting our program, The recommendatlons should he compre- hensive-in order to advance the attack on all fronts--and yet sufficiently specific Io serse as a blueprint fm action, Moreover, it was essentla[ that the program be understood and accepted by both tbe selenlists and Ibe policy making repre- sentatlves of the American people. The present report represents our attempt to itaeel these specifications. It is presented in t ~ o volumes, of whlclr this is the first. "qolume ] is the summary ~<dumt~ and is intended for ~side dlslrlbutlon. It includes Ihe Commission's lecomme~dations for a national program to conquer heart disease, cancer and stroke. Volume II, Io be publisbed in a more limited edillon, is made up of the ftdl reports of the eight subcommitlees into ~bieb tbe Commission divided for a systelnatie approach to problems confronting it. It also includes additional scientific and technical doeulnentatiou developed at the Commission's request by other illdivid uals and groups. The first two chapters of Volume [ eouMittttc the backdrop agafilsl ~bicb he Commlsmot) s proposals a ¢ to be ~iewed. Chapter One seeks to measme Ihe impact ipf heart disease. <aucer aad slroke on tile Americatl people in te]uls of deaths, disability, aud ecornolrtie eosts--azld d<scrifies current progress ill seientlfio kJlowfi~dge ~Iiic'It offers hi>pc for itnmediate and rultll.e tedtletious ol tbis toil. (:haptel T~ o dls~ usses Ihe Nation's ( ut rent state of readlncss Io com- bat these tbtee (fi~eases, ~olltrastblg the illalq)ower, facilities, alld odler F43SIIUICe$ now at0ilable wilh those wbicb ale needed to mount a fulbscale attack, both in tile delivery of medical service and in the dkcovcry of new knowledge. Chaplets rl'hree filr~ugh Se~en present the $5 specific rceornmc~dations of the Conmdssbm, These are gl'onped under fit'e broad headings, related to spetific areas of need h>r aelitln. Chal~ter I:igbt deals dilc<tl) ~Hlb fi,glslalivc and orga- ili~atJOllal profi]ems wi)ieh inl~st be tt sol~ed if tll~ simeifie recomlnendatlolls are to he lull)' effective. The Collll~dsslou's sngge$1ious lur I×pendilutes~ ueeded to 11111) oHI Ihe pie" posed plograms are labulated ill Collneetion +xith each s]lecJflf lee(Hnlllellda" Ibm. Suunnary tables, whkh imlicate tbe total funds ricmunlended and eOlulmre these ~ilh existing levels .f t+xpen¢filure, t+ill he found in Appendix A, ~,oi slderell bro;l/ll~, tile ( .o3~]~/iSSl(in ~ 3,J rec+)l~/mendat ions are Of tll O +/e/It ral I)pe8. Ix HEART DISEASE, CANCER AND STROKE

X HEART DISEASE, CANC[R AND STROKE The first of these categories includes those recommendations which a1¢ di. rooted specifically at the throe diseases in question. These constitute the frontal assault on problems related to the conquest of heart disease, cancer and stroke. Included in this category are the recommendations comprising the major Innovative thrugt of the report--the establishment of a national network of regional centers, local diagnostic end tr¢~tlv.ellt ~tati~ and medlca[ ¢omplex¢~ designed to unite the worlds of scientific reBearch, medical education and medical care. This proposed national network would bring within reach of ei'ery physlciall and every patient, region by region and community by com. ~lunity, the very best ~n the diagnosis and treatment of heart dlsea~, cancer and stroke. It would, in our judgment, have an immediate impact. It would save many lives and prevent widespread suflerlng--mersiy by making medical and scientific excellence in heart disease, cancer and stroke readily accessible tn those wt~ose lives depend on it, The national network program is described in detail in Chapter Three of the report. In addition, Ihe direct assaah on the three diseases requires ~veral uther ur- gently needed programs. These include the strengthening of storewide labora- tory programs for heart disease control, a national erfurt directed toward the deLection of cervical cancer, the establishment of highly specialized research units fur intensive study nf specifiu disease problems, and augmented support of research in heart disease, cancer and stroke. But heart disease, cancer and stroke cannel realistically be considered apart from the broad problelos of American science and medicine. Therefore the second category of recommendations--no less essential than the first--ls designed to stresxgthen the total n~tlonal ~e'~uree f~ ad~al~ng ~ie~tifi,¢ knowleclgn ~n~l providing medical services. Skilled manpower for the attack on heart disease, cancer and stroke must be drawn from the national re~ervolr of health manpewer--and thai national reser- voir is seriously inadequate. Therefore, the Commission has recommended direct and forthright governmenia~ support of medical education and other essential training programs. Successful local programs for control of heart disease, cancer and stroke depend upon stro~tg community health resources; therefore, die Commission has recommended programs to bt~ttress the~e efforts. Similarly, r~eareh on specific disease prublen~s depends upon a variety of supporting resources and raechanisms which are the subject of separate reeomtnendalions. $elentific knowledge on heart disease, cancer and stroke must be eitlcieully communicated among selen- tists, to practitioners, and to the public; thus, a number cf recommendations are aimed at pro~denr~ cJf comrauuieatlon. In sum, if we are to conquer heart disease, cancer and stroke, we must, as a nation, rededicate and redirect our efforts toward this hlgh purpose. We must strike boldly at the specific problems posed by each disease through a nation. wide approach which represents a major innovation in American medicine, At the same time we must strengthen and support our entire health resource upon which the innovative attack must be based. 1

co°°I Io,,, . ,voIu°o, ONTENT PART I PART II APPENDICES Page Letter of Transmittal .......................................... ili Names of Commission Members and Staff ......................... v Acknowledgments .............................................. vii Perspective .................................................. ix Introduction ................................................. xiii Problems, Resources and Needs .................................. 1 Chapter 1. Tile Dimensions of the Problem ................... 1 Chapter 2. National Resources and National Needs ............ 15 Toward the Conquest of lfeart Disease, Cancer and Stroke .......... 26 Chapter 3. A National Network for Patient Care, Research and Teaching in Heart Disease, Cancer and Stroke ............... 28 Chapter4. Application of Medical Knowledge in the Com- nmnity ................................................ 38 Chapter 5. Development of New Knowledge .................. 47 Chapter 6, Education and Training of llealth Manl~wer ....... 53 Chapter 7, Additional Facilities and l~,e~ourees ............... 63 Chapter 8. Recommended Changes in Legislation and Organiza- tion .................................................. 70 A. Summary Taldes ......................................... 78 B. Members of Commission and Staff ........................... 84 C. Ilistory and Operation of the Commission ...................... 87 D. Agencies and Professional Organizations Contacted .............. 92 E. List of Witnesses ......................................... 94 F. Bildiugraphy .............................................. 102 G. Acknowledgments ........................................ 114 xl HEART RIREASE, gANCEE ENO STROKE : i

] 7 ODUCT OH In his Special Heahh Message tu the Congress in February 1964, President Lyndon B, J ~hnson made the following announcement : "1 am establishing a Commission on Heart Di+eese, Cancer and Stroke to recommend steps to reduce the the;deuce o/these diseases through new knowl. edge and more complete at~llzation o] the medical knowledge we already have." Two months later, when the newly Iormed Commission first convened at the White House. he said : "Unless we do better, two+thirds o/all Amerieal~s now living will suffer or die/ram cancer, heart disease or stroke. I expect you to do someth;ng about it+~ Something can be done about it. Every day men and wmnen are dying who need not die. Every hour families are being pluuged into Iragedy that need not happen. Wives are widowed, children left motherless--not for lack of seien. title knowledge, hut for lack of the right caie at the right time. Every available fact points to the same conclusion~hat the toll of heart disease, cancer and stroke can be iharply reduced now, in this nation, in this time. The sweep of scientific progress it+ the past decade has brought most forms of eongenltal heart disease within our powers of correction. Advances in sur- gery make it possible to save patients who would have been damned five years ago; indeed, even one year ago. Rheumatic heart disease now can he virtually eliminated. Many strokes can be foreseen and prevented. Cancer of the cer- vix and uterus can he hrought almost to the vanishing point, and chances are greally 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 immediate future. Successful replacement of defective organs comes closer to reality each day. New methods of cancer detection and treatment are iii immediate prospect. The ~ay is there. All that is lacking is the national ~'ill In give our people the full measure of protection against their three most deadly enemies. The Commission is kc~'nly aware that its Rept)rt will hell+ to prolong l~lc and ease sutfering otlly if it is followed by vigorous aefion. Our aim is to kindle a re-dedication nf our national health resources and a new awareness art the part ot the American people, to the end tlmt hearl disease, cancer and stroke may he sharply reduced, increasingly controlled and uhimately conquered as enemies of Man. The facts provide abundant proof that the goal is worth the strivillg. I/cart disease, cancer and stroke, taken Iogether, claimed 1.2 million Amerl- can lives in 1963--more than 7 out of every 10 deaths in this country. xlll HEART DISEASE, CANCER ANO STROKE

4¥ H~RT DISEASE, CANCER AND ~TAOKE programs aimed at control of heart dJseaec, cancer and stroke. The 365,000 Americans between the ages of 25 and 64 who dled 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 working year. Moreover, this is oldy the beginning of the economic cost of heall dlsease~ cancer and stroke ; an estimated 14.6 million Americans are eufferlng from definite heart disease, and another 15 million from suspected heart disease. At tbe same time, otber facts demonstrate that the nation is capable of mauling 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 dlscase, cancer and stroke. "gesterday~s hopeless ease has become Ioday's miracle cure. We stand on the threshold of still greater breakthroughs in the laboratories and dinlcal centers of the nation. Yet for every breakthrough, there must be follow-through, Many of on,~ scientific triumphs have been hollow victories for most of the people who could benefit fromthem. " The obstacles in our path are tunny and formidable. Hot the least of these is the harsh fact that modern medical care ig too expensive for many o1 our people. Although our recommendations do not rcla~e 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 prevenlable death is a natiDnal r~proaeh. Every year, more such preventable deaths are occurring--for the pace of science is briuglng more .slth~u out roach, but the pace of appEaati~n allows them t~ slip thTo~gh our grasp. We need to n~atch potential with auhicveme~t, to fu~c the woclds of s~:e~ce and practice. We need to develop and support a creative partnership among all ~)ur health resources. This way--vchich i~ tb.¢ vcay of a dclaoeratie ~puhli¢-- is the true palb to conquest of heart dlsea6e, caner and stroke. The first lithe of defense for ou~ pczph'~ hoalth i~ manned by pri~ate p~ai. lioners. The advance in biomedical research is led by individual investigators, The aettittgs itt which th¢~¢ ttxe~ and womerL vcork are our gr¢~ prP,'ate, ¢¢n~- munity and State iastilutions--hospitals, universities) scientific institutes. Individual freedom is Ihe cornerstone of the heahh structure, Individual initiative is clearly visible also in/he work of our great voluntary agencies in the health field. The American 11eart Association, tbe American Cancer Society and others have pioneered in the support of health research and i. speeding the dcllvery ot the benefits ot research to people who need theta, Specifically, the funds raised by these organizations are channeled into research, into education el the publl¢ and trainittg for the heahh professions, and into direct service for patients. Lt, cal and Sta~¢ initiative is demonstrated b~ rapidly developing public heahh State agencies