Stenzler asked me if I had any explanation for the increased severity and frequency of diabetic ophthalmology in black females. For reasons which we do not understand, there is a much greater incidence of the severe diabetic retinopathy in black female patients. Since these are his most productive years, the burden of blindness causes significant financial and emotional hardship for the patient and his family.

It is generally recognized that at least 60,000 diabetic patients in the United States are legally blind. A much larger number of additional diabetic patients has partial loss of vision in both eyes, or blindness in only one eye, and are, therefore, not "legally blind." Considering only the legally blind, with an average cost of $2,000 in public and private aid to each of these 60,000 individuals, we have the staggering amount of $120 million per year for support of the diabetic blind. In addition, the estimated loss of income of $3,000 per blind diabetic individual adds up to a total for both aid and loss of income for the diabetic blind to approximately $100 million annually in this country. Contrast this $400 million average figure with the $4,500,000 available to the National Eye Institute of NIH for its entire research program concerning diabetic eye disease this year-a ratio of almost $100 to support the diabetic blind for each dollar spent on research.

The National Eye Institute is to be commended on recognizing the high priority of diabetic blindness. Indeed, the modest figure of $4,500,000 actually represents a three-fold increase over the funds allocated for diabetic eye research just 4 years ago. But $4,500,000 for all research on diabetic blindness is grossly inadequate since the basic cause of diabetic retinopathy is unknown and there is no effective method of prevention. Furthermore, treatment of retinopathy, once it has developed, is very limited.

Approximately one-third of the total funds this year for diabetic research support the 15-hospital cooperative study to test photocoagulation treatment. Photocoagulation is that technique of coagulating or welding abnormal blood vessels in the retina by focusing a light, or laser beam, on the vessels. Even if this treatment proves definitely beneficial, we already know that many stages of retinopathy cannot be treated by this method. As a member of this cooperative study and of the executive committee that supervises the program, I recognize its importance as it represents the principal therapy now available. But, in actuality, this approach is a stop-gap one, comparable to putting a finger in the dyke. And even when this form of treatment is effective, it may be only temporary and a recurrence of the retinopathy may develop later after an initial success. What is required, and should be given the highest priority, is a major increase in basic research support to determine the fundamental cause of retinopathy and to develop methods of prevention of this dread complication of diabetes.

In addition to supporting the priority need for multidisciplined basic research efforts in all systems affected by diabetes, the National Society for the Prevention of Blindness calls attention to the need for better education of the diabetic population and their families, as well as their physicians and other paraprofessional personnel, dealing with the complex problems of the diabetic patient.

I strongly recommend an increase in appropriations to support multidisciplined and coordinated research, training of research scien

tists, and the improvement of facilities for patient care. I make this request on behalf of my patients as director of the largest diabetic retinopathy center in this country and on behalf of the 5 million known diabetics in the United States who are potential candidates for the severe vascular complications of diabetes.

Mr. Chairman, thank you for the privilege of addressing this distinguished committee.

Mr. FLOOD. Thank you, Doctor.

Dr. Richard Schwarz?

Dr. SCHWARZ. The obstetrician-gynecologist is presented with a different perspective of diabetes. Prior to the insulin era, the combination of diabetes and pregnancy was essentially nonexistent, as the uncontrolled diabetic was either infertile or aborted spontaneously, if she did conceive. Now, with better understanding and control of at least the metabolic aspects of their disease, diabetic women are establishing and carrying pregnancies, and in so doing, bring forth a different array of problems.

It has been estimated that 1 in 3 to 400 pregnant women have diabetes.

In viewing this combination of events one must consider first the impact of pregnancy on diabetes, second the impact of diabetes on pregnancy, and finally the effect on the offspring.

As concerns the effect of pregnancy on diabetes, if one uses the common standard of insulin requirement, there is a significant worsening of diabetes during the course of pregnancy; however, in most cases the requirement returns to prepregnancy levels following delivery. Unanswered questions, however are whether insulin requirement truly reflects the state of the disease, and whether or not pregnancy may accelerate the disease at other levels, such as the vascular or renal. Clearly, patients with advanced renal or retinal disease are at considerable risk during pregnancy. At the other end of the spectrum is the genetically predisposed patient whose disease first becomes apparent as the result of the diabetogenicity of pregnancy. For her this may well be a preventive medical happenstance in that it may serve as a warning to avoid obesity and the later development of adult onset diabetes.

When the diabetic achieves a pregnancy it is a far greater undertaking than it is for her nondiabetic peers. She must expend more time, money and emotional energy, all with a markedly decreased chance of a successful outcome. The diabetic is at increased risk of such complications as pyelonephritis, polyhydramnios and toxemia, and has a perinatal mortality rate, despite the best of obstetric and pediatric care, which is at least three times that for the nondiabetic.

Ten to fifteen percent of babies born to diabetics are either stillborn or die within the first 30 days of life.

The diabetic offspring, if live-born, has a threefold increase in congenital malformations; sixfold if one considers only the lethal defects. In addition, the newborn is subject to jaundice, hypoglycemia, hypocalcemia, respiratory distress, and birth injury because of increased size. There is also an increased chance that the child will ultimately develop diabetes, although the genetic pattern, or probably patterns, of diabetes are so poorly understood that there is no solid basis for advising the patient about that risk.

Finally, when dealing with the pregnant juvenile diabetic there is the acknowledged but usually unspoken concern that she may well

not survive to see her child mature as she faces the ravages of the vascular, renal and ophthalmologic effects of the disease.

In gynecologic practice there is perhaps a more subtle view of diabetes. The gynecologist, often cast in the role of a primary care physician for women, has the opportunity of detecting diabetes, whether his suspicion is raised by persistent vaginitis or glucosuria, or simply because he evaluates blood sugar as part of his periodic health evaluation. He also recognizes the association of diabetes with certain other entities, particularly carcinoma of the endometrium.

Perhaps in the end these perspectives seen by the obstetriciangynecologist more than anything raise a number of questions. What are the genetic patterns of diabetes and how should patients be counseled? What is the mechanism whereby diabetes leads to an increase in congenital malformation? What is the releationship between diabetes, ovarian function and vascular disease? The interplay between diabetes and pregnancy may truly represent a microcosm of diabetes and its protean human manifestations. To understand it may be a giant stride toward the overall understanding of diabetes. To understand it requires carefully planned, coordinated, clinically relevant and obviously funded research. Although there have been great strides in the funding of diabetic research, I urge the distinguished members of this committee to continue and expand this commitment, and particularly to cover the interim period between now and funding through the Diabetes Commission. I would also remind the committee members that, although there has been established a National Diabetes Commission, there is no representative of the discipline of obstetrics and gynecology on that Commission to foster those areas of research I have touched upon.

Mr. FLOOD. Why not?

Dr. SCHWARZ. I do not know, sir.

I thank you for the opportunity to underscore for you one circumscribed area of the impact of this ubiquitous problem of diabetes

mellitus.

Mr. FLOOD. Thank you, sir.

Dr. Field?

STATEMENT OF DR. RICHARD A. FIELD

Dr. FIELD. Thank you for the opportunity to address you and this committee. I will forego the qualifications, as they are a matter of record, and begin with my story.

You have heard many of the aspects of diabetes already. You know that it has been 53 years since the discovery of insulin. You know of the optimism that that generated. That the problem of diabetes was going to come under control, that the diabetic would be normalized has unfortunately not come to pass.

The underlying cause of the foreshortened survival is a bodywide deterioration of the very smallest blood vessels caused by a relentless. thinning of their walls, a narrowing of the passageways for the flow of blood.

There has been a monumental amount of investigation into seeking and defining a biochemical or a molecular or some interrelating disturbances of sugar, fat, and protein metabolism in the diabetic. At the

present time there is no proven translation of any of the known facts which explains this deterioration which occurs in every small blood vessel in the body and brings about a multitude of problems that Mr. Stenzler has cited.

The evidence at hand is most consistent with the theorem that the blood vessel damage is directly related to the duration of the diabetes. Let me characterize for you what happens with a diabetic. On the average, 12 to 20 years of symptom-free existence transpire under our present capabilities of treatments before any problems or disabilities of the underlying advancing small blood vessel changes begin to

appear.

These changes are going on silently all the time in the youngster, in the adult, and in anyone who displays this disturbance of metabolism. Thereafter, or some time between 12 to 20 years, slow but relentless progression manifestation of vascular deterioration takes place. Damage to the eyes, the kidneys, the heart, the nervous system, and peripheral circulation occur. Then after another 5 to 10 years on the average, early death ends the misery of the blindness, the incapacitating kidney function, painful losses of function of the nervous system and usually there is a progressive deterioration in the capacity of the heart. This is frequently punctuated by acute fatal heart attacks.

Let's admit that everybody has to die of something some day. But in diabetes we are dealing with a prolonged situation of disability, incapacity over a prolonged period of years and we are doing so in bulk, involving as many as 10 million people.

In 1955, another advent took place. The oral antibiotic agents were shown to be able to reduce high blood sugar levels in the older diabetic population. Again great optimism flared up. It was hoped that a convenient treatment method for a very large population was at hand and it would improve their outlook in regard to long-term diabetic vascular complications and disease.

I won't try to raise the controversy created by this study as to the possibility that such treatment with oral agents increases the death rate of diabetics.

But let me emphasize the finding of this university group diabetes program which is often overlooked in the heat of the dispute on mortality.

This important finding to me is perhaps the crux of the findings of the project. That is the fact that the treatment did not benefit the patients in regard to preventing the development or the retardation of progression of the manifestation of the vascular deterioration.

Clearly then the oral agents are not the answer that we are seeking. Of all the various health problems you can think of, this has to be the most insidious and long term. It's small wonder that under these circumstances the general public, the governmental representatives, and the millions of diabetics themselves are unaware of the enormity of the existing problem and the gravity of the threat to the health of the Nation.

The identification of diabetes as a root problem is further beclouded by the isolation of various segments of the condition, either into heart disease, kidney disease, and so forth, and gets recorded in vital statistics by the organ which caused the terminal failure. It still has to be put together into one single disease.

I feel quite safe in venturing the guess that diabetes causes more mortality, direct and indirect, more morbidity, more disability, more economic loss, more family and social disruption than poliomylitis, cystic fibrosis, muscular dystrophy, multiple sclerosis, and cerebral palsy all combined and put together. It rivals and perhaps surpasses cancer in regard to morbidity and economic losses since malignancy, by and large, is a short term problem while diabetic disability stretches over decades.

I can support these contentions by citing to you a survey which was done of the diabetic population of the Massachusetts General Hospital in 1957. Every record that was coded for diabetes was examined. The incidence of diabetes in the hospitalized population was 7 percent. If the patient were a diabetic, his chances of being hospitalized were greater by twofold than a non-diabetic of a similar age. Once he got into the hospital, he stayed significantly longer than the non-diabetic population and he stood much less of a chance of getting out of the hospital alive.

The chances were at least one out of five that the diabetic would return and be readmitted during the same calender year. If he ever did get out of the hospital, the chances were 50-50 that he was not better off functionally than when he arrived.

One diabetic out of 14 had a previous amputation. A similar number required amputation or vascular surgery during the hospitalization. Fifteen percent of the total cost of services to diabetics derive from amputations and vascular surgery.

The hospital bill for diabetics is substantially larger, by 50 percent, than for average patients. If an amputation is required, it is double that for other patients. Of the total costs of hospital care for the diabetics, one-third is paid by the patients and insurers; one-third is paid by the community through its taxes to Government; and onethird the Massachusetts General Hospital chalked up as free service. If you project those to 1975 incidence rates, since diabetes is increasing in frequency, and our new inflationary monetary standards, we can guess that over 12 percent of the current patients in the Massachusetts General Hospital have diabetes and that the total annual cost is in the neighborhood of $2 billion and that the cost to the taxpayer is approximately $700,000 at this one hospital alone.

In Boston, the Massachusetts General Hospital is only one of seven or eight major hospitals and we are very fortunate to have the Joselyn Clinic which deals almost exclusively with diabetes. Thus in Boston alone the cost of hospitalization of diabetics must be enormous, at the very least $25 million a year.

I think we have a major medical crisis ahead with this condition. It has been our experience in the past that medical science, both Government and health authorities, do not mobilize their efforts until after a catastrophic event occurs. I think we have here the possibility of averting such a health crisis by the year 2000 if we will take timely application of research. I think it's research that has to be done.

I am an advocate of education. I am an advocate of coordination. The problem in diabetes is that we don't have any of the key answers. I think they can be only derived from research.

Therefore, Mr. Chairman, I support in the strongest possible terms Mr. Heinz's suggestion that a specific addition of 3 percent to each of the several Institute budgets be made.