No. 1, that it is not very good for the patient to be put to bed for a long time. This can be documented by much evidence, the evils of immobilization and bed rest.

Senator MCNAMARA. I am sure you said that without the explanation

Dr. SWARTZ. So that this goes on to a philosophy of this type: We get the patient out of bed, start doing for himself. Now, 20 years ago you were in bed at least 2 weeks for an appendectomy. Now he is up the first day, and so forth. So we are in a position of trying to get people to do things for themselves in the spirit of rehabilitation. Since World War II this is definitely a part of the program. Motivation; do things for yourself.

This is in this spirit that we apply the same principle to having the patient first do as much as he can for himself. If he is paralyzed there is only one way he is going to be able to use his arm and that is to use it himself. No matter what you do aside from that, it is not going to take him out of the category of a disabled individual. This is our approach to the whole problem.

Senator MCNAMARA. This makes no reference to the great numbers of people that live in the slums. I mean you are talking about something else instead of giving me an answer to the question I asked. However, Mr. Spector has a question dealing with financial problems I believe.

Mr. SPECTOR. Just some statistical.

Senator MCNAMARA. Ask him yourself. Go ahead.

Mr. SPECTOR. I just wanted to clarify in the record some figures. In your statement here, Dr. Swartz, you mentioned by 1965, 75 percent of those over 65 will have coverage in the private hospital insurance. When Under Secretary Akins was before our committee she was discussing this point and indicated their estimates based on the projection of present trends would indicate that only about 56 percent of the population over 65 would be covered by private hospital insurance. This means, she said, that of 17.8 million people over 65 in 1965 that about 8 million would not be covered. I just wondered whether you had any explanation for the disparity in these projections as between the figures you have here and those that were developed by the Department of Health, Education, and Welfare, and then if HEW is correct, what are the possibilities of covering these 8 million indicated? About 2 million to 2,500,000 might get their medical care under old age assistance which would leave about 6 million still unprovided for.

Dr. SWARTZ. I would feel much more competent if you asked me a question which was a little more in the medical field. This takes me into a little deep water, and, of course, as you appreciate, as well as I, that statistics and estimates of the future may vary a great deal. Statistics that we use were quoted from the Health Insurance Association of America. We have reason to believe that these may be quite realistic. In 1949 Dr. Louis Bower, speaking about this very matter of health insurance in the future, estimated that between 80 and 90 million people would be insured in the near future with voluntary health plans, and it so happens that at the present minute there are 123 million insured. I have no definite way of knowing whose statistics in the future are going to be correct. Certainly in a country like America where we do depend on initiative of the individual this certainly is possible.

Senator MCNAMARA. Yes.

I think that difference in the figure is probably due to the fact that the Assistant Director of HEW was talking about the problems of people over 65 and the numbers involved were 1512 million, whereas you were dealing with the whole population. This, of course, brings about a disparity in the figures we are using,

Thanks very much, Doctor.

Dr. SWARTZ. Thank you.

STATEMENT OF BERWYN F. MATTISON, EXECUTIVE DIRECTOR, AMERICAN PUBLIC HEALTH ASSOCIATION

Senator MCNAMARA. The American Public Health Association, Dr. Berwyn Mattison, executive director.

Doctor, we would be glad to hear from you. Doctor, I see you have a prepared statement. Is it your desire that we include it in the record at this point as presented, and then have you summarize it?

Dr. MATTISON. Yes, sir, I would be very happy to do so.

Senator MCNAMARA. All right.

(The prepared statement of Dr. Mattison follows:)

PREPARED STATEMENT OF DR. BERWYN F. MATTISON, EXECUTIVE DIRECTOR, AMERICAN PUBLIC HEALTH ASSOCIATION

Mr. Chairman, my name is Berwyn F. Mattison and I am executive director of the American Public Health Association with headquarters at 1790 Broadway, New York, N.Y. I am a physician with nearly 20 years experience in the field of public health at local health officer at both the city and county levels; as a district State health officer in New York State; and as secretary of health for the Commonwealth of Pennsylvania.

The American Public Health Association is in its 87th year and is an association of public health workers and those interested in the field of public health. We have about 13,000 members and fellows in the association representing the top leadership among American health specialists. With the additional members of our 48 affiliates, we have a total membership of approximately 25,000-the largest of any professional public health organization in the world. We have affiliated organizations in 42 of the 50 States and 3 regional branches which include groups of State affiliates in the West, in the South, and in the central part of the United States.

Activities in the field of aging.-For many years this association has been aware of the growing problem of health services for the aging. At the moment most of our activities in this field are focused in the committee on chronic disease and rehabilitaiton which is chaired by Dr. Lester Breslow of California. However, many of our other committees have contributed specific recommendations and procedures for the guidance of those who provide such services. For instance, in 1953 a subcommittee on standards for housing the aged and infirm prepared and published a document entitled "Housing an Aging Population" which covered such subjects as characteristics of the aging process, shifting burden of dependency, housing needs, financial resources available to the aged, distribution and mobility of the aged, as well as a review of various attempts to solve the problem of housing of this segment of the population. The latter considerations included European experience and some experiments in this country with retirement towns, cooperative dwellings, nonprofit units, State aided public housing, etc. I mention this not as an attempt to analyze the problem of housing for the aged-for I am no authority on that subject-but simply to indicate the kind of work which has been done by the American Public Health Association through the voluntary contributions of leading authorities in every field of health protection.

At the present time our committee on chronic disease and rehabilitation has in draft form a manual for chronic disease programs which would enable health departments to better mobilize existing resources and bring them to bear on their own particular problems and needs in the field of aging. It is anticipated

that this manual, by bringing together successful experiences in various parts of the country, will be an inspiration to many State and local health departments to step up their effective efforts in providing better services for the aged.

Another current activity is our joint committee with the American Public Welfare Association on health problems of the aging. This joint committee, established during the current year, has brought together some outstanding figures in both the health and welfare fields for the purpose of "defining and implementing public health and public welfare responsibility for health and health related services for the aging." We hope that this can be accomplished through more effective programs within public health and public welfare agencies; and through strengthened interdepartmental cooperation.

The joint committee plans to assemble information on and publicize successful experiences in providing adequate services to the aging; to delineate areas in which public health and welfare departments can complement one another; prepare guides for State and local cooperative efforts; and encourage demonstrations and studies involving joint health and welfare department participation.

A number of other examples might be given of past and ongoing activities of the association in the field you are considering. However, I shall mention only one or two additional ones. For instance, a manual on the control of nutritional diseases in man which is now in draft form has been prepared by a subcommittee on nutrition of the standing committee on evaluation and standards. This publication will touch on the special nutritional needs of the aged and will doubtless be utilized in continuing our encouragement of nutritionist consultant services to the nursing homes and convalescent homes which are frequently deficient in this regard. And again, a special project supported by the National Institute of Mental Health is being carried out by our program area committee on mental health. This is the preparation of a program guide for public health agencies in the field of mental health. In this material the special problems of the aging will be considered and it is anticipated that additional services will result from the recommendations drafted for that publication. Possible extension of activities.-The organization of our basic membership is through 14 sections, each representing some special discipline or work area. Among those sections which have a very intimate relationship to the problems of the aging are the following: Health officers, public health nurses, dental health, engineering and sanitation, food and nutrition, medical care, mental health, and public health education. Any one of these groups either alone or with our program area committee on chronic disease and rehabilitation might well develop some special project in the field of services for the aging. Even this rather extensive list excludes some other sections that might be interested. For instance, the statistics section already has a subcommittee working on the preparation of monographs to make more rapidly available the information which will be secured through the 1960 decennial census. Much of the material which will be processed by this subcommittee will have a very definite bearing on a continuing analysis of the increasing problem of our aging population.

We have pointed out many times in the past that much of the "problem of the aging" could be prevented through public health means. More extensive use of newer public health and medical techniques on a widespread basis would certainly reduce the load of disability which must be anticipated in the growing segment of our population over 65. Training in the techniques of prevention and early diagnosis is one of the prerequisites for expanding such preventive services. The American Public Health Association has urged strongly increased Federal support for training in public health and we feel that this is one of the bottlenecks to future control of the health aspects of many of these problems.

Some specific problems of aging.-You have already received a great deal of quantitative data concerning the size of this problem and the increase which we must anticipate in the years ahead. Therefore I shall not repeat the statistics which have already been presented. You have also heard a great deal about the methods of financing additional health services to the aging and I shall not dwell extensively on that. However, before leaving the latter point, I should like to provide for the record the text of a resolution passed by the governing council of the American Public Health Association at its 86th annual meeting in St. Louis in October of 1958. It is as follows:

"Whereas health services for the aged are inadequate throughout the Nation;

and

"Whereas good health care is becoming more expensive to provide for the aged because of their high illness and disability rates, the increasing complexity and

rising costs of good care, the growing number of aged persons and their relatively small personal financial resources; and

"Whereas adequate financing is essential to support comprehensive health care of high quality for the aged; and

"Whereas the burdens of the costs of good care for the aged can be minimized for the aged, their families, contributors to voluntary insurance plans, charitable agencies, and taxpayers through arrangements, effective throughout the working lifetime, which provide paid-up insurance for the older years: Therefore be it

"Resolved, That the American Public Health Association support appropriate proposals to provide paid-up insurance for health services required by aged persons, which insurance financing should be accompanied by provisions to protect and encourage high quality care: And be it further

"Resolved, That the American Public Health Association support appropriate Federal, State, and local efforts to improve the financing and adequacy of health services for needy and medically needy aged persons through the supplementary public assistance programs and through other means, such as medical-care programs administered by health departments, and for all aged persons through public health and related programs."

Now with regard to some specific ways in which disabilities can be prevented in this segment of our population. A number of diseases which contribute very considerable numbers of disabled or bedridden patients in the later years can be reasonably well controlled if detected early. For some of these the methods of early detection are being very inadequately utilized. One example is the blindness caused by glaucoma, which, if picked up early by means of more generally available screening tests for increased ocular tension, can be much more successfully treated in those early stages. Another is diabetes, the complications of which can provide long-term disability in its later stages. Here, again, a relatively simple screening test requiring only a few drops of blood is available and has been available for a number of years, and yet is not being widely utilized. This would substantially eliminate the untreated early cases. The early detection of tuberculosis, which still contributes a very considerable portion of disability in the older age groups, has been more widely used than the two examples just mentioned. Here the focusing of case-finding efforts in those segments of the population where a high yield of tuberculosis is to be anticipated should be continued and intensified.

Another type of secondary prevention which is being inadequately utilized is the mobilizing of a series of ancillary services in the treatment of stroke resulting in hemiplegia. Many elderly people are needlessly bedridden because the services of a nurse, a physical therapist, and sometimes a homemaker are not available to the attending physician for early intensive treatment of the paralysis immediately following the cerebral accident. Some health departments have succeeded in mobilizing these community resources on an effective basis along the lines of a pattern described in the Public Health Service pamphlet called "Strike Back at Stroke" and are doing something practical about cutting down what has always been one of our major sources of disability of the aged. More should be encouraged to do likewise.

Because, as yet, at least, we can't prevent aging, there has been some tendency to assume that preventive medicine had little to offer in this segment of our population. Nothing could be further from the truth, for in all of the instances I just mentioned, plus many others, a great deal can be done right now with the services available (but inadequately coordinated) in most communities.

Another major problem is that of assuring high quality of medical and health services in any expanded program for the aging. Regarding this point, the president of the American Public Health Association, Dr. Leona Baumgartner, health commissioner of the city of New York, has recently said:

"While we in the American Public Health Association well realize that economic security and health are closely related *** our competence is, of course, confined to health matters, and we are chiefly concerned with those provisions of the social security titles which deal with medical care for public assistance recipients and for the medically indigent.

"Accumulating experience with these programs reveals some serious deficiencies and problems which are of concern to all the States. It is becoming apparent that, in the absence of any mechanism requiring the localities to establish standards of quality or to put a premium on medical excellence, the average quality of care provided over the country is not as good as it could be. Moreover, the size and scope of these programs offer many opportunities to provide better

medical care through more rational organization of services. These opportunities are being neglected. The accumulating experience which reveals these problems also provides the technology and the skill to deal with them constructively."

One of the ways in which a satisfactory level of quality has been maintained for governmentally supported medical services is represented by the program developed by the Children's Bureau for its crippled children's services. Giving considerable responsibility to States for developing their own programs but estab lishing certain standards (at the Federal level) for eligibility to receive Federal aid, these crippled children's programs have been highly regarded for the quality of service provided. In most instances these programs have been operated by health departments under full-time medical leadership and with very close cooperation between the official public health agency and the organized medical profession in that State. It would seem that this pattern is an extremely valuable one to keep in mind if there is to be any extension of similar services to the aging. Responsibility of official and voluntary groups at various levels.—In a questionnaire which went out from the American Public Health Association at the end of 1958 to all State health officers and to a selected group of city and county health officers, we inquired about the relative importance of various newly emerging health problems and of long standing health problems. In both categories our respondents listed the problems of aging and of chronic diseases very high in their sequence of priorities. They also indicated that if additional personnel and finances were available to them the problems of chronic disease and of services to the aging would receive special consideration. These are indications of a growing awareness on the part of public health officials at both State and local levels of the need for additional attention in this area.

Although the American Public Health Association has not taken a specific stand on the respective roles to be played by national, State, and local agencies, or by voluntary and official agencies in this field, I should like to offer some suggestions based on my own personal experience. When we are dealing with a health program requiring personal services to the individual, whether they be medical, dental, nursing, physical therapy, nutrition or homemaker, the immediate provision of such services or arrangement for their provision can be done better at the local than at either State or Federal levels. We have a great potential in this country of personnel already trained in health matters, and employed by local health departments whose time has been taken up in the past with the control of communicable diseases or those transmitted by water, milk, and food. A great deal more can be done by the public health nurses and the visiting nurse associations of this country to provide adequate home care for the aged. And more can be done by trained medical health officers acting as consultants to the medicalcare programs operated by welfare departments.

But there are many interagency relationships that have not been established which would have to be arranged before these personnel can be used to maximum advantage. Primarily these are relationships between local health departments and local welfare departments. As indicated earlier, studies of these interrelationships of associations are going on now between the American Public Health Association and the American Public Welfare Association.

For example, in some areas the licensing and control of nursing homes is a responsibility of the welfare department. Even while this remains so, it should be possible through interagency arrangements to utilize nutritionists from the health department to advise nursing home operators of the best utilization of their daily diets; to utilize the sanitation personnel of the health department for assurance of proper safety and sanitary standards; and to utilize public health nurse consultation as the basis for improving the continuity of good nursing care. Subjects, such as the periodicity of medical review of cases, should be considered; as should the manner in which drugs and other medications are procured and stored; and also the utilization of all available rehabilitation resources of the community so that bedridden patients might not always expect to be doomed to that state. There has been a grave fragmentation of community services to the aged. In some instances this can certainly be corrected by the reshuffling of responsibilities to provide most of them in a single department. But this is not the only solution and in some instances is not the best solution. Joint planning by health and welfare agencies is doubtless the proper place to start; a clear-cut division of responsibilities with the health department delegated those justified by its competencies would be a second step; and where multiagency authority and administrative responsibility appear to be desirable there can still be a close working relationship on the basis of interagency consultation.