HEART DISEASES

THURSDAY, MAY 6, 1948

HOUSE OF REPRESENTATIVES,

COMMITTEE ON INTERSTATE AND FOREIGN COMMERCE,

Washington, D. C. The committee met at 10 a. m., pursuant to adjournment, in room 1334, New House Office Building, Hon. Charles A. Wolverton (chairman) presiding.

The CHAIRMAN. The committee will come to order.

The first witness will be Dr. Robert Levy, member of National Research Council, New York, N. Y.

STATEMENT OF DR. ROBERT LEVY, MEMBER OF NATIONAL RESEARCH COUNCIL, NEW YORK, N. Y.

Dr. LEVY. Mr. Chairman and members of the committee, may I request, sir, that I be permitted to read this statement which I think will take no more than 14 minutes, and then answer questions at the end?

The CHAIRMAN. That is the procedure that the committee follows. The witness is permitted to make a statement in full before any questioning. You may proceed.

Dr. LEVY. Thank you, sir. I believe it is customary first to qualify. My qualifications as a witness are as follows: I am a certified specialist in cardiology and practice in New York City. I am professor of clinical medicine at the College of Physicians and Surgeons, Columbia University, and director of the department of cardiology at the Columbia-Presbyterian Medical Center; chairman of the subcommittee on cardiovascular diseases of the National Research Council; president of the New York Heart Association; and a director of the American Heart Association.

It is estimated that 1 out of 20 persons in the United States suffers from a disorder of the cardiovascular system; almost half of the deaths after the age of 45 are caused by heart disease. There can be no question as to the numerical importance of this group of conditions.

It is customary to stress the fact that heart disease is the No. 1 killer and that it is among the leading causes of disability. It is responsible for a huge annual economic loss in terms of manpower. But rather than occupy your attention with an expansion of this theme, I would like to emphasize some of the great forward strides that have been made in our knowledge of circulatory diseases during the past 50 years and in the practical application of this knowledge.

The mechanisms of the irregularities of the heart have been clarified to such an extent that these can be recognized at the bedside and accord

ingly can be effectively treated. The electrocardiographic method has been utilized to great advantage in studying both experimental and clinical problems. X-rays have proved their worth in diagnosis. Coronary heart disease, with which the laity has become familiar because it is such a frequent cause of death during the prime of life, can now be readily diagnosticated and many of its victims returned to lives of activity and usefulness. Epidemiologic studies, particularly those made in the armed forces during World War II, have stressed the role of the hemolytic streptococcus in initiating and reactivating rheumatic fever and its cardiac lesions. Certain congenital malformations of the heart have become amenable to surgical treatment; many of the blue babies can now be saved, as you have read in the press. Bacterial endocarditis caused by the green streptococcus, which before the advent of penicillin was almost invariably a fatal infection, can now be cured in a high percentage of cases by injections of this drug. A new era in the treatment of those diseases in which clots form within the vascular system-the so-called thromboembolic diseases has begun with the introduction of the anticoagulants, heparin, and dicumarol, into clinical practice. Of these likewise there has been much in the press of late.

Much has been accomplished; yet much remains to be learned, and I would stress this. The causes of the three most important types of cardiovascular disease, namely, rheumatic fever, hypertension-that is high blood pressure-and arteriosclerosis, are still unknown. In the case of rheumatic fever, it seems probable that an infectious agent is concerned. High blood pressure and hardening of the arteries represent disturbances in pathologic physiology, the nature of which is imperfectly understood. Because the direct approach to therapy is still thus blocked by lack of precise knowledge, flank attacks to halt the progress of these diseases are currently being made. The operation on the sympathetic nervous system to lower blood pressure has been much discussed in the public press and various dietary programs, particularly those which employ rice as their chief ingredient, have been hailed as panaceas. To the patient suffering from a progressive disease, to whom only limited help can be promised from the application of the more conservative methods of management, any new departure in therapy appears to offer hope. Until better and basically sound forms of treatment become available to us it seems fair, in properly selected cases, to sanction trial of such measures. But their use must not be permitted to cloud the viewpoint of wholesome ignorance and thereby retard efforts to explore more deeply into fundamental principles. Painstaking investigation, both in the laboratory and clinic, eventually will discover causes now obscure and so will lead to preventive measures and remedies. There is no other road to the achievement of these ends.

In view of the facts just presented, it is fitting that the Government should appropriate funds for the study of the cardiovascular diseases and that such investigations should embrace every aspect involved. There are certain features of the heart bills now before Congress which merit individual discussion.

A heart institute in which both laboratory and clinical investigations might be carried out, would serve a useful purpose; but such an institute would function most effectively if established as an integral

part of a large university medical school and clinic. There is ample precedent for such an arrangement. For there already exist in various university centers special departments devoted to the study of particular groups of diseases and caring for patients suffering from these diseases. Such departments occupy floors within a building which includes other units or are housed separately. The list of specialties partially though not adequately provided for is a long one and includes cancer, tuberculosis, psychiatry, neurology, obstetrics, and gynecology, urology, ophthalmology, pediatrics, and orthopedics. You will note that cardiology, that is the field devoted to cardiovascular diseases, is conspicuously absent. In a university atmosphere there can be correlation of the various specialties and workers in particular fields can avail themselves of facilities and contacts which do not exist in an institution which lacks these affiliations. It is in the universities that the best medical and scientific talent is concentrated and it may prove difficult to persuade those best qualified to leave their academic surroundings for an atmosphere in which such advantages are lacking. Furthermore, for one interested in academic medicine in its broadest sense, a university affiliation is highly desirable.

These bills place great power in the hands of the Surgeon General of the Public Health Service and the Federal Security Administrator, for the Surgeon General, with the approval of the Federal Security Administrator, may appoint 12 members to the proposed National Heart Disease Council. In view of the fact that this council will be responsible not only for the expenditure of the funds provided but for determining the policies to be followed, it would seem wise to specify that such appointments should be made only after consultation with, and the approval of, such representative national organizations as the National Research Council, the Association of American Physicians, the American Medical Association, and the American College of Physicians. The officers and directors of these groups are in the best possible position to know the outstanding authorities in the field concerned. In the national science bill, introduced in the House by the chairman, Mr. Wolverton, on March 25, 1948, and I understand passed by the Senate yesterday, it is specifically stated that nominations of persons for appointment to the National Science Foundation should be submitted to the President by various recognized and qualified national scientific or educational organizations. In passing, it may be said, also, that the science bill, H. R. 6007, provides for the establishment of a special commission on heart and vascular diseases. I understand that the science bill was passed by the Senate without provision for any such commission.

The CHAIRMAN. I was informed that the Senate thought that it would be a cleaner bill without those measures in it. I am unable to understand the application of the word "clean."

Mr. LEVY. It is my opinion that the integration of various scientific research programs can best be accomplished by having special commissions of this type appointed under the auspices of a single foundation, as provided for in the national science bill.

There is one other point with regard to policy which I would like to mention. In initiating any new project, it is always wise to start modestly. We must learn to walk before we can run. So in setting up funds for special studies, it is well not to appropriate more money

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than can be spent profitably, not to plan more projects than can be staffed by qualified workers, and not to build institutes until it is clear that they are needed. I venture to suggest the following as basic concepts in the consideration of a Federal heart plan:

First, that the National Heart Council be appointed according to the principles previously outlined.

Second, that funds made available by the National Heart Disease Act as passed be expended, at the start, in facilities already existing in the universities, their medical schools and hospitals.

Third, that provisions be made for grants-in-aid for projects sponsored by such institutions. Grants-in-aid could be made also to individuals working independently if the council should deem this proper. Fourth, that fellowships be established in order to train groups of promising young research workers who would, by their growing numbers, make possible the expansion of this program.

Fifth, that a campaign of public education be conducted with respect to diseases of the heart and circulation.

Sixth, that the establishment of a National Heart Institute be deif desired, such an Institute or institutes might be organized; if so, if desired, such an Institute or institutes might be organized; if so. it should be located in an established university medical center.

The CHAIRMAN. Doctor, we see from the statement that you have made, that you have given this a great deal of study and consideration and we value your opinion very highly because of your experience and the contact that you have had with the subject.

It would seem as if you believed that the expansion of heart research should be in the medical schools and universities rather than in a distinctive building located in Washington or elsewhere. Is that a true understanding of your views?

Dr. LEVY. That is correct, sir.

The CHAIRMAN. Any questions, gentlemen?

Mr. HESELTON. Just one question the answer to which I think might be helpful to anyone who has an opportunity to read your statement. Could you furnish the committee a list of the medical schools and universities where there are medical schools such as you have mentioned, as well as their location?

Dr. LEVY. Possibly, Dr. Teeter has that. I am not sure. I can go further than that. There is being prepared at the present, under the direction of Dr. E. C. Andrus, of Johns Hopkins, for the Public Health Service, a complete list of all of the researchers in cardiovascular diseases being carried on in all of the medical schools and universities in this country and that should be available before long. There is a questionnaire that has been sent out. Dr. Rappelye, I know will bear me out on this.

Mr. HESELTON. I wonder, Mr. Chairman, in view of that if the clerk can be requested to obtain it or some arrangement may be made so that that list may be obtained for our use in considering these bills. That is all.

(The list referred to is as follows:)