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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

in particular are in process of accepting greatly increased reeponsibility for pro. grsm~ cDrnbalt Jng the~ tllseaset. At the same time~ society as a whole has a heavy stake in the success of this endeavor. It is appropriate a~d neoessary that the Federal government encourage, stimulate and support the upward thrust of national health, Events of the past two decades have proved beyond quesllon thkt such encouragement and support~ fur from iltterferlng '~ith personal end seienlific freedom, has in fact created the conditicns in which such freedom can realize full fruition, The solatlo, to the problems ~ heart dise~s~ cancer and stroke. can be built only on the foundation of . profound a~d truly national com- mitment to this end. by both pubilc and private resources. The nation's strength clerives from the strength of its people, A national inveslment in the prolonging of' productive lifo for its people pays r[c[~ dividends in national productivity. Good h~alth is good business for the nation. But in a democratic soeiely~ there are other rnotive~ ~r actfon~ more corn- palling still. Henri disease, cancer and strake cut life short; they cattail the enjoyment of liberty; they make futile the pursuit of happiness. One true tneasure of a nation's greatness is its success in making ava~lakle to i~s people the me~ns for pTotectlng end enriching their individual li~es. The President's Commission on Heart Disease, Cancer and Stroke bases its Report on the conviction that the Unlted States will measure up to greamess~ that it will choose to continue and accelerate the forward thrust of medical Tesearc|l 8cross new thresholdg of d~covery; and that il w[f] resolve to make rally available the he.eftts of scientific know[edge to all those whose life and opportunlty for i~di~idual ~lfiJlmenl depend upon them. We do not promise that our program will save a million live~ next year. We do not guarantee to all the millions of victims of heart disease, ~ancer an~l stroke a new lifo free from pain and fear. But we believe that ma~y thousands of men and w~.~en wh~ might live will die, needtessly~ year by year~ until the nation m~kes ~is .ew commitment. We believe that m~ny thousanlls of men and women will suffer and stand idle, ncedlessl~ yeer b~' )'ear, until ~he ~ati~n pledges its full ~"soure¢~ to tke~r ca.se. To these men and women we dedicate this Report. XV HEAR'[ DISEASE, CANCER AHD STROKE

PART i///~hapler O,e PROBLZ E I EZOURCZ . AHD THE DIMENSIONS OF THE PROBLEM The first of the three objectives set for the Conamlss~on was to measure the magnitude of the impact of heart dlsease, cancer and stroke o1/the Anlerl- can people. Such measurements have been made by many people, in various ways. The usual product of these assessments is a set of stalislieal tables. The numbers run into millions, sometimcs billions. The columns drift into abstraction--age- adjusted death rates, nmndloura, productivity. These tabulations are valuable and necessary. They are especially valuable when they furffish clues for a more efficient attack on specific aspects of the prob- lem. But they do not measure the true impact of the three great killing dlseases on the American people. They do not quantitate grief for more than one million American families every year. They do not express tbe personal economic hardship that comes in the wake of a father's sudden, falal heart altack. Nowhere in the tables will you find the heartbreak and the long emotional stress Ihat follow a mother's death from cancer. They may count the number of hours of idleness enforced by chronic dlsabillty, but they do not measure the length of each hour. Tbese represent the true impeel of heart disease, cancer and stroke. They should be read inlo every statistical paragraph, table and chart in the mate. rim that follows. The Changing l'atte~n o/Sickness and Health lleart disease, cancer and stroke are overwbehnlngly the leading causes of dealh in the United States today, l)iseases of the hear t and elreulatory system-- a 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 the olher enemies of man--the great range of infectious diseases, accidents, congenital and nutritional disorders~fede into relative in. signilleance. It has not Mways been thus. The ascendancy of the three great killers is a recent deveffipment. It is, in fact, a byproduct of brilhant progress in biolnglcal selenee and medical service. A few short ileeades ago, tuberculosis was the greatea single menace to American health, Pneumonia and influenza took a heavy tell each year. Infectious diseases of infancy cut off many lives that had barely begun, For the overworked physician of horse-and-buggy days, heart disease and eaneer were far down on his llst of preoccupations. ! HERRT DISEASE, CANCER AND STROKE ~56-4~90-64~2

We are the beneficiaries of a great medical revolution. The first half cen- tury cf scientific medicine has resulted in a swlflly growing population~ a greatly lengthened tifespan, a leve~ of well.belng tar above the highest expectations of our grandfatbers' generation. DEATHS FROM HEART DISEASE, CANCER AND STROKE iN 1963 2 HEART DISEASE, CANCER AND STROKE ]t has also resulted in a helghtenltlg of our own asldrations, Death Dora heart disease or cancer, at a relatively advanced ag¢~ was once personalty tragic but phi]osophicully aceoptefile. Todag we are no longer willing to tolerate what was once "tbo illevita hie." Our new intolerance is based on knowledge--that heart disease~ cancer aefi ~tr~k~ I~e~d not k~ so n~l~y i~eople t~day, ~d that t~m~rr~',~ ~l~ll r~ pye- mature deaths wlil be w~tbin onr power to prevent. From this intolerance comes deter~ninatiot~. The n~gtlitude of the problem, as discussed in this chapter, is nol a slatu5 qvo to be lam~ntefi azld accepted~ btlt a cha/lenge to he met. HEART DISEASE Deserlf~tlon The te~nl bear~ dlsco.~e, as commonly used. includes a large number of condi. lions affecting the heart and circulator!" system. It is not a slng]e disea~, bLIt ;nany. Tile cardiovascular-rentTI diseases--to use the broadly inclusive technical terms--can be divided into three major categories: I } SIrr~k~s--damage to the blood ~ es.~els af[ecling the eenir al nexvo~s system: q2l Diseases of the heart itself and the blood vessels serving tbe fled), inelud. ing rheumatic fever and rheumatic heart disease, arteriosclerosis and de- generati~'e heart disease, functional diseases of the heart, high blood pres. sure and hypertensive heart disease, and numerous other slraeifie disease entities;

STROKES 201,166 HEART DISEASE 707,830 HYPERTENSIVE HEART DISEASE AND HYPERTENSION 73,791 (3) Kidney diseases, including chronic nephrilis and renal sclerosis, which are relaled Io the circulatory system and are therefore included in lhe broad category. Deaths/rom Heart Disease In 1963, 994.74? people in Ihe United States died of the cardiovascular-renal diseases. Of these deaths, about one-fiftt~ 1201.1661 ~ere caused hy s~rohes. B) far Ihe largest share i707.g301~ over 70 percent, were caused by heart disease, predominangy arteriosclerotic heart disease including c<~onary disease t 546,813 I. Hyper/ezlsive heart disease and hypertension aceoun/cd for ahout 7 percent i73,- 791), with Ihe renlaining deaths distrlhuted among other dlsordets of tl~e heart and circu)atory system. Heart diseases land strokes) accounted for more than half Ig0.1 percent) of all deaths in the United States i~ 1963. In 1900. these diseases accounted for only about one death in seven. Heart disease is predominantly, hut by no means exclusively, a cause of death among older people. Ahnu/ 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 oummn- her women as victims by a tactor of nlor¢ than one-lhird.-4H,989 to 295,841. This is a relatively new and sill1 ineomplately understood phenomenon; until about 1930, the heart disease death rates for men and women were of about the same magnitude. ( 1963~994,747 DIED) I PERCENT 10 20 30 40 50 60 70 80 90 100 3 HEART DISEASE, RANCER AND STROKE

~resti~g ~d, ~nex~la~ned ~ariati~s ~xi~ in the g¢ogr~ph~ d~tr~b~ti~ cardiovascular disease deaths h~ the United StaWs. There is higher mortality- /or both men and women in the Eastern and far Western Slates, with lower ~ort~lity ~n tt~e C~sxlral and Mo~tai~ regi~s, Death rates appear I~ b~ higher in large cities than in smaller towns and rural districts, htzI lbese diffor- enees do not fully account for the State-by.State and regional variations. More- ~¢t~ it is helleved that twrson~ horl~ in "hlg~ mortality'~ States carry ,~itb. them a high mortality tendency even though they ma~ die in a "low mortality" State, DEATHS FROM HEART DISEASE 4 HEART DISEASE, gANCER AgD STROKE Illness and Disahilily The |te~rt disea~s, i~x addit~o~x to their dominance al a cause of death, arc the cause of extremely widespread illness and disability in the United Slates. Studies ¢~nducled by the National Health Survey of the U.S. Public Health Service in 196~62 ~dicate that an estimated 14.6 million adults ~uffered ~rom definite heart disease, and nearly as many had suspected heart disease. Of every 100 persons in Ihe population between the t~gcs of ]8 and 79, 13 had definite hearl d~sease a~d 12 more had suspected heart disease. Thus nct~rly one-fourth of the aduh population studied lives in ~ettainty t~r in jeopardy ~f hear~ disease.

Tile most common condillon discovered hy the Survey +++as hyperlensfve heart disease~ witll 10.5 million "definite" aud 4.7 million "suspect" cases. For coro- nary heart disease, the estimates were 3.1 million "definite" and 2.4 million "suspect," In sharp contrast with rnortallty figures, "definite" heart disease was found to be more frequent in women than in men. Women were mote likely to be suffering from hypertensk,e heart disease, while men were more likely tQ have coronary heart disease or heart disease of congenilal or syphilitic origin. The frequency o1 heart disease increases sharply with a~e. Fewer than 2 percent at tfio~c a~ed 11~-24 had definite heart disease, while at I}le other extreme 39 percent of the nlen and 46 percent of rite women aged 75-79 had definite beart disease. Economic Impact The economic cost Io the nation of any disease may be measured in terms of its direct co~t~ in dlagno,ls, trealment, and tehabilltation of patients suffer. lug from the disease and the indirect costs u~soeiated with loss of earnings due to disability and premature death. Heart disease, with its enormous death t¢)ll and still ~reater prevalence as a chronic disabling condition, imposes a muitlbillion dollar hurden on the economy each year, Direct expenditures for hospital and nursing home care, physicians' serv. ices, drugs and ether ~nedieal servlces for persons with heart di~ase anlounted to $2.6 billlem in 1962. Ab~t 15 percent .~f ~he J~taJ dap~ ~f c~r~ h~ !]~e r~a!i~'s short-tprm hospitals are for care of heart disease patients, as are 28 percent of the patient days in skilled nursing homes. One out of lea visits to physicians in private practice are in connection with heart disease. Likewise, the drug b~ll for cardiovascular patients is estimated at 10 percent of all expenditures far proscriptions. The direct costs are only the beginnl.g. Those who are dlsa~ded hi" heart disease add another burden to the economy, owing to loss of oulput. Taking into account members of the labor force, housewives, and others who were unaMe to attend to their u~ual actkitie~, a total of 132 million work clays were lost bl 1962. The~e are equivaIent to 540,000 mall years, ~hich amount to $2.5 billion in terms 011962 dollars. Other losses result from premalure death. As we have seen. approximately a querier of a nlillion people in Ihe mo~t productive years (25-641 died of heart disease in 1963. shghtly more than in Ihe preceding year. Assuming that Ihe deaths occurred evenly over the year. more than $1 hillion worth of output was lost in 1962. Had all those who died in 1962 lived iust one more year. rite economy would have gained $2 billion worth of output. The nation is still payin~ in lost output for the people who died prematurely of h~a~t disease in the recent p~st. Of 26 million deaths due to cardiovascular diseases in the period 19¢sq-1961, 6 million persor~ would have survived to 1962 and worked or kept house if this 5 HEART DISEASE, CANCER AND STROKE

6 HEAR'/ DISEASE, CANCER AND STROKE major cause of death bad been eliminated. The assumption is that the eardlo- vasoalar Iindudlng in this instance stroke) death rate became zero while the rates for all other causes remaln~ unchanged, In money terms the loss in output amounted to $24.5 billion. It may he belpfd to ¢~mpare lhese Ioss, e~ dt~e to heart tllsea¢,¢ to the gro~ aatlonal product ~fite raarket value of all goods and services produced hy the economy). For this purpose the value of output imputed to housewives must be excluded. The sum of dlreet coals, plus losses of output by members of the labor force due to heart disease, amounted to $22.4 billion, or d percent of GNP in 1962. Progress and Prospect The prospects are excdhr~t for reducing the toll of heart disease in the years imraediatdy ~bead. Great strid~ h~e been r~ade tat the past 15 years on the research frontier, Today's challenge is two.leiden bring these advances not just to the fortunate few but to the many wha'ean benefit from them, and to continue to acquire new life-savlng knowledge. .~Iedieal research in the heart disease field has already paid rich dividends on the growing pubiie and private investment in biomedical science. This progrees has been docu moated in depth in the Report of the Second National Conference on Cardiovascular Diseases, based on an intensive review by hundred~ of physicians and scientlsts. The following are a few of many examples: Advances in surgery in the past ten years have already saved thousands of lives and promise to save many more. Patients suffering from aneurysm--a ballooning out and dfinnlng of the walls of an artery--were until recently almost cerlaln to die within a year. Now the damaged section of the blood vessel can be removes and replaced with a sub- stitute vessel made of a plastic material. A recent analysis of 1,000 such eases showed more than 90 percent success, even with extensive aneurysrns of the aorta near the heart. Similar procedures, with similar prospects of suCCess, can also he employed for replacing s~gments ~f blood vessel~ damaged hy ar~rlosderods in the many instances in wMch such damages are localized. Surgery of a MgMy complex nature is now possible on the heart itself, thanks to the developr~ent of artificial machines which can temporariIy substitute for the vital functions of the heart and lungs, Valves of the beart whleh are defe¢. tlve because of congenital henri disease can sometimes be repaired, and valves with acquired damage are also being treated successfully. Research on high Mood pressure has brought into being a number of ex- cellent drugs that effectively lower elevated blood pressure levels. This advance hel already helped to produce, in the hit decade, a significant reduction in the death rates for hypertensive heart dlseasa. The~ drugs also make it possibh for many people who suffer from high blond pressure to return to work and a normal lifo. The~e is no queglon that tbls gain would not have ecourre~ -~i~hout effeetlve research and its application.

We have not yet achieved a similar decline in the death rate from atherosdero. 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 better 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 years; over 3,000 people who might otherwise he dead are now living with ira. planted pacemakers. Arterial embo]lsm--a dreaded complication of acute heart attacks--is now greatly reduced in frequency thanks to anticoagulant drugs, Proralsing work is now underway with dot.di~oiving drugs for the treatment of thrombosis. In still another promising area, hard-won progress is being made in the extremely complex area of transplanting organs--lncludlng kidneys, lungs, iicers, and recently hvarts--into man. Perhaps most dramatic of all, research efforts are now being directed toward the devdopment of an artili¢ial heart to replace a diseased heart. Experimental models 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 a~rosa the entire range of science--is enormously complex. It requires the combined excellence of physicians, engineers, experts in the devdopment el syn- thetic 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 seah may well produce one of the most dramatic breakthroughs in scientific history. Progress in understanding and controlling heart disease has far exceeded the fondest hopes of medical men a generation ago. But the challenges are many and formidable. Genuine control awaits further research discovery. Meanwhile, substantial reduction of the toll of heart disease awaits a major nationwide effort to apply what is already known, CANCER Description Cancers are uncontrolled new growths which invade and destroy living tissue. They are made up largely of cancerous cells which differ from normal cells in many ways, Cancerous growth of the cells in various tissues occurs throughout the biological world. Birds and many species of animals are amieted with various types of the disease. Its causes are not fully underslood--ahhough knowledge of factors relating to its development is growing rapidly. It is now clear that physical, chemical, genetic, viral, environmental, and perhaps other factors are involved. In man, cancer occurs in a variety of forms in many different organs of the body. The frequency el cancers in different sites varies relative to race, sex, 7 HEAI~i" DISEASE, CAgCER AND STROKE

occupation, geography, and other factors. It also varies dramatically wltb the passage of time. Within a single general, ion in the UnJtfd Stttteg one form of cancer---car~itaoma of the lung in raen--hat |nereascd strikingly while enother--- gtomach cancer in men'as 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 I963, the number was 285,362; in 1964, the n umber will exceed 300,000. These figures stand in sharp conlrast to the tituation in 1900, when only 3.7 percent of all deaths were attrlhutcd to cancer and when the dlsea~ stood far down on the llst of causes of mortelity. DEATHS FROM CANCER DEATHS PER REGION 8,175 1~;,470 18,t~45 :23,743 25,470 32,412 31~,e§f~ 59,336 f*4 ,¢45 The rise of cancer as a health ~enace can be charged in large part to the changing age ¢oraposition of our population. Many more people are surviving the infectious diseases of youth and middle age only to t~uccmnb to the dlseaees r~ the more ad~aneet~ years. Yet cancer, like heart disease, is by no means r~served for the aged. In 1963, :qUilT IRSE&SE, CAtlCE¢ ASO srfloKE 45 geroent of cancer deaths were in the age groups under 65. About 9 per- I

eent--representing 25,629 people--were under 45. And cancer is either the first or the second cause of death in children hetween 1 and 14 years, Acute leukemia isthe single most common form of cancer in children. When cancer death rates are adjusted for the changing 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 ratos for men and women, For men, from 1933 to 1963, the cancer death rule 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. Tlltts cancer, wbieb 30 years ago was more of a menace to women titan men. has now reversed itself. Cancer of the lung now accounts for 24 percent of all cancer deaths in males, with s total of 36,895 deaths in 1963. Other leading cancer sites in males are tire prostate (15,446 deaths), colon 113,932), slomach (11,896) and pancreas (8,9~L For women, the leading sites are breast (25,139 deaths/, colon (16,684), uterus (14,147), ovary (8,404) and stomach (7,404). Thirty years ago, in males, stomach cancer accounted for 27 percent of all cancer deaths and lung cancer for only about 4 percent. In females, cancer of the uterus and ot the slomaeh were the two leading sltes--- 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 Ihat about 830.000 people in the United States will he under treatment for cancer in i964. This figure includes an estimated 540,000 new cases diagnosed for tile 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 48,000,000 people now living WlU h~2ollle cancer su~erers. 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 a~ociated with cancer also costs billions of dallars annually. Direct costs for diagnosis, trealmcnl, 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.terra hospitals, a~zountiag for 8 percent of the total days of care in the nation'~ short-term hospitals. The cost of the services ot physicians in private practice for cancer patients is $172 million. As in heart disease, these direct costs are only a part of the total economic impact of the disease. 9 NEAgT 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, hous0wlves, and others who wore unable to attend their usual activities. Those days lost are equivalent to 231,000 man years of produetlvity, or $1 billion in terms of 1962 dollars. Forty-three percent of the persons who died from cancer in 196$ "~ere in thelT most productive years f25~54), This loss to the economy amounted to more than 10~,000 raa~ years. ~ ~30 million. And as in heart disease, the nation is still paying in lost output for the people who 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 in $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. Tht~ sun, of direct ~ost~, plus l~se~ of output by Ir~mb¢~ of tl~e labo~ ~0rc¢, amounted to $8 billion, or 1.4 percent of GKP In 1962. ProgrPs~ and Prospect Today about one cancer patleat in three is being saved. A few years ago th~ ratio was abo~ o~ i~ |our. Tbi~ ~epresents a gaits in lk'~ of abo,~t 45,000 men and women each year. LIVES SAVED FROM CANCER BEFORE 1 GAIN IN LIVES OF 45,000 MEN AND WOMEN 3 10 IIEfd~l I~lSt/tSE, gfdltE~ AH~ STRDI~E Using knowledge now available, this gain can be substantially ex~ndod, .futt by applying widely what we know, we could now save ball of the people who cnntr acl oatlcer ~ "Uterine cancer can be detected at an early and generally curable stage by using a simple, well.established technique; unfortunately, relatively few women seek and ob',aln this ~xamlnallun i~ time. I

New ahn,~opmenls ia tim ear]), det~tioa of breaa cano~r hold forth lhe promlso o~ similar reductions in d~aths from this form of caner. Phydcel examinations u~i~g modera diagao~tic teeh~iques often lead to ~i early ~eognition and e~*ocessful treetment of cancer in many tlte$, Lung cancer can be sharply r~lueed by red.eing cigarette ~moking, Meanwhile medical research is opening up new pathways to diagnosis and I Cure* i The search for cancer-controlling drugs has ai~edy produced ~ver~d which have cured cancers in animals. The National Clneer Chemotherapy Prodram has resulted in the fozmuletlon of 165,000 new drugs. Theae have been tested for possible eff~r on anlmal ~n~rs and approxlmately 100 h.ve ]aeen tried in humeri c.ncer. About 20 of these drug~ have re*ulted in at ]east temporary benefit to human cancer patient~ with marked inc~ase in sur- vival and limiting ~ d;sabillty in pade~t~ wi~h lymphoma i~.din~ Hod~kln's disease, multiple myelom~, ehorioeidtl~elioma, melanoma, and oert~in tumor~ In childre*~. Radiation treatment and ~urgery are being improved and rcfi.e~ i to minimize ~ide ¢ff~ts and maximize benefit. Since W~fld War II, nuclear medicine and ~adioa~ive is,topes have playexl a ! vital role in cancer diagnosis an6 treatment. Detection h~s been enhanced in cancer of the thyroid, brain, liver, s~om.ch. Speclfle radioactive isotopes have been u~d In tbezapy of cancer of the prvst~te, thyroid, end/~one marrow. Th~ ~1~ of Cobalt 60, ce~ium, linear ~ceelerato~s, betatrons, elecdron beam genera. tol~ and other sources of e~iper,~oltage X-ray and gamma r~y beams have made potable high vaergy {~neg~vol~g~) Iherapy Jn ~e avera~ m~lrop~]~ta, area. Here~ the delerriag factor is lack of manpower trained in the u~e of th~ me/hods. Wi~ properly trained radiation therapists available, lmproven*ent in most of the cure rates would be immediately possible for those p~ient~ with l,~ions suitable for such treatment. in the quit for cancer's e~use, biological reeearch is producing important new under~.~nding ~,f the struetu~ and funetion~ of the cell genetic ¢ontrol~, an,:[ the p/~enomena of reslsta~*ee or immunity to dlsease~ac/~ of which may ha'e{) gre~t tlgnillean(:o in cancer control. ll~o~nt r~eareh ia ¥irology has ~hown that th~ leukemtas of several ~p~ies of a~maIs, which are c/o~e/y t~lsted to human le~kemla~, er~ definitely ~,~raI i~ ~isdn. If leukemla in man proves to he initiated by virus,, preventive vaeelne~ might well be in prospect. Cam~r, the number two killer of the American I~ople, i~ a aubbor, and mysl~rioue enemy. But we Can make substantial reduction~ in its toll now, by applying broadly what we know, The future is bright with promise of new sclentifie diseowriea and their ~levelopme~t to iurther usef.I ~pplicatiens. STROKE Oe*crfptlo~ The* br~in, 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 '~| i disease of the blood vessels, a ~troke iesults. Strokes are often fatal For those flEkRT DISEASE, CANCER kNO tlROKE !

t, i, !: i+ ; 12 HEkRT DISEASE, CAN¢£R AND STROKE who survive there may be disastrous impairments such as paralysis, loss of speech, and many others. In general+ strokos can be divided into three main types: (1) those due to oceluslo~ 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 dtle to Igg.h blood pressure or fault of the vessel wall (aneurysm) with hemorrhage into the brtin. The first two aeoounl for the vast majority of cases. Deaths/rum Stroke As ~ve have prevlousSy ~n&eated, strokes ac¢oaat for about nne.fifth of the deaths within the broad category of cardiovascular-renal disease. In 1963, about 201,000 Americans died of strokes. Thus. if stroke is con- sidered separately, it ranks third aga cau~ of death in the United Slates. 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 strok~ deaths occurred in peopTe aged 65 and over. The largest single number 173,388) occurred in the 75-84 age group. floweret, stroke claimed 38,4,11 victims under 65--a total that seems small in proportion but is numerically large enough to rank stroke as Ibe No. 5 killer of people in their most productive years, outranked only by heart disease, cancer. acclde~ts, and sui~ides, Unlike heart disease and cancer, stroke clalms more female than male victims in the United States (106,927 to 94,289). Nonwhite females have the highest death rate from stroke by a substantial margin, but the death rate for white re+ males is lnwer than that for nonwhite males. There is a definite pattern of geo. 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 States have suffered a ~troke. About 8 of every 10 stroke victims survive the acute initial phase of the disease. Most oi them gve for some years thcrea~tcr--usuagy in a serlousiy disabled condition, The existence of these hundreds of thousands of surviving stroke victims is a deeply dlstte~slng fact cf Araerlcail life. It is m~de me, re distre~ill$ by tbe fttct that most of it could have been obviated by the timely appllcation of preventive or rehabilitative Ireatment. The economic burden imposed upon their families and their communities can he estimated. Tbelossofdigngyandtheaccumu[ated misery is beyo~d calculation. Economiv Impact Direct expenditures for services and supplier for diagnosis, treatment, and rehabilitation of stroke victims total g440 million per year according to eonscrva. llve estimates.

DEATHS FROM STROKE |~731 DEATHS PER REGION ' i3 12,074 16,~17 1g,5~3 20,1S17 21,N;~ 30,05? 34,570 41,051 There wore 283,000 patJenls with a pi-~mary diag~]osls of stroke discharged from the natioN's short-terra hospitals in 1962. Stroke victims coasLilute 16 percent o~ the patlents in skilled ilursing homes. Ahhough 80 perce~t o{ the ~troke deaths occurred i~1 people aged 65 and OVer, the losses in olJIput resuItlng from dlsahility and prelllaLure death are equivalent to 179 milllorl inan,hours, or approximately $700 million in 1962 dollars. T[ifs~ o1" eourse~ does nol take into account losses in outpu! f~r those who would ]lave survived to 1962 if stroke had been eliminated as a cause of death. Excluding the~e losses |rom previous year~' deaths, the e¢onomlc costs s~ro~:es to the nation in l~f>2 ~s at~p~oxlma~ely St] bJJJio~. Progress end Prospect Stroke has been for many years a Iragically ~eglecled disease. The health professions have shown little i]~teree~ in iI; t~e public I~as a~cepted it wi~h resignation. At Ih¢ rot*t of this neglect are s~ver~ misco~¢eptions. The most important of these ha~ been Ihe a~s~mptlo~ thai stroke is siJ~p]y "a way of dyln~" a~ter lh¢ body ha~ survived a~l the other rawges of limc-~a~ inevitable as death itsel(. Ar~olher ha~ been Ihe ofbquoted half-truth that ~lroke is "a laler llf¢ edition of 13 HEA#T DISEASE.CANCER AND STROKE

corollary heart dlsease'--a statement now open to more than reasonable doubt. The facts are quite nlherwise. Stroke is proving to be neither inevitable nor irremediable. Slowly mounting interest over the past decade bes revealed genuine hope for stroke victims, both present and future. First, many strokes can be foreseen. Three out of four patients with occlusive stroke have symptoms that forewarn of a disabling attack, Some of tltese warning signs are brief attacks of loss of speech, weakness of limbs, staggering, or loss of eonsclousness. Clearly, any of these signals may be caused by a variety of other conditions. But a physieian, not the patient himsdf, 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 blond vessels supplying the brain. This eondltion can often be corrected by modern surgical lechniques. The precise indications for surgical and medlea] 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 aetlve and productive living. A well-defined and tested program of medical rehabilitation has been developed which, if started early enough and carded through, can make the difference be. tween total dependency and sell.sufficiency. A few such programs are underway, but they arc reaching pathetically few of the thousands wire nan benefit frnm them. Third, ptomlsing new avenues for research are opening up in slroke pro. vention and treatment. Among these are epidemiologie studies to define patterns of distribution of stroke; ahcration of bleed-clotting mechanisms; control of fat met.holism 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 heavily on the patient, his family, his community, and taxpayers everywhere. It is imperative that this disease be brought into the mainstrcam of medical and scientific attention, In develop new knowledge and to apply widely what is already know., 14 HEAF~T DISEASE, CANCER AND STROKE

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16 HEART DISEASE, CANCER AND STROKE pool for medical ears. The scientists who investigate research problems related to these diseases are part of tbe tolal 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. He 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 alf--lnay add or sublraet a decade from his life. Many factors influence his conscious or unconscious decision. One is the state of his knowledge about health melters. 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 cbocses is trained and equipped to detect an incipiently dangerous condition and make the proper referral, and if his community is blessed with the special shills and facilities his condition requires, and if he is able end willing to follow through the prescribed course of treatment--in this happy conjunction of circumstances his life will be prolonged, hls function mdmpaired or restored. Breakage of any link in this chain can nullify the strength of the others. Thus, the deliver)" of the great potentlal of modern medicine depends upon many factors. It depeuds upon an adequate supply of highly skilled manpower. The physician is the most critical single resourcu--tbere must be enough doctors in the community, and Iheir medical knowledge must be up to date. Moreover, they must be supported by a wide range of ~ell.trained assistants. h depends upon a variety of health care facilities and serviced---con. veniently accessible and staffed and equipped to meet the patient's needs. It requires an alert, wdblnformed citizenry, motivated to take early and decisive action in behalf of their own heahh and financially able to meet the COSTS Of care, Manpoa er [or Health Service The brst l~atd fact to he faced is that there is not enough hcabh manpower to meet the needs of the Atnerican people. There are not enough doctors and nol cnougb suppoltlug people. In broad terms. 3 to 4 million perseus are in~olvcd in tbe many aspects of heahh services through employment in dozeus of different oeeupatiens and careers. A full.scale attack on heart disease, cancer and stroke will require expansion of the et~tire work fores in health selvices.

The physician suppiy is beyond question the most oritieal single element in manpower for medical service. The physician calls the shots in every individual ease. And the national toil of deatb and disability is only the sum of individual cases. The number of physicians in the United States has approximately doubled since 1900, while the population of tile countzy has increased two and one.half times. In the decade 1930-1960, 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 tuln of the century. Meanwhile drastic changes have taken place in the practice of medicine. With the forward 5weep of scientific knowledge has cQme the necessity for specialization. In 1930, only one doelfbr 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 pbysieians are under- taking specialized lralning. Specialization bus brougl~t great benefits. But these }lave not been achieved without cost. The number of physicians having "first contact" ~ifft patients as personal or family doctors has fallen sharply. How many physicians are needed to serve our future health needs? The most ¢onsetvative estimate projects a need for 346,000 pbyslclans by 1975, This number is required merely to hold our own in the race against populatiDn growth. It fails to take inlo 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 to those who need it. It is a ~tat.s quo figure. Yet conservative as it is, our eurren[ prospects are for meelblg tbat nuInzber only through extensive importation of foreign-trained pbysicians. Currently our hospitals are heavily dependent upon foreign nationals serving as interns and residents. Clearl) the I'nite~l States should tint be a debtor nation in terms of medical manpower. Yet such is the case today. Aboul 7,700 physicians graduated flom Ihe nation's 87 medical and 5 nsteopatbic schools in 1964. We must be able to graduate an additional 1,000 pet ~ear, starting now. to keep pace with popula- tion growth. Present Irends, including the 12 to 15 new medical schools in various stages el development plus anticipated expansions of existing schools, will yield appioximately 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 slep in tbe right direction. It enaldes the Public Health Service. for the first time, to provide substantial financial assistance in the construction of new medical schools and the expansion of existing schools. But it falls far short of the all-out national effort needed to meet a critical national problen~---the ~hor tage of physicians. 17 HEART DISEASE, CANCER ARD STROKE

The physician supply is beyond question the most critical single clement in manpower for medical service. The physician cafis 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 approxbnately doubled since 1900, while the population of the country has increased two and one-half 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 slighfiy lower than at the turn of the century. Meanwhile drastic cbanges have taken place in the practlee ol medleine. 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 pracllce consider themselves specialists, and seven out of ten graduating physicians are under- taking specialized training. Specialization has brought great benefits. But thcee 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. Tills number is required n~erely 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 Io deliver the best in modern medicine to Ihose who *teed it. It is a status qtto figure. Yet conservative as it is, our current prospects are for meeting that number oalythtoughextensiveimporlatlonofforelgn.tralnedphysiclans. Currently our hospitals are heavily dependent upon foreign nationals serving as interns and residents. Clearly the United Stales should not be a debtor nation in terms of medical manpower. Yet such is the case today. About 7,700 physicians graduated from the nation's 87 medical and 5 osteopathic schools it: 1964. We must be able to graduate an additional 1,000 per year, starting now, to keep pace with popula- tion growth, Present trends, including the 12 to 15 new medical schools in various stages of development plus autie~pated 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 Assistauce Act, enacted by the Congress in 1963 and funded in 1964, is a step in the right directlnn. It enables the Public Health Service, for the first time, to provide substantial financial assislance in the construction of new medical schools and the expansion of existing schools, But it falls far short of the all-out national effort needed to meet a critical national problem--the sbortage of physicians. 17 HEART DISEASE, CANCER AND STROKE

18 HEART DISEASE, CANCER AND STROKE 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 Io full capacity and new schools must be built. Talented )tung people from every stratum of our society must be attracted to the medical profession in greater numbers. ~,'e have great resources to draw upon. In the Unged States only 1 medical student in 10 is a woman, as compared with I in ,I in Great Britain and 3 in 4 in the Soviet Union. In the United States, because of the len~h and excessive coal of medical training, a great proportion of medical students are dra~n from upper-class families--49 percent from fam- ilies with ilxcomes of $10,000 or more per year. Scholarship programs-.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/he only limiting factor in n,anpower re, the control of heart disease, cancer and stroke. For example: the use nf the Papanicolaou smear test for detecting cancer of the uterus can be no more widesBread than the availability of technicians capable of per- [ormlng cytological procedures; the number of laboratory personnel trained in identification of Iht~ streptococcal organism which leads to rheumatic fever is an important factor in the control of rbeumatie heart disease; rehabilitation of stroke patients depends upon an adequate supply of tbel'apists and nurses skilled in up.to-date technhiue.~. One of the ironies of out time is the existence of manpower shorlages across the entire range of health occupations in a time cl~aracterized by rnanpowet surpluses. Binding productive work for the young, the retired, the handicapped, the tech- imlogieally displaced w ul ker is a m aj or challenge of/he day. Yet the health disciplines exist as an island of scarcity in a sea of plenty. Each of th~se groups, whose idleness is a personal and national crisis, is an u ut upped rese, voir for h~.alth set vice. To take advantage of it, the heahh profes- sions must reexatnirlO and re~truelore their patterns of work. They must experi- ment boldly with new kinds of teamwork between highly skilled mud lesser skilled warkcrs, and then ~ork closely with the educational forces of Ihe nation to design training programs to attract and [nepare whole new groups of people for service to health. Facilities [or Health Services A century ago a hospital was a final port of call, a place in which to die. People passed il~ porea[s with averted eyes. 'Ik)day's hospital repres(mts a citadel of hopes--some true, some false. It is looked upon as a place where daily miracles are performed. ]n many hospitals. the miraculous has become almost rotltlu~, Ihlt iu others, standards of care ar~ far below what they should be The years since World War II have wimessed a genuine revolution in hospital care in the United States. Thanks in large ineasure to the llospital and Medical Facilities Construction (lIill-Burtont Program of/he Public lleallh Service, the t f

map of the nafion'~ medical facilities has heet) redrawl~. Ilill-Burton funds have helped to build mo~ than 7.000 hc)spitals and other centers for medical ~rvicc. They have added more ~han 300~OO0 h~spital h(~ds and over 2.000 other faeillties Io Amerlea's health resources. This has been achieved at a Iotal cosl ol¸ $6.8 billion, of which slightly less than one.third came from the f'ederal Covernment--the remainder coming from IDeal ~,Ollr(les, But weak points remain in our hospital armament, There ltro ~erloLts shol"t agc~ of h~ds scrvlrt~ many fast-growillg ~uhurh/tll area~. The older hospltal~ in the central cltles of metropoEitan areas are urgently in need of replacemallt (,~ illodez~/izatlon. These large and oJlce great metropolitan hospilals, many ~f them ns~elated w~th /~r~iversilies, sllould be the eenlers of excellence, tlq~ foundation slC, nes of our Cnlire system i)f delivering th~ best itt medical c~re, Instead they have heen allowed t~ deteriorate physically. Many are poorly located in terms <bf lhe changing population patterns of the city. In odditi~n ~here is a serious shortage ,~f faci[itic~ for the care ~( chronically ill pathelts, Tod~y, many hods in general hospilals, equipped to provide i~a×imum service, are heing o~eupied hy patients wilh I~ng-term illness who could be better served, al a fraction o[ the cost in ht)th money and I)ro(esslona] time, in f~ei[itle~ ~peclallv designed to meet their zleeds. State hosplt~l eonstruetion i ~ ,, ,.~ authorities ~el,orl thai o t~ational t~l,al ~,f 531I.INI/~ ,~ddili~nal Iong-lerm hed~ in ,.r~" ¢hrold(: dls~age h~spitals ,'rod illlrsillg hllgae~-are Ileedell Io iIl~(~t tile, present , • ,,I,!¸ • demand. With a rapJd~¸ expanding aged pol)ulalion. Ihe h~ng-term c~lre require- • i¸!!¸¸,~: ment~tesuletoillcreaserapidly• . I" ~ ,, Commlmicatir)ns ]or Ifaalth .S~r t'i~e .... ~ ~ ~ ~ L The forward ~weep of medical science has brought about ~ kind of "instanl ob~r)leeeenee'" i. medle~d h.owledge. M~st of tl~e physleiane practicing tr)day received their medical education in the 19.30's and 1940's• The fae~ ~t~at they ~tre pr~etlei~g two or Ihree decades later ivouid have been unimportant in earlier. quleter cenluries. Today. it i)o~e.~ a crltlc~l obstacle to Ihe delivery of ul)-to-dale health care, Therefore, a ~ystematle Jlatioawldo p~og~am ~f continuing education for physlelan~ is a categorleal imperative of e~Jl~teml)t~rary medicine. Without a large-scale, effecti~ effr)rl, the worlds of ~eience and practice will ~pira[ ~tid furLher apart, q'he gap between whal is knt~n al/d wll~at is received hy patients will be harder and h~rder to bridge. The imaginative u~e o~ new communieatlm~ media offers Ihe hest hope for necessary breakthrough~ iz~ continuing educatlon. Closed clrcull televi.~io~t, h~mmed from a medical center i~Lto community hospitals at reglflarly s~heduied hour~, is one lyp~ r)f experiment that has been carried out suee~s-~fully hi recent years. Open ~ircuil tele~i~iol~ is s/titable for most medical ~ransmi~slon ~nd ha~ been tried d~ritlg late evening ~nd early mo~nlng hours. New lyl)eS of projeelors a~e heeomlng availahle which enable the physleian to rent and study fllm~ in his own office. 19 HEAR[ DISEASE, CANCER AND STROKE

All o| these approaches are being tested on a small scale in various places around the nalion, under a variety of sponsorships. In lhe Commission's view, what is needed is a greatly accelerated and concentrated push for continuing edu- cation, with sufficient resources of funds and talent to make a genuine impact. Rut neither open circuit nor closed circuit television can reach closed circuit minds. Alert and informed patients can generate a demand for new knowledge where all other motivations fail. This i~ one of the compelling reasons--the uther, as we have seen, being lhe fact that the patient must take the first steps to save his own life--for greatly increased emphasis on informing the public. The public has an almost insatiable thirst for health information. Yet the public remains remarkably uninformed, or remarkably slow to act, on many matters which are quite literally "of life and death," Part of the problem may 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 /he mass media but with the health professions themselves, Science writing has become a highly developed skill; yet rarely are science writers invited behb~d the scenes and truly educated so that they may do an interpretive job. Funds and bnagination are rarely made available to apply the awesome power of lelevislon and radio to a specific health problem requiring specific public action. At Ihe Federal level, the public information funclion has traditionally been viewed darkly. Fears of "self-aggrandizement" and "propaganda" have caused agencies--notably in the health field--to bury or disguise their appropriations for informing the public. This in the beahh field--is both ironic and tragic. The Commission believes strongly that public information is a primary health tool; that the Public Health Service has a duty--a major duty--to deliver authorfialive heahh iaformatlon to the people el the United States; Ihat this function can in fact save many lives in the field of heart disease, cancer and stroke alone; and that it should he openly recognized and supported on a scale commensurate with its importance. Coordinated Effort/or Health Service Throughout this discussion of resources for medical service, especlall~ as related to ptoldems of heart disease, cancer and st]eke, we have laced the fact 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 by community, will never be all Ihat they sltould be in terms of adequate inanlJower. facilities, and supporting services. Therefore there is an overriding need for coordination of effort. We cannot afford duplication of facilities, waste of rare skills on commonplace tasks. The recommendations of the Pre~idenl's Commission dealing with the delivery of health services to reduce the impact of h~art disease, cancer and stroke are designed In achieve two goals: to strengtben the nation's heaffh resources bulb numerically and qualitatively, and to make the best use of resources we no~ HEARTOISEAgE, CAHCER ANOSTgOKE have.

RESOURCES FOR RESEARCII We are living in a time of brilliant progress and still more hriiliant promise in the health sciences. But biomedical leseareh is not a simple mauer. The biologist confronting a I~acteaium is dealing with a s)stem immcasurabl) more eomp[ex than is the astronomer confronting a ~lar. When the biologist undertakes the study of a certain man al~lieted ililh a cerlain disease ill a certain environment, the sub- tleties and eolnglexities n~ultild) to~ard infinit). Biomedical science cannot promise that it will understand henri disease and cancer tomorrow, h cannot swear that its growing but limited understanding will lead inevitahl1 to mean~ of prevention and cure. But it caii point proudly to past and present successes, and hopefull> I~ existing clues and leads. But tdtl+ol+t a major cohtJnuing research effort Ihere is no Impenf advance. I)O i)re~el~Jon. I10 I'~[~ t~f thr~.~e eon~titio~.,. ,'vttent]) be!,otld oslr ~r~sp /~ld to the extent that the quest is ~uccessful. Ihe he~lefit to t~umanit!'. ~'hatever the cost. will be cheap indeed. The Natrtre o[ Research Scientists use file wold rczearcb to describe a process whereby questions are asked of nature and answers are systematically obtained; the object is the on. rlehment of man's knowledge: the driving farce behind it is the curiosity of the in~,estlgator. In the himnedieal sciences, we are dealing with a spectrum of inxestlgation, ranging from fundamenlal biquiry into the nature of living cells, at the 'research extreme.' to ehnleal care nt patients at the developmental extreme/' Inter- mediate slops include lahoralor) investigation of disease, clinical and epidemlo. logical investigation of disease in than, experimentation with drugs and proce- dures, attd cllnieal trials. >,'o band of co[el in this speqlrunl i$ an) there "'pure" or mare "basle*" to tile solution of disease problenls Umn any other. All are essential, and the)' are mutually rein forcing. Where in this sl~ectrum oi activity are the limiting bat riers to progress against heart disease, cancer a~d stroke? In the judgment of the Commission. the! appear to lie ¢hiefl?' at the ends of the speclrmn, On the m~ hand. II~ere is urgent need of more fundamental knowledge of biological prnfesses ihe sLrUclute and function of organisms, and the nature of disease. 011 tl~e other, the~e is a serious lag in Ihe widespread dissembtation throughout n~edical p~actice td advances already ellnirall> lested and proved in the great medical centers. The Commission feels strongb that progress in understanding and eo~:trol of hear~ disease, cancer at*d strake depet~ds to a e~n~sidetable degree on l~e~t funda- mental knowledge of the structure and function of living organisms in health and disease. It urges that every effort he nmd~. to support and quicken the pace of rosen rch addressed to these problems. 21 HEART OISEASE, CANCER AND STROKE

22 HEART OISERSE, CANCER AND STROKE The Conduct and Support o] tlealth Research ~iedlca[ research today requires speclall~ trained people in specially desigaed cnv~roJlmcnts. The lJatior~a] I)oo] of qualified investigators and of illstltutions equipped Io undeztake slgllificant re~,earch programs is strlctl)¸ limited. The basic ul~it ~f medical rescarch today is a str~all learn. ~:oal]~risiiig aa experi- eneet3 invesligator and his immediate associate,s. Their most frequent habitat is the rnedica[ school or graduate school o[ one of our ~real universitles. A lesser numt~er Ihrive iTI ~ I~l~ researcbl.cJli~lllt~d Ii~lbltal~ alld tl!search illgtitules. Thousurlds i~I r~!~earch i/roj~cl~ are t~urrellt]~ tlnder~ay. Almost all of Lhem are built arol~nd the rescarc~l team larger ~r slllal~z¸ (lelleJlllill~ (~n tile SCOl~C ol the I~r~ject. T~lelr c~ts ~a~ge fJom $5.111)ll tE~ $5t)O.0(31) ~h perhaps ')(I i~ll:,,llt ~tf I[lem q~,sti~l~ I~eE~n "~]5,11(ll~ and '~I00.I)OCJ I~t !~ar. ']'he to[a[ annual c~Js~ ~l lhcse t]lousaad~ of research I~rojecL- ]~lus the sul)- porting servic~-~ ~hich l/lait3t~hk them ha~ reached all/~r~lxillla[el! SI hiJ[ioll in the Lni~ed S~a[es. T~lls reprl!~.ents ~ sl)~,c~('tll~tr i!x[l~lnsion i~l I~ Itl~n I~o dec~des~ alld with i,Ipi~l (~x:llall~i~rL has q i~olt~a~k~artJ and ii,~Lc~lwc~rk ~lrganization. Yet thc s!stcm w~Jrks. A~ wt~ ha~e se~l. il has I~rl~du~d ~'lllalk~l~]~ gah~ it~ kT~r~le~lgc. J~al~}¸ ~[ ~hlc]l ~la~ ]~eerl tlansJal~d dire~L]! iulo I~uger li~es alibi freedom from I~ain~ The; (~fJsls o! n~(]i~al r~s~art!ll ,~re [i,'lii] ~r/Jlri a ~rcaL variety ~ sources: university entlol~m~!llts, hld]v~dual and ~l~rporatt! gifts, fountlatiiJ~, iluldh~ and vf/luntar! ~l,~,ertl ]es. ~lat~! Jt!gi~l~Llui~'~. alld the [:t~dcra~ t~c~velt~ment The I~l~deral ~,[[ar~ nlJ~ rt!FJrc~.l~f[Ls ~-orut!llha[ iu(~le [hall tml!-~La]l t,f tile Iidal funds '~l)e~lt for raedi~al research. The I .S, ~l~l~]i~: [l~allll Sez ~it~, Ihl~ug[~ its Natlonal [~slitutes of []eaLth. i~ tile ~rl~l'~ i~iT~lar!¸ supporlh~ ~lgeEkt:~ for medical it~scalch. T]~ t~a~ic I)l~ildi~ block ~[ medical research sup~ort i~ the grar~t-i~.aid ~war~]~t~ t~ ~m i~l~e~ti;at~ t~ EarL~ ~ul a ~]~ccifil~d I~roiec[. The l~r(J~ess Ikcgin~ with t~.~ slll~ftl]ss~JlL iJf a ,~aut tIp~l~ii~at~n c~laJl~illg a research plan. T~ds is reviewed l~y ~clcnLi~ts k~owledgeat~le ir~ tt~e hlve~ti~ator's chosen area of study. If it is a]J~lrovl!d, the illlt!~t]~at~JI ~s al~al~l~'d [unlJ~ If~ pursut' ~lls lint~ iJl Jescarch. This system tla~ a ~umt~cr of I,uilt-ln a~lvar~tages. It permits large-scale use of FederaJ flmds wi~h~Jut I:~lerul cl~.~[o]. ]t keeps Ihe i~litlatlve wilh the individual scietlti~t. Thc ir~w~[~aLol's plan is judged I~! a iury capable of rendering competent sclentilic judgrnenl. The system also [:as s~mc (]isad~ antages. ']'h~ sLJl~ilor~ i~ ul/~ta~Jt,. !ear I~! !~ar: th~s fact not ~lnly creates appreheasion on the part of Itle i~lvt,,-~i~.~lirlg Ii~mk. I~lJ[ also [cml~ls the scicllllsL Io ~l~lect the p~ol)lem pr ollli~ing fq[l[l:k re*Lu r n i al~lcr Ih~llL tht~ Iong-rallge ilroiecl. I~rc, rn ~he starldl~oinl oi t[it~ university, the ~)llrdcrl ~lf estallllshing and mai~- laini~l~, a substantial research en~erl~rlsc ~ itllil~ which scie~tlsts may i~urs~c Iheir set)arat~ go~l~ is a ]~avv/~ne [~o ~leavy f~lf fnost schools already overburdc~n~d wi~h soaring cl~sls t elaLl~d t(~ e~lei r [t!aE~hln/z i)r tlgram~. I'or the ~ranling agency Jlc i~ governmental ~r [~rivate--t~e p~ollferalion of individual granls crcales [remcndot~s administrative pra~lems. For the

scientific manpower pool, the review process is costly in precious time. Olher povernmental mechanisms for support have been developed to fill in around the research project grant procedure, Federal funds are available to aid in constructing research facilities, to help support training programs I'or research manpower, and, in a relatively few instances, to give support in breadth and depth to an institution's research program as a wbole, Eaeh of the~e programs serves a ~ilal purpose, and helps to keep the basic system going. In addition to the research programs of universities and medical schools, tberc ate mlssion.oliented lesearch instdules dedicated to research oil a specific problem such as bean disease or cancer. Here, research is more directly pro- grained. In such an institute are individual scientists working, for example, on vascular surgcry~ others working on testing drugs which may lower blood pressure; examining the muscular lissuc of the heart, and Ihe like. Such centers of research excellence, spearheads o! an albout attack on heart disease, cancer and stroke, are few in nulaber today. A major recommenda- tion of the Commission has to do with the creation of more. BIlL it should hc ren~eulhered that the Commission's endorserllC[l[ OI the center approach does not impl! lack of laitfi in the basic system of individual grants. The t'~o systems are complementary. Their products are mutually reinforcing. dlanpower ]or Research A recent study shows that about 39.7g0 professional health workers were en- gaged i. medical and ht~alth ;{~ated ~esearch in 196(I. This corps forms /he base upon ~dfieh future manpo~ er ?cst UllCes 111 tl$1 be buih, The same report, bnsin~" its estimate on prt~jectiuns as to the total medical research investment anticipated in 1970. projects Ihe natim(s need for medical research nlanpower at the level of 77.000 professional workers at the end of this decade- almosl doulde the I%0 figure. There ~ill, of course, he some normal attritgm in the ranks of t}lC present research manpower pool. Taking this into a~oura, some dS.0(~'l professional ~orkcrs, fully qualified to engage in medical research as independe.I irwestlgalors, must be recruited and trained by 1970. It is t,Mimalcd lutth~t Ill;tl aJHml cme-half of Ihe PII. I)'s aml two-thirds of the M.II.'s in this needed addillon el 45.6(g) will have to come from the present pool uf Ph. D.'s and M.IJ.'s if the mcd is to be m~t This assumptinn has heavy implgallons fitr other manp~t~er Iequirements--including those f~r inedical .,~rvJctn The National Instltutcs ,~f Ilcahh ~f the Public Health Service is the largest single supporter uf training f',Jr medical rescarcfi manpowffr. NIl[ sper~l about 8189 million in fiscal )ear 1961 f~,r ivsear~h training--a 20-fohl increase in a little .vet a d~cade. The largest shale of Ihis cxpemllture (4(I pereent~ i~ for training in Ihc mental heahh fit:hi. The National Ilearl hlstilule support .[ tralni.~ I~taled $16 million; that el the \ratfimal Cancer luslilule, glO miilhm. M~m' tha~b '.~1 percent uf the total NIH Irairiing budget is sl)erd fiJr graduate Induing. 23 HEART DISEASE, RANCER AND STROKE

Facilities [or Research in addition to its exacting demands for highly skilled manpower, modern health research requires a great number and diversity of special facilities and supporting resources. At one extrerne~the extreme nearest the patient--is the clinical research facil- ity where medical care of human palients 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 studying 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. There also exist certain research institutes which combine clinical and basic biomedical investigation. And in addition, contemporary research requires supporting re- sources, such as highly specialized research unitS, animal facilities, and many others. Since 1956 the National Institutes of Health have been supporting the con. struetlon of health research facilities through a construction grant program. In eight years~ 1~I29 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 limes as great. This program continues to make a vital contribution, hut the need for faeili. ties is still outrunning the supply. Communications /or Research The information explosion in biomedical science has created a massive com. muuieations 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 merit. eat library system. At the heart of this system is the National Library of Medicine, now a part o~ the Public Health Service. The NLM publishes Index Medicus, a giant monthly bibliography of medical periodical literature, It operates interlibrary loan services and offers photoduplieation of source malerials. Its operations have been greatly ~trengthened in the past year with the activation, in December 1963, el the computer-based Medical Literature Analysis and Retriaval System (MEDLARS)--the largest such information storage and retrieval system yet devised for a published literature, Monthly publication of the Index Medlcus 24 occupies only a small portion of MEDLARS capacity. Potentially~ it can also HEART DISEASE, CANCER ggg STROKE handle 150 recurring specialized bibliographies plus as many as 37,500 individual

HEART DISEASE, CANOER AND STROKE

PA~T II 26 HEART DISEASE, gANgER AND STgOKE TOWARD THE CONQUEST OF HEART DISEASE, CANCER AND STROKE A HATIONAL PROGRAM FOR A NATIONAl. GOAL Our assessment of lhe nation's rehouses for health service and medical research has accentuated needs and shorlcnmings--for it is these which must he remedied if we are to move toward the conquest of heart diseases, cancer and stroke. These needs are genuine, attd /he obstacles to progress are formidable. But we can count en 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 tile nation. Their work, in turn, is supplemented and suppor'ed by other agencies and groups. Tile public health departments of cities, counties and States are l~nderlng a growing number nf services to those who suffer from heart disease, cancer and stroke, The great national voluntary ageneies--~sueh as the American lleart Assc~ia. lion and the American Cancer Society--perform many services through their local chapters and affiliates aud contribute significantly to research. Indeed, the high level of heaIth now enjoyed by mosl 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, and strok~we must strengthen our alliance for health in a number of ways. The toll of death and disability caused by heart disease, cancer and stroke is a nalional problem--a national disaster. Such a challenge demands a national response. It is the conviction of the President's Commission that orr government has a praJound responsibility, which it is not yet julfy discharging, /or leadership, stimulQtion, and support in the protection o/the health o/the American people. The national program envisioned in the detailed recommendations which follow is designed to provide the needed stimulation and support without violat- ing the basic conditions and freedoms at oar existing heahh partnership. More specifically, our recommendations are based upon the following principles: (1) That the Federal Government shares in the responsibility /or assuring that persons su~erlng /ram or threatened by heart disease, cancer and stroke have ready access to the benefits o/the best in medical service based upon the products o/scientific research ; (21 Tbat the Faders! Government has a major responsibility jar strengthen- ing and broadening the support of research which will generate new knowledge escentiaf to the control oj heart disease, cancel and strohe~

(3) That the Federal Government has a major responsibility/or direct and dit~rsified support o] medical edueat~n and other programs designed to produce the health manpower upon which the control o] heart disease, cancer and stroke depends. It is our eonviclion that the stronger national role involved in the Commis. sion's recommendations in all three of these a~eas---servlee, research, and teach- lug--will enhance and make more productive the efforts of all members of the health partnership. Each public and private resource is indisFensable to the achievement of better health for the American people. Finally, and underlying the other principles, we belie~'e: That tbe nation can well afford and the pea ple will enthusiastically sttpport sub. stantially increased expenditures intended to save Hves today and produce more li]esaving knowledge Jar tomorrow. The nation's resources are enormous and rapidly growing. Our Gross Na. tienal Product passed $500 bl]llon in 1960 and is spiraling upward toward $1 trillion. The projected annual i~lcrease in national productivity for the years immediately ahead is shout $30 billion. Of this increase, the Federal Government will receive an annual increment of some 85 to 46 billion per year, Against this gigantic backdrop, expenditures for health east a small shadow. Disease oasis Ihe 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 inveslmenl in the healOl of Ibe American people than has tbus far been made. Every commitment of resources for a given purpose requires decision. It requires assignment of priority. What price, what priority, human life? 27 HEART DISEASE, CANCEII AND STROKE

28 HURT OISEASL CANCER AND STROKE ? )WAnD THE I;ONQ(JEST OF , ABT ])ISEASE. o iD STROKE A NATIONAL NETWORK FOR PATIENT CARE, RESEARCH AND TEACHING IN HEART DISEASE, CANCER ANO STROKE The first set of recommendations of the President's C~mmi~ion would create a national network for patient care, ree~'arch, and teaching in heart disea~e, cancer and slroke. 'this program is deedglled to bring together the heat in medleal care and the best in medical research, region by region across the nation. It would result in two major h~nefits: (l) The saving n] many human lives and the prevention o] widespread dis. ability, by making the best in modern medical care readily accessible to people suffering from or threatened by heart disease, cancer and stroke in their own communities and regions; (2) The rapid development of new k~wledge about heart disease, cancer and stroke, by creating a greatly increased number of top.quailt), centers for the clinical and laboratory investigation of these diseases strategically distributed throughout the country. In addition to these two major thrusts, which strike at the two most critical needs in the campaign against the three killer diseases, the proposed national net- work would contribute to the up-grading of all medical servlces. Each indivldua] component of the network would serve as a teaching and training center, trans- mitllng to the medical profession and to the publle the latest developments in scientific medicine. The proposed national network is based on the concept that tb~ best patient care is associated with research, h is not envisioned as a totally new and separate pattern of medical service superimposed from above. Rather, it is d~igned to become a part of the existing fabric of medical servie¢~. Existing universities, community hospitals, and research institutes will be the focal points for the cen- ters and elations proposed. In some areas, through the development of medioal complexes, individual regional centers and stations will be related to and inte- grated with e:~isllng hea]lh resources, The system is designed not to duplicate existing resources but to strengthen them. The purpos~ of the entire system is to assist tim doctor in practice in the ears of his patient who is suffering from heart disease, cancer or stroke. It wig make available to every doctor in the country the newest and most eff~tive diagnostic methods and the most promising methods of treatment. • It will, in effect, llnk every private doctor and every community hospital to a national--and indeed worldwide--network transmitting the newest and best in health service. And at the same time it will 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 re~aroh, medical education and patient care, Regior~l Centers /or H~art Disease, Cancer attd Stroke Recommendation 1. The Commission recommends the establishment oJ a national network o/ Regional Heart Disease, Cancer and Stroke Centers /or clinical investigation, teaching and patient care, in universities, hospitals and research institutes and other institutions across the eoutttry. Specifically, the Commission recommends: A. That 25 such centers for heart disease, 20 for cancer, and 1S for stroke he established over a 5-year period; B. That an Advisory Committee on Regional Centers be 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 recommendations forthcoming from this Committee are to be transmitted to the appropriate National Advisory Council to aid the Couacil in making its recom- mendations to the Surgeon General regarding applications for regional centers. 554.9 (IN BILLIONS) 1962 3O0 2O0 100 42,8 0.24 0 GROSS NATIONAL PRODUCT ECONOMIC RESEARCH COSTS COSTS FOR HEART DISEASE, CANCER AND STROKE 29 HEART DISEASE, CANCER AND STROKE

C. That lhe following funds lye appropriated to the appropriate units in the Publlc Health Service to initiate this program for a 5-year period in the various areas! 3O HEART DISEASE, CANCER AND STROKE Type of eE, n I~er Heart Disease. Number of new centers. ]'unds required* ........ 3 4 5 1 2 10 3 25. O 24.5 4 4 50.0 90.0 5 2 12.5 12.0 4 4 32.1 38.9 4 4 50.0 i150.0 Y~aF 4 45, 7 Eancer ..... Number of new ccnterg d Funds required* ........ 160. 0 Number of new centers. 16. 2 3 3 Stroke ..... Funds requlred* ........ ,, 20.0 25.0 * Figurce it1 mil]ionm of doLla rg Descripticm. 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 spcciallsts from all clinical disciplines and the sciences basic to medicine necessary for a comprehensive attack on problems associated with that disease. These specialists wouid have at their disposal all neoessary 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 tile most comprehensive, effective and professional- ized research effort possilde, Each r,'gional center must have an allocation of space appropriate to the pro- gram to be mounted, permitting reasonable expansion. To establish such cen- ters, nonmatehing funds for the construction of new space and/or the renovation of existlng space should he appropriated, in addition to funds for the provision of necessary equipment and staff. Centers already exist, particularly in cancer, which can serve as a nuelens for the development of some of these regional centers. Investments in potential sites will be necessary in places where the nucleus for these facilities does not exist.

The centers would be strongly oriented toward clinical investigation and fundamental research. They would conduct training programs for personnel stafiSng the diagnostic and trealment 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 will have areas for specialized care, and research beds related to laboratory facilities for specialized diagnostic studies and new treatments under iuvestiga. tlon. In addition it will have operating rooms and other facilities for complex diagnosis and treatment. The staff of each center mast be large and varied enough to facilitate investigation and treatment in depth, utilizing multiple scientific methods. A Regional Heart Center, for example, might include inlernisls, eardlopulmonary physiologists, cardiologists, peripheral vascular specialists, cardiac and vascular surgeons, biochemists, statisticians, epidemiologlsts, radiologists, and, in some cases, geneticists. Cancer centers would he 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 spcclalists in the neurological disciplines. In summary, eaeh Regional Heart, Cancer, or Stroke Center would he utah. lished where possible in conjunction with a major existing medical institution. It would be staffed and equipped Io conduct advanced and complex clinical in- ve~tlgntion and related research, plus teaching services and hlgh.quality patient e41r~, It would function as a regional resource for these services, interacting with the local diagnostic and treatment stations and with the other medical resources of the area. A logical, organized program of researeh, teaehlng and patient care in a re- gional center can vitalize the interest in the care of the patient, make available the lats~t techniques and resources in modern therapy and discover new ones for application. By demonstration and professional education, the patients of a whob area may he benefited. Rehabilitation Center~. 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 Vocatlonal Rd~abilitatlon Administratlon, Doubling the number of centers now receiving suppert and increasing the funding of each center as its program may require would provide vitally needed expansion of rehabilita- tion care, research and training, particulaTly 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 National Institutes of Health. The NIH Clinical Research Center Program, 31 HEART DISEASE, CANCER ANO STROKE

32 HEART OISEA$S, CRRCER AND STROKE now in its sixth year. has demonstrated on a modosl scale the great potential of dinleal research units in various parts of the nalion~ Tho Commission considers, however, that its present proposal {or categorical regional centers eonstitu~s an urgently needed next step in edvandng the attack against heart disease, eanocr and stroke. The time is ripe {or the development of research, training and care facilities that would permit the broadest and most comprellensive attack attainable on the • problems of heart disease, cancer and stroke. The Commission recommends, therefore, that the present "Clinical Research Center" program be eontlm~ed and expanded, and that ils name be changed to the Clinical Research Unit program to clarify the relationships between this existing program and the Regional Center program proposed hen~in. Diagnostic and Treatment Stations Recommendation 2. The Commission recommends the estab~shment o] a nationnl t~twork o/Diagnostic and Treatment Stations in communities across the nation, to bring the hlg~est madical sk~lls in heart disease, cancer and stroke within reach o[ every eitisen. 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 that the best in rehabilitative service is rendered to patients r eeeivlng diagnosis and treatment. The number of Stations recommended is based on a careful assessment taking into account the number of existing facilities for each disease area, the national need and the feaslhility of staffing the Stations within a 5.year period. We recognize that the suggested number of Stations will not, in fact, saturate the entire country. There still will he many patients beyond practical access to these facilities. It is our intention that these will serve as pilot demonstrations stimulating still broader coverage under local initiative. The Commission reeomm~ds that half of the Stations established for each disease area be located in medical eChOers, 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 reeonunends that an Advisory Committee be estah. lished in the Public Health Service to develop a national plan fur the establish. ment of these Stations, to review applications far grants, and to evaluate the program in the {ourth year to determine future needs for further program development. It is recommended that the following appropriations he made to appropriate units in the Public Health Service to initiate this program for a five.year period in the various areas.

Type of unit Heart Di~eaBe .... Numhar of new units 30 Funds required* ..... 1.25 ~*tneer ...... Numhar of new unlts 40 Funds required* .... 15. 0 ~troke ....... Number of new units 20 Funds requirede .... 7. 5 llehabilita- Numhar of new units 10 tion....... Funds required* .... 3. 0 1 2 Year 35 40 18.375 26.375 35.25 ,I5 45 ..... 26. 2! 40 ~,0 40 44 30.0 45.0 60.0 75.1 20 30 30 ..... 11.0 18.25 23,5 17.[ 20 30 40 ..... 7.5 16.5 19.5 13.1 *Ftprtt In mllllo~ o f dloll*tt. ]rfifiat ¢on,iructlon or renovation and equipmenL of those Stations should be supported with Federal funds on a nnn-matching basis. StaSng and operating costs of the Stations should be harn¢ in part by the Federal Government and in part by local resources, It is envisioned that such Stations could become selbsupportlng within a 10-15 year period. Emphasis should be placed on local resources for the provision of care for medicallylndigent patlentsln adlagnosti~andtrealment unit. Patientsothar than the medically indigent should pay for services. Description. A typical Heart Station world have the following principal objcetiws: 1. Immediate and emergency care for patients with acute cardiovascular emergencies. 2. Provision of diagnostic facilities tur the screening of patiente with cardio- vascular, including peripheral vascular, diseases to determine whether they will require the more highly technical taeilllies available at the larger medi- cal centers. 3. Outpatient ~erviees for patients with cardiovascular and peripheral vascular disease. 4. Stimulation of interest of medical students and practitioners. 5. Training of physicians in the community. 6. Education of the general public concerning prevention and treatment of heart disease. 33 HEART DISEASE. CANCER AND STROKE ~6-459 0.64-4

34 HEART DIGEASL CAHCER AND STgOKE These Stations will include intensive care units for the emergency scare o[ patients with heart disease. In addltlon, these Stations would prnvlde limited laboratory faeilitles, an outpatient clinic, eleetrooardicgraphle and radiologie services. Patients requiring advanced diagnosis or treatment would be referred to the Regional Center equlpped to performlt. Each Cancer Station would have similar goals and be equipped and staffed to provide parallel types of service to patients and to the medical community. Each would require provision for oytologleal and hlsto-pa~hnlogical laboratories to effea diagnosis. Team care at each Station would include radiotherapy and radioactive isotopes, chemotherapy, and the maintenance of a cancer registry with complete reporting. Each should have access to data processfeg and com. purer analysis. Each Station sholdd be in close contact with the Regional Cancer Center in order to obtain dlreedy from these research centers information and training in newer methods of diagnosis and treatment. The Stations will in turn convey iniormation to other community hospitals and physicians and should also serve as part of a network of facilitles available for collaborative clinical research programs carried out by the large cancer research centers. To fulfi) its graduate eduestionai funotlon within its own communRy, each 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 will have access to the in- formation services provided by the regional centers, and through these centers to the total body of knowledge accumulated in a worldwide re.arch effort, The Stroke Stations will include intensive care units for the emergency care of patients with stroke. They should be established so that they may share ~rtaln facilities and personnel with Heart Stations. Therefore, it is desirable for the Stroke Stations to be in the same area of the hospital as the Heart Sta. tions and tn work closely with them~ avoiding .nneeessary duplication but supporting each other. Thee Stations will include laboratory h~ilities, physical medicine and re. habilitation facilities, outpatient clinic and hospital beds, and provision for dectroeneephalographie, dectroeardlographlc, ne.rohgival, and emergency surgical servlces. Development o/Medlcal Complexes Recommendation 3. The Commission recommends that a broad and I~exible program o/ grant support be undertaken to stimulate the/ormation o~ medical complexes whereby imiversity medical schools, hospitals and other kealtls care and research agencies and institutions work in concert. Specifically, the Commission recommends a major program of institutional grants to university medioal schools [or the ereatlon ol medical complexes which would involve participation by community hospitals and other health care faeilitles, by some of the regional heart, cancer and stroke centers and stations

developed in proximity to each medical center, and by other coarmunlty agencies and institutions. For this purpose, it is recommended that the Pubfic Health Service receive appropriation* 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 approximatdy 10 medical centers would receive approval for such grants in the first year of operation, followed by 5 additional centers in oaeb 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-quallty services in con- nection with a speeill¢ disease, will greatly increase tbe 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 expend their resources so that they can participate in Ihe 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, metropolltan area or region, Funds could be employed in a variety of ways, such as the increase of staff to provide falbtime faculty members for duty at affiliated community hospitals; augmenting staff in other ways to serve the community; setting up necessary administrative r4eehanlsms; and the llke. The resultant complex would strengthen the community hospitals by allowing them to draw on the advanced and costIy 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 uther health professionals in the region, and for coor- dinating all eommunlty services--includ;ng noninstltutional care---through a variety ot cooperative and mutually supportive arrangements with existing agencies, Development o! Additional Centers of. Excellence Reeommendotion 4. The Commission recommends a program of develop. mental grants to medical sclwols to enable these institutions to improve their total capability /or both academic and research programs /or the ultimate purpose o~ creating a greatly increased number o/true "centers o/excellence" in medleal education and research. Specifically, it is recommended that appropriations of $40 million over a 5-year period, beginning with 83 million in the first year, be made to the Public Health Service for a program of nonmatohing grants to be used by institutions at their discretion to strengthen various aspects of their academic and reteareb programs. This proposed program parallels an existing program o| institutional develop- ment administered by the National Science Foundation and should he carefully coordinated with that agency, hs over all purpeses would be: HEART RIEEASE, CANCER AND STROKE

---

speclaltie~ as neurology, cardiology, surgery, physical medicine, and rehab|llta: tlon. The Commission considers the d~v¢Ioprnent of a Natlona| Stroke Progrom imperative if we are to achieve the progress of which we are capable agalnst this raajor killlng and disabling disease. To operate this unit, $1 milllon should be appropriated annually for th~ firtt two years with subsequel~t annual increases unti| $~ rai|lion is rea~ed in ~efi~year. 37 HEART DISEASE, EANRER AND STROKE

3B HEART DISEASL CANCER AND STROKE TOWARD THE CONQUEST OF HEART DISEASE, CANCER AND STROKE APPLICATION OF MEDICAL KNOWLEDGE IN THE COMMUNITY Many individuals, agencies and groups contribute to the healtb services re- ceived by heart disease, cancer and sheba patients in American communities. State and local health departments, in addition ta their traditional and better known responsibilities for the control of eormaunicahh diseases, conduct active programs to serve the chronically ill as well. Voluntary agenales--sucb as the local affiliates of the American Cancer Scelety and the American Heart Assoclation--assist in many ways. There are also the professional organizations--the local medical societies and others--and the various groups providing specific kinds of care such as visiting nnrse asso- elations, 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 hcalJh care a1¢ in short supply in virtually every community. Therefore, the efficient use of existing re- sources is imperative. Yet in many communities the reverse is actually the case, Instead of coordination, there is duplication of services and facilities in some areas, while serious gaps exist in others. There may bc several large general hospitals, furnishing mare beds for acute care than can possibly be utilized by the community, while serious shortages exist in beds for long-term care and programs for those patients who can best be cared for in their own homes. Several hospitals may possess costly equip- ment-such as cobalt devices for cancer care, or heartdung machines--each being used only once or twice a week. Teams ol highly skilled people required to work with this equipment are also standing idle, A beginning response to these problems can he seen in a taw of the nation's more progressive and active communities. The concept of "areawide planning" is being implemented through councils of social agencies, utilization committees, and community health or patient.care councils, These voluntary organizations attempt to achieve coordinated el|otis on the part of various independent agencies and individuals concerned with the health and medical needs of the community's citizens. Such endeavors are of the utmost importance if we are to realize our aspira- tions for programs that will have maximum impacts on heart disease, cancer and stroke. Independent and often rompellng activities ot hospitals, health departments, and medical practitioners--cash working in isolation and often at cross purposes--are not in the best interest of the consumers of health services. the health profession, or the nation. The national network proposed in the previous chapter will do much to strengthen attd coordinate community services for bea tt disease, cancer and slroke,

But much more needs to he done if the full.scale attack on the~e diseases is to he fully effective. The recommendations in this chapter are designed to assure this success by stimulating and supporting community programs and by enceuraglng the communication of health knowledge to the practicing physicians and to the public, Community Planning Grants Recommendation 6. The Commission recommends n special program el incentive grants to communities to stlmul~e tfie development o/a system/or the planning and coordination oJ health activities. Specifically, it is proposed that there be established within the Community Health Services and Facilities Act Program of the Public ilealth Service, malohiag grants to be awarded to community agencies to supper' 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 service~, 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 servic~ relating to heart disease, cancer and stroke is the lack of coordination of services wilhin communillea. Failures in coordination resull in services thai 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 ¢oramunily 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 hut would also belp 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 ineen. tier to as many communities as possible to undertake such a program of plan- ning and coordination. Community ltealth Research and Demonstration Recommendation 7. The Commission recommends that greatly increased emphasis and support be given to programs o/community healtlr research and research training within the Public Health Service, and that the program o/ demonstration projects under the Community Healtl~ Services and Facilities Act oj 1961 be/reed/ram existing appropriations ceilings, more adequately /unded, and more liberally interpreted. It is vitally important that we find ways of using existing manpower and other ~sourees as effieienlly as possible. Indeed we cannot meet the challenge of heart disease, cancer and stroke unless we improve methods for extending the accessibility and delivery of health servieBs intho emnmunity. Research in community health offers one highly promising avenue for efficient UgO of i'esourooa. 39 HEART DISEASE, CkNCER AND |i"gOgE

40 HEART DI|EASE, CANCEE AND STROKE Scientific methods can be appfigd in the hboralory of the community. Epideraiologio research can reveal patterns of disuse distribution which in turn pvrmlts a concentrated attack where it will do the most good, Behavioral research, economies research, and research in public health admin- istration all can contribute to effective planning and programlng. But com. munity health research is a very new field. Few Fcople are ITained to do the job. A major investment in research training and support ot promising research projects in this field ean be expected to pay important dividends. Accordingly it is recommended that the present appropriation for this purpose b¢ 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 ot projects that it has been possible to support, has proved that demonstrations of experimental approaches to the delivery of health care are useful and praetieah The Act authorizing this program was designed to solve the problem of community organization for health service. But it has been narrowly defined and inadequately funded• Freed from its existing restrictions, this program could make a major con. tributlon to the attack on heart disease, cancer and stroke, Support oj Community Programs Recommendation g, The Commission recommends that appropriate units oJ the Public Health Service be given authority and Junds 1or programs el project grants to community agencies, such as public health departments, volnntary agencies, and others, and that the Voeatlonal Rehabilitation ,4dmin. fstration launch a 5-year development program to expand its rehabilitation pro. grams ]or viotims o/heart disease, cancer and stroke. Speeifieafiy, the Commission recommends: A. That the Public Health Service he authorized and landed to initiate project grants to public and other nonprofit organizations for studies, experiments, feasl. billty trials, demonstrations, and training in their respective fields of interest and that a special grants program he initiated by the Publle Health Service in the field of mediea~ i~bebillt atlon. The project grants envisioned in this recommendation would stimulate State and community agencies to deliver expanded and more effective services to pa- flouts suffering from heart disease, cancer and stroke, thereby speeding the up. plication of scientific knowledge to the people who need it. These categorical project grants would provide incentive and encouragement for community pro. grams in such areas as the early detection of incipient heart disease, cancer and stroke; effective systems of referral for patients; application and training in the use of medical rehabilitation techniques for heart, cancer and stroke patients; and the like,

The following tame indicates the appropriations necessary to initiate the new Public Health Service programs and expand existing ones for a 5.year period. Apt~a lt~rt Dineatl~ * ..... , ,., ............ CIIll~i'~',. ,... ~ ~ ........... ., ....... Stroke* ............................ Year 1 ; 3 4 5 1.5 3.0 4.5 6.0 7.5 1.5 3.0 4.5 6.0 7.5 1.5 3.0 4.5 6.0 7.5 Medical rehabilitation* ............. 1.5 3.0 4. 5 6. 0 7. 5 °Fill.tit in mlllrans ¢1 d~UstJ, B. The program recommended for the Vocational Rehabilitation Administra- tion would include (l) 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. etruction of vocational rehabilitation centers and shdtered workabot~; (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 exlnmlion, gtatewide Programs/or Heart Disease Control, Recommendation 9. The Commission recommends that the Public Health Service be given authority and Junds to establish and maintain coordinated gtatewide laboratory/acilities necessary/or heart disease control programs. A total appropriation of $8.5 million over a three-year period is recommended for this purpose2.5 million for each of the first two years and $3.5 million for the third. The laboratoriez established through this program should be designed to per- form laboratory services related to heart disease control, These laboratories should form a part of a coordinated Statewide program of heart disease control, headed by a specific unit within the State health department. Such a program, 41 HEART DISEASE, gANgER AND gTgOgE

42 HEART DISEASE, CANCER AND STROKE to be successful, must coordinate the efforts of the numerous public and voluntary agendas whose work impinges on heart disease control snd must also collaborat~ elo~ly with the private physicisns of the State. The objectives of thls Statewide laboratory network are several: (1) The grouping of beta-hemolytic streptococci. Rheumatic fever is poten- tially preventable through prompt identification end immediate trestment with an appropriate anllmlerohiul agent of patlents sufferlng from beta- henlolytls strepto~oeea] in|cations. Each State should have eoordlnat~ laboratory ~aollities ~o identify the Group A beta.hemolytic streptococcus organism. Where such facilities exist, they have proved a tremendous boon to praeiieing physlcians and have foellltaled rheumatle foyer con- trol programs in that State. (2) The provision of services for the laboratory eontrbl of patients receiving antleoagulant agents. A large number of patlents in the United States are currently receiving anticoagulant drug's; it is probable that the number will grow in the future. The dosage of these drags must be tailored to each patient individuolly and the dosage regulated by carrying out ap- propriate blood tests al frequent intervals. In many ere.as of the eountry~ this service is earrled out hy hosplta]s and private iaboratorlss. In other areas, however, patlent~ could reeelve this type of medication if this serv. ice was avallshle and eonverfient. This Statewide laboratory network would conduct well standardized end controlled tests which could hdp other ]ahoratorles check their methods for acceptable accuracy and also provide leboratory service in areas where it h needed. 13) In conjunction with the Heart Disease Control Program (HDCP) iabora- Iory at the Communicable Disease Center, (CDC), to provide the service of standardization of chemicul laboratory tests Io hospital and prlvate laboratories in the country. The HDCP laboratory at CI)C is perform- ing this service for laboratories all over the United States end abrosd at the present time. Thh Statewide network of )shoratorias could serve as local agents for this valuable program. As Bach, these ]oeul )abora- tortes could also perform chemical determinations and participate in large Inca| snd national epideminlegic studles in cardio'zascular disease; in thls sense~ these lshoratorie¢ would act as a valuable rewouree for cerLaln researol~ programs of natlnnal interest, It must be stressed that the development o~ such a laboratory network to perform the aheve ser¢ieea would make iL possible to aehiave en immediate, specific snd measurable impact in reducing death and dissbility. Each $~ate should, of course, assess ils own needs. The Heart Disease Control Program of the Puhlle Health Service should have [he authorlty and specifieuliy earmsthed funds ~o sssist Ihe States in setting up and ngsrallng the needed facilitlsg. National Cervical Cancer Detection Program Recommendation 10. The Commission recommends the development o~ a national program lor the early detecllor~ oJ nervinal cancer.

This program would have two major components: A. A national education program for the general public so that all women are aware of the availahilily of the cervical cancer screening test. This should he conducted by the Public Health S~rvice 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 Untied States each year. The Commission feels that such a hospital-centered screening program will he most economical, will reach the high-risk, low socioeconomic group and offers/he 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 hy $21/z million each year for a 3.year period, to provide grants to hospitals participofing in this program, An Advisory Commlt- tea should be appointed to hdp plan the development of this program, to review it after the ~¢ond year, and to plan Ior its future development. Total support for cytological examination should he given to hospitals provid. ing care for medicaUy indigent patients, and parfiaI 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 o| other laboratory testa. In providing these grants, consideration should be given first to hospitals providing care for the indigent and the medicany indigent. This national cervical cancer detection program is an intensive effort aimed at a very specific targeL 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 almost invarlably curable. There is no excuse for further delay in launching a major attack that can reduce the death/oll from this form of cancer virtually to the vanishing point. Continuing Education o/ the Health Pro[essions Recommendation II, The Commission recommends that appropriate units o/the Public Heath Service, and the Vocational Rehabilitation d dminlstration, be provided with ]unds and any additional authority that may be necessary to spearhead a national program /or the continuing education o[ the health projessioas. Specifically, the program envisioned has three major dements, as follows: A, The Public Health Service should be provided with funds and additional authority it necessary to stimulate and support, through grants, contracts, or other means, demonstration projects and experiments directed by universities, medical ~ehools, hospitals, and other appropriate agencies, designed to make scientific knowledge on heart disease, cancer and stroke and other subjects systematically and eonvenlenffy available to practicing physicians and other health professionals. 43 HEART DISEASE, CANCER AND STROKE

44 HEART DJ$£ASE, CAKCER AND STROKE The scope of this program should also include conduct and support of research proiccts d~igaed to develop and experiment with new methods of contll~uing education, use of various media, and methods of evaluating their actual impact in u~reding medical practice. Appropriations of $2 million for the gr~t ye=r, $4 million for the second and $6 million for the third are recommended. B. The community hospital oeeuples a particularly strategic po~ition in carry. ing continuing education programs directly to the practicing physician. To ergo. nite and entry out euch programs a given hospital sbeuId appoint a full41me Director of Medical Education plus supporting staff. Members of the alieading staff of the hospital should be encouraged to attend courses and take longer addi. tional training whenever possible. Though, ideally, all community hospitals with 300 or more beds ahould u]tlmatoly mount such a program, it is recommended that ~uch units be establisbed and supported in 100 of these hospitals tlJroughom the Unlted States on a pilot demonstration basi~; if suecesslul, the number of unils can be increased, It is estimated that about $75,000 per year would be needed to carry nut a program o1 this type in each be~llital of thi~ size. A total of $7.5 million annually would he needed inr this program. C. An additional amount of $600,000 per year for 5 years should be appro. prJatad to the Vocational Rehabthtation Adminlstrat~on to provide ~rants to key medical and health fastitutinns and agencies throughout the country for support of short-term tralnlng courses, semin~trs~ conferences, Bud workchops in rcha- hilitatinn services for heart disease, cancer and stroke patients. Continuing edueatfan is a categorical imperatlve ot contemporary me~lieine. Without a large-scale, effectively organized effort, the worlds of science and practice will spiral still farther apart. The gap between what is known and what is reoeivad by patients will be hBrder ann harder to brlage, The greatest single obslaefe to a cohesive program of continuing education for the medical profession is time. The eecond is diversity of interest and needs. The third is the fact that eontinulng education, although it is recognized as a critical problem in medicine today, is not the primary responsibility of any signifiaant eegment of our national health resou roe. Medical schoal~---the logical locus tor the major e~ort--are correctly pre. occupied with undergraduate education first Jnd rese~treh seeondi continuing oducatfan, if it recelveJ any attention at all, must settle for what il left of already inadequate resources. Similarly, community laospllals could contribute greatly to the continuing education of community physleiens, but their firet job is to care far 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 resouret~ in giving due attention to this problem, Public In]ormation o~ Heart Disease, Cancer and Stroke Recommendation 12. The Commission recommends that the Federal gov- ernment, primarily theough the Public Health Service, teeogmze that public

in]ormation is a primary responsibility and a major islstrument ]or the pr¢. vent|on and control o] disease, al~d that this actlv~y be encouraged and sup. ported on a ~cale comraen~ur ate w~h ~ import~n~:~.. Application ot medical knowledge in such fields as heart di~ase, cancer and stroke depends o31 the initiative and cooperation of an informed publio. ']'his is Irue of every step in the process, from prevention and early detection to rehsbill. tation---eaok of which depends on the ~clive participation of the patient ~tnd his fnmiEy. Speeifie~lly, the following projects and progrEtms are recommended : A. The Public Health Service should be authorized, and ~'ueds should be ~IP" pruprlated, to ¢o~traet with commerelal television producers for the preduetion of twvlve 30-minute documentary films each year ef the highest quality, on sub- jects relsted Io fieart dlsease, cancer and stroke and ~*uch other subjects as are deemed desirable. Each film should be budgeted at or about the level ot $150,000 to ~ssure writing and production that will ntake the films competillve with the best of commercial te]evlslon, thereby eneouregln~ their use hi prime vlewing hour~. This price should include a sufflclent number of prlnls te a~ure wideepre~d ilse on local comraercla] le]evislol~ outlets ~cross the naliolt. The eontracl mhould slso provide for the full participation of the producer and hi~ organization in the marketing of the films. The Public Health Service, in conjunction with non-Federal sele~tisls and physici~n~ designated hy the Service, ~ould have ~ull control of the content of each film. The film should be ~vailable ~or eom- merela] sponsorship within a predelermined range of eppropriote product elassl- fiestlons. Tl~e method pruposed--wl~iok consists essentially of a Federal inw~t- ment in oommunie~lions lalenlmweuld cost about $1.8 rni~llon per year. B. The Public Health Service should be authorized, ~nd funds should be ep- prupristed, to th~ Nslional Medloal Audiovisual Center--subsequentl~r de~erthed in eonn~tion with Recommendation 31--to suppcrl through sppreprlate meok- anlsmr~ such as gr~nts or contr~els, the development of effective lelevlslov pro- gF~min~ in the health ~ield on the nalion's educational television stations. The sum of $1 million per year is recommended a~ a beginning figure. Educational ~elevi~ien (E'rVI programs teach school audiences ~t ~11 levels ~rom priraary schoo~ through college, It1 marJy communitles lhe ETV program is viewed wldely by the adult intelleelu~l aed civic lcadershlp ~s well. It repre~ent~ an exce/lent medium f~r attraetlng young people to health e~reers, ~or e~,lsb]ishlng and mainlalning deslrahle health la~blts, and ~or stim~latlng de~irablc com- munltywlde health aetlvltles. In many ~reas, ETV fseilltles can al~o be used for ¢ontlnuln~ edueation of health prefessionais. C. The funtts ~ppruprialed for the O~ce of/nfornaation and l~bllcalions in the Office of the Surgeon General ~hould appear as a fiudget~ry line item. They should be increased by $750,00fl per year 1o llnance such add|. tional act|rifles as the deve[~Jpment ~nd production of a health yearbook similar in seup~ ~nd qu~lily te the A~r]cultural Yearbook; the cre~tlon ef nlaterlals 4~ for free public service announcements on heart disease, cancer, stroke and other }I£ART DI$£ASL CAHgI~n AI~D ~T£0K£

.......... ] ~ieets {~r ~x~ b~ rttdl¢, televi6on, magazln,:s, ar.d ~tbeT ~ed~a; a~tl othez purposes. D, The Public Health Service should be provided with funds to initiate the de'~eh,pme~t d a C~nter for R.eseareh in Itealth Moti~tlon. 1~ addltlo~ t~, spa. elfin hehavioral studies directed at the individual decislonmaklng proce~s in changing patterns of living, the Center would analyze the contents of public campaign materials with reference to their effeetlven~ and influence upon behavior, and it would hopefully concentrate particular attention upon hard- to-reach population groups whieh reject existing educational campaigns empha. sizing individual initiative and changes in li,:ing patterns, ft is estimated that $500,000 per year would be necessary to undertake the support of such a Center. E, The Commission strongly endorses the conchtions and recommendations of the Surgeon General's Advisory Committee on Smoking and tfe~lth which, in addition to conf~rmlng previous reports, stated that smoking is a serious hazard to health and indicated the need |or more aggressive programs in this ar~, It seems apparem that the reductiott of elgttrett¢ smoking affers great posaibillties for the pre~'ention of illness, disability, and premature death in this country, with regard to both cancer and cardiovascular disease. Because public information aud education are primary instruments for the attack on this problem,/he Commission recommends that the sum of $10 million be appropriated to the Public Health Servize over a three-year period for a com. prehenslve national program of education and publio information regarding the hazards of cigarette smoking. The program should he aimed at the education of children, adults, physicians and educators with the assistance of State and local community agencies. A network of smoking control dinies should he provided to a~i~t thcsB ~b~ desire to give up smoklng. New ~nd mo~e efleeti-~ eduea- /tonal material should be developed. It is further recommended that the present budget of $500,000 for public information and education in the Cancer Control Program of the Public Health Service be increased to $1 million for the first year, |1.5 million for the second, and $2 millio~l for the third to permit increased effectiveness in informlng the pu bite about cancer and its prevention and control. 48 HEART DISUSE, CANCER AND STROKE

PART II~Chaptez Five TOWARD TIlE CONQUEST OF HART DISEASE, CANCER AND STROKE THE DEVELOPMENT OF NEW KNOWLEDGE The conquest of heart disease, uancer and stroke requires the contlnutltion and expansion of our highly productive medical research effort in the years ahead. Today's successes in detection, treatmeut and cure sprang from yesterday's research. But many problems related to these three diseases remain beyond our scientific capahillty. Of these, a large nunther appvar to be iust outside our grasp. We stand on the threshold of further advances. To cro~s thls threshold as soon as pesslble-~to take advantage ot the tremen- dous momentum built up by our biomedical research enterprises in the recent past-certain new elements should be added to our existing scientific resources. In addition, current procedures need to be strengthened or modified to assure e'~Td~a:~easi~ g p~oeluctlvlty ~f ~¢w i ffe-savln~ kno'nied ~¢. The national network of regional centers, each primarily oriented toward the solution el a apeoihc disease problem, will generate and verify a tremendous amount of new information on heart disease, cancer and sLr eke. 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 speeiali~d avenues of reeearoh related to heart disease, cancer and stroke. Therefore, other types of research institutions are recommended to supple. ment the products of the centers. Moreover, the Commission has examined with great care the overall program of research support provided by the F~leral Government. In our view, the diversity of funding devices that has develeped over the years to support bio- rnedivai reeearch and training is one uf the nafion's greateet strengths. Clearly, the variety of available mechanisms offers flexlhillty of support and provides iu- stltutions and investigators with an opportunity, within limits, to develop pro- grams consonant with their needs. Indeed, the Commission recommends that Federal agencies wHch support hiomedicai research continue to do so by dlveree means. At the same time, existing procedures should be strengthened and new modes of support should be developed as these are identified and found to be suitable. The Commission's reeommenthttione for tbe development of new knowledge are designed to add further .impetus to the powerful forward thrust of biomedi- cal research, Biomedlcal Researeh Institutes Recommemtatio~ 13. The Commission recommends the establishment el 25 non-categorical biomedical research institutes at qualified institution~ throughout the country, 47 H|AIIT DISEASE, EANCER AND STROKE

48 HEART DISEASE, CANCER AHD STROKE The following table indicates the appropriations that need to be made to the appropriate unit of the Public Health Service to initiate this program for a five- year period: Y~r 1 2 3 4 I 5 Biomedical Research Institutes: Number of new Institutes ........... 5 S 5 5 Funds required* .................. 7.5 15.0 22.5 I 30.0 37.5 ~Fl~t~z iq millionl at dallsrl The Commission recognizes the importance and promise at nnn-eategofieal biomedical research. Indeed, such research is essential In basic under, landing of beart disease, cancer and stroke. Clues of great significance, coming from ~h endeavors, e~n be used e~feetively by research gr~upe i~vestisati~g ~peei~e dlsease problems. For example, through such research, we can hope to attain /be more detailed understanding of /he living cell which may reveal the nature of the delicate change in the balance of eel[olaf activities which manifests itself as cancer. Hope- fully, also, there may be an unraveling of the next layer of understandlng--the manner in which highly specialized cells such as those of the brain, kidney, or heart portorm the specific tanctions wbieb, unlqudy, they contribute to the total living organism. In parallel we can hope to witness revelation of the manner whereby Iha nervous and endocrine systems coordinate and integrale the entire organism. And with such information in hand, incisive understanding of disease, i.e., dis- turbances of this orderly tunctioning, may be expected. Such comprehensive biological understanding will, of course, greatly advance our hope for control of the wide variety of diseases to which man is heir, including cancer and cardiovascular disease~ which combine to account for about 70 percent of adult American mortality. Thus, the devdop~ellt ~f a number c,~ unlver~ity-he, sed hlor~edle~l ~ese, ttreh institutes, at qualified instltulions throughout the eounlry~ would strengthen the national biomedical research effort and add substantially to progress in the fields of heart disease, cancer and stloke. Specialized Research Centers Recommendation 14. The Commission recommends the establishment of Specialized Research Centers /or intensive study o~ specific aspects oJ heart disease, cancer and stroke to supplement th# research and training e~orts o/the regional centers previously described. Specifically, at least 10 Jueh Centers in heart disease, 10 in cancer, and III let ttrobe ~bould be e~tabli~hed i~ vaviou~ health ~tld mcdicd reseaeeb faeiUti~ throughout the country over a 5-year period. ,K

In addition, it is recommended that three Bioengineering Centers and three Rehabilitation Biomedical Engineering Research Centers be established over a 5-year period in order to take advantage of the potential ofEered b~" bioengineer. thg 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, h is recommended that serious eonsideratlon 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 program of Specialized Research Centers, nonmateh- ing funds should be appropriated for construction and/or renovation and for the provision of the necessary equipment and staff. The Advisory Committee on Centers referred to in connection with Recommendation ] would organize, develop, and review plans and projects of these Specialized Research Centers and transmit their recommendations to the appropriate National Ad¢isory Council. The following table indicates the appropriations necessary for the appropriate units in the Public Health Service to initiate this program of Specialized Research Centers for s 5.year period in the various areas: Type of Center Heart Disease. Number of new o~n~¢rs .... Funds required* ........... Year 1 2 2 2 21 2 0.6 1.2 1.8 2.4 I 3.0 Cancer., ..... Stroke ....... Number of new centers ..... Funds required* ........... 2 0.6 21 2 2I 2 1,2 [ 1.8 2.413,0 21 2 2 2 1.2 I 1,8 2.4 3.0 2 0.6 Bioengineer- Number of new centers ..... 1 1 I 1 ...... lag ......... Fund, requlred*. .......... 1.25 1.612.0 115 1.5 Rehabilitation 2. 0 Biomedical • . Number of new centers ..... l 1 1 . . . 5 Engineering. Funds required* ........... 1,0 1,5 i?i 1." *F~,u ~ in m[Uio~ of dullarl. 49 HEART DISEASE, CANCER AND STROKE

The centers proposed here would bring together the combined talents of a multldis¢ip|inary staff fo~" study of special problems related to heart disease, cancer and atroke. For example, in the field d heart disease, centers designed for in-depth reeear~h sud ~alt~g t~ght he esttthl~sl~ed in epldemlology~ genetles, thrombos~s a~l fibrlnolysle, pharmaeoIogy (especially for natural products), etc. fn eaucer, specialized centers of this type might be established in epideraiology~ virology, carcinogenesis, animal cancer, cytopathology, radiobioiogy, clinical pharmacology, immunolng~ enzymolog~ r edlation therapy, nuclear medicine, etc. Examples in the stroke field might hie epldemiology, instrumentation for cerebral blood ~ow and diagnostic tests, experimental eerebrovascular surgery tespechlly in primates known to develop cerebral atheroselerosis), ere. Specialized research and training in bioengineering in the three categorical areas and in rehabilitation offer great potential. Research Project Grants Reeommetulatlon 15, The Commlsdon endorses the existing ~ysteta el review o/re~earch project grants by study sections and advisor7 councils a~ tlze National Inaitule~ o/Health and recornrnend~ intensified ¢~ expanded support o/research in heart diuase, cancer and stroke. Specifically it recommends: A. That a total of $40 million be appropriated to the National Heart Institute, $40 million to the National Cancer Institute, $15 million to the National Imti. tuVz of General Medical Sciences, and 010 million to the National Institute of Neurological Disease* and Blindness in a 3-year paged over and above current appropriations In these Institutes for research pro] act grants. B. That NIH be allowed to use a mechanism whereby tunds approprhted tor spatial-purpose programs would not lapse if unspent at tile end nt the fiscal year. C. That several important areas of research be given special emphasis because of the valuable contribution in the past and their high potential tor the future. For exat~ple, epidemidogi~a~ studies provide eddet~ee .~bieh rosy le~d to tl~e iden fihieation of factors causing a specific disease or condition. Of vital importance is the strong support of broad clinical field trials of drugs and other methods of treatment. As we have emphasized a number of times, there is a eritie¢l lag between the research discovery of a new medication and the rapid evaluation of its effectiveness against a particular form of disease. We must wait too long while individual in~,ostlgators report their limited findings in technical publications which print articles 12 to 18 months after their submission. The broad field trials of the eflloaoy of the Salk vaccine serve as a model of the quick application of an important research finding to the immediate prevention of crippling disabillty and death, We must mount similar clinical trials ot promifing Iheraples in the hidds of heart disease, cancer ~nd stroke. Clinical trials of this nature are expensive and require the collaboration d many institu- tions, but there is no more e;hetive way of getting to all d our penph the lifo- g[gg~' gl$[$~|[~, gAgCgl~ gl~D STR0g[ sa*~ing and llfe-enhancing bounty of medical research.

3~40~ILS gNY ~I3ONVO'3$V3$1O LHV|H L!

52 HEART DISRASE, CANgER AND STROKE effective support of such endeavors, Th0 Commlssionh regommendatlons would greatly enhance the use of this meohtmism and thereby accelerate vitally fmpottan! resear~|L General Svpport ]or Research Recommendation 17. The Commission recommends that the existing Gen. eral Research Support Grants Program o[ the National Institutes o] Health be expanded a~ rapidly as possible to a level o] 15 percent o[ the total NII] re, search and training budoet and that the program be ~ltered to itlerease its e/leotiveness. Specifically, the Commission r~ommends: A. That graduate schools engaged in b~omedieal research, supported by grants from NIH~ should be permitted to receive grants under the general re- search support program ; and B. That general research support grants should be awarded in two categories: (1) Unrestricted funds to be devoted to research, as at present, and awarded on a Iormnla basis; and (2l negotiated awards, based on documented applica- tions, to defray the direct and indirect costs of the suplwrting organization and tervlets provided by e~eh instilutlon to facilitate the conduct of research and which are not ord inertly chargeable ts indirect costs. The l'~ational Institutes of Health have carried out a program of grants to certain institutions for the general support of research for several years. The program is designed to assist institutions in achieving balanced research and teaching programs and in m~etln8 rising costs assoeiated with large-scale re- search programs based on project granls to individual faculty members. It is also intended to help institutions in expanding their physictl resoureea for resear©h and initiating pilot resear0h in new areas--two undertakings which are extremely dif~cult to finance out of general operetta8 funds. The program has beell highly successful in its initial phase. The Commission feels that its continualion~ expanslou and extension are important to the national research effort against heart disease, cancer and slroke. Recoramendatlon 18 The Commission recommends that the Federal Government develop a standard Gavernment.wide pellet ]or payment el the lull eo*ts attrihut~ba to research grant awards. The Commission is convinced from i~s stndtas that the falfu~e to pay the full costs of research through grant award~ is a real deterrent to Ibe farther development of research potential. Because of the great amount el material in Congressional and administrative reports on this subject, it is nol necessary to repeat the basic information in this report, One ot the major policies recommended by the Commission is that Ihe Federal Government has the responsibility for continuing and broadening its support of research which will generate new knowledge essential to Ihe control of heart dleease, cancer and stroke. Therelore, it is strongly urged that a poli0y be adopted for the payment of the full eostt attributable to a research grant under tt standard Government-wid$ approach,

PART If Chapter Six TOWARD THE CONQUEST OF HEART DISEASE, CANCER AND STROKE EOUCATION AND TRAINING OF HEALTH MANPOWER Man)' 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 cemponenh and other social forces are creating demands for medical care far heyond the present capacity of practicing heahh protesslon- ah. The swift growth oi biomedlcal science creates parallel demands for inereas" ing numbers of highly trained acgentists. Moreover, developments in both re- search and the practice of medicine have led to the creation of new technical and supportive diseiplines-~ssential to high-quallty work--whlch are in very short tupply, The education o/a physician or a research scientist requires many years. This long lead time precludes overnight attainment of manpower gosh. But action now is essential if we are not to drop still farther behind, Faced with over- whelming needs and inadequate resources, the Commission recommends pro- grams of intensive effort for manpower development. These involve Federal partleipation--tn 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.professlonal; (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 ahsnlutdy essential dement 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 outllned here simply cannot be realized without increased numbers of physicians, dentists and medical scientists. Therefore, the Commission recommends a program oi forthright support of medical education. The specific reconamendations which fellow and thnse deal- ing with medical school support in Chapter Three are component paris of this fundam©ntal declaration oi policy. Expansion o/Resources/or Preparation o/Health Manpower Recommendation 19. The Commission recommends that legislation be sought to permit forthright support o/medical education, this program to in. elude [ormula grants to the health pro[essions schools, Immediately, there should be full utilization o/the Health Prolessions Educational Assistance Act oJl963andtheNurseTrainingdcto/lP6d. TheCommisslonjurtherrecom. mends substantially greater and more diversified Federal support o{ programs 53 HEART DISEASE. CANCEH AND STROKE

designed to increas~ the supply o/physicians, dentists, and medical scientists. Specifically, the Commission recommends: A. That tile esiliog on appeopriJttlons in the Health Pretensions Eduet~lfunal At~sistttnoe Act be eliminated and that a |everal.fold irJerease in appropriations be provided so that adequate facilities will be available to all seheol~ capable of expanding their output of phy~laions and to offer further stimulus to the development of new schools~ /~. The! active consideration be given to a program of Federal ~upport ~or the e~eatton of 2-year medlca| schDols ~n exlstlng eo~lage~, to aeb~ the most ~'apicl increase fu the number of physicians in training who could then be placed vcltltQut s~bstontid dffheulty for the d~ieat portio~ of their t~nfu$ in ¢xlstin~ medietd schools or community hospitals with adequtlte teaehlng staffs. it is reliably estimated that as many as 2,090 additional spaces could be made availablB in existing raedieal schools if funds were sv~ilable under the Health Profussions Educational Asslstanee Act to facilitate their expansion. Schools have expressed their intent to request grants totalfag more than on,.half bflllon dollars as compared with an appropriation ceiling of $35 mill|on. Most of these expressions of I~tent rater to expai~sion of existing £ac~lit]es rather lh~n construction of new schools. There are comparable demande for expansion of dental a~d public heaith schools. In the Contmisston~ ~iew it ~ ~hedsit~hted arm tragic in the extreme to irustr~te th~ basic intent of the tlea[th Professions Edttentlonal Assistance Act by an arbitrary limitation of funds which, in effect, makes it impossib/e to utilize to the fullest extent the nallon's ¢ap~elty for medleal ~nd dental education. In additlon, it has been estimated that |~om 2,000 to 3,000 vaeaneles exlst in mediea! schools for thlrd-year students. The creation of two-year medical sehool~ it! exlsti~l~ ~oll~ges, ~he~efu ~tude~t~ w~uld ~ei~e ~ b~si~ ~t~nee portion of their training at minimal eddJtlonal expense, would make il pot~ibla to fill these existing spaces in the ~bertest posslble tlme and thereby make the q,.liekest impact on the shortage rd playslclans. Rteru~ment Jar the ltta~h Pro[essions Recommendation 20. The Commission recommends programs designed to attract young people into the health proJessfuns and related disc~lines. Specifically, the Coramlssion recommends: A. That a program of project grant support for health careers edueatlon and r~crultment aedvltles be e~tabllsbed, whereby fends would be made Bwileb~e on a matching basis to community agen¢les or medical institutions, with prefe~nce belr~g i~erx to eex~dlnated com~unlty effo~'t~ to r~nt ~'aeh p~ograr~ ~t~ strengthened hea~th edueatlon programs in grade sebeof~ and junior high ~ehoole, |o communicate health fu fo~nt st|on and interest ~hi~dren in health careers ~ health sol,nee fairs in which leading medical i~si~tutlons would ~pon~or Bad aasist high school students in developing health interest; community speakers' bureaul and SOlIrC~ Of reeruitmetll litei'ttlure on health eagerlY; t~lartamer emp]oylltent oppo~- tunltle~ for young people in labor~tosies, hospitals, health agencies, eta. flee- I~tA~ DISEASE, ¢~R A//D $~ll01<t ommended appropriations to the Publle llealth Sersiee fur thls p~rpoee would be

$1 million Ihe first year, with inoremental stops to a level of $10.6 million in the fifth year of the program. B. That central sources he established for information, production of eduea. tionsl materials and audiovisuals, to sllmu]ate and implement this national program of recruitment for the health sciences, both wlthin the Public Health Service and in the heaclquartere of national professlonal ancl voluntary organlza. tlons. C. That the Heahh Pro~essinns Educatlonal Asslstaneo Act he amended to 9rovlde for a program of Federal scholarships ior lalented medical and dental students in need of financial assislance to complete their pro/essional etlucBtion, with a matchlnp ¢ost.of.educstlon grant to the orofesslonal school accompanying each scholarship. During recent years, the number of college gr~dt~ates has been inereasing~ hut the proportion of college graduates epplylng for medinal school has de- clined, Among the reasons why medlalne as a career has declined in popu- larity are the high cost of medioal Iralning; competition from many other stim- ulating careers, esloocialiy in sclenee; and the comparatlvaly small number o[ scholarship end tr~ining grnnts avellable for medical studente. A considerable number of tellowBhips ere available for graduate work in the sciences through the Natlonal Selectee Foundation, National h~stltutes of Health, the Deportment of Defense, other Government agencles, and private it~dustry, Fellowships are available in other fields under the provisions oi the National Defense Educatlon Act. Yet very few iel]owshlps or scholarships have been made available lot medical students, except ~or those halng Iralned spe~ifically for re~ear¢h work. There are a number of constructive measures which can he taken to overcome these obstacles, There ~hould he an expansion of schelarehlp$ from Federal, Stale, Bnd private agencies ~or students in medlcal schools, e~eeially for those from lower inoome families "~ho cannel afford the high cost, The program of Federal scholarships oripinally proposed for the Health Pro~sslons Ellueatlonal Assistance Act for talemed medical snd dental ~tudents in need of financial es~isteno~ would greatly enhance both the quality a~d quan- tity oi epplleants for medical education by broadening the base of reeruitraent to inalud~ students coming from familie.~ with low or moderato incomes. The matching cost-of.edue~tlon grants of $1,000 for each scholarship would also he of assist snce in meeting the oper atinp defialts of the medical ~nd dental schools. Undergraduate T~diding in Medical ~nd Dental School~ Reco~amendutlon 21. The Comtais~inn recommends the ¢on~inuct~ion and expan~inn oI e~/st/ng gran~ prograra~ to support ltndergrodilctte trdi~ing in medical schools in heart d~ea~e; undergraduate lr~ining in taedi£al and dental schools in can~'er ; onel medlcal ~ndergradual~ training in reh~bilitatinn. In ~dd#ion it recommends the development o] ttn undergraduate ~rdinlng support program in ~troke, ¢~dtaini$~ered b~" the National Institute o] Nev.~ologl. ¢di Db~ea~e~ end Blindue~. 55 HEART DrSEASE, CAHCER AND STROKE

~6 HEART DISEASE, CANO£# AND STROKE Specifically: A. The curx~ra undvrgratlnate training grant appropriations to the Natlon~ Heart Institute should be continued ancI increased by about $1.55 million annaally to permit eligible schools to receive grants of $40,000 per }'ear. B. The undergredute training program in cancer administered by the ~tional Cancer Institute shouM be broadvned to include the d~vclopment o1 demonstration programs in the detection of cancer and care of the cancer patient and expanded so that it is pes$ible to incorporat~ ¢ancer training in training programs for interns and reaidents, C. In view 0f ~¢ t~d for undergr~duo~ t~aittlng in stroke, ~ ie recommended that $2 million be appropriated annually to the National Institute o1 Neurological Diseases and Blindness for th~ development of an undergraduate training program in stroke. D. Additional funds should be made available to the Vocational Rehabilitation Administration to expand its present progrmn for medical ttndergradtmte tra~ing in rshabilltation. It is recommended that $9.5 million be appropriated over a five.year period startinll with $1 million the first year to the l~'ational CBncer ]nstitui~ to provide grants to those medical schools which develop specific educational programB ia these tmpect s o~ cancer control. The following is a ~ttmmary table of recommended appropriafion~: Year AREA 1 2 3 4 5 11eart Disease* ................ Cancer * ........ 1. II 1.5 2. 0 2. 5 ~, 5 Stroke* .............. 2.0 2.0 2.0 ll, ll 2.0 Rehabilitation* 2. ll I 2.0 ] 2.0 2.0 2, 0 Dental school grants* ............... I). 5 0. 5 II. 5 0. 5 0. 5 'Figtu~ ia railli0at of doltt r*. r~d

E. In view o| the important role played by the dentist in the early detect fen of oral cancer and the need for the education of dental students with r~ard to cancer control, the Commission recommends an increase of $10,000 in the annual under. graduate trai~ing granl presently awarded to dental schools by the National Cancer Institute. This will require an additional annual appropriation of S500,O00 to the National Cancer Institute. F. In tha light of the importanee of preventive activities assneiated with control of heart disease~ cancer and stroke greater emphasis should be glvan to preven- tive mediclna in medical school eurrlcula, wlth spevial aitentlon to the chronic disease field. Trataing /or Research Recommendalinn 22, The Commission recommends that the natiottai pro. gram el reseorc~ training grants be enlarged and expanded 04 a rate commensu. rate with the training capacity el or ganiza~inn# so engaged and the national pool el young investigators desirmts el such training. Specifically, the Commission recommends : A. That the existing programs of research training grants and fellowships in heart disease, cancer, and the general medical sciences be expanded ; The following table summarizes the reeormnended appropriations over and above current NIH appropriations to expand the research training programs in heart disease, cancer and stroke: AREA ,115 3 4!s Nlll--Training grants and fellowships* 4, 3 5, 2 6. 3 7.5 I 8- 75 NCI Training granta and fellowships* 4, g 5. 2 6. 3 7. 5 8. 75 NINDB Training grants end fellow- s i~* ............ 1.0 1.0 1,0 1.0 1.0 18. 5 NIGMS--Training grants and fellow- i ships* ......................... 6.0 9.25 ] 15.5 15.5 Training in animal care* ............. 1.2 'Fimarel i~ mlllhml of doLrarl. 0,5 0.75 ].0 I 1.5 17 HEART DISEASE, CAN(:Rg AND STROKE

B. That the National |~s~itute af Ne~rologie~ Diseases a~d P,|~ness t]touid deveIop a research training grants program in the field of stroke, and in addition, that funds should be made available to the Vocatlonal Rehabilitation Administra- tion for t~aining g~e~t~ i~ rchahi~itatlet~; C. That the Division af Research Facilities and Resource~ of NIH be given the authority and funds to support training programs for epeeialisls in aninut] care and medicine. Research is conducted by the minds of trained scientists. It is in the national interest, therefore, to insure a continuing and expanding supply of biomedical scientists adequately trained to guarantee the quality of health research tomorrow. The funding instrument most suitable to the task of alsisting the university, or other researeh-edt:eationa[ organization, in providing such advanced training is the "training grant." This instrument permltt local id~ntifieatlon of young men and women with research potential, provide6 them with appropriate etlpe~lds and, equaily important, by diverse vaeans assists the institution to improve the quality of research training while enlarging its capacity for so doing. This program has resulted in a pronouncet~ upgraging of research treinlng during tile last 5 yeats. Ira eontinustion and growth is vital to the entire ]~eahh research enterprise. Indeed, failure at this time to expand suoh treinlng sup- pc, rt m~t~t, a~tt~m~tlcaUy, limit the ~a~it'.~e ~f th~ e~,ti~e ~atlona[ h~a~tl~ re~ search program in subseqtlgnl yearn. Universitle~ have developed a variety of mechanisms for enriching the experi- ence of potential pbysician-lnvestigator~. The most formal of these lead to the simultaneous award o[ the M.D. and Ph.D. degrees. In any ease, the studenl so engaged must devote several additional years to this experience, as '~'eIl as satisfy the ,'equlremex~ts for the *nedieal degree, under- The following appropriations ate recommended to mount a program in ellnical trainlng in heart disease, stroke and rehabilitation. Year Heart Disease*, ....... , ....... . .... ,t Stroke ............................ AIIEA l 2 J 3 g, 0 7.0 9.0 1,0 1.0 1.0 1,0 1.0 1.0 Rehabilitation* .................... 58 ItEtgT DISEASE, C,~NCER AND STROKE *figure* in t~ih~* .rdoll~r, 4 g 12.5 lg. LO 1, 1.0 L

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 finandal resources ot his family. Without addi- tional support, dearly/he pool ot dinted investigators becomes limited to those whose families posse~ the financial resources to underwrite this lengthy and expensive program. The Commission therefore urges that consideration be given to a new national program providing full financial support in 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. Supporl o/Clinical Training Recommendation 23. The Commission recommends the establishment o] clinical/~llowskips and/ug.tbee clinical investlgatorsfiips in heart disease and stroke, the expansion o/elinleal training programs in cancer, and the establish- ment oI clinical ldlowsgips 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'Diseases and Blindness can only support training that is research orienled. Greater emphasis must be placed on Ihe training of superior clinical physicians. There is a great need for a larger corps of ciinicians wbo are capable of precise diagnosis and providing Ihe best of treatment--clinidans with minds capable of recognizing and applying new discoveries aud clinical observations. To mcct Ibis need, authority should be gray,ted and.the funds appropriated to the Public Health Service Ior the establishment of clinical fellowships and full-time clinical investlgatorships in the ca rdlovaseular field, B. To recruit medical graduates into cancer specialties in which there is a marked shortage nf personnel, the Commission recommends that $500,000 per year be appropriated to the Cancer Control Program in support of residency training in a limited number of speeiahies essential for progre~ in cancer con- trol and 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 relatad to cancer and the details of his training program should he specified at the tbne grant raqu~sts are made. In addition, the existing program of Senior Clinical Traineeships administered by the Cancer Control Program should receive appsopriations of $3.5 million to increase the present number of traineeships to the level of 300. It is further recommended that prlotlty should be given to those speciahi~ necessary in can. car control which have the greatest personnd shortage--for example, radiology, radiotherapy, physical medicine and rehabililation, preventive medicine, pathol- ogy, anesthesiology, and epidemiology. C. A program of clinical fellowships in rehabilitation will substantially in- crease the number of physicians capable of rendering the best in rehabilitative 59 HEART DISEASE, gANgER AND STROKg

60 HE,LqT U~SEAgEI~ANGER AHD STROKE fare. To this end, the Co~mlsslon recommends that [unde be made aval~ch]e to the Vocational Fichchillt~tion Adminittratthn to iniliete such a program, i ~abd~ation o] ~cademic Pos~ions Recommendatio~ 24, The Commlssio~ recommends Ihe establisltraent oJ full- free career awards in uni~rslties a~d o her ~ti~u ions, no o~y lot re. smrc/~ personne~ b~t a~o lor cl~ical investig~ors and clinical p~o/essors, Th~ research career awards grogrant of the National Inetitute~ of Health ha~ made a vi~al contribution by establishing stch]e po~itio~s for career fnvestlgator~~ ~ universifiet, Through thie program lea~ing sclen~i~ have been ~e t~ ~tmI and pursue Jifetim~ research ~reers without dcpondlog upon year-by-year The CommisSion regrets ti~e fact that ~ mor~torlum ha~ been dealared on new appointment~ t~ thi~ program and urg~ thai support I~e iDcrea~] sa that the program may be exp~nded. There is, in addilion, a pre~slng need for the development of stable acatdemio ~iitons to encourage the lifetime port,it of teaching careers in medicine. FCh' ]owthips and career award~ parallel to thoee awarded for retearch are neeeuary to tupport laculty toember~ in cllnlca] investi/fa~tion an~ practice. Such faculty members could vitalize al~d broaden the program of every chnical dep~u:c~ ~d m~ effectively cl~e ~e I~ hetw~ edv*~,.~in~ ~'tentifte • knowledge and application The recommended program weald involve the establichmenl of ~ull.tlme perf. tions in universities end medical schools/or ch'nical investigators or c~ico! pro, jesse,s. In ~ome th~lancee such professorships migi~t be used to recruit some i of our best practitioner~ from a heavy private practice and enable them to con. cenlrate ~n teaching, Reck)remanded approgchttiona to itnp]eme~t thi~ program woal~] 'oe al the level of ~ r~illlo~ and progre~ to $24 :n~llon in 5 yeart~ Tro~i,~ el H~lth Technlcla~ R~otnmendation 25. The Commission recommenda gr~ly incre~e~ e~ort and ~estrnent in ~he recruitme~ and tram~ of he~ technicions and o~het par~edi~ personnel whose thitis ~re ~sse~a[ to the cor~of o~ heart disease, ! cancer a~ stroke. ,~if~ally, the Eommi~on recemme~: A. The establi~hr~ent o~ a coordlnat~ng of/ice within the Department of Health, Ed~on, aEtd Welfare to pr~e itai~on :tmon~ the ag~ncie~ supporting ed uc~. tiontd programs which eoald be of great i~nportanee itl training ancillary health manpower, ~uch as the Manpower DevolopmeDt and Training Act of 1962, the Vocatlonal Educatio~ A~i*tance Act of 1963, and the Economic Opportunity Act : of 1964. B. A program of ~tirnulalion grants admlnlst~r~d by the Po}dlc Health Service, made available to community and junior co][egr s for the deve]opment of teaching ciat~ degree nurse~, lchortttory technJcltm~, and the full range o~" technical per. t~nne] that can s~pport a~td extet~d the work of the frontitne [Ire fesslona/~; apgro.

prlations recommended for this program would begin at the level of $0.4 million and progress to $2 milllon ia the fihh year. C. Increased support of the program for training medical technicians, inelud. ing technologists and other specialists essential to the detection and treatment of cancer, now existing in the CBneer Control Program, ~rom its present level of $1.5 ndIlion per )'oar to $2.5 million in the first year with annual increments thereafter d $1 million. The supply o| health manpower to support a fulbscale attack on heart disease, cancer and stroke can be recruited and developed only if full use is made of exist. ing programs and authorities, ~pedaily 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 thai the health dlsciplln~s suffer [rom chronic shortage at a time when the nation as a whole is experiencing serious problems of manpower surplus. Trainprg el Specialists in Health Communications Recommendation 26. The Commission recommends that the O95ee el In. ]urination and Publications in the O~ee o/the Surgeon General be allocated a specific annual sum o/$1 million solely/or training specialists in health com. munieo~ions. Specifically, the Commission recommends: A, A grant program to educational institutions for the development of pilot training programs ia the field of medical communications. Such grants should support the development of a core curriculum, the payment ot faculty, aml pro- vidon of stiFcndo for traine~s. A univerdty which has hath a medical center and a tchool of journalism would 6erve ~s an excellent setting for these pilot training progtaras in communications, B. Provision of fellowships for the on-the.job training of a variety of per- sonnel in the gathering and writing of sdenco inforn~atlon 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 comers and 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 dearly on health subjects. Cuntlnuoas dssessment el Health Manpower Needs Recommendation 27. The Commicsion recommends the establishment in the ffttreatt el State Services (Community Health) o~ the Public Health Service o/a heald~ manpower unit, comparable to the research manpower unit el the National Institutes o] Health, responsible /or continuou~ assessment o~ national manpower requirements ]or health services. $1 HEART DISEASE, OkNGER AND STROKE

......... T~ Such a unh would have the fo]~owing responsibililies: (1) To develop basvllne information on mecllcal manpower and ahalyze its meaning; (2) to develop t~atio~a[ goal~ tel~tlng to medical m~t~power ~ r~ources; (3~ ~ ~lu~ a~i suppor~ gtudies and demonstralions related to delermlnlng manpower need~ defining specific problems, and recommending improved tralnlng and reorult- meat programs to overcome thes~ manpower problems; and (4) to di~seminal~ information on all aspecl, o~ health manpower. Appruprlations of ~.S milllon for thc first year, increasing to 81 ml]lion by the fihh year, are recommended. It has been estimated that by 1975 there will }Je a need for l'/~,000 addillon~l technlcia~s were added, the requirement becomes stnggerlng. H~,wcver, no ~ood estimates o~ nee*] ar~ available, Studies h~ve b~ niade in re~nt yearB of tho needs ~or physlcian~, dentist~, a~d nurs~, but the heahh techni¢ia~ ~eld ha~ beon largely i~nored. Therefore, the Commlssion ~urthvr suggests that th~ Surgeon C.en~ra] appoln~ a group ¢o study the problem of health technicJa~ personnel an~] develop recom- mendat[on~ [or it~ ~o]utio~. 62 HEART DI$~$E, CAWCEIt AND STROKE

PART IfOhapterSeven TOWARD THE CONQUEST OF HEART DISEASE, CANCER AND STROKE ADDITIONAL FACILITIES AND RESOURCES Many additional facilities and resources are required tu mount the fun-scale attack on heart disease, cancer and stroke envisioned by the Commission. The two parallel thrusts of the campaign--the application of existing knowl- edge through patient ears and the development of new knowledge through re- search--both defend upon supportthg services which, like tile basic manpower and facil~tlea already diseussed~ are in short supply. E:cpanding Patient Care Facilities Recommendation 28. The Commission wheleheartedly endorses the 1964 Jmendments In the llospltul and Medial Faeillti~s Conslruetion (Hill.Burton) det and urges thelr /ull implementatiun. It ie Jurther r~eommended that more lands be made available Jot the expansion o/long-term ~are Jaefflties affiliated ~oilk hospitals. The Hill.Burton program for the construction of hospital and medical facilities, administered hy the Public Health Service, has been one of the most remark- able aehievements in the history of hringing better health Io 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 HilI.Burton Act, in addition to extending the llfe of the program, contain important new provisions whleh will enable the program Io meet there changing chagengea more effectively. It provides for-- l, A new grant program for modernization or replacement of puhBe and non- profit hospitals, and other health facilities, giving special consideration to those located in the more densely populated areas where the greatest noad exists. 2. A program of project grants qo help develop comprehensive regional~ metro- politan area, or other local area plane for health and rdated facilities. 3. A single category of long-term r~re facilities, which combines the pre- viously separate grants programs for chronic disease hospitals and nursing homes, and lifts the an nusl ceiling from $4~ million to S7O million, 4. The u~e by States of 2 fereent of their allotments (up to $50,000 a year) to assist in the efilelent and proper administration of the State plan. The Commission, in endorsing this forward-looking leglslation, considers that the continued strengthening of the nation's patient care faeiliB~ is an indisFen. 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. eases and requiring such care. HEART DISEASE, CANCER AND ETROKE

HEART DrsEASE, OANCER AND STROKE Streng:henlng the Federal Hospital Program Recommend~ion 29, The Commission r¢com~ner~ ~ha~ exis~ F~erol Aospit~d Jy~tem~ ~mlni~:ercd by zbe Fetera~ Admini~tra:ion ~ the Publlc Hea~ Service be glven au~l~rity and J~nds ~ will enaSle them w ~men~ their eor~ribution to research, |r~inlng ~ patlen~ care in hear~ di~ee~e, ~m- cer ~ 8tr~e, Speciiically, the Commission ~coramend~ : A. That th~ Veteran~ Administtatlon ~e ~iven increased ~ppropri~tlon0 to c.rry out research in a~ng and chronic diseaee, including hc~vt discard, cancer and ~trolce; th~ sp¢oi~c authority and funds to m~ko t~areh proj~t ~ant~ to ~liated medical schools ~o~ coll~borati~ re.arch projeet~ in the*e £eld~; ~md the in,teemed appropriation n¢ce~ry ~o fu~her develop its existing pros.ram of ~ientif~¢ manpower training. B, The Division of H~p~tal~ of th~ publi~ H~th $~rvie~ b~ appropriat~ funds n¢ce~ar y [or r~nov.llon and th~ d~velopment of ro~eareh ~p~e¢ in exiMi~g facilities, ~nd ~or incr~ase~ research and trninlng ectlvltle~. With its 168 hosplt~l~, 89 a~ili~t~ with medi~ ~hoo]~ and 91 out.atilt clinic~ and re~ioual o~c¢~ the V~e/ans AdminiBtration hu ~e largest systom of health ¢a~ |~cihti~ in the world. ]. the pasl year 610,000 pa~ient~ were adm|U~ to VA hosplta]~; 3,693,000 wer~ followed as outp~lient~. Of the p~tient~ ad- mitted, 107,000 had cardiova~ul~r disease and 40,000 had cancer, newly di~. .o~d in about ~0,O00. A professional ~taff of more th~n 9,000 phy~i~ianB, p~y~h~]ogi~, socill workcr~, and Ph, Dt scientist* provJd~ ~ high level of ¢~e as well e~ partlcip~te extensively in research, eduction, and traini.g activities. The YA i~ carrying on a vi~oro.~ pro~am of fundaraent~l and clinical research. Its ~taff p~rticipated in 6,500 research projects in Fiscal Year 1964, with 2,000 o[ them related to heart di~e~s¢, cancer, ~nd neurological dls~. Much of this re.arch effort is conducted in a~soeiation wlth 78 VA-a~liatcd medlca] ~hools. In th~ ~r~a of education end training, nearly 18~00~ undersTadu~e and gt~d. 1late ~tudent~ in medicine or allied £eld~ received some part of their training in ¥A ~a~ilitl¢~ in 1~. Among th~ were 10 percent of the nation's mc~Jca] rc~idenl~. The Commi~iot~ commend~ I}~is mejor ~ontr~butlon Io t~ natlon'~ rc~e.~reh and training el~ort .nd urges that th~ V~t~ran~' Administration b~ ~upported in f.rther d~wloping thee vitally important pr~rams. It urge8 al~o that the ~mallet but Btill signi6cant Public Health Service hosptt~d system, which has t~kcn promising ~tep~ tc*~,ard ~n increased rce~a rch and train. ing ~rogrem in rcc~t year~, be suppor rod in the development of its ~ul[ pot~ti~d ~or re~arch and training as well as patient care, Medi~ Libr~rie~ Recommendation 30. T~e Commi~aion recommend~ ~ha~ the Notional Library oJ Medicine be ~thorized and ~deq~ely ~uppor~ed ~o ~erce ~s lc~i~ aa~ ~ce~ry Ju.ctlon ~ zl~e prirr~r~ ~ource jot ~rreng~enin~; ~1~ n~io~*~ medlcal library ~y~tem.

Specifically, the Commission recommands: A. That $2 million per year for a 5-year period be made available to the National Library of Medicine for intramural re~zearch and developmental activities to explore new technologies for more efficient management and dissemination of the world'B biomedical literature ; B. That not leas than |30 million per year fur 5 years be authorized and apprppalaled to the National Library of Medicine for a program of grants and contracts to support improved msdiDal library services in lh~ United SLates-- including fucilitlas, resources, training of personnel, secondary publicadons~ and library and communications research; C. That broadly conceived legislation be initiated c]earlp authorizing the National Library of Medicine to assist medical libraries in the ways recoramended herein. Communication of information to scientists and practitioners is critically im- portant to progress in research and application of medical knowledge. Medical llbt aales are the primary vehicle for accomplishing this communications process. Yot the nation's medical library system is grossly inadequate for the task, due to a serious inthalanee of extramural support. For example, in 1964 the Public Health Service appropriations totaled over $1 billion. But less than $1 ~niliion accrued directly or indirectly to the extramural support of medlaal 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 HteTmure and through its sponsorship and pp~ration of the MEDLARS system, the largest computer-based information ~torage and retrieval aystem pal to be devised, the NLM hes demonstrated its abilily to improve the methodology and efllelancy of thle rnedlcal library network, It is urgent that further steps be taken to enable NLM to improve the effialency of th~s network. But to exercise its prppcr leadership the NLM requlre~ both broadened legic. laliw antherilies and additional funds for the purposes of ~trenglhenthg and en]argfug its intramural actlvldcs, end fur the purpose of conducting the typu of exlremural suppo ~" program the Commission has in mind. The Commission's recorameedatla~s are directed simultaneously to the etrengtbening of NLM and to the balstering of the other components of th~ nation's medical [thrarp network. Natlanal Medical Audfuvisu~l Ce,zter Recommendation 31. The Commission recommends tltat the Public Health Rerviop Audiovisual Facility be enlarged in scope and strengthened so that may beeotae a Natlottal Medical Audiovisual Cant er. To tbls end we recommend the following specific st~ps: A. The ppprppri~lion of $1.5 million for necessary renovation and expansion of the existing physical plant, B. Appropriation of $1.5 million fur the first year, sealed upward to $~ mil- lion for the filth year~ to develop an intramural program at the Audiovisual Center whleb would include production, experimental use and evaluetfun of HEART OIREgRE, CANCER AND STROKE

16 HEART OISEAS£.CANCER AND STROKE educational materials in such areas as radio, televislon, inotion pictures, pro. grammed instruction, ere.; rv~areh and training programs in audiovlsual tie.Ida; international cxebenge of medioal molion pleturesi and other purposes. C, Authorization of an vxtramural program of granls ~nd fdlow~ipg and appropriations to support such a program heginnlng at the level of $1.5 mllllon would enable the Audiovlsual Cenier to support selectively promising proje~s in audiovisual communications at raadlca] schools, eommnniiy hospltalJ! and other in~itutlons and to assist, ~rough training grants and fellowships, I~a the dev~lopmont of a national cadre of medlcal c¢*mmunleations speeiali~s. In addition to the program outlined above, the National Medical Audiovlsual Cenier Should exert immediate and strong leadership in two communlefftions media of p~rticularly hlgh promise for ¢ontinuiag education of the health These are, first, the field of cio~ed circuit television which is already being used sporadically, to a limited extent, by raedical schools, bospitals and other health agenoies; and second, the use of portable projector* for cartrtdgt./ypo • ~lmB which are especially adaptable to private use fly physicians in their own offices, at tiratm of their own daoosltt~ We therefore recommend that: (a) an appropriation of $2 million per year, initiaIly, be lnade tn the National Medical Audiovisual Center for the }pacific purpose of developing, dissemint~ting and evaluating closed circuit television programs on subjects of vital interest 1o tbe health professions, and (bl an initial appropriation of $1 milliou per year be made to the Nalional Medical Audlovisual Center to produce shorl films for use in cartridgt~.tppe projectors, and to prostate the ~idc~pread u~ ~f this prorai~ing ixet¢ exluc, attc~t,al device by the medical profession. geodetical Progtan~s Recommendation 32. The Commission reconwleads improved systems #or the collection, inlerpretatlon, and dissemination o/ stat~tics essential to the understanding and efflelent control o# heart disease, cancer and stroke. Specifically, the Commission recommends: A, A project grant program to the Statea admlnlstercd by th~ National Center for Health Statistics to finance the salary of competent statisticians and supporting services, designed to improve the qu~llty and !imellness 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 murtallty data, The turn ~f g750,~0 ~beuid be apprczpriat~d t¢ i~iti~tte this pr~gr~nt, intrenched to I~l.g million in the second year and reaching a level of $3.5 million by the fifth year; B, Fu[lsupportoltfiePublicHeahhServleereque~tforfundstosurveyho~pllal dlseimrg~ records on a sampling basis. C, Stimulation by the Public Hetthh Servi~ of studies of medical practice to determlne ~ethod$ of troalment in everyday use.

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. . ...... ] F~¸~ 68 HEART DiSEASE, CANC[R ANO STROKE D. That the DRFR be given the spt~-qfic legislative authority and appropria- tions ne~e~ry to t~uppot't training p,'ol[rHml~ ~[or veterln~Tian~, htlt, bartdryme~l, and other animal disease Sl~cialists. App~l~r~t~on Icve~ ~¢eomme~eEl |oY ~he~e ~et~vi~os ~T¢ $1(~ rnilllem t'oT ~h~ first year increasing to $20 miUion by the fifth year. Many strlkln~ ~dv~n¢~s Ln di~ea~a cont¢ol cou|cl not have been ach~:ve~ withou~ the use of laboratory animals, As ~esear~h vistas widen1 the deiced- once on animal te~t systems becomes greater. The need is t*ot onl~ for iiaer~ased number bu[ also for improved quality~ both in respect to freedom from disease and to ~ps¢ificlty of genetic mt~keup. The sop~alsllcated resettrch o| today, clemands ~ent]tlv¢ instrumenls w~icla ¢~n reprodu¢ib]y record subtle cha~ges. If the research animal, which r~pre~ents ~t~eh ~ ~:nsi~ system, b~ "~i~t~e ~ tl~eas~ r~T "~iab|~ I~ei~ ~rmlti~.~'~i~, res¢l~ inconslantly or nnpredlct ~tbly to experimental situatl~*ns~ t~lne, money1 I~nd the e~:psrlraent a~¢ lost. Such oeoutrenees a~e~ ~tt fact, not un~ommo~ ]nade- q~a~ animal housing faeillt~es, often h~' promoting a high incidence of infeetlon, have ~reque~lt]y accounted for ~uch experimental failures. The Commls~ion~ recommendation~ ttre designed to strengthen our laboratory animal resource in a number of wa:,'s to ~ssur~ that biomedical re~eatch in Ileart dlseaso, cancer and strok~ will not be d~layed or negated by failures in the su~pl~/l nature, and condition of htbo~ator y tlnl~als. Cl~ri~gh~use t~r Drug ln/orra~tion Recommendation 3g, The CommiSsion endorses current proposalt lor the est~bllshment el a National Drug In/ormation Cl~a,ing~ouse, in asso~at~n with the National Library of Med~elne, servin~ and supporting governmental and noug~vernmental d~ug ~n]ormat~on un~s. Th~ prop~ed clearinghouse would includ~ htll ~rdormation on the ehtanleal structttr~ at~ biological properties of all known colnpoun~ts and the d~[iv~t]v~s of such chena~eals, ~ith regard for their cellular, environmental, and ~oeial e~tct~, atures ¢ordDrence proceedlnga~ government reporls, trod other recoed~. Furlher, the clearinghouse would produc~ both for general ~nd sptcifa¢ user~, a~notttted bigriographie~, systemati~ file~ of information on dr~'s in fortes suitable for rep]i~atlon, critical reviews, compilations o~ evaluated data~ j udgm~ntal r~poiate~ to individual inquiries, and oth~r lpproprial¢ informatlon, Improper use of drugs is tod~y an itnporta~t ¢att~ of avoidable dlse~tse. ~he gaps an~ wa~tefal ~lup|ieation a~so¢ilted with ps~n| independent eflorls ~o handle drug information ~re responsible for ranch inaporta~t irdormafion failing the consumption o~ medi~ations and other chemical products, the propoa~d cle~r- ingitouse will serve t~n important Itation~l need. International Resettrch and Training Programs Recem~a¢nd~t~ 35, The ¢oram~io~ ~ndcr~ the p~ir~elp~e ~hat ~t~pport of research ~utsbte the U~ited State~ by comt~etent /~re~gn nationals, collage. ............... ....... nm~]

rative research involving American and jorei#n laboratories, trabllng o] American sci~nlists in joreign laboratories and el/oreign scientists in Ameri. can laboratories ~re in our natlonai interesg ~nd endorses programs designed to achieve such ends. The Commimion suggests the following guidelines: A. Cooparatlve research projects and programs representing joint efforts of American and foreign investigators should be budgeted from funds appropriated In ~tlppor| el domestic rather than international r~sear¢h. B. Health ~arch and t raining in those nations wheralg there are substantial amounts o| Public Law 480 funds should he supported to a maximum extent pus. alble up to th~ limits o~ Ihalr resources of Irained manpower and research facilities. C. Increased opportunities shou]d be made available to foreign graduates to allow them to come to the United S~ates for further training in i~orl~edica] 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 countrles where re- teareh and training activities are good, the following guidelines are recommended : (a) Federal agencies supporting research and research training should con. linue such activities in all nations in which such opportunities exist; (b) Thecriteria for judging applications for ~earefi grants from such coun- tries should be unusually rigorous with respecl to the quality of the project proposed and the competence of ',fie investigator-applicant; (c) The magnitude of our health research support program should rdlect local opportuniti¢~ 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 Attach~ in that nation, iheuld enter into negotiation with appropriate officials of the nation concerned with a view to establishing the terms and limits ot the research support in que~iun. International rt~earch offers unparalleled opportunities |or advancing our knowledge ot heart disease, cancer and sttohe Ior a number of reasons. The United States has by no means a monopoly on ~ientifie excellence in these fields. Moreover. the contrasting patterns of disease in different cultures may offer important clues to their control, stlg further, the interchange of research philosophy and methodology between nations has proved highly produc- tive. The Commission therefore urges that international programs be maintained at levcle consistent with the mutual interests of the nations and scientists inwlved 69 HEART OISEASE, CANCER AND STROKE

PART I/Chaplet Eight 7O H£ART OISEASE.¢ANOER AND STROKE TOWARD THE CONOUEST OF HEABT DISEASE, CANCER ANO STROKE RECOMMENDED CHANGES IN LEGISLATION AND ORGANIZATION Federal action in azty field depends basically upon two factors: legislative authority as expressed in laws pa~ed by the Congress, and funds appropriated by file Congress each )'ear to carry out these authorized activities. A third fac- tor important to the efleedvene~ of Federal programs is the organizaiional ~trueturo of the agencies involved, Many of the l'eeonlmendations of the Commission, as described in the pre- eedgig chapter, can be earried out by the Public Heahh Service or other agell ci~ opelating under their existing authorillee. As has been noted in the ease of each separate reeommezidation, many of tile programs proposed will require ~ddi- tionai appropriafions H the attack against heart disease, cancer and strobe is to be advanced at an accelerated pace. Some of the recommended actions, however, cannot he undertaken without cha~ge~ fn existing legi~lafive amboriig or the e~eatloa ~f ~e.a authority. There- fore, in this Cbepler, rt~oramendafions concerning the most important ]eghla- live needs are iudicated. In addition, it inclode~ a recommendation for reorganization within the Depart. ment of Health. FMucation, end Welfare which would, in the Commission's view, greatly facilitate and strengthen the full.scale campaign against heart dig~ease, cancer and stroke. I. LEGISLATIVE RECOMMENDATIONS The first legislative r~mmend~fion of the Commi~tlon, e~ tat forth below is for a comprehensive amendment and recodiflcation of the Public Heslth ~erv. ice Act. The reasmls underlying thlt reeomnc~ndatlon ~tem from the fact that the presellt Act is seriously obsolete• The type of national attack needed to re- duce the toil from heart disease, cancer and stroke cannot he fully mounted until more effective legislative devicea are made available. However, recognizing the lhne required and the d~tfieu]ty involved in securing the drafting and enactment of a ]efiislative modification of such magnitude, interim legislative proposalt are recommended for those new or changed au, tkorizatlons so important to the ealapaign against hetlrt disease, cancer ~lnd slroke thnt they cannot await the omnibus revision. 1. RevisDn o/the Public Health Service Act The last major overall revision or codification of the Public Health Set,ice Act was done 20 years ago. In the intervening 20 years, however, there have been tremendous change~ in ag areas of the health field. The rapid growth of the biomedical research effort

has produc~l numerous pressing needs for more effective leglslative devices. At the same time the growth in imperlano~ of the chronic dis~us~s has had s great impact on health programs. The recognized need for eomprehenslve com- munity health services demands of the Public Health Service a mission and a program at action that tar exceed the confines of public health agencies in the past. The response to this changing challenge has thus far lahen the form of piece- meal, spasmodic amendments to the basic Act as particular pressuree and needs 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 muet be a thoroughgoing and comprehensive revL$1on and reeodifieation of the Pnhlie Heahh Service Act. The matter should be given intensive study by experts in the field, and a legal instrument suflahle to the health needs of the nation in these times and for the fulure should be developed and enacted. Because ~udies of legislative change tend to be prolonged and ]aborlous, it is important that a deadline he set/or completion of this action. Recommendation h is recommended that the Department oj Heohh, Education, and Wellare establish a task ]orce to develop a comprehensive revision and reendifieatlo~ o] the Public Heohh Service Act b7 Novem her 1,1965. 2. Expansion a[ Resources jar Preparation el Health Manpower The Commission recommends that legislation be sought to permfl ~orth. right support o] medical education, this program to include ]ormula grants to the health pro]essions sedool~. Immediately, there should be [ttfl utilization o] the Heahh Pro[essions Educational Assistance Act el 1963 and the Nurse Tralnlng Act o] 1964. The Commission /urther rec#mmeeds substantially greater and more diversified Federal support o] programs designed to increase the suppl7 o J physicians, dentists, and medical scientists. 3. Constructlon and Operation o] Health Research Facihties The need to expedite a direct and immediate ressareh 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 thee areas. The principal deficiency which greatly hampers the efforts of the National Institute* of Hcahh in the~e 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 ol mental retardation research taeilltlcs. 71 HEART DISEASE, CANCER AND STROKE

72 The present 50 percent ceiling for other then men~l retardation re~oarch fociIities works a most severe hardship on those institutions |~ les6 economically favored parts of the country which cannot compete, in rJli6ing matching monie~, ~zlth th~ hrge, ~st~hl'tshcd re,~earch e~mI~[e~e~, Yet fiteu: ~tler a~l firtatxclally weaker re~rch iostitutlon~ are the very enes wc must strengthen if we are to achieve a truly broad, regional expansion of otzr research effort. There is also a ]ach o1" nonmalchiog authorily for the construction o~ research lecililles that are national or reglonal ia their scope. Therdore, heo~use o[ the urg~lt Jze~d to exprdRe the nationa] research effort on heart dlsease, cancer and stroke, the folIowing rcct~mmcndatinns are raade : Recornrrter~dacfon~ A. There sheufd he an inereale in the ann~al appropriation authorization ~/or Itealt~ re~earc~ /acidity e~nstruction /rom ~he present $S0 million to at le~ ~lSO mil~ion. B. The pprticipraion by ~he Federal Go~ernment ~lwuld be ir~rectsed from 50 to 75 percet~. C. New sub~tan~iue a~thori~y ~hould be given Io construct, on a nortraateh/4lg basis, and Io provide/or th~ operation o/, by cor~a¢~ o~ otherwise, research lac~i~ie~ /or at~tfortal regint~ res~rch ~atr~se~. 4, Cor~lr~ction and Operation o/ Foc~ities /or t~e dpplicalion o/ the Fruits o/ Re~rc~ O~e o~ the maj or recommendations of the Commission i| designed to assure that heart disease, cancer and stroke is accessible in all areas of the nation. The Commission's view Is hesed upon its conviction that the ealue of the national investment in research is wasted unless the fruits of re~eltrch are applied for the benefit o{ eft the people when t~d where the need exists. F~r these parp~se~, a grant prt)gram is proposed for the establishment of di~gnostlc and treatment stations in appropriate academic and community fostRutions. The operational ~up.oort for care in ~uch ~tatlons wou]d~ a~ io a]] such institution~, come ~ronl a variety of sources. This propesa] does not in any way a~ecl the normal methods of peymenl for care, ~uch as direct payment by patlents and thlrd-party payments through private insuranee~ public welfore peymen~s, and other sollrces. The proposed participation is in the ~ature of a stimulation grant to hell) provide tlie nucleus for operations and help assure that the best qua]it y o~ servio~ is available for all of the people. Reeornraetu~atinn New ~b~antine authorily ~Imuld be gfoen /or ialtl¢l eon~trttctlon, reaoua. ~/ort, e~ipmera, ~ac~ ~euelepraer~ o~ ~egfo~effy or/erred ~hgao~tio ~nd ~retn- merit stalfons ~ ~o provide n~ees~ary ir~e~t~ue t~rout;h partial operating gra~ ~uppprt /or ~ nut,us o/ Itigld~- qutdi~ed st~l~ in ~he~e ~ta~iorts. 5. Aut~orizvcio~t /or Necessary Trar~/or o/Program Fututs wither an Ir~titut~, and ~or Limlt~d Tra~er oj Fund~ hetwee~ lnslltute~ J __

A. It is of paramount importance that the Directors of the various Inslitutes, with the approcal of tha Director of the National Inslt .tea of Health and alter fully informing the respective Appropriations Committee~ of the House and Senate of the reasons for such aetinn, he given the authority to transfer funds from one pro- gram to another within tbelr overall annual Institute appropriation. It is impossible for Institute Dirootors, who testlfy before Congr~s in the spring of one heeal 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 alter 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 nninlr criticism be. cause it has returned sizeable amounts ct unspent reserves Io the Treasury. If the Institute Directors had I~exihle authority to reallocate funds ulcer proper con. suitalion, they could redirect funds from programs which cannot be initiated be- cause of lactors beyond their control to programs in'which a sizeable heoklog of scienti~caUy approved applications has built up. B, It is also important that a proviso reinstaling the right of the Director of the National Institutes of HBahh to transfer a limited porlion of one Institute budg- et to another he 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. Reoommendation A. It is recommended tha¢ tim Institute Directors, alter appropriate eon~ulta. tion, be given the authority to traces[or [unds within their overaU anrmd It~ stltute appropsfectlon. B. The previous authority oI the Director o/the National Institutes o[ Health to trans/er limited ]unds ]rom one [gstltute to another should he re. instated. 6. More Effective and Flexible Use o[ Grants and Contracts [or Research and De~elopmem The Commission is convinced that the national eampaign against heart disease, cancer and stroko could be accomplished more effectively and expeditiously if more flexible utilization were possible in the use of contracting authority and if there were continuing avallability of appropriated funds. In regard to contracts, the Public llealth Service currently earsfes out its ar- rangemonts under authority delegated from the General .Services Administration which has restrictive limitations eonoenfing advanced payment, the inclusion of construction costs and muitlp/e.year agreements. 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 mechanism to pro. gram needs in the accomplishment of the research mission. 7S HEART DIS£ASE, CANCER AND STROKR

14 HEART DISEASE, CANCER AND STROKE With regard to the single-year availability of funds, the Commission has noted thai the Public Health Service is the only Federal organization with e major re. soatoh and development program thltt does i~ot have raultiple.year fund avail- ability which permits the ¢ontinuing use of funds for this purpose idler the end of a fiscal year. Far tbe i%regoing reaso]~e, the following recommendations are made: Reeommendetthns A. The Public tteakh Servile should be g/van basil authority in research con. ~r~ols to ~ L Cor~rail su.opor t/or e~te~ed pe~ia~/s ot tin,e, e,g.. ap to 5 ~'ears a~d advan2e pa),tacnts; 2. Provide/or construclinn I~hen such is e~sential to the nc¢ompllehment o/ the contract purposes; 3. CotUraet ~or d~nlo*~ and domiciliary care where necessary to achieve reJearch pttrposes ; 4. Provide /or the design and conduct o/ broad and coraprehensi~e researel~ and developmen~ programs in which the contractor has w/de latin*de/or nclinn in ~cl~ie~ilg a giaetz ob/octile. B. The Public Health Service should be ~iven multiple.year/und availab~ity /or r ~earclt and development acti~illes, 7, pro~oct Grant Authority /or Heart Disease Control, Cancer Control, and Chronic Disease Programs, and/or the l~lianal Center/or Health Statistles The Public Health Service authority Io make project grants in its programs clea~ing ~ith heahh appli0alion activities in eo~m~ni~ies is ineonelstenL "~h~, the Venereal Disease Control and Tuberculosis Control Programs as wail as the Neurology and Sensory D~sease Control Progran~ have project grant authority. In addition, the Community Health Set vloe~ and Facilities Act Program also has a limited type of project grtml authority. The Commission is particularly ooneerned with the lack of such authority in the llearl Disease C~ntrel, Cancer Control, and Chronic Disease program~. Also, the National Center for Health Statistics does not haee such ~uthority de. epile the faet that the improvement of vital and health statistie~ at their eou~e is essential to progress in the~e Health program areas. While the inclusion of a general authority ~or all control programs to ]nake pro~ect grants i~ slrongly reeorar0eaxded ~ t~ eomp~eb.e~xs~ve ~e~t~x ~ the Public Heaith S~viee Ae~, it is believed u~gent that Interim authority fo~ project grants be extended to the grograms mentioned in order that the recommettdatinne of the Presldent'~ C~m- mission on Heart Disease, Cancer and Stroke can be implemented more fulty w~th~ut delay. Recommendation It is reeornmended ~hal the lleart Disease Control, Cancer Control. trod Chronic Disease Program~, and the ?isaianal Ceater [or Heulth Statistics be autherized to make project grants.

H. Authori~otivu ]or a Program /er the Support and Stimulalion o[ e National M~diaal Libraries Network |t is eiaar that a major factor ilththiting the reduction of the b~rden of heart disease, cancer and stroke involves th~ inadequacy of eommunicativns in the field of the medical scienee~. Moreover~ it is clear~ es with the problems of health man. power supply~ that the correct[on and improvement needed can only be achie~,ed by aLtacking the fundamental reasons underlying the de~ci~ncies, One of these fundamental factor~ involve~ Ihe itlaclequaci~s of the ~nedical li- braries throughout the rlationlanother effect o| the ~cienLil~c reva]ution in which the advancement of knowledge has outstripped the abillty Io manage it. Consequently, in order to facilitate scientific comra~nicatio~, substanlias legis- lation is nec~Hary, providing a flcxibia program of plannln~., stimulation ~nd support of an improved National Medical Libraries Network to ~s~ure all areas and all medical schools, ~cialllists, and practitioners of the benefit of effective aeee~s to all medical data and in[ormatien. l~e.comme~da~ivn .4 legi~ltuiae propasal should be developed and enacted provleliog [or the ~upport and *limuiolivn oI a National Medical Lthrarles N*uvork. Par~iaular ~eatian ~hould be given to authori~ativns r¢lo~ing ~o recornmentlt~io~ t,] ~¢ Pre~ident'~ Corami~sion o~ ftear~ Disease, Cancer end Stro~ col~cernthg ~l~e e~tabli~hment oI ~ ne~wor~ o/medical librarle~ thdudlng ~ I~ed number o/ regivnal llbrarias; library" [eall~y con*true~ivn; trainln~ ]or medical librarians; ~nd ~ program o] reaearch designed to improve syslem~ ~d method~ o~ ban. dli~g medio~l I~er ature. 9. ~mbli~hment o[ Revolvivg Fund [or Ihe Natio~a~ Medical A udiovi~ual Center One of the importanl recortlm~ndations af th~ Coalmis~ion calls for the expa~aion of the Public ] le~alth Se~vive Audiovisual Facility at the Communicable Di~ase Center into a Nalional Medical Audiovisual Center. P~rti~ular refer- ence in this ~egard is made to th~ operatiol~al Irial of th~ u~e of a projector for th~ in.ofliae continuing education of p~actlehLg physicians in wMcb the ~udio. visual center wauld be oherged with ~spa~lsthility for the production of a series ed ~lms on heart disease, cancer and stroke subjects. In oeder Io carry trot Bucb a pragram it i~ desirabl~ that the audlovlsue] center have the maximum flexibility to p~rmit iL to ea~ry out ils projects in a most e~eient manner. The eslablisb- ment of a revolvlng fond fiscal arrangement, with the accompanying authority to sell ar rent its productions, would greatly facilitate the ability of the center to Carry out tbe~e pro~r&ma. RecommendaZion I~ is recommended that o~thoriaation ]or t~e e~ta~li~hment o] a revolving Jund w~h ~ny necessary ~uthor~ia~ to permit the ~de or rental o] medical ~udiovi~ual productions a~ appropriate be given to permit the National Medical .4udiovisual Center el the CDC to carry out ~ ~u~ction w~h maxlmura e~civn~y. I0, Comprehensive .4mendment Io the Vocational RehobiIDation Act HEART DISEASE,CANCER RNO STROKE

7G HEART DrSEASE,¢ArtG£1~ AND STaOK£ Much o| what has been sai~ with regard Io t~c ncec] for ~as~c revision o! t'ne Pu[~][¢ Health $c~ioe Act aE~lies to the Vocational Rehsbili~afion A~t. Th0re iB a oonsldera]~]~ degree oX oUsole~ccnce i~ this Icgi~l~tlon, and many of the Stroke oanno~ be implemented wit}~ full efl'eet~vcncss u~ider existlng ~utho~ity. A num~>er of ~o~nmendatlon~ partlcu]arly in the r~anpower and ~ommunice- tion~ ar~as could ~ a~omplishe~ through ~e Comm~mlty Health Services and ~'~c~ti~ ~an~ p~o~m ~ it ~e ~r~ene~ by ~e ~ ~e'~ ~ t~ re. s~rlct[ng p~r~e '~out~ide t~ hospilal particularly for ~h~ chronio~l~y ill or aged J~cr~ons~'+ ~nd if ~t~ appropriations ~Jllng were removc~. The~e reeo~rncnda. expanded program of research and der~onstratlo~ in Cor~nunlty Health Servlces ~or the r~ore e~ecti~e utiiizatlon of he~hh manpower; sLir~ul~tlon ~rants for the development o~ th~ oapac/ly o~ com~unlty c0]]c~es foz tralnin8 middle.level ~ea]th tcchnlclan r~anpcwer~ support an~[ ~tlmu]atlon o~ contlnuetion c~[uca. tion programs; in~ntJ~e gra~ts to stJroulatc ¢oOlmu,lity planning al~ cool'~ina- tion of he~Ith servi~; ~nc] developmental grantB to st~mulalc anc~ ~ist the unl. versify mcdi0a] cedar to extend its resources ~d ¢ompelenoJes to th0 ¢ommu~]tlcs i~l its area, Recom~e~d~on T/z~ ~h~ Comv~un~y ~alth $~r~ a~d F~ics Ac~ b~ ~te~ded ~o ~]im. ~rtic~r[y /or c/zro~ ~ or ~ed p~wo~" ~ ~pe~io~ o/ the ~ro. Act. ~. REORGANIZATIOH ~E¢0~MEN0~ION The ~j~ci~io programs ~c]~d to ¢o~at ]~eart ~sease, c~neer, ~nd ~troke and tho leglsktlon necessary to initlate and oarry out th~ exp~nded natlona] e~ort, as recor~r~en~]~ by ~he Com~flJ~Ion, to]ate prlmari[y to the DeD~r~mcnt of H~]t h~ E~uc~tlon, ~n~ Web,are. T~e Comr~s~on considered whet~er ~e exi~ling a~, mJni~r~t[vc and pcrsoi1~e] resources wi~hln the Dcpartr~ent were ~dequat~ ~or the development o~ t]~o proposed programs, come ai)i~renL to t]~e Comfits/on th~t~ in the health area at ]east, the De,oar truest of Hca]th, F.~ucatlon, and Welfare lacked adequale executive deplh ~nd functional or~anizat ion to ~ro~'ide ~he le~dcrship~ ~upport, ¢oordinatlon~ and review re~[ulred ~y it~ ]~rge and eor~pl~x pro~ram~. Such defioJe~¢ies oould l~e obstacles t o e~c- llv¢ development of the recornmenc[ecI program~ for t]~e control o~ hear~ ~i~se, oanccr and stroke.

Furthermore, it became ap,oarent to us that the Pabli¢ Health Service and l~articulsrly the Natloaal Inaitule~ of Health would he absolutely unable to inltlale the ~weeplag recommendations we endorse in the body of this repotl unless its personnel for~ is increased alJpreeiably, and unless present Federal salary ceilings are ratted signiffeanfly to ffeth retain existing personnel and to atlrae~ new personnel. We are aware o{ the fact that the National Institute~ of Health is *till losing some of its top ~cientisls and ndministretor8 because its salary scales do not compete wlth salary scales for comparable positions in medical sthool~, universities and industry. The ma~or problem ~eems to he an insufficient number o~ high.level policy po~i- tions to provide effac~ivc leaflet thip and cno~dinatlon of the Department's many prngraras wh}ch are hesic to t he inlernal strength o f the nation. The Department has only i~ve such positions: Secretary, Under gecrelary, two A~si~tant Secre- taries, and an ASvisory Special Assistant to the gecretary (Heelth and Medical Affairs}. ]t also ]1as ~ caree~ Administrative Assi~ant Secretary and a General Count. These people are expected In provide effective leadershi]~ of a Depart merit with over 80,000 eraplayees, with ~bout 1~0 programs (over 40 in health), and with annual expendilurea of $5 l~illlon from budget appropriations and about $1g hil. lion from Irust funds. Even from a casual study o{ the situation, and certainly in comparison with other Departments of GovernmenL, it seems ohvlous that strengthening o{ the Department of Heahh, Education, and Welfare at the top is greatly ~eeded. Recomrnet,daitor* The Comrnisslon recommends ehet a reorganization el the Departmen$ o[ Heal~, ~u~#ion, and Wel/are be e#eetnd to provide ~pecifl¢ hlgh-/~v¢/po~@', direction and coordinoZion o] health programs, with adequate ~upporting 17 HEART OI$EASE, CANRER AND STROKE

Sumnlary of Approp~ Rec~11~ Includii~ ]lxe~e for New Proipams and Ilncaeases for Exl~lng Programs and Comparison With Estimales of Cunent Le,eels of $~0pm.t Z NO. Chapter Estimated Current Level of Title Support l '(1965) ' A National Network for Pationt Care, Re- search and Teaching in tleart Disease, Cancer and Stroke .... ± 153- 25 Year 2 3 4 5 3 237.875 364. 475 421.4 453. ,15 4 Application of Medical Knowledge in the 49. 65 45. 15 Community .................. 18. 5 61.65 63. 15 53. 15 5 Development of New Knowledge ........... 152. 8 56. 55 83. 7 107. 9 40. 2 49. 5 6 Education and Training of ]lealth Manpower 37. 7 45.'05 63. 95 78. 15 93. 75 110, 65 7 Additional Facilities & Resources ....... 1 I. 2 52. 25 .~ff~. 00 6 [. O0 66. 00 72.50 TOTAL ......................................... 356. 75 503. 175 674. 675 666. 50 739. 25 ~ I~ ¢ml~ tce~s~A ~or wTdeh ~.~a¢ ~tlcla ~mmHmdati~ aa~ tm~d¢ iD th~ ~ t ~ k ~ d dolg~

Chapter Three: A Nationzl Network for PaUemt Care, Research and Teaching In Heart Disease, C~pcer and Stroke Re¢omnlendation Year No. Title l 2 3 4 0 l RegionaIDisease,CentereCancerfOr IlearZand 126. 5 198. 1 205. 9 ' Stroke ................. ~ z87. 5 Ig30. 7 2 Diagnostic and Treatment 138.25 33.75 Stations ................ 36,75 66.875 106.125 3 4 g Development of Additional Centers of Excellence .... 3. 0 62. 5 37.5 50.0 75.0 6.0 9.0 10.0 12.0 L0 1..25 1.75 2.0 A National Stroke Program Unit ................... 1.0 Subtotal ............... 153.25 ~37,875 136g. 4~5 ,i~h,g :~53.45 LI~Iur~S~ mUl~nz~fd~UItl. 79 HEANT DIEEAE|,CANCER AND STROKE L~~> ._~

8O HEART DISEASE+¢ANOH AKD STROKE Chapter Four: A~lic4ticn Dr Medical Knowicd~ In the Community Recommeridation No, Title - ,,,, 6 Community Planning (;rauts ................. 7 Community llealth Re- search and Dvmonatra- tJon .................... 8 SupportofCommunitypro- grams .................. ,,, ,,., 9 Statewide Programs for tieart Disease Control .... 5.0 18.5 2,5 5.0 10.1 10 National Cervical Cancer Detection Program ....... 11 Continuing Education of Health Professions ....... .,,,, ]2 Public Information oa Hear t Di~ase, Cancer and Stroke .................. , ,..,,, Stlbtotal ................ t i~igxtt~J itt iltultonl el dollarl. Year 1 2 3 11.0 1.0 1.0 6.0 7.0 2~5 18.0 2.5 3.5 7.5 10.0 12.1 14.1 7.55 , 8.05 9,55 49. 65 61.65 63. 15 1.0 8.0 5 1,0 10.0 24,0 50.0 .,, ...... .. ¢ 05 45.15 4.05 55,15

Chapter FJve; The Development of New Knowledge Year 0 22. 5 ]~eco|ng]tonda Lion No, Title 13 Biomedical ReSearch In- stitutes ................ $pecia]ized Research Cen~rs ................. 15 ]~e~arch I~roject Grants... 16 Contracting Authority for Research and Devdop- ilten| .................. Subtotal ............. t vl~ l~ ml]heaz et ~grL 7~G~9 0.64-7 1 2 t7.5 15.0 4.05 6.7 35.0 47.0 lO.O 15.0 56. 55 00. 7 4 5 30.0 37.$ 9.4 10,2 12.¢ 55.0 .............. 81 HEART DISF.ASE,©ANCER AND STROKE

82 H[ROT RfSEASE, CANC£R AND STROKE Chapter Six: Educatlm and Training of Health MAnpower No Titl~ 1 2 3 20 Reeruitme, t for the lleehh Professions .............. ] 1,0 2,5 5,0 m 21 Undergraduate Training in Medical and Dental Schools ................. 7. 05 7. 55 8. 05 22 Training for Research ...... 16. 1 21. 4 23 24 25 Recommendation Support of ClinicalTraining. 10.0 Stahaization of Academic Portions ............... 8.0 12,0 16,0 27.1 14.0 10. 0 4 5 7.5 10.6 8.55 8.5~ 32,7 38,5 17. g 20.0 20.0 24.0 5.6 "7.0 Training of Health Tech- nicians ................. 1,4 2.8 4.2 26 27 h Training of Specialiste in llealthCommunicatlons., 1.0 Continuous Assessment of llealthManpowerNeeds. (~5 Stthtotal ................ 45.05 1,0 1.0 0.7 0.8 63.95 78.15 FiSu~ h~ mUI~Bz of doUlet, 1.0 1.0 0,9 1.0 93.75 110.6~

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APPENDIX B Members of Ihe Commission and Stuff

Dr. John S. Meyer, Professor and Chairman, Department of Neurology, Wa~ Slate University College of Medicine, Detroit, Michigan Mr. James F. notes, Chairman of the Board, Equitable Life Assurance Society, New York, Now York Dr. E. M. Pal,per, Professor and Chairman, Department of Anesthesiology, Col- lego of Physicians and Surgeons, Columbia University, New York, New York Dr. Howard A. Rusk, Professor and Chairman, Department of Ph~,~ieal Medicine and Rehabilitation, New York University Medical Center, New York, New York Dr, Paul W. Senger, Surgeon, Charlotte, North Carolina General David Sernoff, Chairman of the Board, Radio Corporation of America, New York, New York Hr. Helen B. Taussig, Emeritus Professor of Pediatrics, Johns Hopkins Unl- versity, Baltimore, Maryland Mrs. Harry S. Truman, Independence, Missouri Dr. Irving S. Wright, Professor of Clinical Medicine, Cornell University, Medi. eel 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. Lilienfdd, Protessor and Chairman, Department of Chronic Diseases, Johns Hopkins Unlvetslty School ed Hygiene and Public Health, BalD- more, Maryland Executive Secretary Mr. Stephen l, Aekerman, Associale Chief for Planning and Analysis, Bureau of State Services (Community Health), Public Health Service, U.S. Deparlment of Health, Educstion, and Welfare, Washington, D.C. Sta~ Associate Dr. John D. Turner, Olfice of the Director, National lleart Institute, Public Health Service, U.S. Department et Health, Education, and Wdfare, Betheeda, Maryland. IVriter Mr. Horace G. Ogden, Information Officer, Bureau of State Services (Commun- ity Health), Public Health Service, U,S. Department of Ifealth, Education, and Welfare, Washington, D.C. Public Relations Mr. Leafan E. Marlin, Information Offieer~ National Heart ]nstitute, Public Health Service, U,S, Department of Health, Education, and Welfare, Bethesda. Maryland 8S HEART DISEASE, CANCER AND STROKE

S:a~ ,4s3/~s Dr. Nemat O. Berhani, Head, Heart Disease Control Program, Bureau of Chronic Dheases, California Hepartmenl of Public Health, Berkeley, C'alifornia Mr. Louis Carrese, Program Planning Of~cer, O[~ce ot the Director, l~alional Cancer Institulo, Public Health Service, U.$. Deparlment of Health, Education, and Welfare, Bethesda, Maryland HL M~ureen Henderson, A~sociate Profe~t ot PTe~e~ti~ M~di~ a~d Markh Scholar, University of Maryland School of Medicine, Baltimore, Maryland Dr. William L. Kissich, Assistant to the Special Assistant to the Secretary ( Healrk and Medical A~airs), U,S, Depertment ot Health, Education~ al~d Welfare~ Washington, D.C. Dr. Bnyard Morrison, Clinical Branch, Collaborative Research, LNational Cancer Institute, Public Health Service, U.S. Department of Health, Education, and Welfare, Bethcsda, Maryland Mr. Marcus Roseublum, Associate Special Assistant to the Sur{~e~n General for Seienfific lnformatlon, public Health Service. U.S. Department of Health, Edu. enrich, and Welfare, Washington, D.C. Dr. David Schottenfeld, A~sooiato Directorp Admitting and Diagnostic C]inl~ Memorial Hospital, He~ York, New York Mr. Danid Zwi~k, O~ce of the Ch'nd, Bureau of Medical Services, Publi~ lteatth Service, U.S. D~arlmen~ of Healdi, Education, and V/sitar, Silver Spring, Maryland Co~ul~a~ Mr. Mike Gorr~an, Executlve Director, National Committee Agalnsl Mental Illness, Washington, D.C. Mr. 8oisfeuillot Jones, president, Emily and Ernest Woodruff Foundation, Atlanta, Georgia Dr. Morton L. Levin, Pzolamor of Cancer Epblemiology, Roswdl Park Memorial )nstitule, BufFa}o, New york /Idmi~tra~ive and Cleric~ Mrs. Frances Cart Miz~ Billie Ann Coen Mice Zi Ddk Mrs. Selma Freedman Mr. George Krelner Miu Roherta Laney Mr. Jell R~lswiuics~ll Miss Joan Sh~ltz Mrs. Jalie Thomas Mrs. Marjorie V. Thompson Miss Mary Triantis Miss Diane Withins IL 86 HEART Dr$EASLCANC,~ AND ST~OKE

APPfiNDIX C TIlE HISTORY AND OPERATION OF THE COMMISSION The Formation of the Commission In hi* Health Message to Congress early in 1964, President Lyndon ]]. Johnson stated: "Cancer, heart diaeaso and strokes stubbornly remain the leading causes ot death in the United States, They now a~ict lg million Amerlcans--~wo. thirds of all Amerieens now living will ultimately suffer or die from one d them. "These dle~ ~s ar~ lwt exln filxl~l tc~ older ~ople. • "Approximately half of the cases of cancer are found among persons under 65. • "Cancer causes more deaths among children under ag~ 15 than any other disease, • "More than half the persons suffering from heart dlseale are in their most productive years. • "Fully a third of all persons with recent slrokea 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 publio and prteate, also are investing considerable amounts in these e~orts. "The llo',~ o{ ne~v discvv ~ties, ne~> drngs, and new techniques is imprassi~e and hopeful. "Much remains to he learned. But the American people are not recvivlng the f~l[ bene~ of whet roedi~l cee~a~¢h hes ulre~dy e~mptlelxed, l~ part, thh ia 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. "1 am establishing a Commission on Heart Disease, Cancer and Strokes to reeorgmend steps to reduce Iha incldcnc+ oj these diseases thr~gk new knowl. edge and more complete .tilization o/the medical knondedge we already have. '~'L'ha Commission will be made up of persons prominent in medicine and pub+ 1i¢ alfalre. I expact It to complete its study by tbe ¢ed of this year and submit recommendations for action." On 1~1 aroh 7, the President announced the names ot the members of this Com. minion and on April 17, 1964, the Coramlssion held its first meeting in the White ltouee. ThePresldentaddressedtheCommissionasfollows: "I,~[¢s eyed G~atlemeu: 0 a beautiful days llke t~ie, the P~esldent and e~hool boys have a hard time staying indoors. 1 think we would set 8 good example for the Nation, and we would adrance the cause thai brings us togee, her, ii we we would tsbe time fur a brisk walk outside this morning. 1 am a subscriber 81 I#[IIT IqSE/ll[+~llC[ll gg| STROKE Lt,

i. .......... ~r H~T OISEAS[, CANCER AND STROKE to the view once expressed that if you want to know if your brain is flabby, you better feel your legs. "Health is something that we treasure in this house where you are gathered this morning, and I know it is treasured in every heus¢ throughout our lap~t and around the wosid, h was sald several centuries agu. health is the greatest of all po~ssions. A pale cobbler is bettor than a sick king. "The work that you have begun today is work in which I have the keenest and greatest and the most personal interest. You are here to beg4n mapping an attack by this Nation upon the throe great killers, the three great eripplera-- heart, cancer, and stroke disease. Th¢~ thre~ 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 magnitude of the impact of these diseases upon the Nation ; second, to evalu- ate our resources for aequlring new heowledge that we already have; third, to identify the obst aehs which stand in the way of advanalng knowledge and give us guidelines on overcoming these obstacles. "To this group I do not think I n~exl to tall you how vitM Otis is. Unless we do better, two.thirds of all Americans now living will auger or die from eano0r, heart disuse, or stroke. 1 eXFcct you to do somethlng about it. Five million Americana e year are struck down in the prime of life by heart attacks, often fatal. Every two minutes cancer atrth~ a man or a woman or a child in this country. Every year strokes leave 200,000 Americans dead and another II million incapacitated. "1 want us to put our great resources--and they are unlimited--to work ao overcome thls. We can, and because of the work you will do, I bdieve we edit. So let me say this: 1 know there are some differing viewpoints about the prospects ior success in these fidds, but from what some of you on this Com- mission have reported to me, and from some other sources that I bdinve 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 anll strokes. "The point is, we must conquer heart disease, we must eonquer cancer, we must conguer strokes, This Nation and the whole world cries out for this vie- tory. I am firmly convinced that the accumulated brains and determination of this Commission and of the scientific community of the world will. befoi'¢ the end of this decade, come forward with some answers and cures that wc need so very much. When this occurs--not 'if,' but 'when,' and f enlphesize 'when'--we will face a new challenge and that will be what to do within our economy to adjust ourselves to e life span and a work span for the averag¢ man or woman of lO0 years. "Knowing Government as ] dop I am sure some Ptosldeut some day will be appointing a commission to study that very great problem, and ] would b¢ pleased to be that President. If you do your woch wall and if you do your woch with dispatch, maybe I will have that privilege. i .

"I have often been reminded myself of Shakespeare's llne, 'A good heart is worth gold.' f am glad mine is good new and if the doctors and the Secret Service and my guardians in the pres.~ will just permit me to get my exercise, I anted to keep it that way. "I want to thank you very much for beginning the work that I think will ultl- mutely win the hardest fight that we have ever fought, and I would suspect that just as we look back on Lincoln's proolamation a hundred years ago, when he took the chains off the slaves, ] would suspect that some day your grandchildren and greah great grandchildren will be looking at this picture made this morn- ing in this beautiful ros~ garden, all the thorns are inside, and see the leadership of 50 States who are willing to give their talents and their eneTgies and their imaginations, and stay awake at night and roll over and go get a glass of water and coma back and think some more on how to get the i~sults that we knew are within our reaoh. "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 tank that you have today undertaken to get rid of the caus~ of heart disease and cancer and stroke in this land and around the world. What ran be more satisfying titan to feel that you haea preserved not a life, but millions of them, ior decades, l 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 soelal security, we are interested in the civil rights bill that we consider most essential to our leadership in this country a~,d in the world, we are interesled in the pay bill that will keep our good civil servants here, we are interested in the immigration billlhat will permit families te 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. "Tbere 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. +'Thank you." Orgonizulion oI the CommiJslon The Commission organized itself into the following Subeonuaittees with the following Chairmen : Heart Disease Cancer Stroke Rvsearch Manpower Communications Faeilllle~ Rehabilitation --Dr. Irving Wright --Dr. Sidney Father --Dr. John Meyer --Dr. Philip Handler --Dr. Edward Demps~y --Mr. Emerson Foote --Mr. Arthur Hanisch ~r. lloward A. Rusk The Chairmen constituted the Executive Committee of the Commission. HEART OISEASIL C~HCER AND STROKE

90 HEART DIREASE,¢kNCER A~D STROKR Methods o] OoeraClon T~ Commi~sio~ ~ablJ~o~l Ihe t~owin~ metho~Is oJ op~a~ion: 1. Tho col]ecfion of Jnforl~allon from agencies, gro~s, end instltutlolls con. c~med ,sit~ Rtx~ ~i~ lhrou~h l~ter s, ~a~f ~i~iLs, ~rc~y~, et~. 2. The holding o~ hea~ngs at which expert witnesses from the widest possiblo range of in~ros~ both public and private, pre.sented their views and dis- ~. The ~roparallon o~ ~ho report and ~ts re~ommencl~tions and their ~ubrnis~ ~on to the President. A I~Rcr was sent to lhe profr~slona] organizations a~td voltmtary healt~ a~en. cie~ |istod in Appendix D, informing them o~ the appointment o~ the Commi~ ~o~ and indicating Ihat the Commi~ion "wo~ld welcome • written ~tatement ~ting forth the ovorell views of tho organization on tb~ problems per~ent to flao mission o~ Ihe CommJ~Jo~ Rnd any sugge~tlone and ~oeommendation~.I' The response to this request w~s most grJti~yJng e~ the Commission expre~ itJ ' ~ppr~iafiol~ to tlm~ organi~atlon~ ~or their a~llstan~. In epproaching itn ts~, the Faeilitl~ Subeommlttee confidorecl ~t deslrBble to determine the ov~ra][ need for p~tien~ e~re, research, ~nd ~lueation~l |a~ilitie~. As no estimate o~ National needs was available, tho SubCOmmittee undertook ~t N~tlonal survey of m~Jiead, dental, ost~pathJe, public health, and veterinary ~ools; o~ reseereh e~ters; and of community hospil~]s to obtain in~ormatlon re~ardJng their needs, lolans, a~d problems concerning the con~truetlon of n~w Sl~e~ and the re~ov~tlon of ol& Ther~sultso~thissurveyer~porteAind~tl in Volume 2. During November, the Second Nationa] Con~r~c~ on Cardiov~cul~ I)i~ waJ held, Severs| hundred cardiologists and sci~atlst~ spent over a year pre- paring a s~rvey of the entire fiol~ of cardlova~eul~r diseases ~or r~ow aM di~euseion ~t this Conference. All o~ this material was made ~vailable to the Comnfisslon, and the Commi~sion would like to express il~ appreciation to Dr. E. Cowles A~drus, Conferen~ Chairman, and to th~ Conference par~idpants ~r their generous a~i~t anee, |n view of the ~eod ~or obte]ning inform~tlon ~nd view~ on the e~on omlc ltsp~¢18 of heart di~e.a*e, c~n~or and stroke, the Comml~ion obtained a detailed analysis o~ the eeonomlo ~o~ts of these disease~. In ~ddllion, Dr. Wahor H~ll~r, Chs|rman of the Counci~ of Ee0nomle Ad~sors to the Prosident, e~lled log~h~r a group of economists ~or ~ m~ot[ng on September 30, R96~, to discuss this ar~, A r~port o~ thi~ ra~mg i~ pre~nted in Volume 2. Th~ Commission exptes~e~ its gratitude Io Drs. H~ller, Arrow, de JanosJ, I~neen, K[arman and ~itovsky for their help. Each of the Subcommittee~ held he~rlng~ to which were invited individual experts, repres~ntati~s of selected voluntary h~alth a~encles B~d pro~*.~ion~ organizations and o~elal Fed~rel, State, and local heelth agencle~. The o~tnions ant] re~ommendetlons o~ th~Be indivRlua]s were o~otaJned, and ~n oflficial tr~n. script was made o ~ each of thei~ meellng~.

A total of 4.5 euch meetlnss were held, and more than ]~ experts appeared ot these hearings, and the Commission is deeply ~rate~l to those who came to th~se meetings, most of which were held in Washington. Rlore than 7,500 pages o~ testimony, amounting to many rnilllons o~ wo~ were obtained. A ]i~ o| th~se wltneeses appears a~ Appendix ~. E~¢h ot the Subcommittees reviewed th~ te6ti~ony, in ~dditlon to b~ekgrouna materlal, and prepared a report i~cluding r~comm~nd~t]on~. Each of these reports was then reviewed ~oy the Eze~ul~ve Committ~, whlch held 10 meetlng~ during the term ef the Corom'~n~ The Co~umi~ion ttsel~ m~t as a whQle 6 tlm~ ~vera] of which were two day~ in length, Io revJ e'~' th~ reports and recom- m~nJ~tion~ of e~ch of Ihe Subcomrnltte~ a~d o:~ the Ex~cut ire Com~t~. T]~e~e reports we~ br~)ught to~t]~er in ~ ~ni~ed ~hlon to sei've a~ the repor~ o~ the Commi~slon, 91 HEART DISEASE, CANCER AND STROKE

APPENDIX D 92 HEART DISEASE,CANCER AND STROKE Agencies and Professional Organizations Contacted 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 A~sociation of Cancer Research American Association of Dental Schools American Association of Ohsteta'icians and Gynecologists American Cancer Society American College of Cardiology American College of Chest Physicians American College of Obstetricians and Gynecologists American College of Physicians American College of Preventive Medicine American College of Radiology American College of Surgeons Amerlean Dental Association American Diabetes Association American Heart Association American Hospital Association American Medical Association American Medical Women's Association American Neurologlcal Association American Nurse' A~oclation American Nursing Home A~ociation American Osteopathic A~soeiatiun American PuMic Health Association American Society of Clinical Pathologists American So0iety of Medical Technologists American Society of Neurosurg~ons American Thoracic Society Arthritis and Rheumatism Foundation Association of American Medical Colleges Association of Life Insurance Medical Directors Anociation of Rehabilitation Centers Atsoclation of Schools of Public Health Associatlou of State and Territorial Health Oflkors Association of State Chronic Disease Program Directors Catholic Hospital A~soeiation College of American Pathologists Group Health A~ociation of America Group Life Insurance, Inc. Health Insurance Council

Health Insurance Institute Institute of Lite Insurance Inter-Society Cytology Council International Unlon Against Cancer Leukemia Soclety Li(e Insurance Mcdleal Research Fund National Association of $oala] Workcr~ l'qational Donta[ Assodat ion National Health Council Nations] League for P/urslng National Medical As~oalation National Rehabilitation Association National Society for Crippled Children and Adu)ts Public H~th Cancer Association Soal~t y o~ Actuaries Society of Public Health EdueatorB U.S. Conterencc of City Health Officers HEART DIEEAEE.OANCER AND STROKE

APPENDIX E 94 HEART DISEME.gANCER AND STROKE List of Witnesses Who Appeared Belore the Subcommittee Hr. Frank Adair, Breast Cancer Specialist, and Past Preeident, Amerlean Cancer Society, ~ew York, New York Mr. Scott Adams, Deputy Director, 1National Library of Medicine, Bethesda, Maryland Dr. Robert A. Aldrich, Direotor, National Institute of Child Health and Human Development, National Institutes of Health, Dethesda, Maryland Dr, Otis Anderson, Medical Liaison, American Medical Association, Washington, D,C. Dr. E. Cowles Andros, Professor Emeritus, Johns Hopkins University School of Medicine, Baltimore, Maryland Mr. Daniel Bailey, Assistant to the Dirc~tnr~ National Library of Medicine, Bvthceda, Maryland Dr, A. B. Baker, Professor and Chairman, Department of Neurology, University of Minnetota Medlea[ Seoal, Minneapolis, Minnesota Dr, Gordon Barrow, Director, Cardiovascular Disease Control Service, Georgia Department of Public Health, Atlanta, Georgia Mr. Carl Berkley, Consultant, HCA Laboratories, Princeton, New Jersey Dr, Robert Bowman, Chiet, Laboratory of Technical Developmenb National Heart Institute, National InBtitutas o1 Health, Bethesda, Maryland Dr, David Brand, Chief, Heart Disease Control Branch, Division of Chronic Diseases, Bureau of Slale ~ervices, Public Health Service, Washington, D.C. Dr, Lester Dreslow, Chief, Division ot Preventive Medical Services, California Departraent of Public Health, Berkeley, California Dr, Ray Brown, Director of Program of Hospital Administration, Duke Unlver- sity Medical Center, Durham, North Carolina Dr. Kevin Bunnell, Associate DiTeotor, Wcttern lntersta~ Commission for Higher Education, Boulder, Colorado Dr, Mary I, Bunting, Provident, Radcliffe College, Cambridge, Massachusetts, and a Commissioner, U.S. Atomic Energy Commission, Cermantown, Mar)'. land Dr. T. H. DuRerworth, Representative, Society of PuMi¢ Health I~ducatota, Inn,, Washington, D.C. Dr. John L. Geughey, Jr., Atsociate Dean, Wtstvrn Reserve University School of Medicine, Cleveland, Ohio Dr. Philip Cohen, Chairman, Department of Biochemistry, University of Wis. ¢onsin, Madison, Wisconsin Dr. Clifford Cole, Chief, Neurological and Sensory Disease Service Program, Division of Chronio Diseases, Bureau of Stttte Services, Public Health Sere. ice, Washington, D.C. Dr, Donald A. Covah, Asumiate Director, Institute of Physical Medicine and Rehabilitation, New York UniversBy Medical Center, New York, New York

Dr. Hussel W. Cmnley, Exeoutive Director, Medical Arts Publishing Founda- tion, Houston, Texas Dr. Emerson Day. DRector, Strung Oiale, New York, New York Dr. George Denver, lntthute oI Physical Medicine and Rehabilitation, New York Unlveralty Medical Center, New York, New York Dr. Bowen C. DeeR, At~i~ant Director (Planning), National Se~e~ee Founda- tion, Washington, D.C. Dr, D. Denr~y.Brow~ Je.racs Jackson Patnara Professor of Neurobgy, Harvard Medleal School, Harvard University, Boston, Massachusetts Dr. Harold S. DishK Senior Vice President for Medical Research and Medical Affairs, American Cancer Society, New York, New York Dr. Leonard Diller, Chief, Psychological Suction, Institute of Physical Medi. eine and Rehabilitation, New York University Medical Center, New York, New York Dr. James P. Dixon, President, Antloeh College, Yellow Springs, Ohio Dr. Patrick Doyle, Deputy Commissioner, Vocational l~ehabilitatlon Adminis- tTatloia, l~pa~tmer~ r~! Health, Eduea~ir~n, and Welfare, Washington, D.C. Dr. Rennin Dttlbeccop Salk Institute for Biological Studied, San Diego, California Dr. Charles Dtmham~ Director, Dieisiun of Biologo and Medioine, Atomic Energy Commission, Germantown, Maryland Dr, Charles E. Dunlap, Chairman, Department of Pathology, Tulane University School of Medicine, New Orhanl, Louisiana Mr. H. P. Dunning. Program Management Officer, Cancer Comrol Branch, Divi- sion of Chronic Diseases. Bureau el Slate Services, Public Health Sorvlee, Washington, D.C. Dr. Ha~ry Ea$1e. Alb, ert Einstein CoBege of Medle~r,e, Yeshi'cs Unive~slty, New York, New York Dr. Paul E/Iwood, Executive Director~ Sister Elizabeth Kenny Foundation, Min- neapolis, Minnesota Dr. Kenneth Endicott, Director, National Cancer Institute, National Institutes of Health, Belhesda, Maryland Dr. I,ester Evans, Consultant in Education for the tteahh Professions, University of Illinois Medical Center, Chicago, l litaeis Dr. Shirley C, Fisk, Deputy Assistant Secretary of Defe~lse, Health and Medical, W~shingtzB, D.(3. Dr. Reginald Fit¢, Dean, University of New Mexico School of Medicine, Albu- querque, New Mexico Dr. C. Miller Fisher, Assistant Clinieal Professor of Neurology, Department of Neurology, Massadausetts General Hospital, Boston, Massachusetts Mr. Leslie Fiery, RCA Lehoratorios, Princeton, New Jersey Mr. Pierre Frsdey, gxeeulive Secretary, Council for the Advancement of Seienee Writing, Phoenixvise, Pennsylvtmta Dr. Aaron Ganz, Chtef, Reeeareh Career Section, Research Fellowships Branch, National IB~titute of G~eral Med'~al Seieho~, Natlo~al Iastitutcs M Health. Betha~da, Maryland 95 HEART OISEA~E, CAH~IEK AKD STROKE

96 H~RT DISEASE.CAN~ER AND STROKE Dr. Leo J. Gebeig, Chief, Bureau of Medical Services, Public ||ealth Servioef Washington, D.C. Dr. Louis Gerber, Chief, INur slog l~omes and IRelaJed Facilities Branch, Division of Chro~io DiscRses, Bureao of State Servicc~, PoblH Health Service, Wash- inglon, D.C. Dr. David Gel~nd, Chairman, Rohohillmtion Committee, American Medical Asso. elation, Philadelphia, Pennsylvania Dr. Ell Gbizberg, Professor of EconomHi, Graduate School of Business, Colum- hla University, New York, New York Mr. John S. Gleason, Jr., Administrator of Veterans' Ai~airs, Veterans AdmbiHtra- tion, Wachlngton, D.C. Mr. KermR Gordon, Director, Bureau of the Budget, Wachlngton, D.C. Accom- panied by Mr. Sutton and Mr. Loweth Dr. Saxon Graham, Associate Concer l~scaroh Scientist, Roswell Park Memorial Institute, Boffalo, New York Dr. |farald M. Graning, Chill, DivHion of Ho6pi~al and Medical FacilitH~ Bureau of State Services, Puhllc Health Servlc~, Wachbigton, D,C, Dr. Eugene Guthrio, Chief, Division of Chronic I)Heas~, Bureau of Stale Services, Public Health Service, Washington, D.C. Mr. John FIa~n, Rehabilitation CoosuBant assigned to Coordinating CommiN~s on Nation-wMe Strobe Programs, American Heart Association, New York, New York Dr. Rohert Haggcrty, Profossor and Chairman, Department of P~]iatrice, Uni- versify 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. Seymoor Harris, Lit~auer P~o~ssor of Political Economy, Graduate School of Public Administration, Harvard Ubiver~ty, Boston, Massachusetts Miss Inc~ Haynes, Dir~tor, National League for Nursing, INe~' York, New York Dr. Albert Heyman, Pro~sor o~ Neurology, Duke U~iverslty School o~ Medicine, Durham, North Carolina Dr. Herman K, He~ler ~eio, Ubiwmity Hospital, C~eland, Ohio Dr. Milton Hoher man, Am~rlean Board of Physical Medicine and Rehabilitation, New York, New York Dr. Go~|rey Hoehbeum, Chief, Bohavioral Science Section, Division of Commu- bity Health Servlc~s, Bureau of State Servlccs, Public HeaBh Service, Wach- ington, D.C. Dr. Vane Hoge, Assistant Di~lor, American Hospital Association, Washbigton Service Bureau, Washington, D.C. Dr. A. Hollaender, Oak Ridge National Laboratory, Oak Ridge, Tennessee Dr. Donald Horbig, O~ce of Science and Teohnology, Executive Office of the Peesiden~, Washington, D.C. Dr. Wsrreo V. Huber, Chi~, Neurology DivHion, Veterans Administration, Washington, D.C. Dr. Charles Huggins, Ben May Laboratory for Cancer Research, University of Chlc~z~o, Chicago, Illinois

Mr. J. Stewart Hunter, Assistant to tl,e Surgeon General for Information, Public Health Service, Washington, D.C. De. Ceoxge ~tmes, C~mralaslones tff~ Et.ahh, New York CRy Dep~Araeut of Health, New York, New York Dr. Robert S. Jason, Dean, Howard UJliversity College of Medicine, Washington, D.C. Mr. Bets feuillat Jones, President, Emil)' and Ernest Woodruff Foundation, Atlanta, Georgia Mr.Tom Io~e~, Etbi~on, Inc., Somer "dlle, Hew ~ersey D~. Charles Kane, Professor of Neurology, Boston University School of Medicine, Boston, Massachusetts Dr. N~rvln K~fe~, Cb~f Medical Director, Th~ Eqult tdile Lite A~aue¢ Society, New York, New York Dr. Jay llillary Kelley, Office of Selance and Technology, Executive Office of the Pnsldeat, Washington, D.C. Dr. F, Ellis Kelsey, Special Assistant to the Surgeon General for Scientific Com- munication, Public Health Service, Washington, D.C. Hr. Charles ¥. Ki~ld, Asaod~te D~Tezto~ fo~ I~ternation~ A~ti~iti~, N~tloual Institutes of Healfih Be/heeda, Maryland Mr. Earl Klein, Chief, Division of Publication, Office ot Labor Statistics, Depart- meut o~ Labor, Wa~sbingtov,, D.C. Dr. Ralph Knuttb Director, National Heart Institute, National Institutes of Health~ Bethesda, Maryland Dr. Paul Kotin, A~oziat~ Direzto~ for Fielfi Studies, National Caner ~n~titute, National Institutes o[ Ifeffith, Bethesda, Maryland Dr. Predrle J. Kottke, Department of Physical Medicine and Rehabilitation, Ualverslty of Minnesota, Mi~neapeR~, ~¢llu~c~ot ~ Dr. Edward J. Kowalewshi, Chairman, Commission on Environmental Medicine, American Academy of General Practice, Kansas City, Mlasourl Dr. L~onaed Le~ht, DR~toy. National Goala Project, [gatlo~al Plau~i~ fi A~i- ation, Washington, D.C. Dr. Lyndon E. Lee, Jr., Chief, Extra.VA Research Divifion, Department of Medb ¢ir~ a~d Surget y,VeteTan$ Adminltl~ati~n, Wa~Mngtc:a, D£, Dr. Philip Lee, Director, Heahh Service, Ofllee of Technical Cooperation and Researeb, Agency for International Development, Washington, D.C. Dr. Russell Lee, Director, Pale Alto Medical Clinic, Pale Aho, Ca/itornla Dr. Joseph Letter, Chief, Cartcer Chemotherapy National Service Center, National Cancer Institute, National Institulas of Health, Bethesda, Maryland Dr. Arthur Lesser, Director, Division ot Health Serviee~, Children's Bureau, Welfare Administration, Washington, D.C. Dr. Nathanid I.¢vin, University of Miami School of Medicine, Miami, Florida Hr. Herbert Lichtman, Medical and Research Director, Leukemia Society, Inc., New Yo~k, New York Dr. James Lieherman, Chief, Medical Audiovisual Branch, Communicable Disease Center, Bureau ot State Services, Public Health Service~ Atlanta/Georgia 8gklW gIMASL f~gg~gg gl~ $'~Rggt

98 HHRT DISU$1~ CJ, NCEIt AND STROKE Dr. Arthur Locsiin, New York University College of Medicine, New York. New York Dr. Herbert Lockdey, Department of Neurosurgery, State University of Iowa College of Medicine, Iowa City, Iowa Dr. Irving London, Professor and Chalrman, 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. elne and Rehabilitation, New York University Medical Center. New York, New York D~. Champ Lyons, Professor and Chairmau, Departmcnl of Surgery, University of Alabama School of Medicine, Birmingham, Alabama Dr, Colin M. Maabcod, Ofl~ce of Science and Technology, Executive O fllee of the President, Washington, D,C. Mr. Rudolph Mallina, Consulting Engineer, Hastings, New York Dr. Morton Marks, Clinical Neurologist, New York Ihiverslty Medical Center, New York, New York Dr. Jessie Marmorston, G~inical Pxofessor of Medicine, University of Southern California School of Medicine, Los Angeles, California Dr. Richard L. Masland, Director, National institute of Neurological Disoas~ and Blindness, Nationat lnstllt~tes of Health, Bethesda, Maryland Dr. J. F. A. McManus, Department of Pathology, Univecsity of Indiana, Bloom. ingtton~ Indiana Dr. Joseph McNinch, Chief Me/deal Director, Veterans Administration Cantral Office, Washington, D.C. Dr. M. Sedgwick Mend~ Director, Kaiser Foundation Hospital Rehabilitation Center, Vallejo, California Dr. H. Houston Merritt, Dean, College of Physicians and Surgeons, Columbia University, N¢w York, New York Dr. Thomas Mermen, Assistant Director for Commissinns, American Associa. tion of Junior Colleges, Washington, D.C. Dr. George E. Miller, Direetor~ Research and Medical Education, University of Illinois Collage of Mtdisine, Chicago, Illinois Dr. Clark Millikan, Consultant in Neurology, Mayo Clinic, Rodlester, Minnesota D~. George E. Moore, Director, Roawdl Park Memorial Institute, Buffalo, New York Dr. Mare J. Musser, Deputy Chief Medical Director, "¢etetans Administration, Washington, D.C. Dr. Mauriee Odoroff, ChieI, Program Analysis Branch, Institute of General Medical Sciences, National Institutes of Health, Rethesda, Maryland Dr. fames O'Leary, Professor and Chairman, Department of Neurology, Washington University, St. Louis, Missouri Dr, Richard Orr. Director, Institute for Advancement of Medical Communica- tion, Betht~da, Maryland Dr. hvine Page, Director, Research Division, Cleveland Clinic, Cleveland, Ohio Dr. Ogieaby Paul, Professor of Medicine, Northwestern University School of Medicine, Chicago, Illlnoia

Dr. Edmund Pellegrino, Professor and ChMrman, Department of Medicine, Uni- versity of Kentucky College of Medicine, Lexington, Kentucky Dr. Paul Q, Paterson, Associate Chief for Operations, Bureau of State Services, Public Health Service, Washington, D.C. Dr. Micceyslaw Pesczynskl, Director, Rehabilitation Program, Highland View Hospital, Cleveland, Ohio Dr. Harry T~ PhiBfpa, Dizectar, Divi~ of ChroMe Diseases, Massachusetts Department of Public Health, Boston, Massachusetts Hr. Leland E. Powers, Associate Director, Association of Amerloan Medical Col- hges, Evanston, Illinois MT. David Prccwitt, Prnduuer in Charge of Science Programs, N~lionM Ednea- tlona[ Television and Radio Center, New York, New York Hr. 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 Bu~Ialo, Buffalo, New York Dr. I, S. Ravdin, Vice President for Medical Affairs, University of Pennsylvania, Philadelphia, Pennsylvania Dr. Lewis C. Bobbins, Chief, Cancer Control Branch, Division of Chronic Diseases, Bureau of State Services, Public Health Service, Washington, D.C. Dr. Rerhert H. Rostnherg~ Chief, Re~c,t~ ¢¢¢s Analysis Brat~h, Ot~ce of Program Planning, O$ce of the Director, National institutes of Health, Bethaeda, Maryland Dr. Allen Russek, Institute of Physical Medicine and Rehabilitation, New York . University Med~clfi Center, New York, New York Dr. Joseph Sadusk, Medical Director, Bureau of Medicine, Food and Drug Administration, Washington, D.C. Dr. A. L SaM, Professor of Neurology, State University of Iowa. Ames, Iowa Dr. John J. Sampson, President, American Heart AIsociation, New York, New York Dr. Sidney Scheflis, Cardiologist, Baltimore, Maryland Dr. Harold W, Sehrtapat, Chief, Re~'.,~ar oh in lWiernal Medicine, Voter mrs' Admit,. istration, Washington, D.C. Dr. Robert L. Schoenfeld, Rockefeller Institute, New York, New York Dr. James Shannon, Director, National Institutes of lIeahh, Bethesda, Maryland Dr, Murray J. Shear, Special Advisor, Intramural Research, National Cancer In- stitute, National Institutes of Health, Bethesda, Maryland Dr. Cecil Shops, Professor of Medical and Hospital Administration, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania Dr. John F. Sherman, Associate Director for Research Grants and Awards, Na- tional Institutes of Health, Bethesda, Maryland Dr. Robert Sacker t, Section of Neurology, Mayo Clinic, Rochester, Minnesota Dr, Charles Shieldg Georgetown Um~arslty Schad of Medlcitle, WsskingtOrl, D.C. 99 HEART DtSEASF~CANCEg AND STROgE

100 H[ART DISEASE, CANCE# AND STROK[ Dr. M. B. Shimkin, FeIs Research Institute, Phfladalphia, Pennsylvania Col. Robert Shira, MC, USA, Chief of Dental Service, Walter Reed Army Medical Center, Washington, D.C. Dr. Austin Smith, President, Pharmaceutical Manufacturers' Association, Wash- ington, D.C. Dr. William Spencer, Texas Institute for Rehabilitation and Research, Baplnr Universi/p, Houston, Texas Dr. Jeremiah Stamler, Director, Division of Adult Health and Aging, Chicago Board of Health, Chi,~ago, Illinois Dr. Eugene Stead, Chairman, Department of Medicine, Duke University Medical Center, Durham, North Carolina Dr. Frederick L. Stone, Director, National Institute of 0,eneral Medical Sciences~ National Institutes of Health, Betheeda, Maryland Mrs. Ethel Mac Strueben, Director, Conference Group on Medical-Surgical Nursing, American Nurses Association, New York, New York Mr. Daniel Sullivan, Representative, Society el Public Health Educators, Inc., Washington, D,C. Miss blary E. Switzer, Commissioner, Vocational Rehabilitation Administration, Department of llegtth, Education, and Welfare, Washington, D.C. Dr. Edward Tatum, Rockefeller lnstitule, 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 ot Medleine, New York University, New York, New York Dr. James L. Troupin, Director of Professional Edueatlon, American Public Health Association, New York. New York Dr. Maurlce Vi~ehnr, Chairman, Department of Physiology, University of Miunesota, Minneapolis, Minnesota Dr. T. Phtilip Waalkes, Asscciate Director tor Collaborative Research, National Cancer institute, National Institutes of Health, Bethe~da, Maryland Dr. George Wakerlin, Medical Director, American Heart Association, New York, New York Mr. John Walden, hlformation Officer, Division el Chronic Diseases, Bureau ot 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 Ret/~rdation. Washington, D.C. Dr. William Wendell, Institute of Physical Medicine and Rehabilitation, Nect York University Medical Center, New York, New York Mrs. Margaret We~t, Assistant Chief, Division nt Public Health Methods, Offi~ of the Surgeon General, Public Health Service, Washington, D.C.

Dr. Frederick Whitehouse, Director of Rehabilitation, American Heart Associa- tion, N~w York, New York Dr. I~ Holland Whitney, Amerle~n Telephone and Telegraph CorapaRy, New Ycrk, New YQrk Dr. Robert W. Wilkins, Professor and Chairman, Department of Medicine, Boston University School ot Medicine, Boston, Massachusetts Dr. William WiB~rd~ Dean, University o~ Kentucky C~llege o( Medleh~e, Lcxlng- ton, Kentucky Dr. Duel Wolfle, Executive Director, Amerlean Association for the Advancement ot Sclenee, Washinglon, I).E. Dr. Paul Zamecniek, Director, John Collins Warrell Laboratories of C. P. llunt- ington Hospital of Harvard University at Massachusetts General Hospital, Bos- ton, MassaehuJetts Dr. Charles Gordon Zubrod, Director of Intramural Research, National Cancer ]nstitate~ National Institutes of Health, Bethesda, Maryland Dr. Vladimir Zworykin, RBA Laboratories, Princeton, New Jersey 101 HEART DIS~AGE, CANCER AND STROKE

APPENDIX F 102 HEART DISEA$E, EAN¢£R AND STROKE BIBLIOGRAPHY Abbey, J. C., et al.: Television in Health Sciences Education : Home and Hospital Viewing of Continuing Education Broadcasts Under Three Presentation.Response Conditions. Journal of Medical Education 39: 693-703, 1964. Acheson, R. J.: The Epldemiology of Acute Rheumatic Fever (to be published). Adams, S.: Hospital Libraries: Underdeveloped base for continuing education. lIospitals gg: 5~5¢, 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 Programs el Care: Jones criteria (modified) for guidance in diagnosis of sheumatic hear. Circulation IS: 617~20,1956. American Heart Association: Report and Recommendations of the Second Na. tional Conference on Eheumatie Fev~ Prevention, 1963 (in press). American Medical Association: Council on Medical Service: The Hifl.Burton Study: A review of the Hospital Survey and Construction Act since 1946. Chicago, IlL, 195g. American Nurses' Association: Facts Aboul Nursing. New York, 1966. Anon., The Availability and Financing of Nursing-Home Care. Blue Cross Re- ports2: 1-16,1964. Association of American Medical Colleges: Financial Assistance Available for Graduate Study in Medicine, 7th edition. Evanston, BL, 1963. Association of American Medical Colleges: A Proposal br a Program of Federal Asslstsnce to Medleal Education. Evanston, ill., 1963. Bailer, J. C. 111, King, H. and Mason, M. J.: Cancer Bates and Risks. PHS Publication inn. 1148, U.S. Government Printing Office, Washington, D.C., 1966. Edict, S.: Arshythmias: paper prepared for the Sckeommlttoe on Heart Disease of the President's Commission on Heart Disease, Cancer and Stroke. Ballet, 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. E,, et eL: Cardiac Infections, Bacterial Endooarditis and Pericaedltis: papers prepared fur the.sccond National Conference on Cardiovascular Diseases. Washington, D.C., November, 1964. Bloomquist, H.: The Status and Needs of Medical School Librarie~ in the United States. Journal of Medical Education 88: 145-).63, 1963. Burob, G. F., et aL : Primary Myocardial Diseaee: paper prepared for the Second National Conference on Cardiovascular Diseases. Washington, D.C., Novem. bar, 1964.

Burchdl, H. B., et al.: Pulmonary Vascuhr Disease and Cur Pvraonale: paper prepared |or the Second National Conference on Cardiovascular Diseases. Washington, D.C., November, 1964. Christakis, G., et ah: The A~i-Eo~nnary Club: A Dietary Apgeoaeh Io tho Pre. vtmtion of Coronary Heart DSseass. A ~even-year report~ pre~nted at the American FuMic Health Association annual meeting, New York, Octoher 7, 1964 ( unpublished ). Commission on Chronic Igness: Chronic Illness in the United State~, Care of the Long.Term Patient. Harvard [hiversity Press, Cambridge, Mass., 1956. Committee on Appropxiations, Suhcommittce on Department ot Health, Educa- tion and Wolhre and Department of Labor: Federal Support of Medical Re- search (Jones Report), U.S. Government Printing Ofilc~, Washington, D.C,, 1960. Comroe, J. H., Jr., Editor: Re.search and Medical Education. Report of the Ninth Teaching Institute. Asse.~iation of American Medical Colleges, Evanston, llh, 1962. Crocetti, A. F.: Diag21ostic and Surgical Facilities for Congenital Heart Diseas~ in the United States, Johns Hopkins School of lIyglene and Publlc Health (to Do published). De CUrIo, L M., Amster, W. and Here, G. R.: Speech ARcr Laryngectomy. Syra- cuse University Pt e,/s, Syracuse, N.Y., 1955. deSola Price, D. J.: Little Sclence, Big Science. Col umbia Univeralt y Pre~!s, New York, 1963. Dietriek, J. E. and ]ierson, E, 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. U, 1962. EbDorL A., Jr.~ Two.Way Radio in Medical Education. Journal of Mcdlcal Education 38 : 319-328,1963. Epstein, F. H.: The Epidemiology ol Coronary Heart Diseases. A review (to DO published ), Evans, L J.: Crisis in Medical Education. University ol Michigan Prass, Ann Arbor, 1964. Ewing, O. R., The Nation's Health, a 10.year program: A report to the Presi- dent. Federal Security Agency, Washington, D.C., 194~3. Gardner, W. H, and Harris, H. E.: Aides and Devices for Laryngectomccs. Archives of Otolaryngology 73 : 145-152,1961, Garrett, J. F. and Levine, E. S,: Psychological Practices with the Phyalcally Handicapped, Columbia University Press, New York, 1962. Gartland, H. J,: Blueprint for a Professional Hospital Library. Hospitals 38(12) : 58-59, June 16.1964. I03 HEART DISEASE, CAHC[R ANt) STROKE

104 HURT DISEASE, CANCER AND STROKE Gi~s]er, R. H. and Yast, H. T.: A Survey of Current Hospital Library Reeources, flcspltais aS(f2) : 55--57, June 16, ]gcA, ~nzherg, E.: The Optimistic Tradition and American Youth, Columbia Unl- veralty Press, New York, 1962. Gordon, E. E,, et ai,: Stroke ~Conm~unity Servlcee) : paper prepared for the Second National Conference on Cerdlovas~ular Diseases. Washington, D.C., November, 1964. Harris, N. E.: Technical Education in the Junior College--Hew Progre~ for ~w Jobs. Araerlean As~oalation of Junior Coliesee, Washln~on, D.C., 1964. Harris, S. E.: '[he Economics of Atneal~n Medicine Macmillan, N~w York, ]964, Hartrcft, V~ ~: Etlalogy and Pathegenesls of Arteriosclerosis: paper prepared for the Subcomntlttee on Research of the President's Commission on Heart Disease, Concer and Stroke. Halntzelmann, F.: Factors ]n Prophylaxis Behavior in Treatin8 Rkeemstlc Feve~ : an exploratory study. Jourvai of Health and Human Behevior ~: 7~-8I, 1962. Hallersteln, If. K, and Ford, A. B.: Comprehensive Care of the Coronary Patient: a challenge to the physioian, Circulation 22: ))66-1)70, )960. Higgins, I. '1~ T.: The Epldenliology of Congenitai Heart Disease (to be pub- fished). Hochheum, G. M.: Modern Theories of Conuaunicatlon. Children ?: 13-18, 196f~ Hochkeum, G. M.: Relating to HeaIth Education. Address to the Joint Meeting of the National Health Councli's Committee on Research and Committ~ on Health Edueatfon. New York, Decemher lO. )959. Hoobler, S.: Hygerlension: paper prepared for the Subcommittee on Research of the President's Commission on Heart Disease, Cnttcer anl] Stroke. Hughes, 1'. M.: Guldalln~ ~'or Apbosbo American Archives of Rehabilitation Therapy 9: 4-)0,1961. Institute for Social Research, Survey Re~arch Center: The Impact of Scier~e i~l the Mass Media; s report on a netlonwlde survey for the National A~soeiation of lieionc.e Writers. The University of Mie.higen, Ann Arbor, )958. Jones, R. J., Editor: Evolutio~ of the Atherosclerotlc Plsgee, University ef Chicago P~e~.~, Cldea~o, 196~. Joint Coranllsslon on Mental fi]ne~ and Health: Final Report, Action for Mental Health, Baeic Bochs, Inc~, New York, )961. Kaiz, L., et ai,: Heart Failure: paper propared for the Second National Co~. ference on Cardiovascular Diseases, W~shlngion, D.C., Novemher, 1964. Keidi~ J. D., Rowe, R. F. and Vlsd, p.: Heart Disea~ in Infan~ and Childhood. Macraillan, New York, )959.

4~ ! LI Ktdd, C. ~'.: Amerlean Unlversitie~ and Federal Race.arch. Belknap Press, Cam- bridge, Mass., 1959, Kirklin, d., el al.: Cardinva~ular Surgery: paFers prepared for the S~cond Natlostd C~nf~e~ o~ Cardi~aealar Di~. Vf~ngto~, D~., Non,m- her, 196k Klalner, L. J., Gibson, T. C. and White, K. L.: The Epidemiolog~ of Cardtao Failure (in he publbhed}. [.add, A. C.: Cerebrova~cular Disease in an Employed Population, Jnllrnal of Chronio Dis~ts¢~ 15:98.5-990t 1962. bhttlson, B. F. and Richman~ T. L.: The Case of the bllsslng Mileposts, Co~- reunify/Iealth Services, Publle Affairs Pamphlet No. 180-% Public Health Affalr~ Coramlt~, N~ Yo~k, 1962. Miller, G. E.p et al.: Teaching and Loari~ing In Medleal Schools. Harvard Uni. veralt y Press, Cambridge, Mass., 1961, ~lllllk~, C, It., Si~rt, 1L G. and l~/~i~nt, ], D., Edltor~: C~rebTd Va~- nolar Disease|. Grcne and Stratton, New York, 1961. Mobs, bL D.: Servtce Thrn'agh Placemenl in the Junior Colleges, America Asso- elation of Junior College, Washlngton, D.C,, 1962. bltathkin, S. J., Editor: Economies of lfigh~r Edueatton. U.S. Doparlme~t of Health, gdu0ation and WelIare, Washlngton, D.C., 1962. Nadas, A. S.: Pediatric Cardiology, 2nd edition. Saunders, PhileddphiI~, 1963. National Academy of Selenees--National Research Council, Division of Medical Sciences: Communications Problems in Biomedleal l:tesoareh. Wathin~on, D,C., 1963. National Academy of Sdenc¢~, Committ ~e on Science and Publle Policy: Federal S'apl~olt of B~i~ R~a~oh h I~,tltut inns o f Hlgl~ I.~anfmg. Washhgto~, D.C., 1954. National Academy el Soieneos, Committee on Utillzatior~ of Salentifio Engineer- ing Manpower: Toward a Better Utilization of Scientific and Engineering Talent. Washington, D.C., 1966, National Health Education Committee, Inn,: Does Medical Researoh Pay O~-- InLay? InDollar~? NowYork, 1964. National Healt Ingtitote: Staff Report on Developmental Gran~, 1964 (uup~li~edL National lnstltulcs nl Health, National Institute of Neurological Diseases and BIIndnels: Survey Report, Cerebral Vascular Study Group. Bahesda, Md., 1961. National lnaltut~s ot Health Cltniosl Research Centers program: Special Report. 1963 (anpuhllsh~). National Inatltnt~s o/Health: blaterlah on International Re~earoh and Tralning 7~6-419 C~64-9 HEART DISEASE, CANCER AND ATROK[

106 HEART OI$[ASLCRNCER AND STROKE Supported by the National Institutes of Health. prepared for the Commission by the Office of International R~earch. Betheada, Md., 1964. National Health Couneih I/ealth Careers Guidebook. New York, 1955. National League for Nursing Committee on the Que~tlonnaire Study of Prac- tical Nursing Schools: Education for Practical Nursing, 1960. New York, 1962. National Merit Scholarship Corporation: Guide to the National Merit Scholar. ship Program. Evanston, IlL, 1961. Orlans, H,: The Effects of Federal Programs on Higher Education: A study of 86 institutes and colleges. The Brookings Institution, 196~. Osgood, C. and Osgood, M.: Approaches to the Study of Aphasia, a report of an inter-disoiplinary conference on aphasia. University of Illinois, Urb~aa, IlL, 1963. Page, L H., etal.: Atheroseleroeis: papers prepared for the Second National Conference on CardiovaScular Diseases. Washington, D.C. November, 1966. Pattison, IL A., Editor: The Handicapped and Their Rehabilitation, Thomas, Springfield, Ill., 1957. President's Commission on National Goals: Report, American Assembly, Co- lumbia University, Now 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., 1968. President's Science Advisory Conunittee: Scientific Progress, the Uaiversltlos, and the Federal Govenlmeut. U.S. Government Peinting Offiea, Washington, D.C,, 1960. President's Science Advisory Commltt~e: Meeting Manpower Needs in Science and Technology. U.S. Government Printing Office, Washington, D.C., 1962, President's Science Advisgry Committee: Life Sciences Panel: Some New Teeh- neiogies and Their Promise for the Life Sciences. U.S. Government Printing Office, Washington, D.C., 1968. President's Science Advisory Committee: Report. Scieuee, Government and Information: the responalbllltles of the technical community and the govern- mvnt in the transfer of information. U.S. Government Printing Omen, Washing- ton, D.C., 1963. Price, D. K.: Government end Science: Their dynamlo relation in Amoriuan democracy. New York University Pre~s, New York, 1954. Progre-~ Report of the Joint Study of Extraeranial Ar~rla] Occlusion, pnmmted at the Fourth Conferenee on Cdrebral Vascular Diseases, Peineeton, NJ., Jan- uary, 1964 (in pre~a). Rantz, L. A,, etal,: Rheumatic Fever-~2ollagen Disease: papers prepared for

the Second National Conference on Corcliovasuular Diseat~es. Washington, D,C, Nowmher, 1964. Rheumatic Foyer in C)~ildran and Adole~eal~. Annals of Iaternal Mediclne 60 : (SUpp. 5) Fe~0ruary, 1964. Ritehie, D.: Stroke: A study of r~owry. Doubleday, Gardan City, N.Y., 1961r RiVEd, A. M.: The R0)e of the F~eral Governm~at in Financing Higher Educa. tion. The Bzookingr Institution, Washington, D.C.~ 1~61. Roter~tock, I. M,: Pu~ic Acceptance of Influenza Vaccination Programs. Amerlcaa l~evlcw of Respiratory Dise,ccs 83: 171-174, 1961. Edhe, C. H. W.: A Survey of th~ Activlsies of Medical Suhools in the Field of Continuing Medical Education. Journal of Medical Education ~8:82~28 19f~. Ruhe, C. H. W.: The American Medleal Associntlon'~ Program of Aceredltatinn in Continuing Medical Education. Journal of Medlcal Education 39: 570~78, ]964. Rtmk, H. A.: Rebabilit~tinn Medicine, MoshS', St. Louis, Mo., 1958. Saekott, D. L. aed Wir, k~lstoin, W.: The Epldemiolngy of Aortic and Perlpsural AtherolclerosiB: A ~leeted review (to he publlshe,1), Surnof[, D.: The Sushi Impact of Computere~ An atldrews to she American Banker* AE.seeiatinn NationaI Automation Con(erence, New York Wofld'B Fair, July, 1954. Subnelder~ J. H.: Survey of Projects Related to the published Literature StEp- ported by Gzanla and Edntraels From the Public Hoalth Survjce. NetinnB] Li. brary of Mediciao, Betheeda, Md., January, 1964 (unpublished). Suhuman, L. M.: Th~ Epidemiology of Thromboembolic Disorder* (to t~e poblished), Suhweit2or, M. and Gaaring, F,: The Epidemiologr of Hypertension (to be publlshea), $hep~, C. G., Wall G. A., Jr. ~ntl J~cobso~, C., E~itor*: Medical Education and Medical Coro--Interaetinns and prospects. Report to the Eighth Toaehlng In- stitute, A~oriation of American Med]cBI Colicges. At*oci~icn of American Medical Coll~ge*, EvtmBton, ]ll., 196f. Sherry, $,, otal.: Thrombeambolic Di~rdcr*: paper pr*pared for the Sueo~d N~tinn~l Cooferenco on Corthovascubr Dic~t~e~ V/a~hington, D.C., bic~vora- her, 1964. Spring, W. C., Jr. and ffonirk~r, F.: Drag It~formatinn for the Biomedical Com- munity: A report of | preliminary ~tudy of th~ needs for a National D~ug |n- formation Cle.~rlnghou~*. Pub|i~ Health Service, Washington, D.Cr, 1953. SEamier, J., et al.: Atheroscicrosls. Community Sur~iee Aepect~ of Coron~try 101 HEART DISEAEE, CANCER AHO STROKE

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Wrlght, I. S. and Millikala, C. H., tkiitol~ : Cerebra/Va~ular Disease~. Grune and Stratton, ~,'ow York, 1958. Wright, 1. S,, et al.: Core~rova~ular Disease: papers prepared for the Second National Confgrence on Csrdiovasettlar Diseases. Was]lington, D.C.. November, 1964, Wright, I. S.: The Etiology and Pathogenesis of Myocardial lnforetion: paper prepared for the Subcommittee o~1 Research of the Preaidont's Commission on Heart Disease, Cancer and Stroke. Wright, 1, S.: The Pte~nt St~tu~ and Future NeeA~ for AutleaaguL~nt Therapy: paper prepared for the Subcomittee on Heart Dise~ of the President's Com- mission on Heart Di~ea*e, Cancer and Stroke, Zilvcff~tttit, D. B.: T~,e [t/i~t~llsr~ ~{ t~ #.rtcri~l Wttl[; pa~ ~to~ar~t ~or tl~ Subcommittee on Research of the President's Commission on lfoart Dhease, Cancer and Stroke. 113 HEART OltEAS(,CA~RIER ANO STROKE

APPENDIX G ACKNOWLEDGMENTS The accomplishment of the Commission's study and report was made possible by the valuable services of the following: Mr, Wayne Bard Mrs. Frank M. Barry Mr, G. Stanley Beane Mrs. Charlotte Bloom Mrs. Catherine Bowling Mrs. AgnesBrewster Miss Lynn Brewster Mr. William S. Brooks Miss Olga Bulka Miss Brenda Bu rkevich Mr. Bruce Carson Dr, Helen Chase Miss Elaine Conies Mrs. Mary Creep Mr. Ru~-sell Dean Mrs. Mildred Doutsch Miss Julia Dickinson Dr, Pat risk J, Doyle Mrs, Jacqucline EI]ington Mrs. Marion Fleming Mr. Harvey Geller Mr, Irving Goldberg Mrs, Tavia Gordon Dr. Lee Hansen Mr. Arehie Hardy Dr. Arthur L. Harris Mr. Wade L. Harry Miss Marjorie T. Hayes Miss Nancy Hedges Mrs. Marjorie Herbert Mr. Calvin Hopewell Mrs. Eleanor Howell Mr. J. Stewart Hunter Mrs. Dorothy M, Johnson Mrs. Anna Keller Miss Barbara Lane Mrs. Mildred K, Lassman Miss Marilyn Lebedzinski Dr. Forreat Linder Dr. Clam C. Lianenberg, Jr. Mr. Erlk Lunde Mr. Herbert Mathewson Mrs. Thelma Miller Miss Janet Mitchell Mr. John A, Mossherg Miss Dawn Patten Mrs. Maryland Pennell Mrs. Elsie Phillips Mrs. Martha Phillips Miss Helen K. Powers Mrs. Dorothy Rice Mr. Elmer Riggleman Mr. Morton Bobbins Mrs, Virginia Shuler Miss Dolores Shupenka Mr, Hartman B. Spence Miss Bonnie Starner Mrs. Pat rieia Strdke Mrs. Vermel Thompson Miss AnnetteTouya Mr, Clark L. Tynes Mr. Samuel B. Wehh, Jr. Dr. Burton Weisbrod Mrs. Willie Wells 114 HEART DBEASE, CANfER AND $TROKf ~s ...... j

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