Ffllt CALIFORNIA Report at the Caliiernia Chronic Disease Investigation Prepared in accordance with the pro ‘ “HS DEPARTMENT Assembly Concurrent ResolufiOn No.‘ ' ' its :49; \ and JUN 3 “949 , Printed in accordcmce with the ovi- \ i . HERA?“ . . stone of House Resolution No. 58 ( 49) “NEW“ 0? were , ,.-. U 3. v #0 BY ASSEMBLYMAN JOHN I". THOMPSON "1 Chairman. Assembly Committee ' .. on Public Health LgALIFORNIA STATE DEPARTMENT OF PUBLIC HEALTH WILTON L. HALVERSON, M.D., Director of Public Health L January, 1949 *‘I A CllflflNlC DISEASE PflflflflAM Fflfl CALIFIIRNIA Repertieifthe California Chronic Disease Investigation Prepared in accordance with the provisions of Assembly Concurrent Resolution No. 42 (1947) and Printed in accordance with the provi- sions of House Resolution No. 58 (1949) BY ASSEMBLYMAN JOHN F. THOMPSON Chairman, Assembly Committee on Public Health CALIFORNIA STATE DEPARTMENT OF PUBLIC HEALTH L WILTON L. HALVERSON, M.D., Director of Public Health I Ianuary, 1949 PUBLIC HEALTH LIB, LETTER OF TRANSMITTAL State of California, Department of Public Health 760 Market Street, San Francisco 2, California January 10, 1949 Honorable Earl Warren, Governor Honorable Goodwin J. Knight, President of the Senate Honorable Sam L. Collins, Speaker of the Assembly State Capitol, Sacramento 14, California DEAR SIRS: By the provisions of Assembly Concurrent Resolution No. 42 (1947) the Department of Public Health was directed to investi- gate the problems involved in the reduction of deaths and disability from cancer and other chronic diseases; to report to the 1949 General Session of the Legislature the results of its investigation; and to make recommendations as to a program for the; reduction of such deaths and disability. The department—recognizing that the chronic disease problem involves many and varied interests—called upon leading professional and lay persons in the State for guidance, advice, and assistance. An advisory committee and technical advisory groups played major roles in the chronic disease investigation. As director of the State Department of Public Health, I respect- fully submit the report of the chronic disease investigation. In so doing, I take great pleasure in pointing out that this is not the report of the department alone—but rather the report of the department and the advisory committee working together as a team, ably assisted by the technical advisory groups. Respectfully, WILTON L. HALVERSON, M.D. Director, Department of Public Health ill—181203? (3) ASSEMBLY CONCURRENT RESOLUTION No. 42 Adopted in Assembly April 14, 1947 Adopted in Senate lune 6. 1947 WHEREAS, It is the desire of the Legislature to provide in every way possible for a program to reduce the deaths and disability from cancer and other chronic diseases in the State; and WHEREAS, It is necessary in making such provision that the Legisla- ture be fully informed on the problems relating to such a program; now, therefore, be it Resolved by the Assembly of the State of California, the Senate thereof concurring, That the' State Department of Public Health is hereby requested and directed to investigate the problems involved in the reduction of deaths and disability from cancer and other chronic diseases and that the State Department of Public Health report to the 1949 General Session of the Legislature the results of its investigation and make recommendations as to a program for the reduction of such deaths and disability and the costs thereof; and be it further Resolved, That the Chief Clerk of the Assembly is directed to trans- mit copies of this resolution to the Governor of California and to the State Director of Public Health. (4) CHRONIC DISEASE ADVISORY COMMITTEE Robert Ash, Secretary, Alameda County Central Labor Council, A. F. L., Oakland Edwin L. Bruck, M.D., Chairman of the Council, California Medical Association, San Francisco Rt. Rev. \Villiam J. Flanagan, General Director, Catholic Social Service, San Fran- c1sco Joe Hart, Modesto Kenneth W. Haworth, M.D., Health Officer, Napa County, Napa (Humboldt County. Eureka, when appointed) \Valter C. Kennedy, Second Vice President and Chief Underwriter, California-\Vestern States Life Insurance Company, Sacramento Howard Lambert, Community Services Director, C.I.0., Los Angeles R. B. McClellan, Chairman of Health and Hospitals Committee, County Supervisors' Association, Lompoc Lawrence B. O'Meara, D.O., California Osteopathic Association, Los Angelcs Edward S. Rogers, M.D., Dean of School of Public Health, University of California, Berkeley Mrs. Russell Scott, Chairman of Health Committee, California Congress of Parents and Teachers, Salinas William P. Shepard, M.D., Third Vice President, Metropolitan Life Insurance Com- pany, San Francisco Howard F. \Vest, M.D., Medical Director, Los Angeles County Department of Chari- _ ties, Los Angeles G. Otis VVhitecottou, M.D., Medical Director, Alameda County, and Trustee, Associa- 'tion of California Hospitals, Oakland Charles \Vollenberg, Director, State Department of Social Welfare, Sacramento (5) TECHNICAL ADVISORY GROUPS Cancer Commission California Medical Association Lyell C. Kinney, M.D., Chairman San Diego John \V. Cline, M.D ______ San Francisco L. Henry Garland, M.D.--San Francisco E. Eric Larson, M.D _______ Los Angeles Orville N. Meland, M.D _____ Los Angelcs Harry E. Peters, M.D __________ Oakland Henry J. Ullman, M.D.__Santa Barbara David A. Wood, M.D _____ San Francisco J. Homer \Voolsey, M.D ______ Woodland Epilepsy Medical Advisory Board. Northern Section. California Society ior Crippled Children Robert B. Aird, M.D., Chairman San Francisco Crawford Bost, M.D _____ San Francisco Alvin H. Jacobs, M.D.___San Francisco Henry Ncwman, M.D _____ San Francisco George H. Schadc, M.D.--San Francisco Northern California Rheumatism Association James Rinehart, M.D., Chairman San Francisco (6) Heart Advisory Committee California Tuberculosis and Health Association» S. J. McClendon, M.D., Chairman San Diego Howard Bosworth, M.D _____ Los Angeles Louis E. Martin, M.D ______ Los Angeles Charles A. Noble, Jr., M.D. San Francisco William Paul Thompson, M.D. Los Angeles Harold Rosenblum, M.D.-San Francisco (Committee Consultant) Bay Areaszommittee American Diabetes Association I. Lyon Chaikofi, M.D _________ Berkeley Mary B. Olney, M.D ______ San Francisco Hobart Rogers, M.D ___________ Oakland Francis Scott Smyth, M.D. San Francisco H. Clare Shepardson, M.D. San Francisco Bureau of Dental Health California Department of Public Health Hugo Kulstad, D.D.S., Chief San Francisco ‘u chTENTs Page Letter of Transmittal ____________________________________________________ 3 Assembly Concurrent Resolution No. 42 ____________________________________ 4 Chronic Disease Advisory Committee _______________________________________ 5 Technical Advisory Groups _______________________________________________ 6 Introduction ___________________________________________________________ 9 Summary of Findings and Recommendations ________________________________ 11 A Chronic Disease Program for California __________________________________ 18 Magnitude of the Chronic Disease Problem in California __________________ 18 Necessary Services and Facilities for an Effective Chronic Disease Program Research ______________________________________________________ Preventive Services _____' ________________________________________ 23 Statistical Services ______________________________________________ 24 Professional and Vocational Training and Education _________________ 25 Health Education _______________________________________________ 26 Diagnostic and Therapeutic Services _______________________________ 27 Hospital Care Services ___________________________________________ 28 . Other Institutional Care Services __________________________________ 30 Home Care Services _____________________________________________ 33 Future Chronic Disease Program _________________________________ 34 APPENDIX A. Demographic Studies ____________________________________________ 36 A-1 California's Population and Chronic Disease _____________________ 38 A»2 Chronic Disease Mortality in California _________________________ 45 A-3 Morbidity Data From the California Disability Insurance Program- 61 A-4 Estimates of Chronic Illness in California _______________________ 91 B. Services and Facilities for the Chronically Ill _________________________ 95 B-l Services and Facilities for Chronically Ill Welfare Clients _________ 98 13-2 Hospitals and Related Facilities in California ____________________ 103 B3 Notes on Bedside Nursing Services in California __________________ 109 B-4 Vocational Rehabilitation Services in California __________________ 112 B-5 The Crippled Children’s Program in California ___________________ 121 C. Expert Opinion __________________________________________________ 126 C-1 County \Velfare Directors _____________________________________ 130 C-2 Administrators of County General Hospitals _____________________ 136 C-3 Presidents of Hospital Conferences _____________________________ 141 C-4 Presidents of County Medical Societies __________________________ 144 C-5 Local Health Officers _________________________________________ 149 06 Presidents of Local Osteopathic Societies ________________________ 154 C-7 Executives of Voluntary \Velfare Agencies _______________________ 158 D. Reports of Technical Advisory Groups ______________________________ 163 D-1 Cancer _____________________________________________________ 165 D-2 Heart Disease ___ 191 D-3 Diabetes _ ______ 197 D-4 Epilepsy _ _ ___________ 201 D-5 Dental Disease ____________ ___- 206 D-6 Rheumatism ________________________________________________ 208 E. Pertinent Investigations Conducted in California and Other States ______ 210 E-l Studies in California ___________ _ 211 E-2 Planning for the Chronically III in Other States __________________ 213 E-3 Planning at the Local Level in Other States ______________________ 217 ( 7 ) INTRODUCTION ORGANIZATION or THE INVESTIGATION The chronic disease investigation was conducted by the California Department of Public Health. with the advice and assistance of an advisory committee and technical advisory groups. The advisory committee, appointed by the State Director of Public ~ Health, provided guidance and assistance in all phases of the investiga- tion—from initial planning through the final report. Technical advisory groups for specific chronic diseases—cancer, heart disease, diabetes, epilepsy, and dental conditions—were requested to study the problems relating to these specific diseases and prepare reports incorporating their findings and recommendations. The reports —presented in Appendix D—prepared by these groups were used exten- sively in drafting the findings and recommendations. Although attempts were made to obtain similar reports on alcoholism and rheumatism, it was not possible to complete the work on these two subjects within the time allotted for the investigation. The staff of the State Department of Public Ilealth, working closely with the advisory committee and the technical advisory groups, collected and analyzed statistical and other data for the investigation and assisted in the development of the findings and recommendations of this report. SCOPE AND METHODS OF THE INVESTIGATION The advisory committee, at its first meeting, agreed that the investi- gation should: (1) Obtain data on the magnitude of the chronic disease problem in California, (2) obtain information on present services and facilities, (3) obtain information on necessary services and facilities to cope with the problem, and (4) develop, from these data and related materials, recommendations for a program to reduce deaths and dis- ability from the chronic diseases. The following methods—approved by the advisory committee—were used to obtain data and to provide information essential for chronic disease program planning: (1) Analyses were made of pertinent investigations carried out in California and elsewhere; (2) Statistical studies were made of chronic disease deaths in Cali— fornia, illness and disability from chronic disease in California, and the age distribution of California ’s population; (3) Expert opinion was obtained from county welfare directors, administrators of county general hospitals, presidents of hospital con- ferences, presidents of county medical societies, local health officers, presidents of local osteopathic associations, and executives of voluntary welfare agencies; (9) 10 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA (4) Studies were made of present services and facilities for the chronically ill; and (5) Studies of specific chronic diseases were made by technical advisory groups composed of leading clinicians in the respective fields. The advisory committee, utilizing the data and related material from these sources and aided especially by the detailed reports of the technical advisory groups, developed and approved the findings and recommenda- tions of this report. SUMMARY OF FINDINGS AND RECOMMENDATIONS MAGNITUDE or THE CHRONIC DISEASE PROBLEM Chronic diseases ”“ accounted for the deaths of 66,518 persons in California during 1947—more than two-thirds of the total number of persons who died in the State that year. Forty percent (26,108) of the chronic disease deaths occurred ainong persons Inider 65 years of age. Cardiovascular diseases and cancer were the leading causes of death. The number of persons who die each year from the chronic diseases is only a fraction of the total number of persons who sulfer from chronic illness. The best available data suggest that in 1947 California had approximately 104,000 persons disabled the entire year by chronic ill- ness and approximately 351,000 disabled for periods ranging from one week to one year. Over two—thirds of these 455,000 persons were less than 65 years of age. The estimated number of diagnosed cases of cancer during 1947 in California was 50,000; the number of diagnosed cardiovascular cases was several times as large. During the first year of operation (1947) the California disability insurance state plan, covering less than one-third of the State’s population, paid disability benefits amounting to more than 7 million dollars for a total of 380,000 weeks of illness due to certain of the chronic diseases. This expenditure, partial compensation for wage loss, did not include the cost of medical care, hospitalization and allied services required for most extended periods of chronic disability. The cases included in the above estimates are, of course, those which have been diagnosed. Accurate estimates cannot be made of the number of undiagnosed cases. There are indications, however, that without being aware of it as many as 100,000 Californians have heart disease and 70,000 have diabetes. There are relatively few families not affected by a chronic disease at some time. There is hardly any area in the State that is unaware of the effects of these diseases on the welfare load and on the demands for medical, hospital, nursing and related services. A significant proportion of disability from chronic diseases might . be prevented with present medical knowledge. For example, it is esti- mated that 30 percent of the patients that now die of cancer could have been cured 1‘ had they received prompt and adequate treatment when ' the lesion first was discoverable. ‘ For specific diseases designated for study by the Chronic Disease Advisory Com- mittee, see page 18. 1' That is, these persons would have survived at least five years without evidence of the disease. (11) 12 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA NECESSARY SERVICES AND FACILITIES FOR AN EFFECTIVE CHRONIC DISEASE PROGRAM To meet the growing and already extensive chronic disease problem in California, the following services and facilities are necessary: I. Research Advances in combatting certain of the chronic diseases still depend on research. California has a number of professionally qualified medical and allied research institutions. However, grants from the Federal Gov- ernment and other public and private sources have not been allocated to some Of these institutions because of the lack of physical facilities neces- sary for carrying out research. It is recommended that the specific needs of California research institutions for additional physical facilities essential to the conduct of expanded research programs on the chronic diseases be determined. Such determination should be made by the State Department of Public Health in cooperation with the research institutions and appropriate professional societies. 2. Preventive Services A considerable amount of chronic illness and disability could now be prevented it effective use were made of existing knowledge and tech- niques. Early discovery Of and prompt medical attention for many of the chronic diseases are basic factors in control. Screening methods for the detection of certain of these diseases (eg. heart disease and diabetes) are being developed and some are now ready for wide-scale application. Accident prevention, industrial hygiene, professional and public educa— tion concerning the chronic diseases, and intensification of efforts against those communicable diseases which lead to chronic conditions—all play a significant role in preventing illness, disability and premature death. Although private and public agencies in California are carrying out some activities in the field of prevention, as yet only a beginning has been made. ' It is recommended that the development and utilization of preventive services for the chronically ill be undertaken by local health agencies with the cooperation and approval of local pro— fessional societies. The preventive program should include professional and public education concerning the chronic dis- eases, mass-sereening methods ( where proven medically sound) for early detection of chronic diseases, intensification of com- municable disease control programs with specific emphasis on these diseases leading to chronic conditions, and accident pre- vention activities. 3. Statistical Services Continuing statistical studies of the causes of death and illness are essential for knowledge of the chronic disease problem in California. The State Department Of Public llealth receives death certificates; how- ever, it has no specific authorization for continuing statistical studies of chronic disease. Data on illness and disability from chronic disease ‘ A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 13 are important, but difficult to collect. Not until recently has any effort been made to tap the sources of these data within the State: e.g. a few hospitals are furnishing information on cancer cases to the Tumor Registry of the State Department of Public Health, and the department is receiving disability statistics derived from the state disability insur- ance program. There is need for further development of sources and methods of obtaining current information on the incidence, prevalence and duration of cancer and the other chronic diseases in California. It is recommended that the State Department of Public Health maintain statistical services on a continuing basis as part of a chronic disease program. Special attention should be directed to the development of methods and sources for obtain- ing current data on chronic illness, without universal, regular reporting of individual cases of all chronic diseases. The tumor registry should be expanded on a voluntary basis to include all hospitals and clinics, and where practicable, private physi- cians—with at least partial reimbursement for the expenses of reporting. 4. Professional and Vocational Training and Education An effective chronic disease program depends in a large measure upon the knowledge of several professional groups including physicians, dentists, administrators of. hospitals and other institutions, nurses and medical social workers. All these require continuing educational oppor- tunities if they are to be expected to utilize current advances in their fields. Patterns of postgraduate education for physicians are being developed in the cancer and heart fields. Parallel programs should be made available to other professional groups, and comparable programs should be developed for other chronic diseases. It is particularly impor- tant to extend educational opportunities to personnel in the rural areas. A shortage of personnel for nursing care requires that special attention be devoted to recruitment and adequate training of nurses and auxiliary workers. It is recommended that the professional education and training programs of state and local professional societies be expanded ; that cooperative planning be. undertaken with the postgraduate training programs of the several professional schools and voluntary health agencies; and that the State Department of Public Health assist in the planning of programs of advanced professional education and training in the field of the chronic diseases. For financing such programs, state funds should be made available where there is a demonstrated need to augment contributions of professional societies for professional education. N 0 claims should be made, by agencies of the State, on the services of individuals trained through the use of such funds. It is further recommended that adequate programs be developed by qualified hospitals for the training of practical nurses. 5. Health Education Public understanding of What can be done by the individual and by the community to reduce deaths and disability from the chronic 14 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA diseases is essential to a successful attack on these diseases. Heretofore, a few voluntary associations and insurance companies have concerned themselves to some extent with health education about the chronic dis- eases. School systems and health departments have devoted their health education efforts primarily to the communicable diseases with only sporadic and fragmentary attention to chronic diseases. Health depart- ments and schools as well as professional groups could contribute sig- nificantly to the solution of the chronic diseases problem by increasing public knowledge concerning it. It is recommended that expanded programs for education I K of the public on cancer and the other chronic diseases and on . accident prevention be conducted by voluntary organizations interested in health, by professional societies, hospitals, educa- tional institutions, and health departments. \ \ 6. Diagnostic and Therapeutic Services The diagnostic and therapeutic services essential for an effective chronic disease program are inseparable from medical care services as a whole. Based on preliminary but necessarily incomplete information it appears that diagnostic and therapeutic services are generally avail- able in the urban areas of California but are not readily accessible to persons living in certain rural parts of the State. Measures are needed to make known the availability of these services in urban areas and to attain greater accessibility and coordination in the rural areas. Improve- ment of quality in diagnostic and therapeutic services must be con- stantly sought through such means as postgraduate education. Inti- mately related to the problem of diagnostic and therapeutic services is the great need in California for further hospital and nursing home beds ‘ for the chronically ill. 3 1 It is recommended that local communities with the guidance \ \ and support of local professional societies and health depart- \ ments work toward the goal of making available adequate diag- . l. nostic and therapeutic services either in their own communities or through arrangements with nearby communities. 7. Hospital Care Services Hospital facilities for chronic illness, equal in quality to those for acute illness, are needed to bring the best of modern medical care to those with chronic disease. As noted in the report “Hospital Facilities In California” by the State Department of Public Health, “’ ' " there is danger in the present drive for more hospital beds that attention would be centered too greatly on acute general beds when a substantial share even of the need for them could be met by the planning of chronic disease facilities as a part of general hospitals.” It was noted in the same publication (March, 1948) that there were only 3,434 acceptable hos- pital beds for chronic care in California compared with an estimated need of 18,684. This lack of beds for chronically ill patients increases the load on already hard pressed facilities for acute patients, especially in the county hospitals. Many communities in California are now using as general hospitals for acute patients facilities which are unacceptable as defined in the A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 15 above-cited report. The conversion of these facilities to use for chron- ically ill patients is not a satisfactory solution to the problem of chronic care. Additional funds are needed to meet the demand for chronic disease beds in California. Hospital facilities for the chronically ill should be closely associated functionally and geographically with gen- eral hospitals and should serve to stimulate clinical interest and research in the chronic diseases. On a long-range basis the need for tuberculosis and possibly other facilities will decrease and the conversion of those which are suitably located and constructed into facilities for the chron- ically ill may eventually be desirable. It is recommended that the California Advisory Hospital Council devote appropriate attention to hospital beds for the chronically ill in establishing priorities during the remaining period of the state hospital construction program; and that additional resources be sought to aid: ( a )- the construction of other facilities for the chronically ill—construction consistent with the recommendations of the California hospital survey, and (b) the development and empansion of custodial, nursing home, home care, and rehabilitation services, to ease the demand for hospital beds. ( For more detailed recommendations on hospital care services, see page 29.) 8. Other Institutional Care Services After maximum benefit has been received from hospitalization, many chronically ill patients need further care either in nursing homes or custodial facilities. At present there are approximately seven thousand nursing home beds in California. All authorities agree that additional nursing home facilities for both private and public patients are critically needed. Cost of such care is one of the prime problems. Custodial facili- ties in California are inadequate and vary greatly in quality of care provided. Some serve merely as a “dumping ground” for many types of patients. In addition to persons requiring nursing or custodial care there are many for whom substitute (boarding) home care would suffice. Development of nursing, custodial, and boarding home care is greatly needed. It is recommended that sufficient nursing, custodial and substitute home care facilities which meet adequate standards be made available by local communities to care for the needs of the chronically ill. These facilities should be correlated with the hospitals of the communities. In the smaller communities par- ticularly, consideration should be given to placing nursing and custodial units adjacent to general hospitals. 9. Rehabilitation Services Persons with chronic illness are too frequently regarded as hopeless invalids. Many who are now dependent on others for daily care can be brought to the point of taking care of themselves. It has been demon- strated that rehabilitation services can get large numbers of chronically ill persons back into productive employment. Instead of remaining on welfare rolls they become self-sustaining members of the community. Vocational rehabilitation services, and more recently rehabilitation cen- ters which serve the handicapped population irrespective of vocational 16 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA status, have been available in California. These, however, are limited programs. The state program, which is now covering an estimated 15 percent of the vocationally handicapped, is particularly inadequate in the rural areas. Of equal importance is the development of rehabilitation service as part of the general hospital and medical care services through- out California. It is recommended that rehabilitation services be expanded, with particular emphasis on the needs of vocationally handi- capped persons living in rural areas. A special study should be initiated—jointly by official and voluntary organizations con- cerned with the problems of rehabilitation-—to determine the most eflective methods for establishing rehabilitation services for all elements of the population who would benefit, not merely those who would gain vocationally. 10. Home Care Services Hospital care would be unnecessary in many instances if proper home care services were available. It has been demonstrated that the cost of adequate home care for the chronically ill is less than that of institutional care; and the patient is often happier while receiving care in his own home. Diagnostic and therapeutic services, including specialist care, are required for chronically ill persons living at home. Bedside nursing care, housekeeper service and medical social service would all reduce the need for the more expensive institutional care, yet all three are conspicuously inadequate especially in the rural areas of the State. A key problem is the provision of bedside nursing service in which practical nurses might be extensively used. ' It is recommended that local communities develop compre- hensive home care programs for the chronically ill including diagnostic and therapeutic services, bedside nursing, medical social service, and housekeeping service. These should be integrated with the hospital and other services. 11. Future Chronic Disease Program Up to the present time there has been no agency in California which has been charged with or which has assumed responsibility for study of the chronic disease problem; and for coordination of activities related to the control and prevention of chronic disease or to the facilities and services available for the chronically ill. Even the foregoing brief state- ment of the chronic disease problem indicates its complexity and empha- sizes the need for permanent study, continuing recommendations and intelligent coordination of activities in this field. Chronic illness concerns not only the chronically ill and their families, but also the community. In fact, the primary responsibility for providing services to the chroni- cally ill rests with the individual and the local community. Continuous study of the problems related to chronic illness by an agency representing the state as a whole, is in the public interest. Public interest also requires that the agency designated to carry out this purpose must adequately represent all groups that are concerned with the chronically ill. As this report has demonstrated, research, preventive services, statistical studies, rehabilitation, health education, professional services, hospital and insti- tutional care, and home care services—all play a part in an over-all A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 17 approach to the control of chronic disease and the amelioration of its effects. A representative agency to observe, assist, encourage and coordi- nate these activities at the state level is both warranted and essential. However, emphasis must still remain on the responsibilities of local communities. It is, therefore, recommended that the Legislature authorize a chronic disease program by enacting the following specific proposals: ‘ (a) That there be established within the State Department of Public Health an advisory chronic disease council,- that this council contain adequate representation from professional groups concerned with chronic diseases and from the public at large, with the director of the. department, a member ex officio; and that the members of the council serve for stated terms and be appointed by the Governor from a list of nominees selected jointly by the State Director of Public Health, the chairman of the Senate Standing Committee on Public Health and Safety, the chairman of the Assembly Standing Committee on Public Health, and the president of the California Medical Association. This council should advise and assist the department in the coordination of the various phases of the chronic disease pro- gram outlined in this report, and in its responsibility for encouraging local communities to provide adequate services for the chronically ill. The department, with the advice and assist- ance of the council, should submit to the Governor and the Legislature prior to each regular session of the Legislature a full report on chronic disease prevalence, control, prevention, facilities and care in the State,- (b) That the specific needs of California research institu- tions for additional physical facilities, essential to the conduct of expanded research programs on the chronic diseases, be determined. Such determination should be made by the State Department of Public Health in cooperation with the research institutions and appropriate professional societies; (0) That the State Department of Public Health should maintain statistical services on a continuing basis as part of a chronic disease program. Special attention should be directed to the development of methods and sources for obtaining current data on chronic illness, without universal, regular reporting of individual cases of all chronic diseases. The tumor registry should be expanded on a voluntary basis to include all hospitals and clinics, and where practicable, private physicians—with at least partial reimbursement for the erpenses of reporting. (d) That the State Department of Public Health assist in the planning of programs of advanced professional education and training in the field of the chronic diseases. For financing such programs, state funds should be made available where there . is a demonstrated need to augment contributions of professional societies for professional education. No claims should be made, by agencies of the State, on the services of individuals trained through the use of such funds. 2—L—8179 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA MAGNITUDE OF CHRONIC DISEASE PROBLEM IN CALIFORNIA Chronic diseases are the leading causes of death and illness in the population of California today. A very substantial number of those affected by chronic illness are young and middle aged persons, although the likelihood of developing a chronic disease does increase as people grow older. Each year more and more persons in California are being counted among the victims of the chronic diseases. The diseases cause tremendous economic loss, as well as sufiering, disability and death. DEATHS PER Ioo,ooo POPULATION IN CALIFORNIA - SELECTED CHRONIC DISEASES* SELECTED COMMUNICABLE DISEASES* |9|O I920 [930 |940 ‘ The definition of chronic illness usually used is "illness (excluding pulmonary tuberculosis and mental disease) lasting a period of three months or more which pre- vents the patient from following his customary daily routine and which necessitates medical or nursing care at home or in an institution." For purposes of compiling statis- tical data, however, it is often necessary to use a definition of chronic illness based on specific diagnoses. For such statistical purposes the chronic disease advisory committee selected the diseases listed below. This list is by no means all-inclusive since many other diseases also cause long periods of illness. Cancer and other tumors Multiple sclerosis Cardiovascular-renal diseases Chronic pulmonary disease (nontuberculous) Diabetes mellitus Ulcer of the stomach or duodenum Rheumatism and arthritis Diseases of the female genital organs and breast Alcoholism Diseases of the bones, joints and organs of move- Cirrhosis of the liver ment Anemias Diseases of the Organs of hearing and vision Senility The toll of death on the California population from these selected chronic diseases (excluding multiple sclerosis and chronic pulmonary disease for which mortality data were not available on a trend basis) has been compared with the toll of death from the following communicable diseases: Pneumonia and influenza; tuberculosis (all forms) ; diarrhea and enteritis; typhoid fever; scarlet fever; whooping cough; diphtheria; measles. (18) A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 19 Deaths From Chronic Disease in California - During the past several decades there has been a sharp and steady increase in chronic disease deaths and death rates, whereas mortality from communicable diseases has declined. TREND OF MORTALITY: CALIFORNIA 1910-1940 Selected chronic diseases Selected communicable diseases Deaths per Deaths per 100,000 100,000 Total deaths population Total deaths population 1910 _________________ 13,187 554.6 9,810 412.6 1920 _________________ 20,934 610.9 14,199 414.3 1930 _________________ 36,372 640.7 12,341 217.4 1940 _________________ 52,610 761.6 8,700 126.0 In 1947 chronic diseases accounted for 66,518 deaths in California— more than two-thirds of the total number of persons who died in the State that year. Forty percent of these chronic disease deaths occurred in persons under 65 years of age. Among all causes of death in California, diseases of the heart and cancer occupy first and second place respectively. Other chronic diseases that are important causes of death are intracranial lesions of vascular origin (brain hemorrhage and apoplexy), nephritis, arteriosclerosis, dia- betes mellitus and cirrhosis of the liver. Each of these diseases—and cancer particularly~takes the lives of a substantial number of people in the early and middle periods of life. Half of all people who die of cancer are under 65 years of age, and many die of cancer of accessible sites such as the breast, uterus, skin and buccal cavity—sites where large savings of life can be expected with early diag- nosis and treatment. It has been estimated that 30 percent of the patients who now die of cancer could have been cured * had they received prompt and adequate treatment early when the lesion was first discoverable. DEATHS FROM MAJOR CHRONIC DISEASES: CALIFORNIA 1947 Total Under 65 and deaths 45 45—61; over Diseases of the heart ________________ 32,535 1,562 10,212 20,761 Cancer _____________________ '_ ______ 13,681 1,320 5,473 6,888 Intracranial lesions of vascular origin __ 7,652 263 1,890 5,499 Nephritis __________________________ 3,903 395 1,167 2,341 Arteriosclerosis and other diseases of the circulatory system _____________ 2,880 111 431 2,338 Diabetes mellitus ___________________ 2,027 121 689 1,217 Cirrhosis of the liver ________________ 1,801 395 943 463 Other selected chronic diseases ________ 2,039 407 729 903 Total selected chronic diseases ____ 66,518 4,574 21,534 40,410 Estimates of Chronic Illness in California The number of people who die each year from the chronic diseases is only a fraction of the total number of persons who suffer from chronic illness. Diabetes, rheumatism, alcoholism and epilepsy are far more important as causes of illness than as causes of death. The amount of chronic illness in the general population of Cali- fornia is not known precisely, and there is great need for more adequate ‘ That Is, these persons would have survived at least five years without evidence of the disease. 20 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA current information in this field. In the absence of actual illness data for the general population of the State, estimates based on the National Health Survey (1936-1937) are used here as they have been used in other studies of chronic disease. The estimates are as follows: DISABLING CHRONIC ILLNESS National Health Survey Findings Applied to California: 1947 Estimated Estimated number of weeks of cases disability Cardiovascular-renal diseases _________________________ 109,000 1,900,000 Rheumatism and allied diseases ________________________ 58,000 1,000,000 Cancer and other tumors _____________________________ 29,000 410,000 Diabetes mellitus __________ _ _________________________ 9,000 220,000 Chronic illness causing permanent disability _____________ 104,000 5,410,000 All disabling chronic illness ___________________________ 455,000 9,090,000 Under 25 ___________________ 71,000 25434 ______________________ 285,000 65 and older ________________ 99,000 These estimatesare minimal and exclude many early or mild cases of chronic illness because they refer only to disabling illness——illness caus- ing at least seven consecutive days of interference with usual occupation. The estimate for cancer is particularly low. During 1947 there were about 14,000 cancer deaths in California, and from this (using a ratio of 3.5 cases per death) it can be estimated that there were approximately 50,000 cases of cancer alive at some time during the year. Recent investi- gations in selected areas have demonstrated that diabetes is much more prevalent than has been supposed and that there probably are 100,000 diagnosed cases of diabetes in California (approximately 1 percent of the population). Accurate estimates cannot be made of the number of undiagnosed cases of chronic disease, although indications can be cited for heart disease and diabetes. A Los Angeles study of miniature X-ray films together with follow—up examination of suspicious cases showed that about 1 percent of the population surveyed had clinically significant, previously unknown heart disease. This indicates that for California as a whole there may be 100,000 persons with unrecognized heart disease. Tests for diabetes were made on over two-thirds of the population of Oxford, Massachusetts, in a recent survey. In addition to those known beforehand to have the disease, previously unrecognized diabetes was found in 0.7 percent of those tested. Applying this ratio to California it can be estimated that there may be as many as 70,000 persons'in the State who have diabetes but are not aware of it. Data From the California Disability Insurance Program The California disability insurance program provides the only available current data on illness and disability in a sizeable, though selected, segment of the population of the State. Approximately two and one-half to three million employed persons are covered under the disa- bility insurance program which offers partial compensation for wage loss due to illness. Although the sample is large, it should be noted that the data from this program do not necessarily reflect the extent of illness and disability in the total population. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 21 During the first year of operation (194-7), the California Disability Insurance State Plan paid benefits for 89,160 spells of disability, of which 37,715 (42 percent) were due to chronic diseases. More than seven million dollars were paid out of the State Disability Fund for a total of 380,000 weeks of chronic illness. This sum by no means covers even the total wage loss. Also costly was the associated loss of productivity, as well as the expense of medical care, hospitalization and ancillary services required for most extended periods of disability. In 30 percent of the spells of chronic disability, benefits were exhausted; that is, the maximum benefits to which the claimants were entitled were paid. It is probable that most of these claimants were still disabled after their insurance benefits were exhausted. The cardiovascular-renal diseases, cancer and other tumors, rheu- matism and arthritis, alcoholism and diabetes accounted for more than one-fourth of the paid spells of disability and nearly one-third of the amount of money paid for all disabilities during 1947. DISABILITY INSURANCE—STATE PLAN Paid Spells 0! Disability Reported Terminated. 1947 Number of paid spells of Number of Amount disability «(weeks paid paid Cardiovascular-renal diseases _______________ 13,425 154,845 $2,952,075 Cancer and other tumors ___________________ 5,005) 53,901 1,027,169 Rheumatism and arthritis __________________ 3,184 35,014 660,986 Alcoholism _______________________________ 700 7,737 142,240 Diabetes mellitus _________________________ 540 5,833 111,659 Other selected chronic diseases ______________ 14,161 123,123 2,325,970 Total selected chronic diseases ____________ 37,715 380,453 $7,220,099 Under 45 _____________________ 14,098 45-64 ________________________ 17,797 65 and older ___________________ 4,128 Unknown age _________________ 1,092 All disabilities ___________________________ 89,160 804,027 $15,267,016 Population and Chronic Disease The magnitude of all aspects of the chronic disease problem in California is directly related to population changes. Not only is this problem—as are many others—intensified by the great increase in popu- lation, but it is also intensified by the increasingly large numbers of persons in the middle and older age groups. Disability and deaths due to chronic diseases, although found in all age groups, increase in preva- lence as age increases. The census of 1870 reported only 12 percent of the California population to be 45 years of age or older. By 1900 this group had increased to 22 percent, and by 1940 it had reached 31 percent. This trend will probably continue. As medicine and public health con- tinue to make progress in the field of communicable disease control, more and more persons will live to the ages in which the chronic diseases are most prevalent. Effects of Chronic Illn'ess Chronic illness often has a devastating influence on the family in which it occurs. The resources of the average family may not be com- pletely overwhelmed by the cost of acute illness. Chronic illness, however, frequently keeps the family breadwinner away from work for many 22 A CHRONIC DISEASE PROGRAM FOR camrost weeks or months and results in severe economic handicap or even com- plete economic dependency. Chronic illness in a housewife disrupts care of children and the running of a household, and in many cases causes break-up of the family unit. To almost every community chronic illness is a heavy burden. A substantial share of the clients of welfare agencies are chronically ill persons who often have become dependent primarily because of long- term illness. The extended periods of care required by chronically ill persons result in great demands on the medical, hospital and related services of each community—services which frequently are strained to meet even the needs of acute cases. In recent years striking advances have been made in the prevention and treatment of many acute diseases. Although few such dramatic advances have been made with regard to the chronic diseases, substantial reduction of death and disability from cancer and other chronic diseases is possible with present medical knowledge. Proper application of this knowledge would improve both the health of the citizens and the economy of the State. NECESSARY SERVICES AND FACILITIES FOR AN EFFECTIVE CHRONIC DISEASE PROGRAM 1. Research Advances in the control of the chronic diseases depend largely on medical research. Such research is aimed at gaining knowledge of: (1) Physiological and pathological processes, (2) the natural history of diseases, (3) diagnosis of conditions, and (4) methods for the cure or alleviation of disease. The chronic diseases cannot be studied alone because chronic disease may be the outcome or end-point of acute disease. One cannot be too emphatic about the fact that research into chronic disease must become a part of the general investigative effort in medicine. It must be integrated with the general pattern of research in institutions already existing. But there should be increased effort and efficiency through adding facilities (buildings, equipment, etc.) and attracting increasing numbers of interested persons to the field of chronic disease. Medical scientists may be attracted by better physical facilities, better clinical facilities and closer association with the basic sciences, as well as by better financial income to themselves. Best results in research are obtained by coordination of many allied interests. It is necessary to have laboratory buildings, the clinical material found in teaching insti- tutions and hospitals, and scientists nearby who are investigating allied fields. Such research groups can usually be found in the centers of higher learning or in large general hospitals. Within the boundaries of Cali- fornia there are several medical schools and other research institutions. It is axiomatic that adequate research can be conducted only by those qualified men and women who have the appropriate interest. The scientist should not have his efforts subject to control beyond the primary direction of elfort to special subjects suitable for investigation by him. From the standpoint of the quantity and quality of its research institutions California has a unique position. Many first-rate institutions already exist within the State. Further development awaits only addi- tional funds for physical facilities and personnel. /” A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 23 There are many sources of funds for investigation along special chronic disease lines such as the: (1) American Cancer Society, (2) National Foundation for Infantile Paralysis, (3) American Society for the Study of Hypertension,l(4) American Heart Association, (5) Ameri- can Rheumatism Association, (6) National Tuberculosis Association, (7) the groups organized for the study of alcoholism, and many others. There is another reservoir of funds which is now only occasionally being tapped; namely, funds from industries for the investigation Of problems in which they have an interest. Examples are: (1) the dairy industry for study of brucellosis, (2) the canning industry for research into nutri- tion and botulism, and (3) the meat packers and frozen food industry for studies in nutrition. In addition, state funds might well be used to investigate diseases directly affecting the public health and resulting in chronic conditions, such as certain communicable diseases. It is recommended that the specific needs of California research institutions for additional physical facilities essential to the conduct of expanded research programs on the chronic diseases be determined. Such determination should be made by the State Department of Public Health in cooperation with the research institutions and appropriate professional societies. 2. Preventive Services Preventive services in the field of chronic disease must be based on: (a) Our present medical and public health knowledge of these dis- eases, and . . (b) Continuing and expanding research in methods of preventing chronic diseases and chronic disability, and methods of preventing pre- mature deaths from these diseases. If effective use were made of existing knowledge and techniques, a considerable amount of chronic illness could be prevented and chronic disability could be reduced. Certain factors are known to be related to some of the chronic illnesses: obesity to heart disease and diabetes; diet to kidney disease; specific occupational conditions to cancer, particularly skin cancer; certain acute diseases, such as rheumatic fever, to heart and other chronic diseases; and some apparently minor conditions, “precan- cerous lesions,” to cancer. The prevention of accidents will reduce the number Of injuries which today are causing a large amount of chronic disability. Early discovery of, and prompt medical care for, many chronic diseases are basic factors in preventing disability and premature death from these diseases, e.g., cancer, diabetes, diseases of the heart. Econom- ical “screening” methods for the detection of these diseases are being developed and some are now ready for wide-scale application. In contrast to the extensive use of preventive measures for the com— municable diseases, we have only begun to make use of preventive meas- ures in the field of the chronic diseases. Although the specific measures may vary, the basic public health approach to the chronic diseases is the same as to the communicable diseases, i.e., the effective mobilization of community resources to carry out the recommendations of medical, pub- lic health, and allied sciences. In California, we have the medical and public health resources to put our present knowledge to work. The effective utilization of these 24 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA resources should be aimed at assisting the people in a program of chronic disease prevention through: (a) Recrienting medical, public health, and other professional groups to an increased emphasis on chronic disease prevention ; (b) Helping the people learn how to prevent chronic illness and disability and stimulating the people to use this knowledge ; (e) Preventing communicable diseases which lead to chronic con- ditions; (d) Adjusting environmental conditions to reduce chronic disease hazards; (e) Detecting chronic diseases in their early stages, including devel- opment of mass-screening methods; and (f) Conducting research in the prevention of chronic illness and disability including the mental factors involved. It is recommended that the development and utilization of preventive services for the chronically ill be nndertahcn by local health agencies with the cooperation and. approval of local pro- fessional societies. The preventive program should include professional and public education concerning the chronic dis- eases, mass-screening methods (where proven medically sonnd) for early detection of chronic diseases, intensification of com- municable disease control programs with specific emphasis on those diseases leading to chronic conditions, and accident pre- vention activities. . 3. Statistical Services Statistical research in a chronic disease program should develop and utilize current information on chronic disease incidence, prevalence; disability, and mortalityaby age, sex, race, residence, occupation, and other demographic characteristics of the population. The use of such statistical services has been demonstrated in part in the collection, analysis, and presentation of data for the present chronic disease investigation. These services, which should be provided on a con- tinuing basis as part of a chronic disease program, are not now regularly provided by official or voluntary agencies in California. Although general mortality data are Obtained by the State Depart- ment of Public Health from death certification, there is no specific authorization for continuing studies and analyses of chronic disease mortality in California. With respect to morbidity (i.e. illness) statistics, not until recently have efl’orts been made to tap the various sources of chronic disease mor- bidity data within the State. For example, through the use of federal funds for cancer control, a tumor registry has been established in the State Department of Public Health. The tumor registry is regarded as a basic element in the cancer control program, but now includes only a minority of institutions in the State treating cancer. If extended through- out the State it would provide data for epidemiological studies, indicate types of cancer for concentration of control efforts, serve to measure the progress of control programs and stimulate professional educational activities. General morbidity data for a large segment of the employed popula- tion of the State have been made available by the State Department of Employment from diagnostic information on disability insurance claims. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 25 The data from this new disability insurance program will become increas- ingly valuable as they accumulate over a period of years. However, in View of the inherent limitations of these data, other sources of illness data are needed to complete the fragmentary picture obtained from the disability insurance program. As yet there is no mechanism established for obtaining current data on chronic disease morbidity pertaining to the general population. The State Department of Public Health .should maintain statistical services on a continuing basis as part of a chronic disease program. Special attention should be directed to the development of methods and sources for obtaining current data on chronic illness, without universal, regular reporting of indi- vidual cases of all chronic diseases. The tumor registry should be expanded on a voluntary basis to include all hospitals and clinics, and where practicable, private physicians—with at least partial reimbursement for the expenses of reporting. 4. Professional and Vocational Training and Education For the effective accomplishment of any broad and comprehensive plan of activity in the chronic disease field a program of education must be provided for each professional group involved. This program should be directed: (1) To the continued professional improvement of the individuals in each classification; and (2) to the broader understanding of the program as a Whole and the integration of all services and activities involved. Among physicians active postgraduate programs are already under way sponsored by the California Medical Association, many of the county medical societies, the local, state and national voluntary health associa- tions (as in cardiovascular disease and cancer), and the medical schools. Some administrative aid and financial assistance have been provided through the State Department of Public Health. Constant efforts are being made to extend these educational advantages to physicians prac- ticing in the outlying areas. Other professional groups, such as dentists, hospital administrators, nurses, medical social workers, etc., already have state-wide and local organizations. These organizations provide educational programs of varying extent for their membership. In the development of a coordinated chronic disease program all groups will need to be indoctrinated as to the over-all plan so as to promote effective relationships among the pro- fessions involved. Of particular importance in the care of the chronically ill is the development of adequately trained and supervised practical nurses. It is recommended that the professional educational and training programs of state and local professional societies be expanded and cooperative planning undertaken with the post- graduate training programs of the several professional schools and voluntary health agencies: and that the State Department of Public Health, assist in the planning of programs of advanced professional education and training in the field of the chronic diseases. For financing such programs, state funds should be made available where there is a demonstrated need to augment 26 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA contributions of professional societies for professional educa- tion. No claims should be made on the services of individuals trained through the use of such funds. It is further recommended that adequate programs be developed by qualified hospitals for the training of practical nurses. 5. Health Education Health education aims to create an understanding of good health habits and to motivate behavior contributing to the improvement of the health of the general public. A basic element in health is morale, i.e., the effective desire for good health that leads to action for attaining and preserving a state of complete physical and mental well-being. Health education should build health morale for the individual, the family, and the community. Many individuals fail to seek proper medical care even when it is available—either because they do not understand or are not sufficiently impressed with the necessity for obtaining it, or do not know how to go about getting it. Consequently many diseases reach a stage of chronicity before they are even discovered. Health education programs are now being conducted in California by a number of agencies. Among these should be mentioned the school systems, voluntary health associations, professional groups, and health departments. The American Cancer Society, the American Heart Asso- ciation and many other voluntary groups have started campaigns to teach the public the facts about particular chronic diseases, and what should be done about them. The medical profession has supported these efforts. Health departments have not engaged extensively in organized educational activities directed to the control of the chronic diseases. These public agencies have skilled health education personnel and other resources which should be used in the chronic disease program. Councils of social agencies and other community organizations have begun to engage in those health education activities designed to make their com- munities actively aware of the chronic disease problem, of the available services and facilities to meet this problem, and of the need for additional services and facilities. In California, school health services are almost as varied as the com— munities. They range from very excellent in some areas to very limited services in others. The experiences of many communities need to be col- lected and made available to people in other areas. Only a beginning has been made in school health education concern- ing the chronic diseases. In many instances this responsibility has been left to a school nurse who is so busy keeping routine records that she has insufficient time for educational work. In order to be really effective, school health education in the field of the chronic diseases must be given at least the same amount of attention as that now directed toward immunizations, venereal disease, and tuberculosis. Health education should not be conducted in haphazard fashion, but should be the respon- sibility of trained personnel with definite goals in mind. Besides class room instruction an adequate school health program in California should include among its efforts directed against the chronic ’H A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 27 diseases: a more complete examination of school children, improved follow-up Of those with defects, and better health training of teachers. Many teachers in our schools have had little or no training in health education. A teacher well trained in health is an invaluable asset in the detection of some chronic diseases. It is recommended that expanded programs for education of the public on cancer and other chronic diseases and on accident prevention be conducted by voluntary organizations interested, in health, by professional societies, hospitals, educa- tional institutions, and health departments. 6. Diagnostic and Therapeutic Services Diagnostic and therapeutic services are inseparable from medical care as a whole. They can be performed only by persons with sufficient- training and proper knowledge. They entail detailed examination and treatment of individuals suffering from illness. Special techniques and skills, including laboratory and X-ray studies properly coordinated, are often needed to help determine the condition of the individual and the treatment needed. Diagnostic and therapeutic services are available in California to the indigent, through: (a) The staffs of the county hospitals; (b) the staffs Of free clinics in connection with teaching hospitals, teaching institutions and certain general nonprofit hospitals; and (c) the staffs of special clinics, (e.g. venereal disease) either attached to institutions or Operated by departments of public health. Individuals in low income groups who are above the indigent class may obtain these services from the personnel of part—pay clinics where these exist attached to teaching institutions, general hospitals or organized private clinics. The individ- ual who is able to pay may obtain diagnostic and therapeutic services through private physicians. While these services are generally available in the urban areas of California, measures to make known their availability are needed. In the rural areas, more services are needed, and greater accessibility and coordination should be developed. Facilities for the care of chronic illness seem to be more lacking than physicians. These facilities include : (1) Hospitals of all categories— private, nonprofit, and public; (2) nursing homes, both public and private; (3) custodial institutions; (4) clinics, which are free, part-pay or full-pay; and (5) offices of private physicians. The distribution of these facilities throughout the State varies considerably. Metropolitan areas with large segments of population possess more of these facilities and personnel than do the rural areas of the State. Travel to get to some of the larger centers when necessary is sometimes difficult and many feel that coordination among the services is lacking. Services for the care of special types of chronic illness should be integrated with the general medical care pattern of the community. It is not feasible to separate the care of one type of chronic illness from another. For example, the care of epilepsy does not require different physical facilities from those needed in the care of other chronic or recurrent illness; it does require the development of personnel and 28 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA laboratory service of a dififcrent character from that which might be used in other sections of the same hospital. It is to be emphasized that diagnostic and therapeutic services should be not only quantitatively available but also constantly improved in quality. A definite program is needed for the continual betterment of diagnostic and therapeutic services through such means as post- graduate education. The agencies which should be stimulated to develop diagnostic and therapeutic services should be away from centralized authority and largely in the communities where needs are best understood. It is recommended that local communities with the guid- ance and support of local professional societies and health departments work toward the goal of making available adequate diagnostic and therapeutic services either in their own com- munities or through arrangements with nearby communities. 7. Hospital Care Services Hospital facilities for the chronically ill may be classified into three broad groups: (1) Special facilities for the treatment of chronic ill- ness—facilities adjoining large general hospitals and operating in con- junction with or as part of the general hospital; (2) general hospitals which have rooms, wards, sections, or pavilions assigned for the treatment and care of chronically ill patients (this is a modification of (1) above) ; and (3) separate and independent hospitals which specialize in the treatment and care of chronic illness. The State Department of Public Health, the agency designated to carry out the provisions of the Federal Hospital Survey and Construc- tion Act applicable to California, reported in a recent publication on “Hospital Facilities in California” that: “The maldistribntion of hospital facilities between rural and urban areas and the need for more beds in general are recognized, as is the public responsibility to correct these inadequacies. llut there is danger in the present drive for more hospital beds that attention will be centered too greatly on acute general beds, when a sub- stantial share . . . of the need for them (acute general beds) could be met by the planning of chronic disease facilities as a part of general hospitals.” In the same publication, “Hospital Facilities in California,” the following table was presented showing the relative shortage of beds by category, as of March, 1948: Shortage Estimated Available (including need acceptable replacements) General ________________________ 42,039 20,568 21,471 Mental _________________________ 46,710 28,310 18,400 Tuberculosis ____________________ 9,598 2,231 7,367 Chronic ________________________ 18,084 3,434 15,250 The shortage of hospital beds for the chronically ill is obviously not an isolated problem—one apart from the over-all problem of hospitals and related facilities in California. The lack of beds for chronic patients increases the load on already hard pressed facilities for acutely ill patients. The lack of adequate nursing homes, custodial facilities, and home care services also contributes to the load on facilities for the acutely ill and tends to convert the few existing hospital facilities for the chronically ill into custodial institutions. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 29 For the first two years (1947, 1948) of the five-year construction program under the state-wide plan, priority has been given to hospital beds for patients with acute illness. During the remaining three years, funds will be available for other types of facilities (e.g. chronic, tuber- culosis, etc.), since it is required that, at the end of the five-year period, there be an adequate balance among the categories of facilities. Unfor- tunately, the construction which can be undertaken with the assistance Of federal and state funds available under the five-year program will fall far short of meeting the needs for chronic hospital beds. It is doubt- ful whether even one thousand chronic hospital beds will be constructed under this federal and state assistance program, whereas the estimated need is approximately fifteen thousand additional beds. It should be pointed out that the need for chronic disease facilities cannot be met satisfactorily by converting unacceptable acute hospital facilities for this purpose. The recommendations listed below are more detailed than those presented in the Summary of Findings and Recommendations on page 15. A. In establishing priorities for the third, fourth, and fifth years of the state-wide hospital construction program, the California Department of Public Health and the California Advisory Hospital Council should devote special attention to the need for additional chronic hospital beds in California. The department and the council, recognizing that only a small part of the total need can be met under this program, should encour- age the type of chronic hospital construction which could serve as a pattern for this type of patient and also serve to stimulate clinical interest and research in the chronic diseases. B. In approving applications for other types of facilities (e.g. tuberculosis) consideration should be given to the fact that on a long-range basis the need for such facilities will probably decrease, and that their conversion into facilities for the chronically ill may eventually be desirable. C. In addition to the federally and state financed construc- tion, every encouragement should be given to: The construction of other chronic facilities consistent with the recommendations of the California Hospital Survey; and The development and empansion of custodial, nursing home, home care, and rehabilitation services, to ease the demand for hospital beds. D. Special facilities (whether prii'ate or public) for the care of chronically ill patients should be constructed adjoining general hospitals. Hospital care for indigent chronic patients should be available in both tax-supported and voluntary hos- pitals; for indigent patients, such care should be financed from tax funds. E. The following recommendations of the California Hos- pital Survey are endorsed: “That provision be made for the care of certain types of - chronic disease in geperal hospitals in small communities. 30 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA “That regulation of nursing homes for the care of chronic patients be enforced to guarantee a high grade of service in this type of institution. “That the medical staff organization in general hospitals, wherever possible, should include a chronic disease service under the guidance of staff men interested in this type of patient. “In rural regions where the needs of the population justify the maintenance of separate nursing units, arrangements should be made for the establishment of such services for chronically ill patients in centrally located general hospitals.” 8. Other Institutional Care Services When maximum benefit has been Obtained for the chronically ill from the intensive medical care available in hospitals, further institu- tional care with continuing medical and nursing supervision is Often required. This may be provided in nursing homes, custodial facilities and substitute homes. Each of these types of institutions is intended to meet the needs of certain patients. Nursing homes are designed for those who require daily nursing care, but not daily medical attention; general medical super- vision is needed for patients in nursing homes. The function of custodial institutions is to provide a residential type of care for patients Whose infirmities necessitate long-term attendant service. Substitute homes (boarding homes and private homes for the aged) constitute a valuable facility for persons who are able to care for themselves in a slightly protected environment but who have no homes of their own or who cannot be cared for in their own homes. In 1948 there were in California the following institutional facilities (other than hospitals) : Total number Type Number of beds Nursing homes _________________________ 360 7,308 Custodial institutions ___________________ 3,000 (approx.) Boarding homes for aged _________________ 1,500 (each with 15 persons or less) Private institutions for aged ______________ 76 5,000 (approx) Recent inspections of these facilities show a Wide range in standards of care; some could be rated excellent but many provide only the most meagre care. Accommodations for custodial patients are particularly inadequate, with care Often comparable only to that of the ancient alms- house. The critical need for more beds for nursing care and custodial care was almost unanimously cited in replies to questionnaires directed to local professional groups throughout the State (physicians, hospital administrators, welfare directors and health officers). Nursing homes in California are Operated exclusively under private auspices. The number has not increased to meet the needs because of the discrepancy between the high cost of Operating these units and the limited funds available to patients who should have the care. The question of governmental subsidy for such care or construction of nursing home facilities deserves further study. The 3,000 custodial beds available in California are for the most part in county institutions and are used for indigent persons, many of A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 31 whom are aged. In many counties, the custodial unit serves as a “dump- ing ground” for placement of all types of patients whose individual needs are not ascertained. Often no real study is made of the physical condition of the patients or what could be done to rehabilitate them. The problem of care for chronically ill persons in nursing and cus- todial facilities is complicated by the provision of the Social Security Act which cuts off the Federal share of grants for Old Age Security and Aid to Needy Blind when recipients enter public institutions. In Cali- fornia, the State’s share of these grants is paid to the counties when the recipients enter county facilities. For the month of June, 1948, such subvention payments totaled $63,500 with the average payment per case approximately $27. It should be noted that these subvention payments have no relation to the cost of care required by patients or the quality of care rendered. Substitute home facilities in California are provided to some extent by boarding homes and private institutions for the aged. County wel- fare directors report an urgent need for more substitute home facilities at costs which can be met by welfare clients and others with fixed mar- ginal incomes. While substitute home facilities are not intended for bed patients, it has been found that many of those admitted become bedridden and require considerable nursing care. Provision is now rarely made for the transfer of such patients to more appropriate facilities. It is recommended that sufiicient nursing, custodial, and substitute home care facilities which meet adequate standards be made available to care for the needs of the chronically ill. These facilities should be correlated with the hospitals of the communities. In the smaller communities particularly, consid- eration should be given to placing nursing and custodial units adjacent to general hospitals. 9. Rehabilitation Services Rehabilitation service is aimed at the restoration of handicapped individuals to the fullest physical, mental, social and economic usefulness of which they are capable. Thus far efforts in this field have been directed largely to the vocationally handicapped. Another group deserving of attention are invalids who are now dependent on others for daily care but who could be made capable of taking care of themselves. Rehabilita- tion of a bed-fast patient to the point of walking represents a substantial saving in family and often times community cost, even though the patient may not be employable after treatment. Tremendous strides have been made in physical medicine and related services during and since the recent war. Newspaper accounts of legless persons driving automobiles and persons bed-fast for years who now fully care for themselves and earn a living are dramatic illustrations of the advances being made. In California rehabilitation services are limited almost exclusively to the vocationally handicapped. The California Vocational Rehabilitation Act passed in 1921 accepted the provisions of the Federal Vocational Rehabilitation Act passed by Congress in 1920. There has been no additional legislation. The Bureau of Vocational Rehabilitation of the California Department 32 A CHRONIC DISEASE PROGRAM roe CALIFORNIA of Education provides the following services to individuals with a demonstrable employment handicap: vocational guidance and coun- selling; medical, psychiatric and dental examinations and treatment; hospitalization; nursing care; physical and occupational therapy; pros- theses; training; and placement. These services are rendered through six district offices, seven branch offices and eight local offices (the latter set up primarily to refer high school children to district and branch offices). There are at present about eighty training officers for a population of ten million. Since this number of workers is only touching an estimated 15 percent of the problem, it is obvious that many areas, especially the rural areas, have inadequate services. Appropriations for the Fiscal Year 1948-1949 total $2,246,000. The Federal Government provides approximately 70 percent of these funds including the entire cost of administration. Under the present law state funds may not be expended for administrative purposes. The Bureau of Vocational Rehabilitation has been reluctant to accept for services severely handicapped persons. To some extent this reluctance is due to questionable employability after maximum rehabili- tation. Another factor is the lack in California of rehabilitation centers where highly specialized personnel and equipment can be concentrated for the rehabilitation of the most difficult cases. These centers could serve not only the vocationally handicapped (under the state program) but all elements of the population who would benefit from the services. Such centers should be integrated with general hospital services. Although the bureau attempts to provide complete service so far as possible, there are several factors which do limit certain benefits: e.g. hospitalization may not exceed ninety days unless special authorization is obtained; the maximum amount which can be paid to any one physi- cian for any case during any period of 12 consecutive months is $350; training is generally limited to a period not to exceed two years. A “suc- cessfully rehabilitated” person is one who is employed in a productive occupation suited to his ability and is earning at least one-half of the legal minimum wage. For the year ending June 30th, 19-18, there were 4,406 persons successfully rehabilitated after eight to nine months of services (median) at a cost of $383.94- per case (average). Statistical data maintained by the, bureau are designed principally to furnish information for federal reports and are inadequate for pro- gram evaluation and program planning. Current information on the number of handicapped persons of employable age in California is not available nor is information on the number of such persons who are receiving services from agencies and sources other than the Bureau of Vocational Rehabilitation. It is recommended that rehabilitation services be expanded, with particular emphasis on the needs of vocationally handi- capped persons living in rural areas. A special study should be initiated—jointly by official and voluntary organizations con- cerned with the problems of rehabilitation—to determine the most eficctivc methods for establishing rehabilitation services for all elements of the population who would benefit, not merely those who would gain vocationally. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 33 10. Home Care Services Hospital care would be unnecessary in many instances of chronic disease if proper home care services were available. The cost of adequate home care for the chronically ill has been found to be considerably less than that of hospital care ; and the people are Often happier while receiv- ing care in their own homes. The extent to which chronically ill persons can be cared for at home depends on the extent to which local communities have available the necessary services: physicians’ care, visiting nurse services, medical social service and housekeeping service. The chronically ill patient at home needs the care and guidance of a personal physician. General practitioners are more generally available throughout California than in the majority of states, though still insuf- ficient in some of the less populated counties. Medical specialists may also be needed periodically by chronically ill patients at home. Formerly concentrated in the larger cities, there is a growing tendency for spe- cialists to settle in the smaller cities and towns, especially through the influence of group practice. Improving transportation facilities are tend- ing to make visits to specialists less difficult for ambulant patients. Since chronic disease tends to create medical indigency it is most important to plan for methods to expand and extend the medical facilities available to this ever increasing group. This can be done in “outpatient clinics” preferably in connection with general hospitals where all diag- nostic and therapeutic facilities are at hand and specialists are available for guidance and consultation, or by subsidizing care in the Offices of private physicians. Neither of these methods has been sufficiently devel- oped throughout the State. Bedside nursing services make it possible for many patients to be cared for at home with their families—patients who otherwise would be occupying hospital beds. In California, voluntary agencies such as the American Red Cross and the Community Chests have assisted in financing visiting nurse asso- ciations in approximately 30 communities, most Of which are urban. At present only about 160 public health nurses are employed by these visit- ing nurse associations. There is roughly one visiting nurse to every 28,000 persons living in the 30 communities served, or one visiting nurse to every 50,000 of the State’s total population. The public health nursing staffs of city and county health departments are not now in a position to offer bedside nursing service. To provide adequate bedside nursing services for chronically ill persons throughout the State, it will be necessary to: (1) Increase the number of nursing personnel available for bedside nursing services; (2) develop bedside nursing services in rural areas; (3) expand existing services in urban areas; and (‘4) develop services in those urban areas which now are without them. Consideration should be given to develop- ment of these services through local voluntary societies, professional groups and the local health department. Qualified hospitals should estab- lish courses Of instruction in practical nursing, and recruitment activi- ties for such courses should be conducted. Much wider use should be made of practical nurses working under the supervision of public health nurses, for duties which do not require the training and experience of a graduate nurse. Nursing care should be planned on the basis of the type 3—L-8179 ./ 34 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA of personnel required to perform the needed functions. Public health nurses, registered nurses, practical nurses, and members of the family may each be utilized in certain situations. Adjustment of the chronically ill patient to the personal and social problems of long-term illness can be greatly assisted by medical social service. The guidance of a medical social worker often makes it possible for a chronically ill person to make the change from hospital to home and to remain at home rather than in an institution. In California, medical social service is available only in a few areas. More widespread use of medical social services in local areas throughout the State should be encouraged. The activities of these workers should be integrated with those of community social service agencies and visiting nurse associations. Housekeeping service makes it possible for certain chronically ill patients to remain at home. It is an important aid in caring for such chronically ill persons in their own homes, and in reducing the strain on medical, hospital, nursing and related services. The value of such service has been demonstrated in other areas of the country, particularly in New York City. In California, there is no organized houskeeping serv— ice of any magnitude, although in a few communities private welfare agencies occasionally offer a limited service. The development of house- keeping services in local areas throughout the State should be encouraged as an important means of caring for chronically ill persons in their own homes and reducing the need for hospitalization. To show what can be accomplished through local planning and the integration of medical, hospital, nursing and welfare services, demon- stration home care programs should be established in one or more areas of the State. It is reconnncmlcd that local comnmnitics develop compre- hensive home care programs for the chronically ill including diagnostic owl therapeutic services, bedside nursing, medical social service, and housekeeping service. These should be inte- grated with the hospital and other services. 11. Future Chronic Disease Program Up to the present time there has been no agency in California which has been charged with or which has assumed responsibility for study of the chronic disease problem; and for coordination of activities related to the control and prevention of chronic disease or to the facilities and services available for the chronically ill. Even the foregoing brief state- ment of the chronic disease problem indicates its complexity and empha- sizes the need for permanent study, continuing recommendations and intelligent coordination of activities in this field. Chronic illness concerns not only the chronically ill and their families. but. also the community. In fact, the primary responsibility for providing services to the chroni- cally ill rests with the individual and the local community. Continuous study of the problems related to chronic illness by an agency representing the State as a whole. is in the public interest. Public interest also requires that the agency designated to carry out this purpose must adequately represent all groups that are concerned with the chronically ill. As this report has demonstrated, research, preventive services, statistical studies, rehabilitation, health education, professional services, hospital and insti- tutional care, and home care services—all play a part in an over-all approach to the control of chronic disease and the amelioration of its A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 35 effects. A representative agency to observe, assist, encourage and coordi- nate these activities at the state level is both warranted and essential. However, emphasis must still remain on the responsibilities of local com- munities. It is, therefore, recommended that the Legislature author- ize a chronic disease program by enacting the following specific proposals: (at) That there be established within the State Depart- ment of Public Health an Advisory Chronic Disease Council; that this council contain adequate representation from profes- sional groups concerned with chronic diseases and from the public at large, with the director of the department, a member ex officio; and that the members of the council serve for stated terms and be appointed by the Governor from a list of nominees selected jointly by the State Director of Public Health, the Chairman of the Senate Standing Committee on Public Health and Safety, the Chairman of the Assembly Standing Commit- tee on Public Health, and the President of the California Medi- cal Association. This council should advise and assist the department in the coordination of the various phases of the chronic disease program outlined in this report, and in its responsibility for encouraging local communities to provide adequate services for the chronically ill. The department. with the advice and assistance of the council, should submit to the Governor and the Legislature prior to each regular session of the Legislature a full report on chronic disease prevalence, con- trol, prevention, facilities and care in the State; (b) That the specific needs of California research institu- tions for additional physical facilities, essential to the conduct of expanded research programs on the chronic diseases, be determined. Such determination should be made by the State Department of Public Health in cooperation with the research institutions and appropriate professional societies; (0) That the State Department of Public Health should maintain statistical services on a continuing basis as part of a chronic disease program. Special attention should be directed to the development of methods and sources for obtaining cur- rent data on chronic illness, without universal, regular report- ing of individual cases of all chronic diseases. The tumor registry should be expanded on a voluntary basis to include all hospitals and clinics, and where practicable, private physi- cians—with at least partial reimbursement for the expenses of reporting ,- (d) That the State Department of Public Health assist in the planning of programs of advanced professional education and training in the field of the chronic diseases. For financing such programs, state funds should be made available where there is a demonstrated need to augment contributions of pro- fessional societies for professional education. N0 claims should be made, by agencies of the State, on the services of individuals trained through the use of such funds. APPENDIXES APPENDIX A DEMOGRAPHIC STUDIES Summary California’s Population and Chronic Disease: In California two major long-term population trends directly affect the magnitude of the chronic disease problem. These trends are: (1) An increasing number of persons in the middle and upper age groups; and (2) an increasing pro- portion of older persons in the population. Prior to 1900 there were fewer than 500,000 persons 45 years of age and older; by 1940 this group had grown to over two million. By 1960, it can be estimated that it will amount to a minimum of three and a half million, and it may reach five million. The census of 1870 reported only 12 percent of the population to be 45 and over. By 1900 this group had increased to 22 percent, and by 1940 it had reached 31 percent. Although chronic disease is by no means limited to persons in the older age groups, the prevalence of chronic disease increases sharply with age. Chronic Disease Mortality in California: During the past several decades in California, there has been a sharp and steady increase in the number of deaths from chronic diseases, and in the crude death rates from these diseases, whereas mortality from communicable diseases has declined. Seven percent of the people dying of chronic disease in California during 1947 were under 45 years of age, while 32 percent were in the productive middle years of life between 45 and 64. Among all causes of death in California, cardiovascular-renal diseases and cancer occupy first and second place, respectively. Thirty-four percent of all cardio- vascular-renal deaths and 50 percent of all cancer deaths in California during 1947 occurred in persons under the age of 65. Diabetes, rheumatism, and alcoholism—although not as significant as the above two disease groups as causes of death——are important causes of disability in California. Data From the California Disability I nsurange Program: Disability insurance data constitute the only available current information on chronic disease morbidity * in any sizeable segment of the population of California. Approximately two and one-half to three million employed persons are covered under the California Disability Insurance program which offers partial compensation for wage-loss due to illness. Different types of coverage are provided in the program—coverage under either the state plan or coverage under one of a number of voluntary plans. The plans vary to some extent with respect to waiting periods and amount and duration of benefits paid. During the first year of operation (1947), the California Disability Insurance State Idaii paid benefits for 89,160 speHs of disabihty, of which 37,715 (42%) were due to specific chronic diseases. More than 7 million dollars were paid out of the State Disability Fund for a total of 380,000 weeks of chronic illness. Thirty-nine percent of the spells of disability due to chronic diseases occurred in persons under 45 years of age. In 30 percent of the spells of chronic disability, benefits were ‘ Morbidity refers to incidence, prevalence and duration of illness. (36) (x A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 37 exhausted; that is, the maximum benefits to which the claimants were entitled were paid. It is probable that most of these claimants were still disabled after their insurance benefits were exhausted. The cardiovascular-renal diseases, cancer and other tumors, rheu- matism and arthritis, alcoholism and diabetes accounted for more than one-fourth of the paid spells of disability and nearly one-third of the amount of money paid for all disabilities during 1947. Estimates of Chronic Illness in the California Population Based on the National Health Survey.- In the absence of current morbidity data for the general population of California, National Health Survey (1935- 1936) estimates are used here as they have been used in other studies of chronic disease. Although rates based on these estimates are subject to many qualifications, no better sources for such rates have since been developed. Applying National Health Survey rates to the total popula- tion of California for 1947, it is estimated that approximately 104,000 persons were disabled for the entire year by chronic illness, and at least 351,000 persons were disabled for periods of from one week to one year. Over two-thirds of these 455,000 persons were under 65 years of age. On the basis of the National Health Survey it is estimated that in California during 1947 there were 109,000 cases of cardiovascular-renal diseases, 58,000 cases of rheumatism and allied diseases, 29,000 cases of cancer and other tumors, and 9,000 cases of diabetes mellitus. These estimates are minimal and exclude many early or mild cases of chronic illness because they refer only to disabling illnessdillness causing at least 7 consecutive days of interference with usual occupation. The estimates for cancer and diabetes are particularly low. Other sources indicate that the total number of diagnosed cases of cancer in California during 1947 was probably about 50,000, and the total number of diagnosed cases of diabetes may have been as great as 100,000. 38 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA APPENDIX A-l CALIFORNIA’S POPULATION AND CHRONIC DISEASE In California two major long-term population trends directly affect the magnitude of the chronic disease problem. These trends are: (1) An increasing number of persons in the middle and upper age groups result- ing primarily from iii-migration to the State; and (2) an increasing proportion of older persons in the population resulting largely from progress in control of communicable diseases and in reduction of infant deaths. Although chronic disease is by no means limited to persons in the older age groups, the prevalence of chronic disease increases sharply with age. In a population in which either the number or the proportion of older persons is increasing, the magnitude of the chronic disease problem is also increasing. The Number of Older Persons For over a century California’s population has been characterized by continuous and rapid change.“ The increase in the total population of the State has been of tremendous proportions (Table 1). This has been due primarily to iii-migration, and has been far greater than could have occurred from natural increase alone. Along with the growth of the total population there has been a similar growth in the number of persons in the middle and upper age groups (Table 2). Prior to 1900 there were fewer than 500,000 persons 45 years of age and older; by 1940 this group had grown to over two million. By 1960, it can be estimated that it will amount to a minimum of three and a half million, and it may reach five millibn. The Proportion of Older Persons Until 1940 not only was there a steady increase in the number of older persons in California, but the relative proportion of these persons also showed a continuous rise (Table 3). The census of 1870 reported only 12 percent of the population to be 45 and over. By 1900 this group had increased to 22 percent, and by 1940 it had reached 31 percent. The trend was operative for the country as a whole, and reflected the fact that with progress in medicine and public health, more persons were surviving to the older age groups. Since the early censuses, California’s population has been on the average considerably older than the population of the total United States (Table 4). In 1940 the median age of California ’s population was higher than that of any other State. The proportion of children in California had been relatively small until 1940. Young adult persons had always made up a large share of the in-migrant population, while elderly persons had also at various times been attracted to the State. I For discussion of changes other than those related to major age trends (l.e. changes in geographic distribution, race, cultural elements, etc.) see Commonwealth Club of California. Research Service ; The Population of California; San Francisco. 19 46. -l A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 39 Changes Since 1940 In the years between 1940 and the present, California ’s population experienced changes even greater than those of previous years. How- ever, since there has been no general population census for the total State since 1940, statistical information on the magnitude of these changes is limited—particularly with reference to age. Partial information shows that with respect to the proportion of older persons in the population, there has been some reversal in the upward trend that had been operative in California for over half a cen- tury (Tables 5 and 6). Although the number of persons in the middle and upper age groups has continued to increase, the relative proportion of such persons was somewhat smaller in 1946 than it had been in 1940. This is probably due to ( 1) the very heavy iii-migration of young adult persons; and (2) the war and postwar “boom” in the birth rate. It is questionable whether or not the change in trend will continue into the future. For the next several decades it will depend upon the extent to which continued in-migration of young adults and the current reservoir of young children are offset by the aging of the present adult population, by the in-migration of elderly persons, and by the probable drop in the birth rate from recent levels. Regardless of trend in the proportion of older persons, however, it may be expected that the number of such persons will continue to increase. TABLE 1 GROWTH OF THE TOTAL POPULATION OF CALIFORNIA 1870-1940 AND ESTIMATES 1945-1960 Year Population Your Population 1870 _____________________ 560,247 1045 _____________________ 8,822,688 1880 _____________________ 864,694 1946 _____________________ 9,529,282 1890 _____________________ 1,213,398 1947 _____________________ 0,876,000 1900 _____________________ 1,485,053 1950 Low estimate ________ 9,600,000 1910 _____________________ 2,377,549 High estimnte ________ 10,270,000 1920 _____________________ 3,426,861 1060 Low estimate ________ 11,100,000 1930 ___________________ __ 5,677,251 High estimate ________ 13,500,000 1940 _____________________ 0,907,387 SOURCE: 1(‘870-1947—United States Department of Commerce; Bureau of the ,ensus. 1950 and ISM—California State Reconstruction and Reemployment Commission. 40 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA TABLE 2 GROWTH OF THE POPULATION AGE 4564 AND 65 AND OVER CALIFORNIA: 1870-1940 AND ESTIMATES 1950 AND 1960 Age 45-6/1 65 and over 60,977 5,978 133,036 17,025 198,065 40,304 252,861 76,846 422,833 125,263 697,332 200,301 1930 ______________________________________________ 1,187,877 366,125 1940 ______________________________________________ 1,594,566 555,247 1950 Low estimate __________________________________ 2,350,000 870,000 High estimate _________________________________ 2,510,000 930,000 1960 LOW estimate __________________________________ 2,890,000 1,180,000 High estimate _________________________________ 3,500,000 1,440,000 Estimates for 1950 and 1960 are based on the Reconstruction and Reemployment Commission estimates of total population. They were made on the assumption that Cali- fornia would experience the same relative increase in the proportion of persons in the above age groups as has been predicted for the United States. The estimates are not intended as precise predictions. but rather as general indications based on available information. SOURCE:C1870-1940—United States Department of Commerce; Bureau Of the ensus. 1950 and UGO—California State Reconstruction and Reemployment Com- mission: P. K. Whelpton, Forecasts of the Population of the United States 1945-1975. TABLE 3 AGE DISTRIBUTION OF THE POPULATION OF CALIFORNIA - 1870-1940 Percentage of the population " Year Un der /,5 45-64 65 and over 1870 __________________________________________ 88.0 10.9 1.1 1880 __________________________________________ 82.6 15.4 2.0 ' 1890 __________________________________________ 80.1 16.5 ‘ 3.4 1900 __________________________________________ 77.7 17 .1 5.2 1910 __________________________________________ 76.9 17.8 5.3 1920 __________________________________________ 73.7 20.4 5.9 1930 __________________________________________ 72.5 21.0 6.5 1940 ._ ____________ 68.9 23.1 8.0 I Refers to population of known age. SOURCE: United States Department of Commerce; Bureau of the Census. TABLE 4 MEDIAN AGE OF THE POPULATION UNITED STATES AND CALIFORNIA 1870-1940 Median age “ Year California United Sta tcs b 1870 ________________________________________________ 25.7 20.2 1880 ________________________________________________ 25.2 20.9 1890 ________________________________________________ 26.6 22.0 1900 ________________________________________________ 28.3 22.9 1910 ________________________________________________ 29.4 24.1 1920 ________________________________________________ 31.2 25.3 1930 ________________________________________________ 31.5 26.5 1940 _____ ____ __ __ 33.0 29.0 I The median age is the age which divides the population into two equal parts—50 percent of the population is younger and 50 percent is older than the median age. '1 For median age of each state in 1940 see U. S. Department Of Commerce; Statis- ticalAbstract of the U. S. 1947; Table 25, p. 27. SOURCE: United States Department Of Commerce; Bureau of the Census. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 41- TABLE 5 CALIFORNIA POPULATION OVER AND UNDER VOTING AGE 1940 AND ESTIMATES 1948 Number of persons Percentage of persons Age 191,0 1946 191,0 1946 Under 21 _________________ 2,021,846 2,893,500 29.3 30.4 21 and over ________________ 4,885,541 6,635,782 70.7 69.6 All ages _____________ 6,907,387 9,529,282 100.0 100.0 SOURCE: United States Department of Commerce ; Bureau of the Census. TABLE 6 AGE DISTRIBUTION OF URBAN AREAS WHERE SPECIAL CENSUS PROVIDED RECENT AGE DATA'—1940. 1946 Number of persons Percentage of persons 1’ Age 191,0 1.9.46 1.940 19/;6 Under 5 __________________ 185,377 342,142 5.6 7.9 5-9 __--___ ________________ 175,183 249,017 5.2 5.7 10-1. _____________________ 435,588 508,799 13.1 11.7 20—29 _____________________ 584,731 785,217 17.5 18.0 30-44 _____________________ 842,196 1,113,536 25.2 25.6 45-04 _____________________ 819,778 1,017,228 24.6 23.3 65 and over ________________ 293,719 341,630 8.8 7.8 All ages _____________ 3,336,572 4,357,569 100.0 100.0 IThe areas are the cities of Alameda, Oakland, Richmond, Burbank, Glendale, Long Beach, Los Angeles, Pasadena, Santa Monica, San Bernardino, San Diego, San Francisco, Stockton, and San Jose; and the unincorporated parts of San Diego County. These areas contained 46 ’percent of estimated total population of the state in 1946. (They would have contained a considerably larger percentage had the special censuses included suburban areas outside city limits.) b Refers to population of known age. SOURCE: United States Department of Commerce; Bureau of the Census. TABLE 7 0 AVERAGE NUMBER OF YEARS OF LIFE REMAINING AT SPECIFIED AGES WHITE MALE POPULATION OF THE UNITED STATES—1900 AND 1940 Life expectancy Average years remaining Percent increase Age 1900 19/;0 1900—1940 At birth ___________________________ 48.2 62.8 30.3 At age 20 __________________________ 42.2 47.8 13.3 At age 40__________-____-______-___ 27.7 30.0 8.3 At age 60 __________________________ 14.4 15.1 4.9 At age 80 __________________________ 5.1 5.4 5.9 SOURCE: United States Department of Commerce ; Bureau of the Census. TABLE 8 NUMBER AND PERCENT OF PERSONS IN EACH AGE GROUP CALIFORNIA: 1870-1940 Number of Persons 4,0" 1870 1880 1890 1900 1910 1920 1930 1940 Under 5 ____________________ 68,277 93,426 106,530 125,937 193,659 275,727 405,367 453,494 5-9 _______________________ 61,526 90,206 111,704 137,005 176,192 280,279 465,394 435,092 10-14 ______________________ 51,785 80,809 111,166 126,889 173,945 259,276 424,126 478,715 15—] 9 ______________________ 40,043 80,356 111,641 128,084 196,034 243,326 428,684 544,601 20-24 ______________________ 50,014 84,412 123,162 136,549 234,121 274,768 475,127 574,930 25-29 ______________________ 57,376 80,150 120,744 1 34,269 246,426 307,435 496,029 612,849 30—34 ______________________ 57,972 76,197 107,761 129,103 225,610 306,588 482,664 580,749 35-39 ______________________ 57,893 67,227 89,545 123,122 200,819 310,057 488,620 557,520 40-44 ______________________ 47,700 61,850 79,568 104,214 174,286 262,353 443,499 519,624 45-49 ______________________ 27,482 49,313 63,473 81,939 146,878 232,161 393,547 485,199 50—54 ______________________ 18,020 42,939 55,526 69,530 119,293 194,440 331,479 443,161 55-59 ______________________ 8,627 22,428 40,464 52,504 82,095 149,213 255,289 366,487 60-64 ______________________ 6,848 1 8,356 38,602 48,888 74,567 121,518 207,562 299,719 65-69 ______________________ 3,118 8,267 20,205 35,206 52,565 82,225 155,746 231,076 70-7 4 ______________________ 1,757 4,776 11,321 23,192 35,567 57,378 107,564 158,878 75 and over _________________ 1,103 3,982 , 8,778 18,448 37,131 60,698 102,815 165,293 Not reported ________________ 706 __1_ 7,940 10,174 8,361 9,419 13,739 ____ All ages ________________ 560,247 864,694 1,208,130 " 1,485,053 2,377,549 3,426,861 5,677,251 6,907,387 877 VINHOJI'IVO 21021 NVHDO‘HJ EISVEISIG DINOEHO V Percentage of Persons Age 1870 1880 189’) 1.900 1910 1.020 1.930 19110 Under 5 ____________________ 12.2 10.8 8.8 8.5 8.1 3.0 7.1 6.6 5-9 _______________________ 11.0 10.4 9.2 9.2 7.4 8.2 8.2 6.3 10-14 ______________________ 9.2 9.3 9.2 8.5 7.3 7.6 7.5 6.9 15—19 ______________________ 7.1 9.3 9.2 8.6 8.2 7.1 7.6 7.9 20-24 ______________________ 8.9 9.8 10.2 9.2 9.8 8.0 8.4 8.3 25-29 ______________________ 10.2 9.3 10.0 9.0 10.4 9.0 8.7 8.9 3034 ______________________ 10.3 8.8 8.9 8.7 9.5 8.9 8.5 8.4 35-39 ______________________ 10.3 7.8 7.4 8.3 8.4 9.0 8.6 8.1 40-44 ______________________ 8.5 7.2 6.6 7.0 7.3 7.7 7.8 7.5 45-49 ______________________ 4.9 5.7 5.3 5.5 6.2 6.8 6.9 7.0 5054 ______________________ 3.2 5.0 4.6 4.7 5.0 5.7 5.8 6.4 55-59 ______________________ 1.5 2.6 3.3 3.5 3.5 4.4 4.5 5.3 60-64 ______________________ 1.2 2.1 3.2 3.3 3.1 , 3.5 3.7 43 65-69 ______________________ 0.6 1.0 1.7 2.4 2.2 2.4 2.7 3.3 70-74 ______________________ 0.3 0.6 0.9 1.6 1.5 1.7 1.9 2.3 75 and over _________________ 0.2 0.5 0.7 1.2 1.6 1.8 1.8 2.4 Not reported ________________ 0.1 __ 0.7 0.7 0.4 0.3 0.2 -_ All ages ________________ 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 I Excludes persons residing on Indian reservations. SOURCE: United States Department of Commerce; Bureau of the Census. VINHOJI'IVO HOJ NVHDO’HJ HSVHSICI OINIOIIHO V 8? 44 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA NOTES AND DETAILED REFERENCES TO SOURCES FOR POPULATION TABLES TABLE 1 (1) (2) (3) TABLE 2 (4) TABLE 3 (7) TABLE 4 (8) (9) TABLE 5 (10) TABLE 6 (11) (12) TABLE 7 (13) TABLE 8 (14) 1870-1940—U.S. Department of Commerce; Bureau of the Census; 16th census of the United States; Population second series, California Bulletin: Table 3, p. 9. 1945-1947—Bureau of the, Census releases; P. //6 No. 3; P. 25 No. 8; P. 25 No. 1;. Figures given are for total population excluding the armed forces overseas. 1950 and 1960—California State Reconstruction and Reemployment Commission; Estimated range for population growth in California to 1960; tables 3, 5 p. 10, 16. 1870-1940—16th census of the United States; Population, second series, California Bulletin ; table 8, p. 17. 1950 and 1900 Same as (3) above. 1950 and 1960—P. K. “'hclpton; Forecasts of the Population of the United States 19/,5-19’75; U.S. Government Printing Office, Washing- ton, D.C.; 1947; table III p. 81 (table II p. 76). These forecasts were prepared in cooperation with the Bureau of the Census. Same as (4) above. California Same as (4) above. U.S.——16th census of the United States; Vol. II, Part I; table 8, p. 26. Bureau of the Census release; P. 25, No. 8, Estimates are as of July 1, 1946. Bureau of the Census releases. Alameda ______ P-SC, No. 102 San Bernardino P~SC, N0. 173 Oakland ______ P-SC, No. 129 San Diego _____ P-SC, N0. 172 Richmond _____ P28, No. 280 San Francisco- P—SC, No. 135 Burbank ______ P-2S, No. 248 Stockton ______ P-28, N0. 304 Glendale ______ P-SC, No. 176 San Jose ______ P-SC, N0. 204 Long Beach_-__ P»SC, No. 169 San Diego Los Angelcs ___ P—SC, No. 180 County (unin- Pasadena _____ P—SC, No. 177 corporatcd Santa Monica__ P~SC, No. 175 parts) ______ P-SC, No. 174 The special census were taken at various different dates between May 1945 and January 1948. The majority, however, were taken in 1946, and the average date of the censuses was April 1946. US. Department of Commerce; Bureau of the Census; 16th census of the U.S.; US. life tables and actuarial tables 1939-1941; table J, p. 10, 11. Same as (4) above. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 45 APPENDIX A-z CHRONIC DISEASE MORTALITY IN CALIFORNIAa During the past several decades in California, there has been a sharp and steady increase in the number of deaths from chronic diseases, and in the crude death rates from these diseases. This trend in chronic dis- ease mortality has focused attention on changing medical and health problems deriving from a growing and an aging population, and from progress in medicine and public health. With the great increase in total population in California there has been great increase in the number of persons dying of chronic disease.b Until 1940 the proportion of older persons in the population was rising and the crude death rates for the chronic diseases also were rising. After 1040, when war and postwar changes resulted in a smaller proportion of older persons and a larger proportion of children and young adults, there was a decrease in the crude death rates for these diseases. Mortality from communicable diseases in California has declined steadily. The trends " have been as follows (Tables 1-3) : Percentage of Crude death rate per Number of deaths all deaths 100,000 population Selected Selected Selected Selected communi— Selected communi- Selected communi- chrom’e cable chronic cable chronic cable diseases ‘1 diseases “ diseases diseases diseases diseases 1910 _____ 13,187 9,810 40.7 30.3 554.6 412.6 1920 _____ 20,934 14,199 44.4 30.1 610.9 414.3 1930 _____ 36,372 12,341 54.9 18.6 640.7 217.4 1940 _____ 52,610 8,700 65.5 10.8 761.6 126.0 1945 _____ 62,290 8,677 66.8 9.3 706.0 98.3 1947 _____ 66,518 7,875 68.6 8.1 673.5 79.7 Although chronic disease mortality increases with age, it is by no means llmited to persons in the older age groups (Table 4). Seven percent of the people dying of chronic disease in California during 1947 were under 45 years of age, while 32 percent were in the productive middle years of life between 45 and 64. Age is not the only factor afiecting chronic disease mortality. Each of the spec1fic chronic diseases has its own mortality trend. As shown by recorded mortality statistics, the trends are affected not only by popula- tion characteristics such as age, sex and race, but also by factors asso- ciated with the original recording of information on death certificates, —1G:ateful acknowledgment is made to the National Ofl‘lce of Vital Statistics, Wash- ington, D. C., for the provision of unpublished data used in this report. h “Chronic disease” is used here to refer to the specific diseases selected by the Chronic Disease Advisory Committee which could be traced on a trend basis. 0 Trends are shown beginning with 1910 which is the first census year for which systematic mortality data are available for California. a For the list of selected chronic and communicable diseases see Table 1. 46 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA and the statistical processing of death certificates. These factors include changing use of terms by the medical profession and statistical selection of the primary cause of death when more than one cause is recorded. An additional factor since 1940 is the use of population estimates rather than actual population counts as bases for rates for years in which great population changes were occurring. CANCER In California cancer has advanced from sixth among the leading causes of death in 1910, to second place in 1947. As a cause of death, cancer is today exceeded only by the cardiovascular-renal diseases. The trend of cancer mortality in California is summarized by the following statistics (Tables 1-3) : Crude death Age-adjusted ‘ rate per rate per Number of Percentage 100,000 100,000 deaths of all deaths population population“ 1910 ___________ 2,013 6.2 84.7 113.2 1920 ____________ 3,800 8.0 110.9 134.7 1930 ___________ 7,170 10.8 126.3 146.5 1940 ___________ 10,128 12.6 146.6 146.6 1947 ___________ 13,681 14.1 138.5 " Examination of the age-adjusted rate shows that in California apart from the aging Of the population there was no increase in cancer mortality as a whole between 1930 and 1940. Between 1910 and 1930, however, the age-adjusted rate rose though not nearly to the same extent as the crude death rate. It would be expected that for this period improvement in diagnosis and in certification of cause of death would be important factors though their extent and effect cannot be measured. Although aging of the population accounts for much of the increase in the number of deaths from cancer, cancer mortality is not limited to aged persons. The cancer death rate increases with age, but there is a substantial amount of cancer mortality among younger and middle aged persons (Table 4). Of all persons dying of cancer in California in 1947, 10 percent were under 45, and 40 percent were between 45 and 64—and only 50 percent were 65 years of age or older. For different sites of cancer separately for men and women, the trend of cancer mortality has varied greatly. Epidemiological studies of mortality in other states ° indicate that for women age-adjusted mortality has been decreasing in recent years, while for men it has been increasing with a particularly sharp rise in cancer of the respiratory system. Because they were not separately classified until recently, certain of the important sites of cancer cannot be traced on a trend basis. For 1947, however, the number of deaths in California attributed to the different sites of cancer is shown in attached Table 5. ‘Adjusted to the age distribution of the California population in 1940—the age- adjusted death rate is the rate that would have applied if the proporion of persons in the various age groups had been the same in 1910, 1920 and 1930 as it was in 1940. bAlthough it is known that on the average California's population was consider- ably younger in 1947 than it had been in 1940, sufficiently detailed age data are not available for the computation of 1947 age-adjusted death rates. , c M. L. Levin :The Epidemiology of Cancer; American Journal of Public Health; Volume 34, No. 6, pp. 611-620. Pi A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 47 CARDIOVASCULAR-RENAL DISEASES Between 1910 and the present, changing diagnostic concepts of the medical profession, and changing practice in statistical assignment of the primary cause of death resulted in shifting of terms within the total group of cardiovascular-renal diseases. Part of the deaths which in 1910 or 1920 would have been attributed to intracranial lesions of vascular origin (cerebral hemorrhage and apoplexy), or to nephritis, are today assigned to heart disease or to other diseases of the circulatory system. For this reason the trend of these diseases will be considered as a Whole. The trend in California has been as follows (Tables 1-3) : Crude deal]: Age-adjuster] rate per rate per Nun: ber of Percentage 100,000 100,000 deaths of all deathx population population 1910 ___________ 9,064 28.0 381.2 523.4 1920 ___________ 14,999 31.8 437.7 549.1 1930 ___________ 25,608 38.6 451.1 542.9 1940 ___________ 37 ,651 46.9 545.1 545.1 1947 ___________ 46,970 48.4 475.6 __ It will be noted that between 1910 and 1947 the number of deaths from cardiovascular-renal diseases increased from under 10,000 to almost 30,000. By 1947 these diseases accounted for approximately half of all deaths. Most of this increase, however, is attributable to aging of the population. The age-adjusted death rate increased between 1910 and 1920, but between 1920 and 1940 it remained practically stationary (it actually decreased, but the decrease was not of significant size). As with other chronic diseases, the death rate for cardiovascular- renal diseases increases with age. llowever, a considerable proportion of people dying of these diseases are in the younger or middle age groups (Table 4). In 1947, 5 percent of those dying of cardiovascular-renal diseases in California were under 45, and 29 percent were between 45 and 64. . Cardiovascular-renal diseases as a whole are a very broad group and comprise many different specific diseases. Although it is not possible to trace the mortality trend for these specific diseases, an approximation can be made by considering the trend of mortality in California at different ages (Table 6). The age-specific death rates show that for persons under 45 years of age the death rate from cardiovascular-rel1al diseases has been decreas- ing. It is at these ages that the effects of infectious processes on the heart and kidneys are evident. For persons between 45 and 74 the death rate from these diseases has remained relatively constant, while for those 75 and older it has actually been increasing. At these ages the arteriosclerotic and other cardiovascular-renal diseases are prominent. Although not available on a trend basis, for 1947 the number of deaths in California attributed to different forms of cardiovascular- renal disease are shown in Table 7. 48 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA DIABETES MELLITUS The statistics for the trend of diabetes mortality in California are summarized as follows (Tables 1-3) : Crude death Age-adjusted rate per rate per Number of Percentage 100,000 100,000 deaths of all deaths population population 1910 ___________ 378 1.2 15.9 20.7 1920 ___________ 596 1 .3 17.4 21.0 1930 ___________ 1,016 1.5 17.9 20.9 1940 ___________ 1,708 2.1 24.7 24.7 1947 ___________ 2,027 2.1 20.5 __ Diabetes, a more specific disease category than cancer or the cardio- vascular-renal diseases, accounts for a much smaller number of deaths. It will be noted that the age-adjusted death rate for diabetes has not been decreasing but actually showed some increase between 1930 and 1940. This seems paradoxical in view of the greatly improved method of treatment following the discovery Of insulin. However, treatment of diabetes does not cure the disease and it is probable that its elfect has been to postpone death. It has also been postulated‘ that there has been an additional increase in the prevalence of diabetes attributable to the increased food intake and lessened output of physical energy charac- teristic Of modern American life. ALCOHOLISM Although very important as a social problem and as a cause Of illness and disability, alcoholism is not significant as a direct cause of death. In recent years alcoholism alone has appeared less frequently 011 death certificates, and when it has appeared in combination with other causes Of death, it has rarely been selected as the primary cause. Death cer- tificates showing cirrhosis of the liver frequently fail to specify whether or not the disease is associated with alcoholism. For these reasons the mortality data for alcoholism are limited. When, because of lack of other information they must be used, they should be used in conjunction with other information. This has been done for the California data and will be presented in a separate report. I New York State Health Preparedness Commission; A Program for Care of (he Chronically Ill; Legislative Document No. 69 (1947 ). A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 49 RHEUMATISM Rheumatism, like alcoholism, is important from the standpoint of morbidity but not of mortality. As a primary cause of death it accounted for only 88 deaths in 1947 (Table 1). It can be estimated,‘ however, that during 1947 in about 1,200 deaths rheumatism was mentioned on the death certificate though it was not selected as the primary cause of death. However, even this is a very small number when compared with the estimated 48,000 cases of rheumatism causing at least one week of disability in 1947 (see report on morbidity estimates based on the National Health Survey). ’X‘ it it it 3)? If The general trends of mortality in California for chronic diseases as a whole, and for the main groups of chronic diseases have been described. It has been shown that with the growth of the population and the aging: of the population more people in California have been dying Of chronic diseases. Many diseases such as rheumatism have a high rate Of prevalence and cause considerable disability, but only occasionally result in death. In the case of cancer, certain forms of the disease such as skin or breast cancer are much less likely tO be fatal than other forms such as digestive or respiratory cancer. Because they are available mortality records are Often used as indices of morbidity and as the sole indication Of the mag- nitude of the problem of chronic disease. However, mortality data are not adequate for this purpose. There is need for systematic collection of statistical information on illness and disability, as well as on deaths. I Based on a special tabulation of second and third causes of death for a. one-month (January, 1947) sample of death certificates. 444-8179 TABLE 1 NUMBER OF DEATHS SELECTED CHRONIC DISEASES AND SELECTED COMMUNICABLE DISEASES CALIFORNIA: 1910-1947 (By Place of Occurrence) Number of deaths ,, 1910 1915 1920 1925 1930 1935 191,0 1945 1947 Cancer—Total ' __________________________________________ 2,013 2,795 3,800 5,292 7,170 8,369 10,128 12,307 13,681 Buccal cavity and pharynx_ __ _______ 92 112 148 224 279 311 311 382 376 Digestive organs and peritoneum __________________________ 1,070 1,565 2,006 2,731 3,462 3,908 4,404 5,331 5,741 Female genital organs ____________________________________ 281 369 525 762 1,017 1,167 1,356 1,424 1,685 Uterus " _____________________________________________ _ 330 481 667 845 925 1,006 1,039 1,180 Breast ________________________________________________ 170 257 370 529 750 861 1,126 1,389 1,391 Skin __________________________________________________ 63 97 116 101 165 194 191 201 255 Other and unspecified sites _______________________________ 337 395 635 945 1.497 1,928 2,740 3,580 4,233 Respiratory system b __________________________________ _ _ _ _ 296 447 ' Y 691 1,063 1,368 Benign tumors and tumors of unspecified nature ______________ 89 99 114 196 328 375 344 346 389 Cardiovascular-renal diseases—Total ________________________ 9,064 12,393 14,999 19,792 25,608 31,244 37,651 44,444, 46,970 Intrncrunial lesions of vascular origin _____________________ 2,033 2,682 3,647 4,147 4,980 5,137 6,128 7,413 7,652 Diseases of the heart—all forms __________________________ 4,283 5,737 7,055 10,317 14,794 19,691 24,618 29,892 32,535 Other diseases of the circulatory system ____________________ 653 922 1,016 1,238 1,263 1,721 2,223 2,944 2,880 Nephritis (including arteriosclerotic kidney) _______________ 2,095 3,052 3,281 4,090 4,571 4,695 4,682 4,195 3,903 Diabetes mellitus __________________________________________ 378 518 596 775 1,016 1,464 1,708 1,935 2,027 Rheumatism and arthritis _________________________________ 34 38 42 61 66 78 67 104 88 Alcoholism _______________________________________________ 208 183 35 122 187 214 165 204 191 Cirrhosis of the liver ______________________________________ 442 428 331 425 614 939 1,278 1,511 1,801 VIN’HOJFIVO 80d WVHDOZRI EISV’HSICI OINIOHHO V Anemias 103 169 261 334 203 149 137 146 133 Diseases of the organs of vision _____________________________ _ 3 5 2 2 2 1 5 _ 3 Diseases of the ear and mastoid process ______________________ 31 50 64 130 227 223 110 47 34 Ulcer of the stomach or duodenum 123 181 174 437 466 676 664 762 825 Diseases of the female genital organs and breast c ______________ 106 92 114 133 186 135 101 98 61 Diseases of the bones, joints and organs of movement ___________ 45 67 102 47 72 94 52 38 36 Senility 551 436 297 371 227 157 204 343 279 Tuberculosis __________ 4,910 5,586 _ 5,555 5,934 5,657 4,496 3,887 3,840 3,449 Pneumonia and influenza __________________________________ 2,465 3,011 5,725 4,368 4,762 4,658 4,068 4,007 3,660 Diarrhea and enteritis _____ 1,224 1,120 1,570 1,482 1,053 550 499 568 623 Specific acute communicable diseases '1 ________________________ 1,211 943 1,349 976 869 413 246 262 143 Total selected chronic diseases 9 ________________________ 13,187 17,452 20,934 28,117 36,372 44,119 52,610 62,290 66,518 Total selected communicable diseases ____________________ 9,810 10,660 14,199 12,760 12,341 10,117 8,7 (X) 8,677 7,875 Total deaths from all causes ___________________________ 32,401 @1138 47,196 56,800 66,249 72,456 80,270 93,176 96,968 ' Excluding leukemias and Hodgkins disease. 9 Diseases selected by the Chronic Disease Advisory Committee 1' Not separately classified for earlier years. for which mortality data were available on a trend basis. eExcluding venereal, puerperal and tumors. SOURCE: State of 02111., Department of Public Health, Vital ‘1 Typhoid fever, scarlet fever, whooping cough. diphtheria, Statistics Records. measles. gulf: Sublic Health Service, National Office of Vital IS cs. VINHOJIVIVO 31021 WVHDOHJ HSVHSIG DINOHHO V IQ TABLE 2 PERCENTAGES OF ALL DEATHS SELECTED CHRONIC DISEASES AND SELECTED COMMUNICABLE DISEASES CALIFORNIA: 1910-1947 (By Place of Occurrence) Percentage of all deaths 1910 1915 1920 1925 1930 1935 1940 1.945 191,7 Cancer—Total '_ 6.2 7.2 8.0 9.3 10.8 11.6 12.6 13.2 14.1 Buccal cavity and pharynv ___ ___- . .3 .3 .4 .4 .4 .4 .4 .4 Digestive organs and peritoneum __________________________ 3.3 4.0 4.3 4.8 5.2 5.4 5.5 5.7 5.9 Female genital organs ____ __ .9 .9 1.1 1.3 1.5 1.6 1.7 1.5 1.7 Uterus ” __ _ - .8 1.0 1.2 1.3 1.3 1.2 1.1 1.2 Breast _____ __' .7 .7 .8 .9 1.1 1.2 1.4 1 5 1.4 Skin ____________________ ___- .2 .3 .2 .2 .3 .3 .2 .2 .3 Other and unspecified sites __ __ __-_ 1.0 1.0 1.3 1.7 2.3 2.7 3.4 3.9 4.4 Respiratory system b ______ ____ _ _ _ _ .4 .6 .9 1 1 1.4 Benign tumors and tumors of unspecified nature _______________ .3 .2 .2 .3 .5 .5 .4 4 .4 Cardiovascular-renal diseases—total _________________________ 28.0 31.7 31.8 34.8 38.6 43 1 46.9 47.7 48.4 Intracranial lesions of vascular origin _____________________ 6.3 6.9 7.7 7.3 7.5 7 1 7.6 7.9 79 Diseases of the heart—all forms ___________________________ 13.2 14.7 14.9 18.1 22.3 27 2 30.7 32.1 33 5 Other diseases of the circulatory system ___________________ 2.0 2.3 2.2 2.2 1.9 23 2.8 3.2 30 Nephritis (including arteriosclerotic kidney) _______________ 6.5 7.8 7.0 7.2 6.9 6'3 5.8 4.5 40 Diabetes mellitus __________________________________________ 1.2 1.3 1.3 1.4 1.5 2 0 2.1 2.1 2.1 Rheumatism and arthritis __ ______ .1 .1 .1 .1 .1 1 1 .1 .1 Alcoholism ________________________________________________ .6 .5 .1 .2 .3 .3 .2 .2 .2 Cirrhosis of the liver _ _________ 1.4 1.1 .7 .7 .9 1.3 1.6 1.6 1.8 Anemias ______________ .3 .4 .6 .6 .3 .2 .2 .2 .1 Diseases of the organs of vision _____________________________ _ " * ’* “ * * ‘ ‘ Diseases of the ear and mastoid process _______________________ .1 .1 .1 .2 .3 .3 .1 " “ Ulcer of the stomach or duodenum ___________________________ .4 .5 .4 .8 .7 .9 .8 .8 .8 Diseases of the female genital organs and breast c ______________ .3 .2 .2 .2 .3 .2 .1 .1 .1 Diseases of the bones, joints and organs of movement __________ .1 .2 .2 .1 .1 .1 .1 " “ Senility __ 1.7 1.1 .6 .6 .3 .2 .2 .4 .3 Tuberculosis ___________ 15.2 14.3 11.8 10.5 8.5 6.2 4.8 4.1 3.6 VINHOJI’IVD '80.! WVHDOHJ HSVESIG OINOHHO V ‘- r 4' r r . ~ . Pneumonia and influenm __ _____ 7.6 7.7 12.1 7.7 7.2 6.4 5.1 4.3 3.8 Diarrhea and enteritis _____________________________________ 3.8 2.9 3.3 2.6 1.6 .8 .6 .6 .6 Specific acute communicable diseasesd ________ '_ ______________ 3.7 2.4 2.9 1.7 1.3 .6 .3 .3 .1 Total selected chronic diseases ° ________________________ 40.7 44.7 44.4 49.5 54.9 60.9 65.5 66.8 68.6 Total selected communicable diseases ____________________ 30.3 27.3 30.1 22.5 18.6 14.0 10.8 9.3 8.1 Total deaths from all causes ____________________________ 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 ‘ Less than 1 percent. 9 Diseases selected by the Chronic Disease Advisory Committee I Excluding leukemias and Hodgkins disease. for which mortality data were available on a trend basis. b Not separately classified for earlier years. SOURCE : State of California, Department of Public Health, Vital 0 Excluding venereal, puerperal and tumors. Statistics Records. '1 Typhoid fever, scarlet fever, whooping cough, diphtheria, United States Public Health Service, National Office measles. of Vital Statistics. VINHOJI'IVO 11001 WVHDOHJ HSVHSIG OINOHHO V 89 TABLE 3 CRUDE DEATH BATES SELECTED CHRONIC DISEASES AND SELECTED COMMUNICABLE DISEASES CALIFORNIA: 1910-1947 (By Place 0! Occurrence) Crude death rate per 100,000 population 1910 1915 1920 1925 1930 1935 1940 1945 1947 Cancer—Total ' ___________________________________________ 84.7 92.9 110.9 111.9 126.3 135.7 146.6 139.5 138.5 Buccal cavity and pharynx _______________________________ * 3.7 4.3 4.7 4.9 5.0 4.5 4.3 3.8 Digestive organs and peritoneum __________________________ 45.0 52.0 58.6 57.8 61.0 63.4 63.7 60.4 58.1 Female genital organs ___________________________________ 11.8 12.3 15.3 16.1 17.9 18.9 19.6 16.1 17.1 Uterus b ___ _ __-. _ 11.0 14.0 14.1 14.9 15.0 14.6 11.8 11.9 Breast _________________________________________________ 7 2 8.5 10.8 11.2 13.2 14.0 16.3 15.8 14.1 Skin________'_ __________________________________________ * ‘ 3.4 2.1 2.9 3.1 2.8 2.3 2.6 Other and unspecified sites ________________________________ 14.2 13.1 18.5 20.0 26.4 31.3 39.7 40.6 42.8 Respiratory system b ___________________________________ _ _ _ _ 5.2 7.2 10.0 12.0 13.8 Benign tumors and tumors of unspecified nature _______________ ‘ * 3.3 4.1 5.8 6.1 5.0 3.9 3.9 Cardiovascular-renal diseases—total _________________________ 381.2 412.0 437.7 418.4 451.1 506.5 545.1 503.7 475.6 Intracranial lesions of vascular origin _____________________ 85.5 89.2 106.4 87.7 87.7 83.3 88.7 84.0 77.5 Diseases of the heart—all forms ___________________________ 180.1 190.7 205.9 218.1 260.6 319.2 356.4 338.8 329.4 Other diseases of the circulatory system ___________________ 27.5 30.6 29.7 26.2 22.3 27.9 32.2 33.4 29.2 Nephritis (including arteriosclerotic kidney) _______________ 88.1 101.5 95.7 86.4 80.5 76.1 67.8 47.5 39.5 Diabetes mellitus __________________________________________ 15.9 17.2 17.4 16.4 17.9 23.7 24.7 21.9 20.5 Rheumatism and arthritis __________________________________ " ‘ ‘ " "' * * 1,2 ‘ Alcoholism ________________________________________________ 8.7 6.1 * 2.6 3.3 3.5 2.4 2.3 1.9 Cirrhosis of the liver _______________________________________ 18.6 14.2 9.6 9.0 10.8 15.2 18.5 17.1 18.2 .' .L i. L t m o {79 VINIIOJI’IVO 80d NVHDOHJ HSVEISKI DINOZIHO V \ T I. F o r ' . Anemias ________ __ 4.3 5.6 7.6 7.1 3.6 2.4 2.0 1.6 1.3 Diseases of the organs of vision _____________________________ _ * ‘ “ "' " ‘ " * Diseases of the ear and mastoid process___..____' _______________ * * * 2.7 4.0 3.6 1.6 "‘ * Ulcer of the stomach or duodenum ___________________________ 5.2 6.0 5.1 9.2 8.2 11.0 9.6 8.6 8.4 Diseases of the female genital organs and breast ‘ ______________ 4.4 " 3.3 2.8 3.3 2.2 1.5 " ’ Diseases of the bones, joints and organs of movement __________ " “ 3.0 " * " * ’ * Senility - _____ 23.2 14.5 8.7 7.8 4.0 2.5 3.0 3.9 2.8 Tuberculosis ______________________________________________ 206.5 185.7 162.1 125.5 99.6 7 56.3 43.5 34.9 Pneumonia and influenza ____ __ Diarrhea and enteritis ______________________________ Specific acute communicable diseases " ________________ Total selected chronic diseases ° _________________ Total selected communicable diseases _____________ Total deaths from all causes _____________________ ‘1 2.9 103.7 100.1 167.0 92.4 83.9 5.5 58.9 45.4 37.1 _______ 51.5 37.2 45.8 31.3 18.6 8.9 7.2 6.4 6.3 _______ 50.9 31.4 39.4 20.6 15.3 6.7 3.6 3.0 1.4 _______ 554.6 580.2 610.9 594.4 640.7 715.2 761.6 706.0 673.5 _______ 412.6 354.4 414.3 269.8 217.4 164.0 126.0 98.3 79.7 _______ 1362.8 1297.8 1377.2 1200.8 1166.9 1174.7 1162.1 1056.1 981.8 ‘ Rates not computed for less than 100 deaths. I Excluding leukemias and Hodgkins disease. ‘1 Not separately classified for earlier years. 6 Excluding venereal, puerperal and tumors. 6 Typhoid fever, scarlet fever, whooping cough, measles. ° Diseases selected by the Chronic Disease Advisory Committee for which mortality data. were available on a trend basis. SOURCE: State of Calif., Department of Public Health, Vital Statistics Records. diphtheria, U. S. Public Health Service, National Office of Vital Statistics. VIN’HOJI’IVO 210d NVHDOHJ EiSVEISIG DINOHHO V 99 TABLE 4 AGE DISTRIBUTION OF DEATHS SELECTED CHRONIC DISEASES AND SELECTED COMMUNICABLE DISEASES CALIFORNIA; 1947 (By Place of Occurrence) Number of deaths ['nder .65 Cancer—total I _________________________________________________ 1,320 Buccal cavity and pharynx _____________________________________ 31 Digestive organs and peritoneum ________________________________ 327 Female genital organs _________________________________________ 248 Uterus _____________________________________________________ 185 Breast _______________________________________________________ 181 Skin _________________________________________________________ 41 Other and unspecified sites _____________________________________ 492 Respiratory System __________________________________________ 102 Benign tumors and tumors of unspecified nature _____________________ 142 Cardiovascular-renal diseases—Total ______________________________ 2.331 Intracranial lesions of vascular origin ___________________________ 263 Diseases of the heart—all forms _________________________________ 1,562 Other diseases of the circulatory system __________________________ 111 Nephritis (including arteriosclerotic kidney) ______________________ 395 Diabetes mellitus ________________________________________________ 121 Rheumatism and arthritis ________________________________________ 7 Alcoholism _____________________________________________________ 71 Cirrhosis of the liver _____________________________________________ 395 45-61; 5,473 157 2,085 850 568 639 58 1,684 734 168 13,700 1,890 10,212 431 1,167 689 16 93 943 65and over 6,888 188 3,329 587 427 571 156 2,057 532 79 30,939 5,499 20,761 2,338 2,341 1 .217 65 27 463 Percent of deaths Under 1,45 9.6 8.2 5.7 14.7 15.7 13.0 16.1 11.6 7.4 36.5 4.9 3.4 4.8 3.8 10.1 6.0 7.9 37.2 21.9 45—64 40.0 41.8 36.3 50.5 48.1 45.9 22.7 39.8 53.7 43.2 29.2 24.7 31.4 15.0 29.9 34.0 18.2 48.7 52.4 65 and over 50.4 50.0 58.0 34.8 36.2 41.1 61.2 48.6 38.9 20.3 65.9 71.9 63.8 81.2 60.0 60.0 73.9 14.1 25.7 99 VINQIOQII'IVO 110d NVHDOHcI HSVHSIG DINOHHO V Anemias _______________________________________________________ 21 21 91 15.8 15.8 68.4 Diseases of the organs of vision ___________________________________ 2 “ 1 66.7 * 33.3 Diseases of the ear and mastoid process _____________________________ 24 4 6 70.6 11.8 17.6 ['lcer of the stomach or duodenum _________________________________ 96 393 336 77.6 47.7 40.7 Diseases of the female genital organs and breast " ____________________ 30 24 7 49.2 39.3 11.5 Diseases of the bones, joints and organs of movement _________________ l4 8 14 38.9 22.2 38.9 Senility ________________________________________________________ * 2 277 ‘ .7 99.3 Tuberculosis ____________________________________________________ 1,538 1,290 621 44.6 37.4 18.0 Pneumonia and influenza _________________________________________ 1,228 743 1,689 33.6 20.3 46.1 Diarrhea and enteritis ___________________________________________ 559 31 33 89.7 5.0 5.3 Specific acute communicable diseases ° _____________________________ 125 11 7 87.4 7.7 4.9 Total selected chronic diseases d _______________________________ 4,574 21,534 40,410 6.9 32.4 60.7 Total selected communicable diseases __________________________ 3,450 2,075 2,350 43.8 26.4 29.8 Total deaths from all causes __________________________________ 20,785 28,460 47,723 21.4 29.4 49.2 * Refers to no deaths. d Diseases selected by the Chronic Disease Advisory Committee I Excluding Ieukemias and Hodgkins disease. for which mortality data were available on a trend basis. b Excluding venereal, puerperal and tumors. SOURCE: State of Calif., Department of Public Health, Vital C Typhoid fever, scarlet fever, whooping cough, diphtheria, Statistics Records. measles. VINHOclI'IVO 210d WVHDOHJ EISVEISIG OINOHHO V .LQ 08 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA TABLE 5 CANCER DEATHS BY SITE CALIFORNIA 1947 (By Place of Occurrence) Cause of Death Number of Deaths Buccal cavity and pharynx _________________________________________ 376 Digestive organs and peritoneum ______________________________________ 5,741 Stomach ________________________________________________________ 1,816 Rectum and anus _________________________________________________ 772 Intestines (except duodenum and rectum) ____________________________ 1,456 Liver and biliary passages __________________________________________ 683 Pancreas ________________________________________________________ 607 Other and unspecified ______________________________________________ 407 Respiratory system _______________________ 1,368 Bronchus ________________________________________________________ 558 Lung ___________________________________________________________ 616 Other and unspecified ______________________________________________ 19-1 Uterus ____________________________________________________________ 1,180 Cervix __________________________________________________________ 620 Other and unspecified______.- ______________________________________ 560 Other female genitul organs ___________________________________________ 50.") Ovary _____________________________ 453 Other and unspecified ______________________________________________ 52 Breast ____________________________________________________________ 1,391 Male genital organs _________________________________________________ 833 Prostate ________________________________________________________ 782 Other and unspecified ______________________________________________ 51 U rinzlry organs _____________________________________________________ 749 Kidney _________________________________________________________ 253 Bladder ___________________ 480 Other and unspecified _____________________________________________ 16 Skin (except vulva and scrotum) ______________________________________ 255 Brain and other parts of the central nervous system _____________________ 315 Leukemias and aleukemius ‘ __________________________________________ 595 Hodgkins disease ‘ __________________________________________________ 138 Other and unspecified sites ___________________________________________ 968 Total b ______________________________________________________ 14,414 I Not included in other tables because mortality data. not available on a. trend basis. b Total is greater than shown in other tables because of the inclusion of the addi- tional categories. SOURCI : State of California, Department of Public Health, Vital Statistics Records. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 59 TABLE 6 TREND OF MORTALITY FROM CARDIOVASCULAR-RENAL DISEASES“ FOR THREE MAIOR GROUPS—CALIFORNIA: 1910-1940 (By Place of Occurrence) Death rate per 100,000 population Under 75 and [,5 115—71, over 1910 ___ ____ _____________ 81.0 1,010.8 6,443.6 1920 ___________________________________________ 68.2 1,0083 7.9110 1930 ___________________________________________ 50.7 1,041.7 8,118.2 1940 ___________________________________________ 42.5 1,101.2 8,332.5 I Includes disease groups as shown in Tables 1- 4. SOURCE: United States Public Health Service, National Office Of Vital Statistics. TABLE 7 DEATHS FROM CARDIOVASCULAR-RENAL DISEASE CALIFORNIA: 1947 (By Place of Occurrence) Number of Cause of death deaths Intracranial lesions Of vascular origin _________________________________ 7, 652 Rheumatic heart disease _____________________________________________ 1, "27 Chronic rheumatic diseases of the heart ______________________________ 1, 706 Acute rheumatic fe1e1 w ith hezut invohemeut “ ________________________ 21 Heart disease (except rheumatic) ____________ _ __________________ ____ :10, 829 Diseases of the co1onary '11t01 10s and angina pettmis ___________________ 11,. 578 Other diseases Of the heart _________________________________________ 1‘), 2 11 Diseases of the circulatory system (other than heart disease) _____________ 2,880 Arteriosclerosis __________________________________________________ 2,131 Other diseases of the circulatory system ______________________________ 749 Nephritis _________________________________________________________ 3,903 Arteriosclerotic kidney ____________________________________________ 2,912 Other and unspecified nephritis _____________________________________ 991 Multiple sclerosis " _________________________________________________ 70 Total " __________________________________________________________ 47.061 5 Not included in other tables because mortality data not available on a trend basis. ‘3 Total is greater than shown in other tables because of the inclusion of the addi- tional categories. SOURCE. State of California, Department of Public Health, Vital Statistics Records. NOTES AND REFERENCES FOR TABLES ON MORTALITY Table 1 (1) U. S. Bureau of the Census, Mortality Statistics, 1910, Table 8, pp. 367—370. (2) Ibid. 1915, Table 8, pp. 448—451. (3) Ibid. 1020, Table 8, pp. 314-316. (4) Ibid. 1925, Part 1, Table 8. pp. 145-148. (5) Ibid. 1930, Table 8, pp. 286-291. (6) Ibid.1935, Table 9, p. 258. (7) U. S. National Office Of Vital Statistics, Unpublished tabulations, 1910. 1915, 1920, 1925, 1930, 1935. (8) U. S. Bureau of the Census, Vital Statistics of the United States, 19/10, Part 1, Table 13,111). 277-279. (9) State of California, Department of Public Health, Vital Statistics Records, 1945, 1947. 60 Table 2 Table 3 Table 4 Table 5 Table 6 Table 7 Text tables of age— adjusted death rates (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) A CHRONIC DISEASE PROGRAM FOR CALIFORNIA Same as (1)-(9) above. Same as (1 )—(9) above. , Population bases for rates—Appendix A—l, Table 1. Population bases for rates—U. S. Bureau of the Census, Vital Sta- tistics Rates in the United States, 1900-1940, Table 1, pp. 840—841, 857. State of California, Department of Public Health, Vital Statistics Records, 1947. Same as (14) above. Same as (1), (3), (5), ('7), (8) above. Population bases for rates—Appendix A—1, Table 8. Same as (14) above. Same as (16) above. U. S. National Oflice of Vital Statistics, unpublished tabulations, 1940. Standard population—U. S. Bureau of the Census, Vital Statistics Rates in the United States, 1900—1940, Table 11, p. 877. The follow- ing age groups were used—under 1, 1-4, 5-14, 15-24, 25—34, 35—44, 45—54, 55-64, 65-74, 75-84, 85 and over; exception to this grouping was made in the case of cancer for 1910 and 1920 since comparable mortality data were not available~for these years the age groups used were— under 1, 1-4, 5-9, 10-19, 20-29, 30-39, 40-49, 50-59, 60-69, 70-79, 80 and over—and the sources for the standard populations were—Appen- dix A—1, Table 8, and 15th census of the United States, 1930, Popu- lation Vol. 11, Table 24, p. 658. Bases for age—specific rates used in computing age-adjusted rates—— same as (21) above; also, 13th census of the United States, 1910,. Abstract of the Census, Supplement for California, Table 7, p. 588, and 14th census of the United States, 1920, Population Vol. 11, Table 13, p. 194. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 61 APPENDIX A-3 MORBIDITY DATA FROM THE CALIFORNIA DISABILITY INSURANCE PROGRAM Operating programs are one of the few sources from Which mor- bidity data can be obtained for diseases other than those made reportable by law. Each Operating program, whether it Offers medical care, dis- ability insurance or other types of benefits, differs in the kind, amount and extent of benefits, in the size and composition of the covered popu- lation and in the administration Of the programs. These differences, and the fact that the programs are not designed primarily as statistical services, introduce certain limitations in the use to which the data can be put and in the comparisons which can be made between the data from any two programs. I. GENERAL PROVISIONS OF THE DISABILITY INSURANCE PROGRAM Purpose of Disability Insurance In 1946 the California Legislature amended the California Unem- ployment Insurance Act tO provide cash benefits for wage loss resulting from illness or injury. Benefits under this system are not paid as reim- bursement for medical care expenditures. Coverage The exact number of persons in covered employment is not known at the present time, but it has been estimated at between two and one-half and three million. Certain classes of employment are not cov- ered by the act. The principal excluded groups are agricultural labor, domestics, self-employed persons and government employees. Two Types of Disability Insurance Two types of coverage are provided by the disability insurance system—the state and voluntary plans; these two forms are described in Sections II and III. At the end of 1947, there were some 8,750 volun- tary plans covering an estimated 678,000 persons. II. THE STATE PLAN Eligibility Requirements In order to receive disability insurance benefits, a person must: 1. Be unemployed because of illness or injury; 2. Serve a seven-day waiting period; 3. File a claim accompanied by a medical statement which includes history, findings and diagnosis. This statement must be signed by a medical doctor, osteopath. chiropodist, chiropractor, dentist, medical officer in a federal medical facility, or by an accredited religious prac— titioner. During 1947, 88 percent of the more than 100,000 claims received under the state plan were signed by doctors of medicine, 9 percent by doctors of osteopathy and the remaining 3 percent by doctors 62 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA of chiropractic.”l (Fewer than one-half of one per cent were certified to by religious practitioners) ; 4. Have earned a specified amount of money in covered employ- ment during a period preceding the disability. This eligibility require- ment tends to exclude from coverage many persons in the under eighteen age group since few persons in this group have earned suffi— cient wages to meet this requirement; 5. Submit to a reasonable physical examination when and if required. Amount and Duration of Benefits Until January 1. 1948, the amount of benefits paid ranged from $10 to $20 per week for a maximum of 23.4 weeks. Payments were made for only full weeks of disability beyond the seven-day waiting period. (Effective January 1, 1948, the maximum weekly benefit was increased to $25 and the maximum duration to 26 weeks. Payments are made for each day of disability beyond the seven-day waiting period.) Claimants may receive disability insurance and unemployment insurance at different times during the same benefit year," but not during the same week. If both types of insurance are received during the same benefit year, payments are limited to one and one-half times the amount payable for either form of insurance. For this reason, unemployment insurance payments may reduce the amount and duration of disability insurance payments. Disqualifications A claimant is not eligible during any week in which he is entitled to receive unemployment insurance, workmen’s compensation, regular wages paid by the employer or GI readjustment allowances. A claimant who is disqualified from receiving unemployment insurance for quitting his job without good cause, leaving his job on amount of a trade dispute or for refusing suitable work is also disqualified for disability insurance. III. VOLUNTARY PLANS Eligibility Requirements Eligibility requirements are essentially the same as under the state plan with the exception that not all voluntary plans require a waiting period. Earning and duration of employment requirements may differ from the state plan and even may differ among the voluntary plans. Amount and Duration of Benefits Voluntary plan weekly benefit payments are at least equal in amount to those paid under the state plan, and some offer as much as full salary. Disqualifications A claimant is disqualified for the same reasons as stated under Section II. ‘ Excludes 942 claims certified to by government medical officers, Chiropodists and- dentists during the fourth quarter of 1947. Certification by these practitioners was not accepted before September 19. 1947. b The 12-month period following the filing of the first valid unemployment or dis- ability insurance claim. ~ A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 63 IV. MORBIDITY DATA—STATE AND VOLUNTARY PLANS Coding of Diagnosis The U. S. P. H. S. coding manual " is used in coding the diagnosis reported on the claim form. ”When two or more diagnoses are reported on the same claim form, the disease which is keeping the claimant off his job is selected for coding. \Vhen it is not clear which one is keeping the claimant off the job, preference is given to the chronic diseases, such as malignant neoplasms, heart and circulatory diseases and diabetes. Data Based on Spells Paid and Reported Terminated Morbidity reports are based on those spells of disability which were paid and reported terminated by the district offices of the Department of Employment. Therefore, many spells of disability which began late in 1947 would not necessarily be reported terminated until 1948. Weeks Paid This is the total number of full weeks for which compensation was received. The partial weeks of disability which were compensated under voluntary plans are not included in these figures. Amount Paid This is the full amount of money paid for the disability. Money paid under voluntary plans for partial weeks of disability is included. Benefits Exhausted This is the number of spells of disability for which maximum bene- fits (to which the claimant was eligible) were paid. The following points should be mentioned in connection with the state plan: 1. Disability insurance payments may be reduced when both unem- ployment and disability insurance benefits have been received during the same benefit year. 2. Since the maximum duration of benefits varies according to the earnings of the claimants, some claimants may exhaust their benefits after drawing fewer than 23.4 weeks (26 weeks in l948) even though the benefits were not decreased by former unemployment insurance payments. Chronic Diseases The list of chronic disease for which the disability insurance data have been prepared has been selected on the basis of the diagnosis and not on the basis of duration of illness. The list does not include all of the conditions which might be considered chronic. but rather diseases which are of particular interest in the chronic disease survey. It is probable that, due to methods of classifying illness for coding purposes, certain acute conditions have been included in the list. Limitations of the data arising from the statistical, Operating and administrative features of the program result, for the most part, in an underreporting of illnesses and injuries in the insured population and in an underreporting of duration of illness. Malingering might have the llThe United States Public Health Service Manual for Coding Causes of Illness According to a Diagnosis Code for Tabulattng Morbirltty Stattstu-s. 64 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA opposite effect, but it is doubtful that this occurs frequently since the benefits payable under the program would only rarely be more attractive than the salary the claimant would earn in regular employment. Unsched- uled visits to claimants are sometimes made and other control measures are used as a check against possible malingering. It is important to remember that the accompanying information is not complete in that it does not reflect the total amount of unemployment resulting from chronic diseases in the covered labor force, nor can the data be projected in any way so that it reflects the extent of chronic diseases in California. Rather, it indicates the extent to which specified chronic diseases are given as the cause of unemployment in a significant, but selected, segment of the California population. SUMMARY OF TABULAR MATERIAL California Disability Insurance data for the selected chronic dis- eases “ are presented in detail in the following Tables 1-12. Disability insurance data constitute the only available current infor- mation 011 chronic disease morbidity in any sizeable segment of the popu- lation of California; and this segment is an important one. In the absence of morbidity data for the general population of California other than estimates based on the National Ilcalth Survey of 1935-1936, the accom- panying tables are presented to assist—even though in a very restricted and incomplete manner—in providing answers to the question : “ What is the magnitude of the chronic disease problem in California?” The State Plan Extent of Chronic Illness—In 19-17 under the State Plan, benefits were paid for 89,160 spells of disability. Of these spells of disability, 37,715 or 42 percent were due to the selected chronic diseases. As shown in Table A, more than seven million dollars were paid out of the State Dis- ability Fund for a total of 380,000 weeks of chronic illness. This sum, which represents 47 percent of the $15,000,000 paid for all causes of dis- ability, by no means covers either the total wage loss or the loss of produc- tivity, the cost of medical care, hospitalization and ancillary services required for most extended periods of disability. Duration of Compensation for Chronic Illness—The average dura- tion of payments for the selected chronic illnesses was 10.1 weeks per paid spell of disability. It is important to realize that payments are not always made for the duration of the illness since a waiting period must be served for each spell of disability and benefits may be exhausted before the claimant is able to return to work. Benefits for 30 percent of the spells of chronic disability were exhausted (Table 3) ; that is, the maximum bene- fits to which the claimant was entitled were paid. It is probable that most of these claimants were still disabled after their insurance benefits were exhausted. “ Diseases selected by the Chronic Disease Advisory Committee at the June 11th meeting of the committee. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA TABLE A DISABILITY INSURANCE—STATE PLAN—PAID SPELLS OF DISABILITY REPORTED TERMINATED. 1947 Selected Chronic Diseases and All Spells of Disability Duration and Amount oi Benefit Payments Spells of Disability for: Selected chronic diseases Paid spells ______________ 37,715 “'eeks paid _____________ 380,453 Amount paid ____________ $7,220,099 Average per paid spell “’eeks _____________ 10.1 Amount ____________ $191.44 Benefits exhausted _______ 11,147 A ll other A ll diseases diseases 51,445 89,160 423,574 804,027 $5,046,917 $15,267,016 8.2 9.0 $156.42 $171.23 11,019 22,466 65 Chronic diseases as a percent of all dis- abilities 42.3 47.: 47.3 51.0 Age as Related to Chronic Disease—Although chronic diseases increase in prevalence as age increases, they occur at all ages. Thirty-nine percent of the spells of chronic disability occurred in persons under 45 years of age (Table B). Benign neoplasms, rheumatic heart disease, nephritis and diseases of the female genital organs are all major causes of disability in persons under 45. TABLE B DISABILITY INSURANCE—STATE PLAN—PAID SPELLS OF DISABILITY REPORTED TERMINATED. 1947 Spells of Chronic Disease in Persons Under 45 Years by Sex Age Under 45 years of age ___________________ Total—all ages Percent under 45 ______________________ Spells of Chronic Disease Men lVomen ___ 5,592 9,106 ___ 20,093 17,622 ___ 27.8 51.7 Total 14,698 37,715 39.0 The cardiovascular-renal diseases become more important as a cause of disability as age increases. This is also true for malignant neoplasms and rheumatism and arthritis. Payments for Certain Chronic Diseases—The cardiovascular—renal diseases, cancer and other tumors, rheumatism and arthritis, alcoholism and diabetes account for more than one—fourth of the paid spells of dis- ability and nearly one-third of the amount of money paid for all causes of disability during 1947. Among the chronic diseases the cardiovascular- renal group leads all others both in number of spells and in the amount of payments. During 1947, almost three million dollars were paid for more than 13,000 spells of disability caused by these diseases. Heart disease, the most important cause of disability in this group, accounted for pay- ments amounting to more than one and one-half million dollars and more than one-fourth of all spells of chronic disability which exhausted bene- fits. Diseases of the circulatory system, especially varicose veins and hemorrhoids, were also important causes of disability in this group. 5—0817!) 66 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA Payments in excess of one million dollars were‘made for disabilities due to cancer and other tumors. The duration of compensation for the benign tumors was shorter on the average than for cancer (Table 1), and the percentage of spells which exhausted benefits was less than half that of cancer. TABLE C DISABILITY INSURANCE—STATE PLAN—PAID SPELLS OF DISABILITY REPORTED TERMINATED, 1947 Payments to: Certain Chronic Diseases Percent of paid spells which Paid Benefits exhausted Chronic diseases spells Amount paid exhausted benefits Cardiovascular-renal diseases _____ 13,425 $2,952,075 5,407 40.3 Heart disease ' _______________ 6,952 1,677,743 3,139 45.2 Circulatory disease " ___________ 5,906 1,157,315 2,053 34.8 Nephn'tis ____________________ 567 117,017 215 37.9 Cancer and other tumors __________ 5,609 1,027,169 1,319 23.5 Cancer _______________________ 2,099 475,663 784 37.4 Benign tumors __‘ ______________ 3,510 551,506 535 15.2 Rheumatism and arthritis _________ 3,184 660,986 1,219 38.3 Alcoholism _____________________ 796 142,240 212 26.6 Diabetes mellitus ________________ 540 111,659 201 37.2 Total _____________________ 23,554 $4,894,129 8,358 35.5 All spells of disability______ _______ 89,160 $15,267,016 22,466 25.2 Total as a percentage of all disabilities ________________ 26.4 32.1 37.2 I Includes rheumatic heart disease. b Includes intracranial lesions of vascular origin. Rheumatism and arthritis was among the leading causes of chronic illness for which compensation was paid under the Disability Insurance Program. This cause of disability was second only to the cardiovascular- renal group in the percentage of spells which exhausted benefits. Alcoholism accounted for the payments of $142,000 for approxi- mately eight hundred spells of disability. Of this number, about one-fifth were for alcoholic psychosis. Voluntary Plans Extent of Chronic Illness—The voluntary plan data show many of the same general characteristics found in the state plan data. The differ- ences which are found may be attributed to the differences in the plans themselves and in the populations covered by the plans. During 1947, approximately 10,000 spells of chronic illness were compensated under voluntary plans in the amount of nearly one and one-half million dollars. Twenty-seven percent of all spells of disability were chronic illnesses, and 37 percent of the amount of benefits were for chronic illnesses. 1g Q A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 67 Duration of Compensation for Chronic Illness—Because of the methods used in coding and tabulating the voluntary plan data during 1947, the average duration as shown in the tables is greatly understated. Nevertheless, it is of interest to note that in the voluntary plans, as in the state plan, the average duration of payments for chronic diseases exceeded that of all other diseases by two weeks per paid spell. About 6 percent of the spells of chronic illness exhausted benefits. This is impor- tant inasmuch as some voluntary plans pay benefits for as long as 50 to 52 weeks in a year; and unemployment insurance payments do not curtail voluntary plan payments as they do under the state plan. Age as Related to Chronic I llncss—More than one-half of the spells of chronic illness reported by voluntary plans were in persons under 45 years of age. Illnesses in this age group represented 71 percent of all spells of chronic disease in women. Payments for Certain Chronic Diseases—The cardiovascular-renal diseases, cancer and other tumors, rheumatism and arthritis, alcoholism and diabetes represent 14 percent of all spells of disability, 23 percent of the amount of benefits paid and 25 percent of the spells which exhausted benefits under the voluntary plans. The cardiovascular-renal diseases are the most important cause of chronic illness in respect to the number of spells paid and the amount of benefits paid. 1 t I! I I. i i It has been mentioned previously that the limitations of the disa- bility insurance data result for the most part in an underreporting of illnesses and injuries in the covered population, and in an underreport- ing of duration of illness. These limitations, and the fact that age, sex and other characteristics of the covered population are not known at this time, make it necessary that no attempt is made to project the data so that they apply to the total population of California. DISABILITY INSURANCE—STATE PLAN PAID SPELLS OF DISABILITY REPORTED TERMINATED. 1947‘ TABLE 1 Selected Chronic Diseases—Duration oi Benefit Payments Average number Number of paid spells Number of full weeks of weeks of disability paid paid per spell Selected chronic diseases Men Women Total Men Women Total Men Women Total Malignant neoplasms 1,310 789 2,099 15,654 9,148 24,802 11.9 11.6 11.8 Malignant tumors _ 1,231 766 1,997 14,759 8,866 23,625 12.0 11.6 11.8 Hodgkin’s disease 38 9 47 458 94 552 12.1 h 11.7 Leukemias 41 14 55 437 188 625 10.7 13.4 11.4 Benign neoplasms and neoplasms of unspecified nature 626 2,884 3,510 4,422 24,677 29,099 7.1 8.6 8.3 Intracranial lesions of vascular origin ________________ 949 217 1,166 14,328 3,290 17,618 15.1 15.2 15.1 Rheumatic heart disease ___________________________ 366 251 617 4,174 3,374 7,548 11.4 13.4 12.2 Chronic rheumatic diseases of the heart ____________ 300 203 503 3,459 2,711 6,170 11.5 13.4 12.3 Acute rheumatic fever with heart involvement ______ 66 48 114 715 663 1,378 10.8 13.8 12.1 Heart disease (except rheumatic) ___________________ 4,709 1,626 6,335 59,960 20,326 80,286 12.7 12.5 12.7 Diseases of the coronary arteries and angina pectoris 2,702 576 3,278 35,243 7,683 42,926 13.0 13.3 13.1 Other diseases of the heart _______________________ 2,007 1,050 3,057 24,717 12,643 37,360 12.3 12.0 12.2 Diseases of the circulatory system (other than heart disease) _ 2,598 2,142 4,740 22,139 21,080 43,219 8.5 9.8 9.1 Hypertension 614 781 1,395 7,426 9,318 16,744 12.1 11.9 12.0 Other diseases of the circulatory system ____________ 1,984 1,361 3,345 14,713 11,762 26,475 7.4 8.6 7.9 Nephritis (and other diseases of the kidneys) __________ 672 758 1.430 6,107 7,617 13,724 9.1 10.0 9.6 Nephritis (including arteriosclerotic kidney) _______ 360 207 567 3,821 2,353 6,174 10.6 11.4 10.9 Other diseases of the kidneys and ureters __________ 312 551 863 2,286 5,264 7,550 7.3 9.6 8.7 89 VINHOJI’IVO HOL'I NVHDOHcI GISVEISIG OINOHHO V n A I. I p A .4 Diabetes mellitus ____ _ 354 186 540 3,720 2,113 5,833 10.5 11.4 10.8 Rheumatism and arthritis __________________________ 1,894 1,290 3,184 20,273 14,741 35,014 10.7 11.4 11.0 Alcoholism ____ 752 44 796 7,266 471 7,737 9.7 10.7 9.7 Cirrhosis of the liver ‘ 235 50 285 2,453 542 2,995 10.4 10.8 10.5 Anemia (pernicious) _____________________________ 78 70 148 823 729 1,552 10.6 10.4 10.5 Multiple sclerosis _ 53 27 80 777 364 1,141 14.7 13.5 14.3 Diseases of the organs of vision _____________________ 773 426 1,199 6,7 58 4,045 10,803 8.7 9.5 9.0 Diseases of the ear and mastoid process ______________ 248 230 478 1,512 1,874 3,386 6.1 8.1 7.1 Chronic pulmonary disease (nontuberculous) _________ 313 246 559 2,842 2,445 5,287 9.1 9.9 9.5 Ulcer of the stomach or duodenum __________________ 2,129 453 2,582 16,424 4,539 20,963 7.7 10.0 8.1 Diseases of the female genital organs and breast (exclud- ing venereal, puerperal and tumors) _______________ _ 4,491 4,491 _ 39,304 39,304 _ 8.8 8.8 Diseases of the bones, joints and organs of movement__ 1,994 1,436 3,430 16,559 12,892 29,451 8.3 9.0 8.6 Osteomyelitis and other diseases of the bone ________ 420 161 581 4,273 1,453 5,726 10.2 9.0 9.9 Diseases of the joints and organs of movement (other than rheumatism and arthritis) ________________ 1,574 1,275 2,849 12,286 11,439 23,725 7.8 9.0 8.3 Senility 40 6 46 601 90 691 15.0 b 15.0 Total—selected chronic diseases _______________ 20,903 17,622 37,715 206,792 173,661 380,453 10.3 9.9 10.1 Total—all spells of disability __________________ 49,866 39,294 89,160 443,819 360,208 804,027 8.9 9.2 9.0 Total selected chronic diseases as a percentage of all disabilities ____________________________ 40.3 44.8 42.3 46.6 48.2 47.3 nIncludes spells of disability reported terminated December, 1946 ability. . b No averages calculated for fewer than ten paid spells of dis- Sonncn : California Department of Employment. Tables A and B of Report 1021, Nos. 1-4. VINHOJI’IVO HOS WVQIDOHd {HSVHSICI OINOHHO V 69 TABLE 2 DISABILITY INSURANCE—STATE PLAN PAID SPELLS OF DISABILITY REPORTED TERMINATED. 1947' Selected Chronic Diseases—Amount of Benefit Payments Number of paid spells Average amount paid of disability Amount paid per spell Selected chronic diseases Men Women Total Men Women Total Men Women Total Malignant neoplasms ____________________________ 1,310 789 2,099 $304,212 $171,451 $475,663 $232 22 $217 30 $226 61 Malignant tumors 1,231 766 1,997 286,940 166,125 453,065 233 10 216 87 226 87 Hodgkin’s disease 38 9 47 8,617 1,718 10,335 226 76 b 219 89 Leukemias ' 1 41 14 55 8,655 3,608 12,263 211 10 257 71 222 96 Benign neoplasms and neoplasms of unspecified nature 626 2,884 3,510 86,298 465,208 551,506 137 86 161 31 157 12 Intracranial lesions of vascular origin ______________ 949 217 1,166 277,354 61,720 339,074 292 26 284 42 290 80 Rheumatic heart disease __________________________ 366 251 617 79,687 62,437 142,124 217 72 248 75 230 35 Chronic rheumatic diseases of the heart ___________ 300 203 503 66,052 50,632 116,684 220 17 249 42 231 98 Acute rheumatic fever with heart involvement _____ 66 48 114 13,635 11,805 25,440 206 59 245 94 223 16 Heart disease (except rheumatic) __________________ 4,709 1,626 6,335 1,160,978 374,641 1,535,619 246 54 230 41 242 40 Diseases of the coronary arteries and angina pectoris 2,702 576 3,278 683,454 140,361 823,815 252 94 243 68 251 32 Other diseases of the heart ______________________ 2,007 1,050 3,057 477,524 234,280 711,804 237 93 223 12 232 84 Diseases of the circulatory system (other than heart disease) _ 2,598 2,142 4,740 426,803 391,438 818,241 164 28 182 74 172 62 Hypertension 614 781 1,395 142,438 172,589 315,027 231 98 220 98 225 83 Other diseases of the circulatory system ___________ 1,984 1,361 3,345 284,365 218,849 503,214 143 33 160 80 150 44 Nephritis (and other diseases of the kidneys) ________ 672 758 1,430 117,781 140,626 258,407 175 27 185 52 180 70 N ephritis (including arteriosclerotic kidney) ______ 360 207 567 73,473 43,544 117,017 204 O9 210 36 206 38 Other diseases of the kidneys and ureters __________ 312 551 863 44,308 97,082 141,390 142 01 176 19 163 84 Diabetes mellitus 354 186 540 72,164 39,495 111,659 203 85 212 34 206 78 Rheumatism and arthritis _________________________ 1,894 1,290 3,184 390,981 270,005 660,986 206 43 209 31 207 60 l l ‘( ‘ ' 9 4 0L VINHOJI’IVO 210,21 WVQIDOHJ GISV’EISIG OINOHHO V . ’1 :- ., s n 9 Alcoholism _____________________________________ 752 44 796 134,084 8,156 142,240 178 30 185 36 178 69 Cirrhosis of the liver 235 50 285 46,873 10,003 56,876 199 46 200 06 199 56 Anemia (pernicious) ____________________________ 78 70 148 15,210 13,241 28,451 195 00 189 16 192 24 Multiple sclerosis _____ 53 27 80 15,132 6,525 21,657 285 51 241 67 270 71 Diseases of the organs of vision ____________________ 773 426 1,199 129,900 75,093 204,993 168 04 176 27 170 97 Diseases of the ear and mastoid process _____________ 248 230 478 29,323 35,233 64,556 118 24 153 19 135 05 Chronic pulmonary disease (nontuberculous) ________ 313 246 559 53,948 45,099 99,047 172 36 183 33 177 19 Ulcer of the stomach or duodenum __________________ 2,129 453 2,582 320,290 84,364 404,654 150 44 186 23 156 72 Diseases of the female genital organs and breast (ex- cluding venereal, puerperal and tumors) __________ _ 4,491 4,491 _ 730,942 730,942 _ 162 76 162 76 Diseases of the bones, joints and organs of movement__ 1,994 1,436 3,430 320,275 240,410 560,685 160 62 167 42 163 46 Osteomyelitis and other diseases of the bone _______ 420 161 581 81,273 26,690 107,963 193 51 165 78 185 82 Diseases of the jomts and organs of movement (other than rheumatism and arthritis) ________________ 1,574 1,275 2,849 239,002 213,720 452,722 151 84 167 62 158 91 Senility _______________________________________ 40 6 46 10,995 1,724 12,719 274 88 b 276 50 Total—selected chronic diseases ________________ 20,093 17,622 37,715 $3,992,288 $3,227,811 $7,220,099 $198 69 $183 17 $191 44 Total—all spells of disability __________________ 49,866 39,294 89,160 $8,568,210 $6,698,806 $15,267,016 $171 82 $170 48 $171 23 Total selected chronic diseases as a percentage of all disabilities 40.3 44.8 42.3 46.6 48.2 47.3 IIncludes spells of disability reported terminated December, 1946 ability. '1' No averages calculated for fewer than ten paid spells of dis- of Report 1021, Nos. 1-4. SOURCE: California Department of Employment. Tables A and B VINQIOJI'IVO 21021 NVQDOHJ {ISVGISICI OINO’HHO V IL PAID SPELLS OF DISABILITY REPORTED TERMINATED. 1947‘ TABLE 3 DISABEITY INSURANCHTATE PLAN Selected Chronic Diseases—Spells Which Exhausted Benefit Payments Number of paid spells spells exhausting Number of Percent of paid spells of disability benefits b exhausting benefits Selected chronic diseases Men lVomen Total Men Women Total Men TVomen Total Malignant neoplasms _____________________________ 1,310 789 2,099 474 310 784 36.2 39.3 37.4 Malignant tumors 1,231 766 1,997 447 299 746 36.3 39.0 37.4 Hodgkin’s disease ______________________________ 38 9 47 15 3 18 c c " Leukemias _ __ _-__ 41 14 55 12 8 20 c ° ° Benign neoplasms and neoplasms of unspecified nature 626 2,884 3,510 83 452 535 13.3 15.7 15.2 Intracranial lesions of vascular origin _______________ 949 217 1,166 596 145 741 62.8 66.8 63.6 Rheumatic heart disease __________________________ 366 251 617 148 141 289 40.4 56.2 46.8 Chronic rheumatic diseases of the heart ____________ 300 203 503 129 108 237 43.0 53.2 47.1 Acute rheumatic fever with heart involvement _____ 66 48 114 19 33 52 ‘ ° 45.6 Heart disease (except rheumatic) __________________ 4,709 1,626 6,335 2,025 825 2,850 43.0 50.7 45.0 Diseases of the coronary arteries and angina pectoris 2,702 576 3,278 1,189 320 1,509 44.0 55.6 46.0 Other diseases of the heart ______________________ 2,007 1,050 3,057 836 505 1,341 41.7 48.1 43.9 Diseases of the circulatory system (other than heart diseases) ___________________________________ 2,598 2,142 4,740 644 668 1,312 24.8 31.2 27.7 Hypertension __________________________________ 614 781 1,395 255 353 608 41.5 45.2 43.6 Other diseases of the circulatory system ___________ 1,984 1,361 3,345 389 315 704 19.6 23.1 21.0 Nephritis (and other diseases of the kidneys) ________ 672 758 1,430 177 232 409 26.3 30.6 28.6 Nephritis (including arteriosclerotic kidney) ______ 360 207 567 134 81 215 37.2 39.1 37.9 Other diseases of the kidneys and ureters __________ 312 551 863 43 151 194 13.8 27.4 22.5 4. 8L VINHOJI'IVO 3021 WVHDOHd HSVHSIG DINOHHO V . hBenefits may have been exhausted through payments of dis- ability insurance or through payments of unemployment and disability insurance. In either case. the last payment was made for disability insurance. $ . C D I ' ‘ ‘ Diabetes mellitus _________________________________ 354 186 540 119 82 201 33.6 44.1 37.2 Rheumatism and arthritis _________________________ 1,894 1,290 3,184 665 554 1,219 35.1 42.9 38.3 Alcoholism ______________________________________ 752 44 796 194 18 212 25.8 ° 26.6 Cirrhosis of the liver _____________________________ 235 50 285 78 22 100 33.2 ‘ 35.1 Anemia (pernicious) _____________________________ 78 70 148 24 25 49 ° ° 33.1 Multiple sclerosis _________________________________ 53 27 80 30 18 48 ° c c Diseases of the organs of vision ____________________ 773 426 1,199 208 124 332 26.9 29.1 27.7 Diseases of the ear and mastoid process _____________ 248 230 478 25 47 72 10.1 20.4 15.1 Chronic pulmonary disease (nontuberculous) _________ 313 246 559 91 70 161 29.1 28.5 28.8 Ulcer of the stomach or duodenum ___________________ 2,129 453 2,582 298 121 419 14.0 26.7 16.2 Diseases of the female genital organs and breast (exclud- ing venereal, puerperal and tumors) ____________ __ 4,491 4,491 __ 889 889 -_ 19.8 19.8 Diseases of the bones, joints and organs of movement __ 1,994 1,436 3,430 428 366 794 21.5 25.5 23.1 Osteomyelitis and other diseases of the bone ________ 420 161 581 149 45 194 35.5 28.0 33.4 Diseases of the joints and organs of movement (other than rheumatism and arthritis) _________________ 1,574 1,275 2,849 279 321 600 17.7 25.2 21.1 ‘Senility 40 6 46 27 4 31 ‘ ° ° Total—selected chronic diseases ________________ 20,093 17,622 37,715 6,334 5,113 11,447 31.5 29.0 30.4 Total—all spells of disability __________________ 49,866 39,294 89,160 12,241 10,225 22,466 24.5 26.0 25.2 Total selected chronic diseases as a percentage of all z = disabilities 40.3 44.8 42.3 51.7 50.0 51.0 IIncludes spells of disability reported terminated December, c No percentages calculated for fewer than 100 paid spells of 1946 disability. SOURCE: California Department of Employment. Tables A and B of Report 1021, Nos. 1-4. VINHOJI’IVO 210.11 NVHDOHcI EISVEISIG DINOHHO V SL TABLE 4 DISABILITY INSURANCE—STATE PLAN PAID SPELLS OF DISABEITY REPORTED TERMINATE. 1941' Selected Chronic Disease—Ago c! Mon Claimants Age groups Total Total 65 paid Under under ‘ and Un- Selected chronic diseases spells 18 18-24 25 25-44 45—64 over known Malignant neoplasms ______ 1,310 1 20 21 228 769 251 41 Malignant tumors ________ 1,231 1 14 15 194 739 245 38 Hodgkin’s disease ______ 38 _ 3 3 21 12 1 1 Leukemias __- 41 _ 3 3 13 18 5 2 Benign neoplasms and neoplasms of unspecified nature _______________ 626 _ 98 98 258 218 38 14 Intracranial lesions of vascular origin _ __ 949 _ 4 4 70 573 276 26 Rheumatic heart disease" 366” 2 28 30 152 141 34 9 Chronic rheumatic diseases of the heart __________________________ 300 1 12 13 115 129 34 9 Acute rheumatic fever with heart involvement ____________________ 66 1 16 17 37 12 _ _ Heart disease (except rheumatic) __ 4,709 1 16 17 432 2,940 1,183 137 Diseases of the coronary arteries and angina pectoris ______________ 2,702 _ 2 2 232 1,770 632 66 Other diseases of the heart ____ 2,007 1 14 15 200 1,170 551 71 Diseases of the circulatory system (other than heart disease) _________ 2,598 - 55 55 644 1,357 462 80 Hypertension ______ ____ __ 614 _ _ _ 53 339 194 28 Other diseases of the circulatory system __________________________ 1,984 _ 55 55 591 1,018 268 52 Nephritis (and other diseases of the kidneys) _______________________ 672 _ 33 33 223 321 79 16 Nephritis (including arteriosclerotic kidney) _____________________ 360 _ 12 12 95 188 55 10 Other diseases of the kidneys and ureters _________________________ 312 _ 21 21 128 133 24 6 17L VINHOJI'IVO '80s! NVHDOHJ EISVEISIG OINO’HHO V Diabetes mellitus _______________________________________________ 354 Rheumatism and arthritis _______________________________________ 1,894 Alcoholism ___ ________________________ 752 Cirrhosis of the liver ____________________________________________ 235 Anemia (pernicious) ___________________________________________ 78 Multiple sclerosis ____ ________________ 53 Diseases of the organs of vision ___________________________________ 773 Diseases of the ear and mastoid process ____________________________ 248 Chronic pulmonary disease (nontuberculous) _______________________ 313 Ulcer of the stomach or duodenum _________________________________ 2,129 Diseases of the bones, joints and organs of movement ________________ 1,994 Osteomyelitis and other diseases of the bone ______________________ 420 Diseases of the joints and organs of movement (other than rheuma— tism and arthritis) _ _- 1,574 Senility ' 4o Total—selected chronic diseases 90,093 Total—all spells of disability ________________________________ 49,866 Total selected chronic diseases as a percentage of all disabilities" 40.3 Am HI 15 101 14.9 ' ‘ 7 7 79 192 65 11 28 28 407 1,034 364 61 2 2 377 340 24 9 2 2 50 151 23 9 1 1 7 43 24 3 1 19 25 7 1 23 25 209 385 136 18 17 17 119 87 18 7 10 10 66 170 55 12 43 44 814 1,073 123 75 128 136 907 771 135 45 44 48 198 138 25 11 84 88 709 633 110 34 _ _ _ 8 31 1 516 531 5,061 10,598 3,328 575 2,979 3,080 17,139 22,259 5,953 1,435 17.3 17.2 29.5 47.6 55.9 1946 IIncludes spells of disability reported terminated December, I SOURCE: California Department of Employment, Table A of Report 1023, Nos. 1—4. VINHOJI‘TVO HOG! NV‘HDOHd {ISVEISIG OINOHHO V 9!. TABLE 5 DISABILITY INSURANCE4TATE PLAN PAID SPELLS OF DISABILITY REPORTED TERMINA'I'ED. 1947' Selected Chronic Diseases—Age of Women Claimants Age groups Total Total 65 paid Under under and Un- Selected chronic diseases spells 18 18-24 25 25-41, 45-61, over known Malignant neoplasms ____________________________________________ 789 _ 13 13 239 462 49 26 Malignant tumors _ 766 _ 9 9 231 452 48 2G Hodgkin’s disease 9 _ 2 2 6 1 _ _ Leukemias __ ___- 14 _ 2 2 2 9 1 _ Benign neoplasms and neoplasms of unspecified nature _______________ 2,884 2 67 69 1,794 925 17 79 Intracranial lesions of vascular origin _____________________________ 217 _ _ .. 21 153 39 4 Rheumatic heart disease___ ___ __ 251 _ 33 33 123 76 10 9 Chronic rheumatic diseases of the heart __________________________ 203 _ 15 15 100 69 10 ' 9 Acute rheumatic fever with heart involvement ____________________ 48 _ 18 18 23 7 _ _ Heart disease (except rheumatic) _ __ 1,626 1 23 24 404 949 191 58 Diseases of the coronary arteries and angina pectoris ______________ 576 1 1 2 97 372 86 19 Other diseases of the heart 1,050 _ 22 22 307 577 105 39 Diseases of the circulatory system (other than heart disease) _________ 2,142 1 63 64 707 1,144 158 69 Hypertension _ 781 _ 8 8 130 518 94 31 Other diseases of the circulatory system __________________________ 1,361 1 55 56 577 626 64 38 Nephritis (and other diseases of the kidneys) _______________________ 758 2 99 101 366 255 20 16 Nephritis (including arteriosclerotic kidney) _____________________ 207 _ 22 22 60 106 11 8 Other diseases of the kidneys and ureters _________________________ 551 2 77 79 306 149 9 8 9L VINHOJI’IVD HOJ WVHDO‘HJ HSVEISIG OINOHHO V Diabetes mellitns ‘ ___________________ 186 Rheumatism and arthritis _ _ 1.290 Alcoholism 44 Cirrhosis of the liver _ 50 Anemia (pernicious) ___________________________________________ 70 Multiple sclerosis ______________________ 27 Diseases of the organs of vision ___________________________________ 426 Diseases of the ear and mastoid process ____________________________ 230 Chronic pulmonary disease (nontuberculous) _______________________ 246 Ulcer of the stomach or duodenum ___- 453 Diseases of the female genital organs and breast (excluding venereal, puerperal and tumors) ___. 4,491 Diseases of the bones, joints and organs of movement ________________ 1,436 Osteomyelitis and other diseases of the bone ______________________ 161 ~ . Diseases of the joints and organs of movement (other than rheuma- tism and arthritis) 1,275 Senility - 6 Total—selected chronic diseases 17,622 Total—all spells of disability ”-9.294 Total selected chronic diseases as a percentage of all disabilities__ 44.8 13 13 39 112 19 3 32 32 389 697 129 43 1 1 24 15 1 3 _ _ 22 19 7 2 7 7 23 35 5 _ 5 5 17 4 _ 1 24 25 158 199 32 12 20 21 108 88 6 7 24 24 117 87 10 8 14 14 207 203 13 16 489 494 2,638 1,197 37 125 101 104 666 577 53 36 16 18 68 66 4 5 85 86 598 511 49 31 _ _ _ 2 4 _ 1,028 1,044 8,062 7,199 800 517 3,843 3,902 18,814 14,016 1,442 1,120 26.7 26.8 42.9 51.4 55.5 lIncludes spells of disability reported terminated December, 1946. l>No percentages calculated for fewer than 100 paid spells of disability. Report 1023, Nos. 1-4. SOURCE: California Department of Employment. Table B of VINHOJI'IVO 210.21 NVHQOHJ EISVEISIO DINOHHO 7 LL TABLE 6 DISABILITY INSURANCE—STATE PLAN SPELLS OI" DISABILITY REPORTED TERMINATED, 1947 Selected Chronic Diseases—Percentage Distflbuflon by Age Groups and Sex Men Women Total—Men and Women 65 65 65 Total Under and Under and Under and all Selected chronic diseases 25 25-44 45-64 over 25 25-44 45-64 over 25 25-“ 45-64 over ages " Malignant neoplasms _________ 4.0 4.5 7.3 7.5 1.2 3.0 6.4 6.1 2.2 3.6 6.9 7.3 5.6 Benign neoplasms ___________ 18.5 5.1 2.1 1.1 6.6 22.2 12.8 2.1 10.6 15.6 6.4 1.3 9.3 Intracranial lesions of vascular origin ____________________ " 1.4 5.4 8.3 _ 2.1 4.9 ° c 4.1 7.6 3.1 Rheumatic heart disease ______ 5.6 3.0 1.3 1.0 3.2 1.5 1.1 1.2 4.0 2.1 1.2 1.1 1.6 Heart disease _______________ 3.2 8.5 27.8 35.5 2.3 5.0 13.2 23.9 2.6 6.4 21.9 33.3 16.8 Diseases of the circulatory system ___________________ 10.4 12.7 12.8 13.9 6.1 8.8 15.9 19.8 7.6 10.3 14.1 15.0 12.6 Nephritis (and other diseases of the kidneys) ____________ 6.2 4.4 3.0 2.4 9.7 4.5 3.5 2.5 8.5 4.5 3.2 2.4 3.8 Diabetes mellitus ____________ 1.3 1.6 1.8 2.0 1.2 ° 1.0 2.4 1.3 ° 1.7 2.0 1.4 Rheumatism and arthritis ____ 5.3 8.0 9.8 10.9 3.1 4.8 9.7 16.1 3.8 6.1 9.7 11.9 8.4 Alcoholism _________________ c 7.4 3.2 ° ° ‘ C c c 3.1 2.0 ° 2.1 Cirrhosis of the liver __________ c c 1.4 c .. ° “ ° ° ° ° ‘ ° Ulcer of the stomach or duodenum ________________ 8.3 16.1 10.1 3.7 1.3 2.6 2.8 1.6 3.7 7.8 7.2 3.3 6.8 81. VINHOcII'IVO 210.1 NVHDOHd {ISVESIG DINOHHD V Diseases of the female genital organs and breast __________ - - — - 47.3 Other selected chronic diseases ' 35.8 26.2 14.0 12.2 ‘ 17.8 Total ______________________ 100.0 100.0 100.0 100.0 100.0 Total Number—Selected Chronic Diseases ___________ 531 5,061 10,598 3,328 1,044 32.7 16.6 4.6 31.4 13.5 13.8 13.8 23.9 100.0 100.0 100.0 100.0 8,062 7,199 800 1,575 20.1 18.4 100.0 13,123 6.7 13.9 100.0 17,797 c 11.9 12.5 15.7 100.0 100.0 4,128 37,715 I Includes anemia, multiple sclerosis, diseases of the ear and eye, chronic pulmonary disease (nontuberculous), diseases of the bones and joints and senility. 1’ Includes unknown ages. c Less than 1 percent. SOURCE: Tables 4 and 5. YINHOJI’IVO Q1091 NVHDOHJ HSVEISIO DINOHHO V 6L PAID SPELLS OF DISABILITY REPORTED TERMINATED. 1947' TABLE 7 DISABILITY INSURANCE-VOLUNTARY PLANS Selected Chronic Diseases—Duration of Benefit Payments Number of paid spells Average number of of disability Number of full weeks paid 7’ weeks paid per spell Selected chronic diseases Men Women Total Men Women Total Men Women Total Malignant neoplasms ____________________________ 197 62 259 1,826 767 2.593 9.3 12.4 10.0 Malignant tumors ____________________________ 184 59 243 1,697 738 2,435 9.2 12.5 10.0 Hodgkin‘s disease ____________________________ 7 1 8 96 9 105 ° ° ” Leukemias __ ____ 6 2 8 33 20 53 c 9 ° Benign neoplasms and neoplasms of unspecified nature 341 509 850 1,292 3,212 4,504 3.8 6.3 5.3 Intracranial lesions of vascular origin _____________ 106 11 117 1,291 166 1,457 12.2 15.1 12.5 Rheumatic heart disease _________________________ 42 11 53 404 165 569 9.6 15.0 10.7 Chronic rheumatic diseases of the heart ___________ 39 11 50 401 165 566 10.3 15.0 11.3 Acute rheumatic fever with heart involvement____ 3 __ 3 3 __ 3 ° __ ° Heart disease (except rheumatic) _________________ 1,071 150 1,221 11,013 1,416 12,429 10.3 9.4 10.2 Diseases of the coronary arteries and angina pectoris 557 35 592 5,810 458 6,268 10.4 13.1 10.6 Other diseases of the heart _____________________ 514 115 629 5,203 958 6,161 10.1 8.3 . 9.8 Diseases of the circulatory system (other than heart disease) 1,370 394 1,764 4,890 2,371 7,261 3,6 6.0 4.1 Hypertension 189 92 281 1,454 1,141 2,595 7.7 12.4 9.2 Other diseases of the circulatory system __________ 1,181 302 1,483 3,436 - 1,230 4,666 2.9 4.1 3.1 Nephritis (and other diseases of the kidneys) _______ 314 165 479 1,383 868 2.251 4.4 5.3 4.7 Nephritis (including arteriosclerotic kidney) _____ 78 24 102 404 216 620 5.2 9.0 6.1 Other diseases of the kidneys and ureters _________ 236 141 377 979 652 1,631 4.1 4.6 4.3 g- 08 VIN’HOQII’IVO HOJ NVH’DOHJ HSVEISIG OINOHHO V E I ' 0 Diabetes mellitus ______________________________ Rheumatism and arthritis ________________________ Alcoholism Cirrhosis of the liver ____________________________ Anemia (pernicious) ___________________________ Multiple sclerosis _ Diseases of the organs of vision ___________________ Diseases of the ear and mastoid process _____________ Chronic pulmonary disease (nontuberculous) _______ Ulcer of the stomach or duodenum _________________ Diseases of the female genital organs and breast (ex- cluding venereal, puerperal and tumors) _______ Diseases of the bones, joints and organs of movement_ Osteomyelitis and other diseases of the bone ______ Diseases of the joints and organs of movement____ (Other than rheumatism and arthritis) Senility __ Total—selected chronic diseases ______________ Total—all spells of disability ________________ Total selected chronic diseases as a percentage of all disabilities _________________________ 91 15 106 516 69 585 462 141 603 3,009 1,226 4,235 19 1 20 119 3 122 29 1 30 141 2 143 10 7 17 66 57 123 7 5 12 99 91 190 394 104 498 1,590 545 2,135 205 78 283 558 271 829 104 31 135 560 175 735 839 63 902 4,571 482 5,053 __ 1,106 1,106 __ 6,148 6,148 1,053 262 1,315 3,534 1,086 4,620 97 23 120 408 118 526 956 239 1,195 3,126 968 4.094 1 __ 1 3 -_ 3 6,655 3,116 9,771 36,865 19,120 55,985 25,700 10,298 35,998 97,884 49,074 146,958 25.9 30.3 27.1 37.7 39.0 38.1 5.7 6.5 6.3 4.9 6.6 4.0 2.7 5.4 5.4 ~.1. 1 9° 00 H mm -] .131 O: O) 4.1 5.1 4.0 6.1 4 8 5.5 7.0 6.1 4.8 7.2 15.8 4.3 2.9 5.4 5.6 3.5 4.4 3.4 ‘ Includes spells of disability reported terminated December, 1946. b Does not include partial weeks of disability (days) compen- sated. l cNo averages calculated for fewer than ten paid spells of dis- abi ity. SOURCE: California Department of Employment, Tables C and D of Report 1021, Nos. 1-4. VIN’HOJI'IVO 410.1 WVQIDOHJ HSVEISIG OINOHHO V 18 TABLE 8 DISABILITY INSURANCE—VOLUNTARY PLANS PAID SPELLS OF DISABILITY REPORTED TERMINATE. 1947‘ Selected Chronic Diseases—Amount of Benefit Payments Number of paid spells Average amount paid of disability Amount paid per spell Selected chronic diseases M en Women Total M en 1V omen Total M en Women Total Malignant neoplasms ____________________________ 197 62 259 $49,375 $17,608 $66,983 $250 63 $284 00 $258 62 Malignant tumors ____________________________ 184 59 243 45,378 16,985 62,363 246 62 287 88 256 64 Hodgkin’s disease _4_ __________________________ 7 1 8 3,084 186 3,270 b b b Leukemias __ _ 6 2 8 913 437 1,350 b b " Benign neoplasms and neoplasms of unspecified nature 341 509 850 36,633 77,279 113,912 107 43 151 83 134 01 Intracranial lesions of vascular origin _____________ 106 11 117 34,797 3,785 38,582 328 27 344 09 329 76 Rheumatic heart disease _________________________ 42 11 53 10,328 3,747 14,075 245 90 340 64 265 57 Chronic rheumatic diseases of the heart ___________ 39 11 50 10,211 3,747 13,958 261 82 340 64 279 16 Acute rheumatic fever with heart involvement____ 3 __ 3 117 __ 117 b __ " Heart disease (except rheumatic) _________________ 1,071 150 1,221 297,104 33,793 330.897 277 41 225 29 271 00 Diseases of the coronary arteries and angina pectoris _ 557 35 592 156,732 10,984 167,716 281 39 313 83 283 30 Other diseases of the heart _____________________ 514 115 629 140,372 22,809 163,181 273 10 198 34 259 43 Diseases of the circulatory system (other than heart disease) __ 1,370 394 1,764 143,451 55,814 199,265 104 7] 141 66 112 96 Hypertension ________________________________ 189 92 281 40,457 25,077 65,534 214 06 272 58 233 22 Other diseases of the circulatory system __________ 1,181 302 1,483 102,994 30,737 133,731 87 21 101 78 90 18 Nephritis (and other diseases of the kidneys) _______ 314 165 479 38,530 21,209 59,739 122 71 128 54 124 72 Nephritis (including arteriosclerotic kidney) _____ 78 24 102 11,091 4,731 15,822 142 19 197 12 155 12 Other diseases of the kidneys and ureters _________ 236 141 377 27,439 16,478 43,917 116 27 116 87 116 49 Diabetes mellitus _ 91 15 106 15,021 1,538 16,559 165 07 102 53 156 22 Rheumatism and arthritis _________________________ 462 141 603 80,364 29,148 109,512 173 95 206 72 181 61 Alcoholism __ _______ 19 1 20 3,049 69 3,118 160 47 b 155 90 Cirrhosis of the liver ____________________________ 29 1 30 4.100 69 4,169 141 38 b 138 97 Anemia (pernicious) ___________________________ 10 7 17 1,949 1,385 3,334 194 90 b 196 12 Multiple sclerosis ______________________________ 7 5 12 2,803 2,350 5,153 b b 429 42 Diseases of the organs of vision ___________________ 394 104 498 45,006 13,160 58,166 114 23 126 54 116 80 Diseases of the ear and mastoid process _____________ 205 78 283 16,643 7,526 24,169 81 19 96 49 85 40 Chronic pulmonary disease (nontuberculous) _______ 104 31 135 16,008 4,455 20,463 153 92 143 71 151 58 7 . ‘ ' v t n 88 VINHOJI’IVO 11091 NVHDOHd SISVEISIG OINO'HHO V Ulcer of the stomach or duodenum _________________ 839 63 902 127,866 11,706 139,572 152 40 185 81 154 74 Diseases of the female genital organs and breast (ex- cluding venereal, puerperal and tumors) _______ __ 1,106 1,106 __ 147,179 147,179 __ 133 07 133 07 Diseases of the bones, joints and organs of movement- 1,053 262 1,315 104,319 27,560 131,879 99 07 105 19 100 29 Osteomyelitis and other diseases of the bone ______ 97 23 120 11,652 2,757 14,409 120 12 119 87 120 08 Diseases of the joints and organs of movement (other than rheumatism and arthritis) _________ 956 239 1,195 92,667 24,803 117,470 96 93 103 78 98 30 Senility ____ 1 __ 1 99 __ 99 1’ __ b Total—selected chronic diseases ______________ 6,655 3,116 9,771 $1,027,445 $459,380 $1,486,825 $154 39 $147 43 $152 17 Total—all spells of disability ________________ 25,700 10,298 35,998 $2,818,187 $1,192,226 $4,010,413 $109 66 $115 77 $111 41 Total selected chronic diseases as a percentage of all disabilities _________________________ 25.9 30.3 27.1 36.5 38.5 37.1 I Includes spells of disability reported terminated December, SOURCE: California Department of Employment. Tables C and D 1946. of Report 1021, Nos. 1-4. 5 No averages calculated for fewer than ten paid spells of dis- abll ity. VIN’HOlI’IVO 210.21 NVHOO’Hd HSWSIG OINIOQIHO Y 88 TABLE 9 DISABILITY INSURANCE—VOLUNTARY PLANS PAID SPELLS OF DISABILITY REPORTED TERMINATE. 1947' Selected Chronic Diseaserells Which Exhausted Benefit Payments Number of paid spells Number of spells exhausting Percent of paid spells of disability benefits b exhausting benefits Selected chronic diseases Men Women Total )1 on Women Total Men Women T0761 Malignant neoplasms ____________________________ 197 62 259 22 14 36 11.2 '-‘ 13.9 Malignant tumors ____________________________ 184 59 243 21 14 35 11.4 ° 14.4 Hodgkin’s disease ____________________________ 7 1 8 1 __ 1 ° __ ° Leukemias __ __ 6 2 8 __ __ -_ __ __ __ Benign neoplasms and neoplasms of unspecified nature 341 509 850 7 12 19 2.1 2.4 2.2 Intracranial‘ lesions of vascular origin _____________ 106 11 117 31 5 36 29.2 ° 30.8 Rheumatic heart disease _V ________________________ 42 11 53 7 4 11 ° c c Chronic rheumatic diseases of the heart ___________ 39 11 50 7 4 11 ° ” ' Acute rheumatic fever with heart involvement____ 3 __ 3 __ __ __ __ __ __ Heart disease (except rheumatic) _________________ 1.071 150 1,221 178 24 202 16.6 16.0 16.5 Diseases of the coronary arteries and angina , pectoris ' ' 557 35 592 91 10 101 16.3 c 17.1 Other diseases of the heart _____________________ 514 115 629 87 14 101 16.9 12.2 16.1 Diseases of the circulatory system (other than heart disease) 1,370 394 1,764 41 31 72 3.0 7.9 4.1 Hypertension _ 189 92 281 22 23 45 11.6 '~' 16.0 Other diseases of the circulatory system __________ 1,181 302 1,483 19 8 27 1.6 2.6 1.8 N ephritis (and other diseases of the kidneys) _______ 314 165 479 10 9 19 3.2 5.5 4.0 Nephritis (including arteriosclerotic kidney) _____ 78 24 102 5 3 8 ° ° 7.8 Other diseases of the kidneys and ureters _________ 236 141 377 5 6 11 2.1 4.3 2.9 178 VINHOJI’IVO 30$ WVHDOHJ EISV'EISIU DINOHHO V I b a. a . ' Diabetes mellitus ______________________________ 91 15 106 5 1 6 ° ° 5.7 Rheumatism and arthritis ________________________ 462 141 603 43 19 62 9.3 13.5 10.3 Alcoholism _____________________________________ 19 1 20 1 __ 1 ° __ c Cirrhosis of the liver ____________________________ 29 1 30 1 __ 1 ° __ ° Anemia (pernicious) ___________________________ 10 7 17 __ __ __ __ __ __ Multiple sclerosis ______________________________ 7 5 12 2 2 4 ° ° ° Diseases of the organs of vision ___________________ 394 104 498 8 8 16 2 0 7.7 3 2 Diseases of the ear and mastoid process _____________ 205 78 283 2 2 4 1.0 c 1.4 Chronic pulmonary disease (nontuberculous) _______ 104 31 135 7 2 9 6.7 ° 6 7 Ulcer of the stomach or duodenum _________________ 839 63 902 15 3 18 1.8 c 2 0 Diseases of the female genital organs and breast (ex— cluding venereal, puerperal and tumors) _______ __ 1,106 1,106 __ 30 30 __ 2.7 2.7 Diseases of the bones, joints and organs of movement- 1,053 262 1,315 20 5 25 1.9 1.9 1.9 Osteomyelitis and other diseases of the bone ______ 97 23 120 3 __ 3 c __ 2.5 Diseases of the joints and organs of movement (other than rheumatism and arthritis) _________ 956 239 1,195 17 5 22 1.8 2.1 1.8 Senility ___ 1 __ 1 __ __ __ __ __ __ Total~se1ected chronic diseases ______________ 6,655 3,116 9,771 400 171 571 6.0 5.5 5.8 Total—all spells of disability _________________ 25,700 10,298 35,998 808 1,018 1,826 3.1 9.9 5 1 Total selected chronic diseases as a percentage — _ of all disabilities __________________________ 25.9 30.3 27.1 49.5 16.8 31.3 1946 I‘Inciudes spells of disability reported terminated December, d' b‘cl'ItIo percentages calculated for fewer than 100 paid spells of . l l . b Represent benefits exhausted through the payment of disability Isa SOgRCE: California Department of Employment. Tables C and D insurance only. Voluntary disability insurance payments are not re- of Report 1021, Nos. 1-4. duced by unemployment insurance payments. VIN’HOJI’IVO 30d WVHDOHd HSVESICI OINOHHO V TABLE 10 DISABILITY INSURANCE—VOLUNTARY PLANS PAID SPELLS OF DISABILITY REPORTED TERMINATE). 1947‘ Selected Chronlc Diseases—Age of Men Claimant- Age groups Total Total 65 paid Under under and Selected chronic diseases spells 18 18—24 25 25-44 45-64 over Unkown Malignant neoplasms e- 197 1 7 8 40 115 33 1 Malignant tumors ___ 184 _ 4 4 35 111 33 1 Hodgkin’s disease _ ___ 7 _ 2 2 4 1 _ _ Leukemias 6 1 1 2 1 3 _ _ Benign neoplasms and neoplasms of unspecified nature ____________ 341 _ 48 48 178 97 17 1 Intracranial lesions of vascular origin __________________________ 106 _ 1 1 16 66 22 1 Rheumatic heart disease _______________________________________ 42 _ 1 1 17 20 3 1 Chronic rheumatic diseases of the heart _______________________ 39 _ 1 1 15 19 3 1 Acute rheumatic fever with heart involvement _________________ 3 _ _ _ 2 1 _ _ Heart disease (except rheumatic) ______________________________ 1,071 2 6 8 193 698 166 6 Diseases of the coronary arteries and angina peetoris ___________ 557 _ 2 2 85 384 81 5 Other diseases of the heart ___- 514 2 4 6 108 314 85 1 Diseases of the circulatory system (other than heart diseasse) _____ 1,370 _ 49 49 608 619 87 7 Hypertension 189 _ 1 1 29 128 31 _ Other diseases of the circulatory system _______________________ 1,181 - 48 48 579 491 56 7 Nephritis (and other diseases of the kidneys) ____________________ 314 _ 26 26 166 104 17 1 Nephritis (including arteriosclerotic kidney) __________________ 78 _ 1 1 40 32 5 _ Other diseases of the kidneys and ureters ______________________ 236 _ 25 25 126 72 12 1 Diabetes mellitus 91 1 2 26 51 11 1 98 VINQIOJI'IVD 30¢! NVHDOHJ EISVHSICI DINOHHO V Rheumatism and arthritis _____________________________________ Alcoholism Cirrhosis of the liver Anemia (pernicious) _____ ___ Multiple sclerosis Diseases of the organs of vision Diseases of the ear and mastoid process _________________________ Chronic pulmonary disease (nontuberculous) ____________________ Ulcer of the stomach or duodenum . Diseases of the bones, joints and organs of movement ______________ Osteomyelitis and other diseases of the bone ___________________ Diseases of the joints and organs of movement (other than rheuma- tism and arthritis) Senility Total—selected chronic diseases __________________________ Total—all spells of disability _____________________________ Total selected chronic diseases as a percentage of all disabilities 462 19 29 10 7 394 205 104 839 1,053 97 956 1 6,655 . I ‘ ‘ ‘ 1 4 5 138 250 66 3 _ _ _ 6 12 _ 1 _ _ _ 12 17 _ _ _ _ _ 1 8 1 _ _ _ _ 3 4 _ _ _ 24 24 185 153 28 4 _ 18 18 111 66 9 1 _ 3 3 32 58 1o 1 _ 33 33 400 362 38 6 2 60 62 550 403 32 6 _ 11 11 55 30 1 _ 2 49 51 495 373 31 6 _ .- - _ _ 1 _ 6 282 288 2.682 3,103 541 41 47 2,124 2,171 12,430 9,472 1,443 184 :b 13.3 13.3 21.6 32.8 37.5 1946 lIncludes spells of disability reported terminated December, 'bNo percentages calculated for fewer than 100 paid spells of disability. SOURCE: California Department of Employment Table C of Report 1023, Nos. 134. VINHOJI’IVO Q1021 WVHDOHJ {ESVEISIG DINO'HHO 7 L8 TABLE 11 DISABILITY INSURANCE—VOLUNTARY PLANS PAID SPELLS OF DISABILITY REPORTED TERMINATED. 1947' - Selected Chronic Diseases—Age of Women Claimants Age groups Total Total 65 paid Under under and Selected chronic diseases spells 18 18—24 25 25-41; 45-64 over Unknown Malignant neoplasms _________________________________________ 62 _ _ _ 25 34 2 1 Malignant tumors _________________________________________ 59 _ _ _ 23 33 2 1 Hodgkin’s disease _________________________________________ 1 _ _ _ _ 1 _ _ Leukemias ________ - ___ ___ _ 2 _ _ _ 2 _ _ _ Benign neoplasms and neoplasms of unspecified nature ____________ 509 _ 34 3-1 345 126 3 1 Intracranial lesions of vascular origin __________________________ 11 _ _ _ 2 9 _ _ Rheumatic heart disease____ __ _ 11 _ 1 1 6 4 _ .. Chronic rheumatic diseases of the heart _______________________ 11 _ 1 1 6 4 _ _ Acute rheumatic fever with heart involvement _________________ _ _ _ _ _ _ _ _ Heart disease (except rheumatic) ______________________________ 150 - 5 61 72 12 _ Diseases of the coronary arteries and angina pectoris ___________ 35 _ _ _ 10 19 6 _ Other diseases of the heart 115 _ 5 5 51 53 6 _ Diseases of the circulatory system (other than heart disease) _______ 394 _ 27 27 211 136 14 6 Hypertension __ 92 _ 2 2 26 48 18 . 3 Other diseases of the circulatory system _______________________ 302 _ 25 25 185 88 1 3 Nephritis (and other diseases of the kidneys) ____________________ 165 _ 32 32 81 49 2 1 Nephritis (including arteriosclerotic kidney)_________- _________ 24 _ 2 2 12 9 1 _ Other diseases of the kidneys and ureters ______________________ 141 _ 30 30 69 40 1 1 Diabetes mellitus _____ ____ __ ___ 15 _ 4 4 6 5 _ , it ~ - . . - 88 VINHOJYIVO QIOJ WV’HDOHJ ELISVEISICI OINOHHO V Rheumatism and arthritis _____________________________________ Alcoholism _________________________________________________ Cirrhosis of the liver _________________________________________ Anemia (pernicious) ________________________________________ Multiple sclerosis ____________________________________________ Diseases of the organs of vision ________________________________ Diseases of the ear and mastoid process _________________________ Chronic pulmonary disease (nontuberculous) ____________________ Ulcer of the stomach or duodenum ______________________________ Disease of the female genital organs and breast (excluding venereal, puerperal and tumors) Diseases of the bones, joints and organs of movement ______________ Osteomyelitis and other diseases of the bone ___________________ Diseases of the joints and organs of movement (other than rheuma- tism and arthritis) Senility ______ __ Total—selected chronic diseases __________________________ Total—all spells of disability _____________________________ Total selected chronic diseases as a percentage of all disabilities 141 All-‘i—l Cl 104 31 63 1,106 262 23 239 3,116 10.298 30.3 _ 4 4 65 69 2 1 _ 2 _ _ _ 2 _ _ _ _ 10 10 49 43 _ 2 _ 15 15 41 22 _ _ _ 3 18 10 _ _ _ 7 37 18 1 _ 2 181 183 747 169 _ 32 32 159 67 2 5 5 13 4 1 _ _ 27 27 146 63 1 2 2 358 360 1,862 835 40 19 18 2,110 2,128 5,802 2,213 84 71 _ b 17.0 16.9 32.0 37.7 1946 =Includes spells of disability reported terminated December, 'bNo percentages calculated for fewer than 100 paid spells of disability.‘ SOURCE: California Department of Employment, Table D of Report 1023, Nos. 1—4. VINXOJI’IVO 210.1 NVHDOHJ HSVEISIG DINO‘HHO V 68 Selected Chronic Dinner—Percentage Distribution by Age Groups and Sex TABLE 12 DISABILITY INSURANCE—VOLUNTARY PLANS SPELLS OI" DISABILITY REPORTED TERMINATE. 1947 Men Women Total—Men and Women 65 65 65 Total Under and Under and Under and all Selected chronic diseases 25 25-44 45-64 over 25 25-44 45-64 over 25 25-44 45-64 over ages ’ Malignant neoplasms ________ 2.8 1.5 3.7 6.1 _ 1.3 4.1 1.2 1.4 3.8 6.0 2.6 Benign neoplasms _____ 1 _____ 16.7 6.6 3.1 3.1 9.4 18.5 15.1 12.7 11.5 5.7 3.4 8.7 Intracranial lesions of vascular origin __________________ ° ° 2.1 4.1 _ ° 1.1 ° ° 1.9 3.8 1.2 Rheumatic heart disease _______ c ‘ ° c c c “ ° ‘ '-' ° Heart disease _______________ 2.8 7.2 22.5 30.7 1.4 3.3 8.6 2.0 5.6 19.6 30.6 12.5 Diseases of the circulatory system _________________ 17.0 22.7 19.9 16.1 7.5 11.3 16.3 11.7 18.0 19.2 17.4 18.1 Nephritis (and other diseases of the kidneys) __________ 9.0 6.2 3.4 3.1 8.9 4.4 5.9 9.0 5.4 3.9 3.3 4.9 Diabetes mellitus ____________ ‘ 1.0 1.6 2.0 1.1 ° ° ° ° 1.4 1.9 1.1 Rheumatism and arthritis _____ 1.7 5.1 8.1 12.2 1.1 3.5 8.3 1.4 4.5 8.1 11.7 6.2 Alcoholism _________________ _ ° ° _ _ ° _ _ ° ° _ ° Cirrhosis of the liver __________ _ ° ° _ - ° _ _ ° ° _ ” Ulcer of the stomach or . duodenum ______________ 11.5 14.9 11.7 7.0 1.9 2.0 2.2 6.2 9.6 9.6 6.7 9.2 Diseases of the female genital organs and breast ________ _ _ _ _ 50.8 40.1 20.2 28.2 16.4 4.3 c 11.3 Other selected chronic diseases ' 37.2 32.9 22.3 15.0 17.5 14.7 17.2 26.2 25.4 21.2 14.3 23.1 Total _________________ 100.0 100.0 100.0 100.0 100.0 100.0 100.0 “ 100.0 100.0 100.0 100.0 100.0 Total number—selected = = = _ = = = —— — = = = 2 chronic diseases _________ 288 2,682 3,103 541 360 1,862 835 40 648 4,544 3,938 581 9,771 . Includes anemia, multiple sclerosis. diseases of the ear and eye, chronic pulmonary disease (nontuberculous), diseases of the bones and joints and senility. b Includes unknown ages. 0 Less than 1 percent. 4 No percentages calculated. Only 40 spells of disability were included in this age group SOURCE: Tables 10 pand 11. 06 p VINHOJI’IVO 210d NVHDO'HJ EISVEISICI OINOHHO V A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 91 APPENDIX A-4 ESTIMATES OF MORBIDITY FROM CHRONIC ILLNESS IN CALIFORNIA BASED ON THE NATIONAL HEALTH SURVEY USE OF THE NATIONAL HEALTH SURVEY The National Health Survey was conducted in 1935-1936 by the United States Public Health Service. The survey was a nation-wide house- to-house canvass of 703,092 households comprising 2,502,391 individuals located in 18 states. It was confined largely to 83 urban areas. Data were obtained by asking a responsible member of each household to recall i11- nesses occurring within the previous 12 months.“ The National Health Survey provided morbidity rates considered applicable to the general population. Although the rates were subject to many qualifications, no better sources for such rates have since been devel- oped. In the absence of more accurate information continued widespread use has been made of the National Health Survey.b In applying the survey data to California for 1947, use has been made only of those rates that would produce minimum estimates—Le. esti- mates such that there was reasonable assurance of the existence of at least the specified amount of morbidity. No adjustment has been made for under enumeration of illnesses, although it is known that there was sub- stantial underreporting in the National Health Survey. Furthermore, no adjustment has been made for age distribution, although the population enumerated in the survey was on the average younger than the popula- tion of California. ESTIMATES OF DISABLING CHRONIC ILLNESS Application of National Health Survey Rates to California for 1947 provides the following minimum estimates of morbidity from disabling chronic illness (Tables 1 and 2) : Estimated Estimated weeks prevalence of disability Cardiovascular-renal diseases ______________ 109,000 1,900,000 Rheumatism and allied diseases _____________ 58,000 1,000,000 Cancer and other tumors ___________________ 29,000 410,000 Diabetes mellitus _________________________ 9,000 220,000 All disabling chronic illness (excluding tuber- culosis and mental disease) ______________ 455,000 9,090,000 These estimates exclude many early or mild cases of chronic illness because they refer only to disabling illness—illness causlng at least seven consecutive days of interference with usual occupation. For “all dis- abling chronic illness,” they refer only to illness which in addition to the seven days disability, causes three months or more of recognized symptoms. -G. St. J. Perrott, C. Tibbits. R. H. Britten; Scope and Method of the National Health Survey; Public Health Report 54, Reprint 2098. b It was used in almost all studies of chronic illness conducted in other states. In California it was used in the Hospital Study of Los Angeles County, conducted in 1947 by James A. Hamilton and Associates ; and also, in the 1947 Report to the Santa Barbara County Medical Society by the Citizens Advisory Committee on Health and Hospital 92 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA The estimates for cancer are particularly low.“ In 1947 there were over 14,000 cancer deaths in California, and from this it can be esti- mated b that there were approximately 50,000 cases of cancer which were alive at some time during the year. ESTIMATES OF NONDISABLING CHRONIC ILLNESS The National Health Survey reported a very substantial amount of nondisabling chronic illness—illness considered to be handicapping and causing symptoms for three months or more, but not causing seven con- secutive days of disability. Thirteen percent of the population covered in the survey reported such illness. Applied to California ’s population in 1947 this is approximately 1,280,000 cases of nondisabling chronic illness. CHRONIC ILLNESS IN RELATION TO AGE One of the major findings of the National Health Survey was that although the prevalence rate for chronic illness increases sharply with age, the greatest number of persons with chronic illness are in the pro— ductive years of life between 25 and 64 (Table 3). The survey showed that 57.5 percent of the chronic invalids, and 64 percent of those with disabling chronic illness not causing complete invalidism were between the ages of 25 and 64. COMPARISON WITH DATA FROM THE CALIFORNIA DISABILITY INSURANCE PROGRAM Because of difierences in the definition of chronic illness, it is not possible to make a direct comparison between estimates based on the National Health Survey and the data obtained from the California Dis- ability Insurance Program. The estimates for the general population of the State, based on the survey are, as would be expected, considerably larger than the figures for the segment of the population insured under the Disability Insurance Program. However, there is general consistency between the two sets of figures. With the exception of cancer, the rank order of the specific chronic diseases is the same. Detailed comparisons are qualified not only by differences in definition, but differences in the age, sex, race and other characteristics of the two population groups. II= 1‘ =l‘ it it 1* =|l= The attached tables show in somewhat more detail the rates of mor- bidity from disabling chronic lllness 1n the National Health Survey, and the application of these rates to California for 1947. The application to California is based on the United States Census Bureau estimate of a population of 9,876,000 as of July 1, 1947. Data in the tables are presented separately for illness causing invalidism (disability for the full 12 months), and illness causing disability for less than 12 months. Wimates for diabetes are also very low—see Appendix D-3. b Using a ratio of 3.5 cases per death. This ratio is based on the findings of special cancer morbidity surveys in selected areas. See H. J. Sommers; The Incidence of Cancer in San Francisco and Alameda Counties, 1938; Public Health Reports, Reprint 2412. Also, H. F. Dorn ; Illness from Cancer in the U. S. ; Public Health Reports, Reprint 2537. The number of cancer deaths to which the ratio is applied includes leukemias and Hodgkin's disease. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 93 TABLE 1 ESTIMATED ANNUAL PREVALENCE ' OF DISABLING" CHRONIC ILLNESS National Health Survey Rates and Applications to California. 1947 Disability for at least Disability 7 days for but less than 1 year entire year Estimated Estimated Rate per prevalence Rate per prevalence 1,000 California 1,000 California Illness population 19/,7 population 1947 Cardiovascular—renal diseases ______ 8.2 81,000 2.8 28,000 Rheumatism and allied diseases _____ 4.7 40,000 1.2 12,000 Cancer and other tumors ___________ 2.7 27,000 .2 2,000 Diabetes mellitus ________________ .6 6,000 .3 3,000 All disabling chronic illness” (exclud- cluding tuberculosis and mental disease) ______________________ 35.5 351,000 10.5 104,000 All disabling illness (both chronic and acute and including tuberculo— sis and mental disease) _________ 159.3 1,573,000 11.7 116,000 I Prevalence—Refers to number of illnesses rather than number of persons. How- ever, for chronic illness there was considered to be negligible reporting of several ill- nesses for one individual. 1’ Disabling Illness —Illness that kept the person from work, school or other usual occupation for at least seven consecutive days; or required hospitalization; or caused death. 0 Chronic Illness—Refers here to illness causing symptoms for three months or more. SOURCE: National Health Survey. TABLE 2 ESTIMATED WEEKS OF DISABILITY FROM CHRONIC ILLNESS? National Health Survey Rates and Applications to California. 1947 Disability for at least Disability ’7 days for but less than 1 year entire year Average Estimated Average Estimated weeks of weeks of weeks of weeks of disability disability disability disability per illness California per illness California Illness per year 191/7 per year 191,7 Cardiovascular—renal diseases _____ 5.5 440,000 (52 by 1,460,000 Rheumatism and allied diseases _____ 8.2 380,000 definition) 620,000 Cancer and other tumors ___________ 11.5 310,000 100,000 Diabetes mellitus _________________ 10.0 60,000 160,000 All disabling chronic illness b _______ 10.5 3,680,000 5,410,000 (Excluding tuberculosis and mental disease) All disabling illness _______________ 5.0 7,860,000 6,030,000 (Both chronic and acute and including tuberculosis and mental disease) .Refers to Disabling Illness—Illness that kept the person from work, school or other usual occupation for at least seven consecutive days ; or required hospitalization; or caused death. ”Chronic Illness—Refers here to illness causing symptoms for at least three months. SOURCE : National Health Survey. 94 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA TABLE 3 DISABLING CHRONIC ILLNESS' IN RELATION TO AGE National Health Survey Findings Percentage of chronic Rate of chronic illness illness per 1,000 population Disability Disability Disability Disability 7 days under full 7 days under full Age 1 year year 1 year year Under 15 _________ 8.6 5.5 12.6 2.4 15-24 ___________ 8.0 7.0 15.9 4.1 25-64 ___________ 64.0 57.5 43.4 11.6 65 and over _______ 19.4 30.0 120.5 55.5 All ages ______ 100.0 100.0 35.5 10.5 IDisabling Chronic Illness—-Refers here to illness causing symptoms for three months or more and causing disability for at least seven consecutive days. SOURCE: National Health Survey. TABLE 1 TABLE 2 TABLE 3 NOTES AND REFERENCES FOR TABLES DERIVED FROM THE (1) (2) (3) (4) (5) (6) NATIONAL HEALTH SURVEY Rates for specific disabling illnesses and all disabling illnesses (chronic and acute)-—computed from R. H. Britten, S. D. Collins, J. S. Fitz- gerald; The National Health Survey—Some General Findings as to Disease, Accidents and Impairments in Urban Areas; Public Health Reports; Vol. 35, No. 11; Reprint No. 2143; Table 1, p. 2; Table 2, p. 6; Table 11, p. 17. Rates for all disabling chronic illness—computed from New York State Health Preparedness Commission; A Program for Care of the Chronically Ill; Legislative Document No. 69, 1947; Table 10, p. 46. This publication gave age-specific rates adjusted to exclude tuberculosis and mental disease based on previously unpublished material from The National Health Survey. These rates were applied to the age distribution of the population covered in The National Health Survey as shown in above reference (1), Appendix A, p. 23. The New York state publication also reported on an analysis of the duplication of chronic illnesses affecting the same person (p. 45). Population base for application of rates to California—estimate of 9,876,000 given by Bureau of the Census Release, p. 25—~N0. 4. Rates for specific disabling illnesses and all disabling illnesses—same as (1) above. Days of disability have been converted to weeks of disability. Rates for all disabling chronic illness—same as (2) above. Since the New York state publication did not show disability rates per illness on an age—specific basis, the rates are estimates based on the ratio of illnesses per 1,000 population in New York State to illnesses per 1,000 population in The National Health Survey. Same as (2) above. ‘v ‘s A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 95 APPENDIX B SERVICES AND FACILITIES FOR THE CHRONICALLY ILL SUMMARY County boards of supervisors have responsibility for providing hospital and medical care for the indigent population, including the chronically ill indigents. Provision is made for them through the County Welfare Department or County Hospitals or both. A survey in 16 Cali- fornia counties, completed June 15, 1948, indicated that care is generally available in county hospitals for chronically ill welfare clients during acute episodes. These patients, once hospitalized, however, are retained long after hospital care is needed because of the shortage of nursing homes, the high cost of nursing home care, and the lack of adequate home care services. In California there is a State Hospital Program, organized along regional lines, which is to include the planning and construction of chronic disease hospital facilities. The need for these facilities in the State is illustrated by the data from the State Hospital Survey abstracted below: Total estimated need chronic hospital beds ______________________ 19,210 . All chronic hospital beds (number of beds) Acceptable ______________________________________________ 3,434 N unacceptable ___________________________________________ 1,848 Total _____ ___ 5,282 County chronic hospital beds (number of beds) Acceptable ______________ ___ ___ ___ 3,434 N onacceptable ______ _ 1,756 Total _________ _ .. 5,190 Non-county chronic hospital beds (number of beds) Acceptable ______________________________________________ __ Nonacceptable _____ —_ _ 92 Total ___________________________________________________ 92 With respect to facilities other than hospitals (e.g., nursing homes and custodial institutions) and with respect to services for the chron- ically ill, there is no overall state program. There are agencies in Cali- fornia concerned in one way or another with certain aspects of care for varying segments of the population. The California Department of Public Health, which is responsible for licensure and inspection of nursing homes, reported that as of August 12, 1948, there were 360 nursing homes licensed in the State with a total bed capacity of 7,308. All of these homes are privately operated and I This estimate is based on the ratio of two beds per 1,000 population—the ratio used in the Federal Hospital Survey and Construction Act, Public Law 725, 1946. It will be noted that this estimate. i.e. 19,210 beds, obtained by applying the ratio to the esti- mated July 1, 1947, California population (9,605,000) is higher than the figures in the March, 1948, publication ”Hospital Facilities in California," where an earlier population estimate was used. 96 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA reports from county welfare directors and hospital administrators indi- cate that the rates are prohibitive for many persons needing such care. Tabulations from the 1947 State Hospital Survey disclosed that in county institutions approximately 3,000 custodial beds were used for domiciliary, ambulatory indigents, many of whom were aged persons. The California Department of Social \Velfare licenses private homes for the aged which had a total bed capacity of approximately 5,000 as of May 1947. For the industrially employed population of the State several agen- cies offer certain benefits afiecting chronic illness. The Industrial Accident Commission of the California Department of Industrial Relations pro— vides workmen ’s compensation (cash benefits and medical care) to those injured as a result of employment. The California Disability Insurance Program administered by the State Department of Employment provides partial compensation (cash benefits) for wage loss due to nonoccupational diseases and injuries. The Bureau of Vocational Rehabilitation of the California Department of Education offers medical care and other rehabilitation services to a limited number of chronically disabled persons (for the most part, those in urban areas) who are potentially employable. Several voluntary health insurance and prepayment plans offer medical care and hospital benefits, but usually these do not cover long-term illnesses and in many cases specifically exclude certain chronic conditions. The US. Veteran’s Administration provides extensive medical care and rehabilitation services for veterans who have service-connected dis- abilities and for other veterans who cannot afi'ord the costs of medical and related services. Under the Federal Old Age and Survivors’ Insur— ance Program and under the Federal Railroad Retirement Program cash benefits are provided to tens of thousands of persons in California—many of whom are chronically ill. Through the Crippled Children’s Service of the California Depart- ment of Public Health, medical care is provided for orthopedic and other physical defects among children under the age of 21 years whose parents are unable to finance such care “in whole or in part.” For chronically ill persons living at home, visiting nurse services under voluntary auspices are available in the larger urban areas of the State; such services have not been extended to the rural areas. The problems of licensure, training and supervision involved in utilizing practical nurses for bedside services in the home have not been solved. Visiting housekeeping services, which would assist many persons with chronic illness in remaining at home, are almost totally lacking in Cali- fornia. Voluntary health agencies (including the American Red Cross, the California Tuberculosis and Health Association, the California Heart Association, the Cancer Commission of the California Medical Associa- tion, the California Division of the American Cancer Society, the Cali- fornia Society for Crippled Children, and the California Chapters of the National Foundation for Infantile Paralysis) have initiated educa- tional and service programs which contribute to the care of certain segments of the chronically ill population. Certain religious groups and fraternal orders provide institutional care and other benefits to their members, especially the aged. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 97 One may note that, in spite of the multiplicity of agencies involved, there are deficiencies in California with respect to a program for the chronically ill particularly in institutional facilities and home care serv- ices. In general these deficiencies are much more serious in the rural areas. Probably the most critical lack of all is in preventive service, such as those developed by the medical profession, health departments and health agencies in the fields of tuberculosis and venereal disease control. Planning for the Chronically Ill, a joint statement by the American Medical Association, American Hospital Association, American Public Welfare Association and American Public Health Associations, rec- ommends: “The basic approach to chronic disease must be preventive. Otherwise the problems created by chronic diseases will grow larger with time, and the hope of any substantial decline in their incidence and severity will be postponed for many years . . .” “In the past, the approach to chronic illness has been pri- marily concerned with institutional care for advanced stages of disease. There is need for a new orientation which places major emphasis on the early stages of chronic illness with a view to pre- venting or at least delaying the progress of the disease process.” California as yet has no state—wide program for the prevention of the chronic illnesses under consideration in the present investigation. 7—14-8170 98 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA APPENDIX B-I SURVEY OF SERVICES AND FACILITIES FOR CHRONI- CALLY ILL WELFARE CLIENTS IN 16 CALIFORNIA COUNTIES As part of the chronic disease investigation, the State Department of Social Welfare conducted a survey of services and facilities available to chronically ill welfare clients in 16 California counties. In meeting responsibility for licensing boarding homes and insti- tutions and for the supervision of the administration of public assist- ance programs serving 240,000 individuals,1 problems in relation to planning for the chronically ill have frequently been brought to the department’s attention. Public assistance recipients receive a minimum grant of aid to provide for the usual day-to-day expenses. Medical care services are provided them through the county medical programs which vary between counties both as to availability of services and the types of services provided. Increased activity by loeal welfare departments in relation to planning for the chronically ill has been necessary in many counties and the department has long been interested in learning specifi- cally what medical and hospital services and other related services were available to public assistance recipients suifcring from chronic illness. A schedule developed for use in conducting the survey contained questions covering the availability and methods of providing the various services and facilities, i.e., hospital care, nursing home care, medical and related services to welfare clients living at home or in substitute homes, convalescent and rehabilitation services, and community activities in the areas to administrative research and coordinated planning. Infor- mation was also secured on eligibility requirements for these services. It was not administratively possible to survey all counties. A sample of 16 counties was selected on the basis of a random selection within the 10 regional groupings of counties established by the Governor’s Inter- department Research Committee. Los Angeles and San Diego Counties constitute separate regions and both counties were, therefore, included in the sample. The remaining counties surveyed were: Alameda, Inyo. Madera, Marin, Mendocino, Modoc, Monterey, San Joaquin, San Luis Obispo, Solano, Sonoma, Sutter, Tulare, Ventura. In 16 counties 148,523 persons are receiving assistance under the categorical aid programs; of this number, 120,019 persons are recipients of Old Age Security. The surveys were made during the period April 15 through June 15, 1948, by the department’s field representatives regularly assigned to the selected counties. Twelve field representatives conducted the sur- veys with four field representatives covering two counties each. In two counties information for completion of the schedule was obtained only from the county welfare director; in the remaining 14 counties, the medical superintendent and/or hospital social service direc- tor were interviewed as well as the welfare director. In counties main- taining separate facilities for custodial and aged patients, the person in charge of the institution was interviewed in all counties with one exception. Additional persons were interviewed in some counties, for 1 This number does not include recipients of general relief; the counties carry full responsibility for this program A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 99 example, public health officers, representatives of councils of social agencies, personnel responsible for licensing boarding homes, staif mem- bers of welfare departments, etc. Information was obtained almost exclu- sively from interviews with persons listed above. From the information secured, it was not possible to determine the number of persons provided the various services or the action taken on referrals for these services. ABSTRACT OF FINDINGS Hospital Care Care is available in general hospitals to chronically ill welfare clients in the 16 counties; in the two counties which do not maintain county hospitals, provision is made for care in private hospitals. At the time of the study there were no waiting lists for the admission of chron- ically ill patients. Six counties reported waiting periods were at times necessary for the admission of chronically ill patients. Separate hospital facilities for long-term cases are maintained in the three metropolitan counties included in the survey; all of these facilities were filled to capacity or there were waiting lists for admission. With one exception, chronically ill patients were retained in the hospital in all counties because of the lack of after-care services and facilities; in one metropolitan county the average waiting period for placement outside ‘the general hospital was 76 days. Nursing Home Care There were no public nursing homes in the 16 counties selected for study. There were no private nursing homes in five of the 16 counties. The shortage of private nursing homes and the prohibitive costs prac- tically eliminates consideration of this type of care for chronically ill welfare clients whose only income is public assistance. The three metropolitan counties have extended county funds to meet the full cost of nursing home care or to supplement the assistance grant. However, the maximum amount allowed in two counties is not always sufficient to pr0vide the type of care the client’s physical condition requires; in one county no maximum has been established and county funds are provided in an amount necessary to procure the type of care required. In another county, public facilities are used rather than arrang- ing placements in less expensive nursing homes where quality of service may be questioned. In two other counties funds would be provided for nursing home care but there are no nursing homes in the counties nor in nearby counties. Eleven counties do not provide funds for nursing home care. In these counties only recipients with outside income can obtain this service.1 Physician's Services General practitioner services are generally provided in hospital clinics and in physician’s offices and in the home under certain circumstances. General practitioner services are provided only in the county hos- pital clinic in four counties and, in three small counties in which clinics are not conducted, all services are provided in the physician’s office or in the client ’3, or in the client ’s home. In one metropolitan county, general practitioner services are providedin the two hospital clinics and patients I A study of 7,384 Old Age Security cases out of the total case load of 188,267 cases was made by the State Department of Social Welfare in June, 1948. This study shows that 53 percent of Old Age Security recipients have no outside income; 24 percent have outside income from $1 to $10: 10 percent have income from $11 to $20; 7 percent have income from $21 to $30 ; and the remaining 6 percent have income of $30 or more. 100 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA under the district medical program receive care in the physician’s office or in the home. In addition to hospital clinic services provided in another metropolitan county, clients residing in the northern section of the county, at a distance from the county hospital, receive care in the physician’s office or in the home. Physician’s services are available in the four clinics serving different geographical areas in another large county and physician’s services in the office or home are provided if the client is unable to attend the clinic. In the remaining six counties physician’s services are provided in county hospital (linies and if the patient is . unable to travel to the elinic,ca1e may be given in the physician’s office or in the home; in three of these counties physician’s seivices are pro- vided outside the clinic 1n eme1gency situations only and care is autho- rized and paid for by the welfare department. There is no plan for providing specialist services in one county and in 11 counties specialist services not available in the counties are secured through private physicians in the county or through medical centers in metropolitan areas. In the remaining four counties, specialist services are available in the county hospital clinics and under the district medical program in a metropolitan county specialist’s services are also provided in the physician’s office or in the home. Dental Care Services In general, dental care services for adults are extremely limited. Twelve counties reported that provision is made only for emergency dental care or care determined necessary by the hospital physicians to meet health and nutritional needs. In three counties the types of dental services provided were not shown. In one county complete dental services are provided adults. In one-half of the counties studied, dental services are provided in county hospital clinics; in the other eight counties services are secured through private dentists and the welfare departments authorize and pay for care in six of these counties. Bedside Nursing Services In nine counties, bedside nursing care was not available in the home. In the other seven counties, visiting nurse associations provide home nursing services and several counties reported this service has been used extensively in the care of chronically ill welfare clients. In five of the seven counties, the visiting nurse associations served particular geo- graphical areas and not the entire county. In four of the seven counties, bedside nursing services are paid for from county funds on the basis Of the actual cost per visit and in the other three counties services are provided without charge. Visiting Housekeeper Services ‘ There were no visiting housekeeping services available in the 16 counties. Medical Social Service One or more qualified medical social case workers were employed in five counties. Drugs and Appliances Drugs are provided chronically ill welfare clients receiving care under county medical programs; usually, drugs are furnished through the county hospital pharmacy and if unavailable in the hospital supply, drugs‘are secured through local pharmacies. In three counties all drugs A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 101 are secured through local pharmacies. The welfare departments in seven counties meet the costs of drugs purchased from local pharmacies. In only one county the provision of appliances was considered an essential part of the medical treatment plan. While provision was made for furnishing appliances in the other 15 counties, the extent to which they were provided was not determined. The welfare departments in eight of the 15 counties met the cost of appliances. Vocational Rehabilitation Services Vocational rehabilitation services are not available in three counties. In the remaining 13 counties services are provided through the State Bureau of Vocational Rehabilitation; with one exception all counties reported that services through the bureau were insufficient to meet the need. There were no private rehabilitation agencies in the 16 counties. Recreational and Occupational Therapy Services In the 16 counties, there were no organized recreational and occu- pational therapy services provided in the home. Boarding Homes and Institutions All counties reported an insufficient number of substitute home care facilities to meet the needs for this type of care. The need for additional boarding homes for aged was stressed by all counties. The cost of care in boarding homes and institutions is frequently prohibitive to welfare clients and only four counties supplement the assistance grant to provide this care. Private institutions for aged are not always available to welfare clients because of long waiting lists, high rates, or restrictions on admissions. Eligibility Requirements It was not possible in all counties to obtain exact information on eligibility requirements because of the lack Of clearly defined eligibility policies and difierences in methods followed in determining eligibility for medical care. Policies relating to eligibility for county medical care have been defined in six counties by a resolution of the board of supervisors, ordi- nances, or special committees. These policies have usually been stated in general terms; in only one of the six counties are the policies further defined for working purposes. In the remaining ten counties there are no written pdlicies governing eligibility requirements. In one-half of the counties, the hospital social service department has responsibility for determining eligibility for medical care and in the other eight counties the welfare departments carry this responsibility. In seven counties all recipients of public assistance are automatically eligible for medical care and, in two additional counties, recipients of Aid to Needy Children and General Relief are automatically eligible but Old Age Security and Aid to Needy Blind recipients are eligible only if their resources are insufficient to meet the cost of private care. In the remaining seven counties, the receipt of public assistance does not qualify an individual for medical care and eligibility for this service must be established by investigation of the resources of the recipient and his responsible relatives. In all counties applicants who are otherwise self-supporting are accepted for care under the county medical program if the applicants or their legally responsible relatives are unable to meet the cost of private medical care. 102 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA In some counties part-pay plans may be arranged for recipients of Old Age Security and Aid to Needy Blind recipients who have resources to meet part of the costs while in other counties part-pay plans are prohibited. Six counties reported that liens are required against real property owned by applicants for medical care. Several counties reported strict adherence to legal residence requirements in cases requiring long- term care. Convalescent and Rehabilitation Services Planned convalescent and rehabilitation services are available to a limited extent in only one county. Research in the Field of Chronic Disease Services and Facilities Eiforts are being made in three counties to study some aspects of the problem. Coordination of Services There were no central planning or coordinating agencies concerned specifically with the chronic disease problem. SUMMARY Hospital care is generally available in county general hospitals for chronically ill welfare clients during acute episodes.1 These cases once hospitalized, however, are retained long after hospital care is needed because of: (1) Shortage of convalescent and nursing home facilities. (2) High cost of convalescent and nursing home care where available. (3) Lack of adequate services in the home. In relation to adequate services in the home: (1) General Practitioner Services—Usually provided in clinics and in the home or office in emergencies. (2) Specialist Services—Usually provided in the physician’s office when not available in hospital clinics. (3) Dental Care Services—~Limited to emergency care. (4) Bedside Nursing Service—Provided in only seven of the 16 counties. (5) Visiting Housekeeping Services—None. (6) Medical Social Services — Medical Social Case Workers employed in only five of the 16 counties. (7) Drugs and Appliances—Drugs are provided in all counties. Limitations are placed on the provision of appliances. (8) Vocational Rehabilitation Services—Services are limited to those provided by the State Bureau of Vocational Rehabilitation. (9) Recreational and Occupational Therapy Services—None. (10) Boarding Homes and Institutions—Facilities are insufficient to meet the need for this type Of care at rates the client can meet. Planned convalescent and rehabilitation services are available to a limited extent in only one county. Administrative research projects have been instituted in three counties. There were no central planning or coordinating agencies concerned specifically with the chronic disease problem. 1 This survey, as noted previously, was not designed to reveal information on the quality of hospital care available to chronically ill welfare clients. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 103 APPENDIX 3-2 HOSPITALS AND RELATED FACILITIES IN CALIFORNIA1 HOSPITAL FACILITIES Tables 1 and 2 on the following page are based on data obtained from the Bureau of Hospitals, California Department of Public Health. Table 1 shows the bed capacity of general hospitals grouped accord- ing to the hospital regions set up under the state hospltal plan. Table :3 shows the bed capacity of chronic hospital facilities (including chrome wards and sections of general hospitals) grouped according to hospital region. Both tables also provide a comparison between ex1st1ng famhties and estlmated total needs. For the first year (1947-1948) of the hospital construction program In California, priority was given to hospital beds for patients With acute lllness. At its August 2, 1948 meeting, the California Hospital Adv1sory Council decided to extend the priority during 1948-1949 for beds for acute illness. At the same meeting the council began consideration of the needs in Callfornia for chronic disease, tuberculosis and children’s hos- pitals. During the coming months the Bureau of Hospitals of the Cali- fornia Department of Public Health will be preparing a plan to include these categories in the remaining years of the five-year program. 1Including nursing homes, custodial facilities, institutions for alcoholics, and homes for the aged. b 1 State agencies having jurisdiction over hospitals and related facilities are listed e 0W 1 The California Department of Public Health has responsibility over district hos- pitals and private hospitals, sanatoria, nursing, convalescent and rest homes. including any institution which maintains and operates organized facilities for the diagnosis, care and treatment of human illness, including convalescence. (Note exceptions: Institutions referred to in following paragraph.) The California Department of Mental Hygiene has responsibility over institutions (hospitals, sanatoria, homes) or other places receiving or caring for mentally ill, allegedly mentally ill, or other incompetent persons, including the mentally deficient, alcoholics, drug addicts. and epileptics. The California Department of Social Welfare has responsibility over county hos- pitals, and private boarding homes and institutions for the reception and care of aged persons. TABLE I GENERAL HOSPITAL 1 BEDS IN COUNTY AND NON-COUNTY HOSPITALS BY HOSPITAL REGIONS: CALIFORNIA, JULY 1. 1948 (Data From State Hospital Plan Brought Up to Date by the California Department 01 Public Health. Bureau of Hospitals) Bed capacity—existing facilities Bed capacity— Popula- All general hospital County general hospital Non-county general proposed construction" tion' beds beda4 hospital beds (Esti- Esti- Hospital mated) mated {region Area (Counties) JasLVof1 need?s Number of beds“ Number of beds“ Number of beds6 Number of beds u , 1947 ‘1 N N C N r on- on- on- ounty on- Total A5315” accepfr Total A3235“ aceept- Total 2:33?" accept- Total hos- county able able able pita] hospital I Sisldyou, Trinity, Shasta, Modoc, northwest ' section of .......................... 80,800 297 249 129 120 113 90 23 136 39 97 74 74 ______ 11 Del N orte Humboldt, northern part of Mendocino ________________________________ 62,800 291 337 201 136 142 126 16 195 75 120 14 ________ 14 III Teharna, Glenn Butte, Plumas, and all Lassen except northwest section ____________________ 110,800 353 479 253 226 200 108 92 279 145 134 ________________________ IV Sutter, Yuba, Colusa Sierra, Nevada, Placer, El Dorado, Amador, Yale and Sacramento..._ 382,100 1,583 1,404 1,148 256 618 571 47 786 577 209 47 ________ 47 V Sonoma, Naps, Lake, and southern part of endocino ________________________________ 169,400 639 642 327 315 2W 154 53 435 173 262 235 22 213 VI San Francisco, Marin, San Mateo, and Palo Alto, in Santa Clara County _____________________ 1,137,600 6,294 5,414 5,116 298 1,582 1,582 ________ 3,832 3,534 VII Alameda, Contra Cmta, and Solano ....... 1,136,800 4,418 2,572 2,241 331 651 480 171 1,921 1,761 VIII Santa Cruz, and Santa Clara exec t Palo Alto“ 59,800 1,009 847 547 300 385 113 272 462 434 IX San Joaquin Stanislaus us, Merc , Calaveras, Tuolumne, and Mariposa ___________________ 387,100 1,565 1,262 736 526 531 272 259 731 464 267 55 25 30 WI VINHOJI’IVO 210d NVHDOHJ EISVESIG OINOHHO V -w ,4 v . X Fresno, Madera, Kings, and Tulare ____________ ' 440,300 1,671 1,309 1,005 304 619 521 98 690 484 206 135 135 ........ XI Baum Bennito, and Monterey except southernmost ___________________________________ 110,400 419 367 358 9 140 140 ___-_-__ 227 218 9 17 _____-._ l7 XII Santa Barbara, Ventura, San Luis Obispo, and southernmost part of Monterey ______________ 269,500 1,008 980 801 179 454 299 155 526 502 24 74 24 50 XIII Mono. In 0. Kern and northwest section of San Bern 190,500 834 767 656 111 376 370 6 391 286 105 61 30 31 XIV Loo RIAngolan and Orange ...................... 3,882,200 18,676 11,404 10,429 975 3,321 3,321 ________ 8,083 7,108 975 775 ________ 775 XV e and San Bernardino except northwat RIsection .............. 356,100 1,414 1,291 822 469 414 187 227 877 635 242 269 83 186 XVI San Di oand mperial ____________ _ 628,500 2,741 1,371 974 397 500 400 100 870 574 297 183 70 113 XVII Al ine ad“lounty with reg nal center at 300 Totals, State-wide _______________________ | 9,605,000 ‘ 43,222 | 30 695 l 25 743 | 4 952 1 10,253 1 8,734 I 1,519 20, 442 | 17, 000 | 3, 433 1 2,159 l 433 I , 1 The U. S. Public Health Service defines a ”General Hospital” as: “Any hospital for in—patient medical or surgical care of acute illness or injury and for obstetrics, of which not more than 50 percent of the total patient days during the year are customarily assignable to the following categories of cases: Chronic, convalescent and rest, drug and alcoholic, epi- leptic, mentally deficient, mental, nervous and mental, and tuberculosis.” 2 As estimated by the Population Committee of the California Department of Public Health. (Military personnel are not included in these estimates.) 3 Basis: For State as a whole, 45 per 1,000 population. For areas comprising the regions within the State, the ratios vary (2.5 for rural areas, 4.0 for intermediate areas and 4.5 for base areas) with adjustments provided for in federal regulations under the Federal Hospital Survey and Construction Act, P. L. 725, 1946. Sec. 622 (A). ‘Includes the few district hospitals, city hospitals and one state hospital (Univer- sity of California Hospital in San Francisco.) 5 Includes all private general hospitals e. g. church nonprofit association, corporation, partnership and individually owned hospitals. Federal hospitals are excluded. 6 Definition of ”nonacceptablc" facilities: 1. Facilities which have not been granted fire clearance by the State Fire Marshal. (This group includes facilities which may be granted clearance upon satis- factory compliance with the recommendations of the State Fire Marshal.) 2. Facilities in buildings with or without fire clearance which contain specific structural conditions which make it impractical to repair or organize for the safety and welfare of the patient. (A review of the facilities classified as nonacceptable shows that most of these facili- ties include aged buildings and those which provide inadequate and inefficient service. Specifically, these facilities will include: A. Converted buildings, B. No tire clearance. C. Inadequate food storage and preparation facilities, D. Inadequate sterilization and operation facilities, E. Inadequate internal arlangement to facilitate movement of patients, cither ambu- latory or on stretcher especially in an emergency, or F. Lack of proper exits.) 7 Includes only those facilities for which final plans have been approved. Construction of these facilities is contemplated in the near future. VINHOcII’IVO H021 WVHDOHd HSVEISIG OINOHHO V 901 TABLE 2 CHRONIC HOSPITAL BEDS1 1N COUNTY. AND NON-COUNTY HOSPITALS. BY HOSPITAL REGION: CALIFORNIA. SEPTEMBER, 1947 (Data From State Hospital Plan. Prepared by the California Department of Public Health. Bureau of Hospitals) Bed capacity—existing facilities Popular Total - - County chronic hospital Non-county chronic tion’ esti- “1 chm” “PM bed” beds‘ hospital beans . (Esti- mated Hospital mated) needa region Area (Countim) as of chronic Number of beds“ Number of beds“ Number of beda° July 1, hospital 1947 beds N N N Accept- onv Accept- on" Accept— on— Total accepte Total accept- Total accept- able able able able able able I Siakiyou, Trinity, Shasta, Modoc, northwest section of Lamen _______________ 80,800 182 55 ________ 65 55 ........ 55 ________ ll Del N orte, Humboldt, northern part of Mendocino .............. - 62,800 126 ________________________________________ r - III Tehama, Glenn. Butte, Plumas and all Lassen except northwat section ______ 110,800 222 49 10 39 49 10 39 ........ IV Sutter, Yuba, Colusa, Sierra. Nevada, Placer, El Dorado, Amador, Y010 and rsmento _________________________________________________________ 382,100 784 213 60 153 213 60 153 ________ V Sonoma, Napa, Lake and southern part of Mendocino ...... 169,400 339 l ........ 179 17 ________ 79 _______ VI San Francisco, Marin, San Mateo and Pain Alto in Santa Clara.- 1,137,600 2,275 2,297 2,297 ________ 2,297 2,297 ............... VII Alameda, Contra Costa and Solano _______________________ 1,136,800 - 2,273 768 83 768 ....... 1 VIII Santa Cruz; and Santa Clara except Palo Alto .............. 59, 520 121 ........ 121 121 ........ 121 -__c.-_ ' IX San J uin, Stanislaus, Merced, Calaveras, Tuolumne, and Manposa 387,100 774 265 ........ 265 265 ........ 265 _______ u : X Fresno, ndera, Kings and Tulare ______________________________ 440,300 881 152 26 126 152 26 126 ________ XI San Benito, and Mouterey except southernmost portion ____________________ 110,400 221 ________ I l v I e $ 4 . ‘ QOI VINHOcII’IVO HOJ WVHDOQId EISVEISIG OINOHHO V XII Santa Barbara Ventura, San Luis Obispo, and southernmost part of Monterey. 269,500 539 50 ________ 50 XIII Mono, Info, ,Kem, and northwest section of San Bernardino ________________ 190,500 381 95 95 ........ XIV Los Ange es and Orange. _____ 3,882,200 7,764 883 791 92 XV Riverside, and San Bernardino except northwest section ____________________ 356,100 712 91 91 ________ XVI San Diego and Imperial ______________________________ 828,500 1,257 ________________________ XVII Alpine unty with regional center at Reno, Nevada _______________________ 300 ________ Totals, State-wide _ ________ 9,605,000 19,210 5,282 I 3,434 I 5,190 3,434 1,750 92 ________ 92 1The U. S. Public Health Service defines a "Chronic Disease Hospital” as "A hospital, the primary purpose of which is medical treatment of chronic illness, including the degenerative diseases, and which furnishes hospital treatment and care, administered by or under the direction of persons licensed to practice medicine in the State.” The chronic beds listed in the above table include beds in chronic disease hospitals (i.e. Laguna Honda Home in San Francisco, Rancho Los Amigos in Los Angeles, and Fair- mont Hospital in Alameda) and beds (in general hospitals) specifically assigned for the care of chronically ill patients, where the number of beds assigned in the individual general hospital is at least ten. It is probable that these facilities are utilized to some extent for cases requiring only custodial care, rather than true hospital care. The above table does not include beds in tuberculosis and mental hospitals, in nursing homes, and in institutions set up primarily for the provision of domiciliary care. Similarly, the above table does not include custodial beds in county hospitals. (At the time of the State Hospital Survey in 1947, the total number of custodial beds in county hospitals was approximately 3,000.) [The Bureau of Hospitals is planning to revise their data on chronic disease facilities when additional information becomes available. With respect to proposed construction of chronic facilities final plans have been approved for an addition of two wards (292 beds) to the Fairmont Hospital of Alameda County. Construction of this addition is expected to begin in the near future] 3 As estimated by the Population Committee of the California Department of Public Health. (Military personnel are not included in these estimates.) 3Basis: Two beds per 1,000 population (Source: Federal Hospital Surrey and Con- struction Act, P. L. 725, 1946, See. 622 (3)). 4 For purposes of this table, district hospitals are included in the "County Hospital" category. 5 Includes all private hospitals e.g. church, nonprofit association, corporation, partner- ship and individually owned hospitals. Federal hospitals are not included, 6 Definition of "nonacceptable" facilities: 1. Facilities which have not been granted fire clearance by the State Fire Marshal. (This group includes facilities which may be granted clearance upon satis- factory compliance with the recommendations of the State Fire Marshal. 2. Facilities in buildings with or without fire clearance which contain specific structural conditions which make it impractical to repair or organize for the safety and welfare of the patient. (A review of the facilities classified as nonacceptable shows that most of these facili- ties include aged buildings and those which provide inadequate and inefficient services. Specifically. these facilities will include: A. Converted buildings, B. No fire clearance, C. Inadequate food storage and preparation facilities, D. Inadequate sterilization and operation facilities, E. Inadequate internal arrangement to facilitate movement of patients, either ambu- latory or on stretcher especially in an emergency, or F. Lack of proper exits.) VINHOJI'IVO 210.1 WVHDOHd EISVEISIQ DINOHHO V LOI 108 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA NURSING. CONVALESCENT AND REST HOMES Table 3 presents a listing, by county, of the number of nursing, con- valescent and rest homes licensed by the California Department of Public Health and the total bed capacity of these homes. These are all private institutions—there are no public nursing homes in California. (For cus- todial institutions, see the following section.) TABLE 3 NURSING, CONVALESCENT. AND REST HOMES ' Licensed by the California Department of Public Health. Bureau of Hospitals; Data as at August 12, 1948 Number Total Number Total of bed of bed County homes capacity County homes capacity Alameda _____________ 46 712 Placer _______________ ‘l 25 Alpine _______________ __ __ I’lumas ______________ __ __ Amador ______________ __ __ Riverside ____________ 5 59 Butte ________________ 2 42 Sacramento ___________ 9 166 Calavei-as _____________ -_ __ San Benito ___________ s- __ Colusa _______________ __ __ San Bernardino _______ 11 145 Contra Costa _________ 4 121 San Diego ____________ 16 339 Del Norte ____________ __ __ San Francisco _________ 31 327 El Dorado ____________ __ __ San Joaquin __________ 5 94 Fresno _______________ 10 165 San Luis Obispo _______ 2 52 Glenn ________________ _- __ San Mateo ____________ G 227 Humboldt ____________ 3 73 Santa Barbara ________ 6 96 Imperial _____________ __ __ Santa Clara __________ 16 327 Inyo _________________ __ __ Santa Cruz ___________ 9 128 Kern ________________ 2 45 Shasta _______________ __ -_ Kings ________________ __ _ _ Sierra _______________ __ __ Lake _________________ 1 10 Siskiyou _______________ _- __ Lassen _______________ __ __ Solano _______________ __ __ Los Angeles ___________ 140 3,793 Sonoinu ______________ 6 68 Madera ______________ __ __ Stanislaus ____________ 4 21 Marin ________________ 3 27 Sutter _______________ 1 3 Mariposa ____________ __ __ Tchama ______________ __ _- Mendocino ____________ __ __ Trinity _______________ __ __ Merced _______________ __ __ Tulare _______________ 2 32 Modoc _______________ __ __ Tiiolumne ____________ __ __ Mono ________________ _- __ Veiitura ______________ 1 7 Monterey _____________ 2 24 Yolo _________________ 1 34 Napa ________________ 4 35 Yuba ________________ __ __ Nevada ______________ 1 7 — —- Orange _______________ 4 104 Total ___________ 360 7,308 .'.As defined in California Department of Public Health Regulations (California Administrative Code, ’Ijitle 17, Section 106) “A nursing, convalescent or rest home is any place or Institution which makes provision for bed care, or chronic or convalescent care, for one (1) or more nonrelated patients who, by reason of illness or physical infirmity. are unable to properly care for themselves." CUSTODIAL FACILITIES At the time of the 1947 State Hospital Survey, in schedules returned by county general hospitals a total of approximately 3,000 custodial beds were reported. These beds are used for domiciliary, ambulatory indi- gents, many of Whom are aged persons. HOMES FOR THE AGED Private homes for the aged 1 are licensed by the California Depart- ment of Social Welfare. As of May, 1947, licensed homes for the aged had a total capacity of approximately 5,000 persons. There are no public homes for the aged in California, although, to some extent, custodial facilities in county hospitals are used for the indigent aged. 1These homes are limited by regulation to accept for care only ambulatory aged persons (65 years of age and older) in good physical and mental health. .- A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 109 APPENDIX B—3 NOTES ON BEDSIDE NURSING SERVICES IN Cll’lLIFORNII-i1 COMMUNITIES IN WHICH BEDSIDE NURSING SERVICE IS PROVIDED Bedside nursing service is available to patients in their homes in 26 communitles in California. As shown in the following list of visiting nurse set-Vices, these agencies operate for the most part in urban areas. VISITING NURSE SERVICES IN CALIFORNIA2 Alameda Conniy——Berkeley Nursing Service, City Hall Annex, Berkeley; Oakland Visiting Nurse Association, 121 East 11th Street, Oakland. Fresno Conniy—-American Red Cross Visiting Nurse Service, 2823 Fresno Street, Fresno. ' Los Angeles County—Community Visiting Nurse Association, 511 Security Bank Building, Glendale; Long Beach Social Welfare League, 021 Pacific Avenue, Long Beach; Los Angeles Visiting Nurse Associa- tion, 2530 West Eighth Street, Los Angeles; Pasadena Visiting Nurse Association, 328 North Lake Avenue, Pasadena; Santa Monica Visiting Nurse Service, 1508 Sixth Street, Santa Monica. Marin County—American Red Cross Visiting Nurse Service, 712 Fifth Street, San Rafael. N enada County——American Red Cross Visiting Nurse Service, P. O. Box 52, Grass Valley. Orange County—Orange County Visiting Nurse Association, Santa Ana. Riverside County—Riverside Visiting Nurse Association, 4328 Orange Street, Riverside. Sacramento County—American Red Cross Visiting Nurse Service, 1300 G Street, Sacramento. San Bernardino County—Redlands Visiting Nurse Association, 114 \Vest Vine Street, Redlands. San Diego County—San Diego Visiting Nurse Association, 737 17th Street, San Diego; Escondido Visiting Nurse Association, Escondido. San Francisco County—San Francisco Visiting Nurse Association, 1636 Bush Street, San Francisco. San Mateo County—American Red Cross Visiting Nurse Service, 224 Primrose Road, Burlingame. Santa Barbara County—Santa Barbara Visiting Nurse Association, 133 East Raley Street, Santa Barbara. Santa Clara County—San Jose Visiting Nurse Association, 74 South Second Street, San Jose. 1 AbstraCt of material presented at the June 11th meeting of the Chronic Disease Advisory Committee by Miss Rena Haig, Chief, Bureau of Pub11c Health Nursing, Cali- 1 D artmentof Public Health. . forna‘Mfifiilfled from California’s Health, California Department of Public Health, November 30, 1947. 110 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA Santa Cruz County—Santa Cruz Visiting Nurse Service, American Red Cross, Santa Cruz. Solano County—Vallejo Visiting Nurse Association, P. O. Box 312, Vallejo. Sonoma County—American Red Cross Visiting Nurse Service, 14 Western Avenue, Petaluma ; American Red Cross Visiting Nurse Service, 629% Fourth Street, Santa Rosa. Sutter-Yuba Counties—American Red Cross Sutter-Yuba Chapter Visiting Nurse Service, Marysville. Venture County—Ventura Visiting Nurse Association, Chamber of Commerce Office, 474 East Santa Clara Street, Ventura. BEDSIDE NURSING SERVICE FOR THE CHRONICALLY ILL Information in regard to bedside nursing service provided to chronic patients during the calendar year 1947 was obtained from the following agencies: Total Visits to Percentage visits chronic of visits to made patients chronic cases Oakland Visiting Nurse Association _____ 23,105 2,921 13 San Francisco Visiting Nurse. Association 19,714 5,940 30 San Mateo Visiting Nurse Association-" 17,079 8,487 50 SOURCES OF FUNDS FOR VISITING NURSE SERVICES Sources of funds for visiting nurse services are listed below: 1. The sponsoring agency (usually the Community Chest or the American Red Cross). 2. Insurance companies: Payments on a fee-per-visit basis. 3. Cancer societies: Payments on a fee basis or payment of nursing salaries. 4. City or county on contract with the visiting nurse association 0n the basis of fee per visit. For example, San Francisco pays the Visiting Nurse Association the cost per visit for patients referred by the City Hospital or by public health nurses. The total amount for this service allowed by the city during 1947 was $4,250. Old age pensioners are not paid for by the city if they are under the care of a private physician. This problem of care for the indigent chronic is serious and is increasing. (The fee charged by a visiting nurse association is usually estab- lished on the basis of a cost study. It varies in different communities from $1.75 to $2.50. Care is given for less than the full cost of the visit or free of charge, depending upon the patient ’s financial situation.) 5. Gifts. PLANNING FOR NURSING CARE Care should be planned and provided on the basis of the nursing functions to be performed and the type of personnel required to perform those functions. Some cases should be cared for by public health nurses, some by registered nurses, others by practical nurses under supervision, and others by members of the family with instruction by the public health nurse. American Red Cross home nursing classes for home-makers are available in most communities in California. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 111 TRAINING OF PRACTICAL NURSES Courses for trained attendants are ofiered at the following hospitals in California: Fairinount Hospital San Leandro Herrick Memorial Berkeley Seaside Hospital Long Beach The League of Nursing Education is working with the Pasadena Junior College to develop a course for practical nurses. Provision for practical experience will be made at one or more hospitals. The Northern California League of Nursing Education and the Adult Education Department of the San Francisco City Schools are cooperating in the development of a course for practical nurses. It is expected that the instructor and facilities for the course will be provided by the Adult Education Department in September 1948. Provision will be made for practical experience in one or more hospitals in San Francisco. MEETING THE NEED FOR BEDSIDE NURSING CARE Planning for nursing care for the chronically ill in their homes should be a part of community planning to meet all of the problems con- cerned with care of these patients. The amount of nursing service required for the chronically ill at home depends on many factors including the following: 1. Available hospital and nursing home facilities for the care of acute and chronic patients. 2. Types of cases cared for at home. 3. Economic status of the population in a community. Developments in public health nursing services which may be required to meet the need in California are: 1. Expansion and increased budgets of existing visiting nurse services. 2. Establishment of bedside nursing services in communities where such service is not now available. 3. The development of bedside nursing service by health depart- ments for all types of patients, including the chronically ill. 4. The employment of trained, licensed, practical nurses to supple- ment public. health and graduate nurse services. 112 A CHRONIC DISEASE PROGRAM roe CALIFORNIA APPENDIX 3-4 VOCATIONAL REHABILITATION SERVICES IN CALIFORNIA The following report of vocational rehabilitation services in Cali- fornia outlines briefly the program of the Bureau of Vocational Rehabili- tation, State Department of Education. The bureau provided the information for the report. 1. Date of Information J une-August, 1948. 2. Name and Address of Agency California State Department of Education, Bureau of Vocational Rehabilitation, Sacramento, California. 3. Name and Title of Director of Agency Harry D. Hicker, Chief, Bureau of Vocational Rehabilitation. 4. Type of Agency and Sponsorship State agency. 4a. Source of Funds: The bureau’s activities are financed by federal and state funds. The Federal Office of Vocational Rehabilitation pays all administrative expenses (and vocational guidance and placement costs) and 50 percent of case service costs; the State pays the remaining 50 percent of case service costs. Total expenditures for the Fiscal Year 1947-1948 were as follows: Item Amount Source of funds Case service costs (including examina- tion, treatment, hospitalization, phys— ical and occupational therapy, train— ing, etc.) ________________________ $771,000 State $385,500 Federal $385,500 Vocational guidance and placement costs ___________________________ 766,522 Federal Administrative costs " _______________ 154,137 Federal Total Expenditures _________ $1,691,659 ‘ Administrative costs include salaries and travel for central ofl‘lce staff and district supervisors, rent, utilities, and supplies. Appropriations for the Fiscal Year 1948—1949 are given below: Item Amount Source of funds Case service costs ___________________ $1,370,000 State $685,000 Federal $685,000 Vocational guidance and placement costs ___________________________ 717,053 Federal Administrative costs _______________ 159,773 Federal Total Expenditures __________ $2,246,826 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 113 5. Area or Jurisdiction Served by Agency State-wide. 511. District and Branch Offices: Services of the bureau are provided through six district Offices and seven branch offices. The areas served by each Of the district Offices, the location of district and branch offices, and the size of professional staff as of August 1, 1948, are given below : Size of pro- fessional Office * sic]? T Area served by district ofi‘ices District Office Del Norte, Humboldt, Trinity, Mendocino, San Francisco _____ 21 Lake, Sonoma, Napa, Marin, San Fran- Branch Office cisco, San Mateo, Santa Clara, Santa Cruz, Fresno ________ 3 San Benito, Monterey, Fresno, Kings, Santa Rosa ___ 1 Tulare, Mudera, Mariposa, Merced. District Office Solano, Contra Costa, Alameda. Oakland __________ 13 District Office Siskiyou, Modoc, Shasta, Lassen, Tehama, Sacramento _______ G Plumas, Glenn, Butte, Sierra, Colusa, Branch Office Suffer, Ynlm, Nevada, Yolo, Placer, El Chico _________ 1 Dorado, Sacramento, Amador, San Joa- Stockton ______ 2 quin, Calaveras, Stanislaus, Tuolumne, ‘ Alpine. District Office San Luis Ohispo, Santa Barbara, Ventura, Pasadena _________ 10 Kern, San Bernardino, Riverside, part of Branch Office San Bernardino 2 District Office Los Angcles County, Inyo, Mono. Los Angeles (city). Los Angeles _______ 34 District Office Orange, San Diego, part of Los Angeles Long Beach _______ 9 County, Imperial. Branch Office San Diego ___- 6 - Santa Ana ____ 1 The present system of district Offices was established in July of 1947. Prior to that time, there were three Offices (San Francisco, Sacramento and Los Angeles) and several branch Offices. The establishment of addi- tional offices in 1947 followed a Department of Finance administrative survey which recommended this action. It is significant to note that there are only nine professional employees serving a total of 23 counties comprising the Sacramento Dis- trict and only 25 professional employees serving a total of 20 counties comprising the San Francisco District. Similarly the Pasadena District serves a very large geographical area with only 12 professional workers. With this distribution of Offices and personnel, it would seem to be clear that large areas in the State—the predominantly rural areas—cannot possibly be covered adequately by the Bureau of Vocational Rehabilita- tion. " In addition to district and branch Offices, there are eight local offices which are set up primarily to refer high school children to district and branch offices. Each of these local offices is staffed by a vocational rehabilitation coordinator who is an employee of a group Of school districts. The central Office, or headquarters of the bureau, at Sacra- mento has a professional staff of four persons. TProfessional personnel include vocational rehabilitation officers, district super- visors, assistant district supervisors, and medical consultants. 8—14-8179 .114 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 6. Agency’s Current Program 6a. Duration of Program: The California Vocational Rehabilita- tion Act, passed in 1921, accepted the provisions of the Federal Vocational Rehabilitation Act passed by Congress in 1920, and appropriated $35,000 per year for rehabilitation service. Prior to 19-13, the program was limited to vocational guidance, training, prosthesis, and placement activities. In 1943, Congress amended the Vocational Rehabilitation Act authorizing appropriations for physical restoration services, services for the mentally and emotionally handicapped, and removing the monetary ceiling on appropriations for vocational rehabilitation services. There is no state legislation in California on vocational rehabilita- tion other than the original act (1921) authorizing participation in the federal program. 6b. Specific Types of Services Provided: The following services are provided or purchased by the Bureau for the rehabilitation of voca- tionally handicapped persons: Vocational guidance and counselling Medical, psychiatric, dental, and psychological examinations Medical, psychiatric, surgical, dental treatment Hospitalization and convalescent home care Nursing care ' Physical and Occupational therapy Prostheses Training Transportation and maintenance grants Placement (including occupational licenses, placement equip- ment, etc.) Case follow-up. A breakdown of the physical restoration case services purchased during the Fiscal Year 1947-1948 is shown below: Number of Average Total clients cost amount receiving per spent Type of service the service client on service Medical, surgical, and dental examinations __ 6,670 $12 32 $82,814 Psychiatric examinations _________________ 150 24 74 3,710 Medical treatment ______________________ 268 46 23 12,389 Psychiatric treatment ____________________ 70 187 67 13,137 Surgical treatment ______________________ 375 121 57 45,589 Dental treatment ________________________ 96 126 87 12,200 Other treatment ________________________ 7 136 71 957 Prostheses ______________________________ 820 101 18 82,979 Hospitalization _________________________ 250 291 08 72,771 Convalescent home care ______________ ____ 10 245 80 2,458 Physical therapy and occupational therapy __ 70 39 77 2,784 Transportation (for medical care) ________ 90 23 21 2,080 Maintenance (for medical care) __________ 70 164 04 11,483 Total _____________________________________________ $345,360 The total amount ($345,360) paid for physical restoration case services (including examinations) represented approximately 20 per- cent of total program expenditures of the bureau during the Fiscal Year A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 115 1947-1948. During the same period, the bureau paid $364,595 for train- ing and miscellaneous case services. 60. Eligibility Requirements for Service 07' Benefits: The manual of the bureau prescribes the following eligibility and feasibility require. ments for rehabilitation service: ELIGIBILITY REQUIREMENTS (1) Age: Sixteen years of age or over. (2) Disability: An established abnormal mental or physical cona dition. (3) Handicap : An established hindrance to successful employment by reason of disability. (4) Residence: One year residence in the State. However, persons who have resided in the State for less than one year and submit evidence of intention and ability to remain, may be deemed eligible. (No residence restriction for war disabled civilians or civilian employees of the United States.) (5) Employment status: Unemployed, unsatisfactorily employed or likely to lose job. . FEASIBILITY REQUIREMENTS ( 1) Age: Upper age limit is usually about 65, but contingent upon health and vitality of the individual. Work expectancy should be at least three years. (2) Degree of Impairment:_Applicant’s physical condition must be such that he can carry on not only in training but also in employment on the job for which training is planned. Homebound cases may be feasible for service under the special program for the severely disabled. The criterion is a prognosis of ability to work sufficiently for complete or partial self-support. At least one—half of legal minimum wage should normally be anticipated. (3) Mentality: He must be mentally capable of receiving instruc- tion and be competent or potentially competent to manage his own affairs without constant supervision. (4) Personality, Character and Family Situation: Emotionally stable or potentially so ; able to get along with others; reasonable honesty, reliability, sobriety, and willingness to work. He must be free to devote his time and energies to the accomplishment of rehabilitation without undue economic or emotional strain. (5) Facilities: Facilities for rendering the services required in the rehabilitation process must be available. Stated negatively, such factors as old age, very low mentality, severe emotional or physical disability, extreme cosmetic difficulty, non- cooperative attitude, habitual drunkenness, habitual moral or criminal turpitude, and similar factors which would make rehabilitation inadvis- able, uneconomic, difficult, or impossible to accomplish, may be indicative of nonfeasibility for service. In addition to the above eligibility and feasibility requirements, the provision of physical restoration services, as stated in the bureau’s man- ual, is based on a number of factors including the following: 116 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA BASIS FOR PROVIDING PHYSICAL RESTORATION SERVICES Physical restoration is not intended to include restoration of every defect, but rather that portion necessary to make the client employable or more advantageously employable. Physical restoration service will be provided only when all of the following conditions prevail: ( 1) Physical restoration may be provided only to disabled persons found to require financial assistance with respect thereto, after full con- sideration of the eligibility of such persons for any similar benefit by way of pension, compensation, insurance, or from any other agency as a matter Of right as distinguished from privilege. (2) Residence: The requirement is the same as for other rehabili- tation services. (3) Treatment is necessary for the satisfactory occupational adjust- ment of the applicant. (4) The condition causing disability is static. (5) The condition is of such a nature that treatment may be expected to eliminate, arrest, or substantially reduce the handicap it imposes Within a reasonable time and for a reasonable cost. (6) The prognosis for life and employability is favorable. (7) There is on file a recent and adequate medical report and diag- nosis, together with prognosis as to susceptibility to treatment and recom- mendations as to methods of restoration. (8) The client understands that the treatment is provided primarily to make him employable and that he will diligently seek employment upon recovery either with or without training. 601. Duration of Services or Bcu‘efits per Case: The policy of the bureau is to provide complete service once the determination of eligi- bility and feasibility is made. For the most part, there are no maximum limits on the duration of benefits or services. However, there are several factors which do limit the duration of certain benefits; e.g., hospitaliza- tion may not exceed 90 days unless special authorization is Obtained; the maximum amount which can be paid to any one physician on any one case during any period of 12 consecutive months is $350; training is generally limited to a period not to exceed two years, but may be extended in appropriate cases. The duration of services for closed cases (successfully rehabili- tated 1) during the Fiscal Year 1947-1948 is shown below: 1 J _ _. Number of Percentage of Duration closed cases all closed cases of (successfully (successfully services rehabilitated) rehabilitated) Under 2 months _________________________ 153 3,5 2- 3 months ________________________ 515) 11,8 4- 5 months ________________________ 607 13.8 6- 7 months ________________________ 752 17.1 8- 9 months ________________________ 665 15.1 10-11 months ________________________ 360 8.2 12-17 months ________________________ 165 3.8 18-23 months ________________________ 454 10.3 > 24—35 months ________________________ 388 8.6 36-47 months ________________________ 261 60 48 and over ______ . ____________________ 71> 1 8 Totals _________________________ 4,406 100.0 1A “successfully rehabilitated" person is one who is employed in a. productive occupation suited to hlS abilities and who is earnmg at least one—half of the legal mini- mum wage (l.e., part-time employment). ‘u A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 117 Statistics are not readily available for duration of services pro- vided to closed cases other than those successfully rehabilitated. 66. Cost of Services: See 6b above and budget and expenditure figures in 4a above. Case costs for closed cases (successfully rehabilitated) during Fiscal Year 1947-1948 are shown below: Number of Percentage of closed cases all closed cases Total cost (successfully (successfully per case rehabilitated) rehabilitated) Under $10 * __-_ ________________________ 1,806 4 41.0 10» 49 _________________________ 824 18.7 50— 90 _________________________ 255 5.8 100-199 __________________________ 798 18.1 200-299 __________________________ 198 4.5 300-399 _________________________ 110 2.5 400-499 __________________________ 102 2.3 500-999 __________________________ 255 5.8 1,000 and over ______________________ 58 1.3 Totals _____________________ 4,406 100.0 * Cases in which medical examinations and job placement were the only services rendered. Statistics are not readily available for case costs for closed cases other than those successfully rehabilitated. Program cost per successful rehabilitation can be obtained by relat— ing total program expenditures to the total number of successfully reha- bilitated cases during the same period. For the year ending June 30, 1948, the program cost per successful rehabilitation was $383.94. 6f. Number and Types of Cases Receiving Services: The case load and closures during the fiscal year ending June 30, 1948, are shown in tabular form below: CASE LOAD AS OF JUNE 30. 1948 Bureau of Vocational Rehabilitation. California Department of Education District Case service category San L08 (As of June 30, 19/;8) Fran- Oak— Sacra- Pasa- Ange- Long cisco land mento dena leg Beach Total Referred status (client has ap- plied for service or has been re- ferred by another agency or person) ____________________ 1,509 1,061 843 1,170 1,777 1,252 7,612 Accepted status (medical exam- ination has been performed and client’s eligibility has been established; feasibility is being determined for these clients)__ 1,110 573 477 496 970 712 4,338 Active (“rehabilitation”) status (client is actually receiving rc- habilitation services eg. physi- cal restoration, training, etc. This group Constitutes the ac- tive case load of the bureau)__ 1,451 559 402 610 1,216 537 4,775 Total ____________________ 16,725 118 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA CLOSURES DURING THE PERIOD JULY 1. 1947 TO JUNE 30. 1948 Bureau of Vocational Rehabilitation. California Department of Education Case closed from “rehabilitation status” (employed and rehabili- tated) _____________________ 1,211 506 283 537 1,269 600 4,406 Case closed from “rehabilitation status" (unemployed or trans- ferred to other agency) _______ 118 45 50 10 45 43 311 Case closed from “accepted status" (closed because of indifference of client; increase in degree of disability; loss of contact, etc.) 233 133 186 128 395 120 1,195 Case closed from ”referred status” (closed because services were declined; services not needed; applicants not eligible; appli- cant not cooperative; applicant needs services other than voca- tional rehabilitation, etc.) _____ 1,051 486 660 524 2,176 1,531 6,428 Total ________' ____________ 12,340 The bureau does not maintain statistics on the number Of “closures from accepted status” and “closures from referred status,” classified by reason for closure. Also, for these two categories which accounted for a total of 7,623 closed cases in the fiscal year ending June 30, 1948, information is not readily available on duration of services or types Of services provided prior to closure. Were such statistics available, the preceding table on case—load and closures would be more meaningful. Accurate and current information, on the number of handicapped persons of employable age in California, is not available. Also, informa- tion is not available on the number of such persons who are receiving services from agencies and sources other than the Bureau of Vocational Rehabilitation, 69. Number and Type of Clients on Waiting List: Although the bureau does not maintain any “waiting list” as such, the “referred status” category may be considered as containing a large number of persons awaiting rehabilitation services. This category is made up Of persons who have applied or been referred for service, and are being contacted and/0r processed for eligibility. Information is not available on the number of each type of client in this “referred status” category. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 119 6h. Coordination With Other Agencies and Organizations: (1) Source of Referrals: Sources of referrals for the six months period end- ing December 3], 1946, and for the equivalent period in 1947 are shown below : Percentage of all referrals July I-Dec. 31 July 1-Dec. 31 Source of referral 191,6 191,7 Educational agencies (principally public high schools, junior colleges, and colleges) _________ 10.6 13.0 Health agencies _____________________________ 14.6 17.1 Insurance agencies (principally workmen’s com- pensation) _______________________________ 17.3 12.1 \Velfare agencies ____________________________ 11.3 8.2 Other government agencies (principally California State Employment Service) _________________ 21.6 25.8 Miscellaneous (including self-referred) _________ 24.6 23.8‘l 100.0 100.0 Total referrals ______________________________ 4,535 7,370 ‘ Approximately half of this group (11.2 %) is made up of self-referred cases. The Bureau of Vocational Rehabilitation has entered into formal agreements with the following major agencies concerning: (1) Referral of cases, (2) exchange of information, and /or, (3) respective areas of jurisdiction : a. California State Employment Service b. California Department of Public Health, Crippled Chil- dren’s Service c. California Industrial Accident Commission d. California Department of Social Welfare (Blind Cases) e. State Personnel Board Although these and other agencies refer cases to the bureau, appar— ently there are no referrals from one important source in the State— the California Department of Employment ’s Disability Insurance Pro< gram. This program, which began in December, 1946, pays cash benefits to eligible claimants for wage loss due to nonoccupational illnesses and injuries. Approximately three million workers in California are insured under the program. (2) Committees and Councils: There are two committees which have been established to advise the chief of the Bureau of Vocational Rehabilitation : The Professional Advisory Committee and the California State Rehabilitation Council. There is a third group—the California Council of Agencies for the Handicapped—in which the bureau participates as a member agency. These groups, particularly the Professional Advisory Committee and the council, could furnish effective leadership in the coordination of services and facilities for the rehabilitation of the disabled and in the development of integrated programs. Concerning the representation on these committees and councils, it is of interest to note that employer groups are not well represented. 7. Describe Agency's Plans for New Programs or Extension of Current Programs A. Rehabilitation Services in Rural Areas: 111 the present fiscal year (1948-1949) an increase in staff has been made to improve services 120 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA in the Fresno-Bakersfield area. Kern County now has a full-time reha- bilitation officer. The Fresno-Merced-Visalia area now has a total of four rehabilitation officers whereas it previously had two. The 1949-1950 Budget contemplates the establishment of a district Office for the Fresno- Bakersfield area and a full-time rehabilitation officer in the Humboldt County area. B. Increased Services: For the current fiscal year, there has been a 55 percent increase in funds available for case services. This will make possible the provision of services to larger numbers of clients. 0. Rehabilitation Centers: There have been many plans for the establishment of rehabilitation centers and sheltered workshops through- out the State. Of perhaps most significance is a plan for establishing a comprehensive rehabilitation center as part of the new medical school at the University of California at Los Angeles. This school has a “reha- bilitation minded” staff and has at least part Of the necessary space and funds for the center. This plan also contemplates the establishment of a Department of Rehabilitation which will have the same status as the traditional departments e.g. medicine, surgery, etc. 8. Comments. Remarks, Suggestions There are a number of important gaps in the present program of the Bureau of Vocational Rehabilitation. A. Rehabilitation in rural areas of the State has lagged behind that in the urban areas. This weakness in the program is attributable to two major factors: (1) Lack of funds for rehabilitation personnel, and (2) lack Of facilities and services in rural areas (cg. medical specialist services, training facilities, accredited hospitals). B. Rehabilitation personnel have been reluctant to accept for reha- bilitation services severely handicapped persons (e.g. cerebral palsy cases) and persons with mental and emotional disorders. To some extent this reluctance is due to feasibility requirements (e.g. that a person be made employable within a reasonable length of time and at a reasonable cost). Lack of facilities, such as rehabilitation centers and sheltered workshops, has impeded the acceptance of some of these cases. Another factor, particularly true of the mental cases, is the fear that these persons will break down on the job and undermine the bureau’s relationships with important employer contacts. C. Statistical data maintained by the bureau is inadequate for pro- gram evaluation and program planning. Statistical services are financed by federal funds and are charged to administration. They are designed principally to furnish information for reports required by the Federal Office of Vocational Rehabilitation. They are not designed to provide current information on active cases (except those successfully rehabili- tated) and on cases rejected for eligibility, feasibility, or other reasons. A CHRONIC DIsEAsE PROGRAM FOR CALIFORNIA 121 APPENDIX B-S THE CRIPPLED CHILDREN’S PROGRAM IN CALIFORNIA The following report outlines briefly the Crippled Children’s Pro- gram of the State Department of Public Health. I. Date of Information August 1, 1948. 2. Name and Address of Agency California State Department of Public Health, Crippled Children’s Services. 3. Name and Title of Director of Agency Wilton L. Halver son, M. D., State Director of Public Health; Fred- eric M Kriete, MD, Chief, Bureau of Maternal and Child Health; Marcia Hays, M..,D Assistant Chief, Bureau of Maternal and Child Health. 4. Type of Agency and Sponsorship State agency, acting in cooperation with federal and local agencies. 4a. Source of Funds—There are three sources of funds available to the program: (1) Federal: In general, federal funds—allocated in accordance with the provisions of the Social Security Act—are budgeted for adminis- t1 ative costs. (2) State: State funds are used to pay for all diagnostic services and all care to nonresident or transient crippled children. Also, Where local appropriations are inadequate, subsidies are available from state funds to supplement local expenditures for care. (3) Local: With respect to local funds, in accordance with the Crippled Children’s Act, each county is required to appropriate an amount not less than one-tenth of a mill for assessed property valuation to finance services for crippled children. 5. Area or Jurisdiction Served by Agency State-wide. 6. Agency's Current Program: 60. Duration of Progi'am—Jl‘he original Crippled Children’s Act in California dates back to 1.927. It directed the State Department of Public Health to seek out handicapped children, to provide diagnostic services, and to furnish, upon certification by the Superior Court of each county, such services as were necessary for the treatment of handicapped children. The act further directed the counties to reimburse the State for the cost of such treatment, and authorized each county to appropriate three mills in each dollar of assessed valuation to pay for such costs. In 1936, enabling legislation was passed to permit the acceptance of federal funds for the crippled children’s program. In 1945, the basic act was amended: (a) To direct each county to appropriate one-tenth of a mill of its assessed property valuation; (b) to 122 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA allocate such funds to either the county welfare department or the county health department to furnish services to handicapped children ; and (c) to transfer the determination of financial need from the superior courts to the local administrative agency (welfare or health department). The law now provides that a county may authorize the State Department of Public Health to furnish necessary treatment services (with reimbursement by the county) or the county may provide the services independently, if the services meet the standards established by the State Department of Public Health. Also in 1945, cerebral palsy and hearing conservation programs were authOrized and funds were appropriated for these programs. 61) Types of Services P1 omded—Services provided under the crip- pled children’s program are: Diagnosis by qualified specialists; Treatment also by specialists; Hospital care in approved hospitals; Convalescent care in approved convalescent homes; Appliances and other allied medical services, such as medical social services, physical therapy, nursing, etc. All Of the above services are provided by personnel meeting standards established by the state and federal governments. For physicians, certifi- cation or eligibility for certification by the specialty boards, and for other personnel, registration or certification by professional associations, are required. The above services cover the following types of medical care: Service A rm coumcd General orthopedic ___________________________ * State-wide Plastic ______________________________________ * State-wide Eye conditions leading to loss of vision __________ * Statewide Other congenital anomalies _____________________ * State-Wide. Rheumatic fever ______________________________ Contra Costa, Humboldt, Merced, Sonoma, Stanis- laus. Hearing conservation __________________________ Alameda, Contra Costa, Humboldt, K e. r n, Los Augeles, Marin, Napa, Orange, San Bernardino, San Diego, San Fran— cisco, San Mateo, Sacra- mento, Santa Barbara, Santa Clara, S o l a n o, Sutter-Yuba, Ventura. ‘The programs in Alameda, Los Angeles, Monterey, San Joaquin, Slsklyou, Sonoma and Tulare are independent. The specific extent and type of services provided in these counties are unknown. An additional service which is Offered by the program is planning for children who either reach the age of 21 and are no longer eligible for serv- ices or who are rejected either for medical or economic reasons. It is the responsibility of the agency to make plans for such childen elsewhere, either by referral to the State Bureau of Vocational Rehabilitation, by referral to other agencies which Offer services, or by assisting in the plan- ning for private medical care. Table I below shows the number and types of services provided to children receiving care under the crippled children’s program during the A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 123 Fiscal Year 1947-48 in counties which authorize the State Department of Public Health to purchase treatment services for them. TABLE I NUMBER AND TYPE OF SERVICES (EXCLUSIVE OF CLINICS) FOR CHILDREN RECEIVING CARE UNDER CRIPPLED CHILDREN'S PROGRAM IN DEPENDENT' COUNTIES 1947-1948 Fiscal Year 1. Total number of cases for whom care was purchased from physicians, hospitals, and related providers of service (Fiscal Year 1947-1948) __ 3,856” II. Total number of cases by types of disabilities A. Orthopedic ________________________________________________ 1,002 B. Eye __.._____' ______________________________________________ 1,096 C. Plastic ___________________________________________________ 739 D. Ear _______________c_-_____________- _______________________ 314 E. Rheumatic fever ___________________________________________ 104 F. Cerebral palsy _____________________________________________ 331 G. Others ‘ __________________________________________________ 372 III. Types of payment by services A. Diagnostic ________________________________________________ 1,534 B. Medical care _______________________________________________ 2,050 0. Hospital care. _____________________________________________ 1,366 D. Other ‘1 ___________________________________________________ 1,842 IV. Total number of iii-patient hospital days for which payment was made 1947-1948 Fiscal Year ________________________________________ 34,095 60. Eligibility Requirements for Services—(1) Medical Eligi- bility. The following definition of a “physically handicapped child” is used for purposes of administration of the Crippled Children’s Program: “A physically handicapped child is a person under 21 years of age who does not have complete use or control of his body or limbs because of physical defects resulting from congenital anomalies or acquired through disease, accident or faulty development. Children having the following handicapping conditions or suffering from a disease, which if not treated, is likely to lead to such handicapping are acceptable for care under the program: 1. Those of an orthopedic nature. Examples: Club foot, polio- myelitic paralysis, cerebral palsy, etc. 2. Those requiring plastic reconstruction. Examples: Cleft palate and lip, contracture or disfigurement due to burns, etc. 3. Those requiring orthodontic reconstruction. Examples: Dental-facial deformities accompanying cleft palate, etc. 4. Eye conditions leading to loss of vision. Examples: Cataract, strabismus, etc. (Ordinary refractive errors are excluded). 5. Ear conditions leading to loss of hearing. Examples : Chronic otitis media, chronic blockage of Eustachian tubes, congenital deafness, etc. “Dependent Counties" are those which authorize the State Department of Public Health to purchase treatment services for them (on a reimbursement basis). b It is estimated that these 3,856 cases represent approximately 40 percent of all cases receiving services under the Crippled Children's Program. c Includes cases diagnosed as poliomyelitis, congenital heart, congenital anoma- lies, cases requiring orthodontic treatment only, etc. dIncludes physiotherapy, appliances, anesthetic services, out-patient services, blood transfusions, etc. 124 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 6. Rheumatic or congenital heart disease. 7. Other disabling or disfiguring deformities. Examples: Extro- phy of the bladder, severe hemangioma, etc.” (2) Financial Eligibility. The State Crippled Children’s Act states that care is to be made available to children whose parents are unable to finance such care “in whole or in part.” The determination of financial eligibility is made by the county agency designated by the Board of Supervisors. Financial eligibility requirements apply to treatment services, not to diagnostic services. 6d. Duration of Services—Duration of services is not restricted under this program because of length or cost of treatment. The objective of the program is to achieve maximum correction for eligible children. 66. Cost of Services—The total cost of services for the 3,856 cases referred to in Table I was $670,059 ; the average cost per case was $173.77. It is estimated that the 3,856 cases represents about 40 percent of all cases receiving services under the Crippled Children ’s Program. It is anticipated that additional statistical data on costs of services will be available within the next few months. 6f. Number and Types of Cases Receiving Serriccs—Sce Table 1 above. 69. Cooperation With Other Agencies and Organizations—The State program has four types of cooperative relationships: (1) State-Federal. This involves relationships with the federal consultation services available through the regional Office of the United States Children’s Bureau. (2) State-County. For counties which purchase their own treat- ment services for physically handicapped children, the State offers finan— cial assistance and consultation services. For counties which authorize the State Department of Public Health to purchase treatment services for them, the department carries out these activities and the local agencies do the case-finding and follow-up work. The State finances diagnostic services in both of the above types of counties. ($ Voluntary Agencies. There are three major voluntary agencies in the State concerned with the crippled children’s program. These are the State Tuberculosis and Health Association, and its important sub— section, the Heart Advisory Committee; the State Crippled Children’s Society; and the National Foundation for Infantile Paralysis. Close working relationships have been worked out and established with these agencies. These relationships cover mainly, the fields of community organization, training and education, and legislation. All three agencies give active support through their local chapters to the crippled children services programs in county health and welfare departments. Special institutes, conducted for professional personnel, have been jointly planned and sponsored by state and voluntary agencies. Much of the published educational material released by the Crippled Children’s Society and the Heart Advisory Committee is prepared jointly by the state and voluntary agencies. (4) Other Official Agencies. Relationships with other Official agencies are based on joint problems and activities. The State Depart- ment of Education and the State Department of Public Health have joint A CHRONIC DIsEAsE PROGRAM FOR CALIFORNIA 125 responsibility in the cerebral palsy program; a coordinating committee meets regularly to plan and implement this program. The State Bureau of Vocational Rehabilitation and the Crippled Children Services have developed referral channels for individual cases and have developed and use a joint fee schedule for purchased medical and related services. Other Official relationships are with the State Department of Social Welfare, local county welfare departments, (particularly where these departments had been designated to administer the program as provided by law), and the State Department of Mental Hygiene. 7. Agency's Plans for New Programs or Extensions of Current Programs No new programs are contemplated for the coming year. In accordance with the, general philosophy of the State Department of Public Health, the Crippled Children Services is encouraging the development Of local administration of crippled children’s programs and the development of local facilities and services essential for these programs. Efforts are being directed towards the extension Of special pro- grams (i.e., cerebral palsy, hearing conservation, and rheumatic fever) to counties which do not now have coverage. The problems of funds and facilities for rheumatic fever and severely handicapped cerebral palsy patients, not now covered by the program, are being surveyed at the direction of the State Legislature. Survey results and recommendations will be considered at the next legislative session. In the extension of these special programs, several factors are important: Cerebral Palsy Program: ‘ (1) Size of caseload of educable, treatable children with cerebral palsy. (2) Availability of specialized personnel (orthopedic physi- . cal therapy, and special teaching). Hearing Conservation Program: (1) Availability of specialized personnel and facilities for diagnosis and treatment within the county or readily accessible to it. (Qualified otologists and approved hospitals.) Rheumatic Fever Program : ( 1) Availability of funds. (2) Availability of special facilities and personnel. (The problem of rheumatic fever is largely one of adequate financing since costs of care for this disease far exceed those in the other categories covered by the Crippled Children’s Program. The long term care necessitates not only adequate funds to cover length of care, but also convalescent facilities and trained personnel in the field of diagnosis and treatment.) Continuous training of professional personnel in the basic crippled children’s program and in the fields of cerebral palsy and rheumatic fever is in process. Federal funds are to be made available next year for a professional training center for cerebral palsy personnel. Nego- tiations are now being carried on which—it is hoped—will result in the establishment of this training center in California. 126 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA APPENDIX c EXPERT OPINION SUMMARY During the period May to August 1948, letter questionnaires, ask- ing for opinion information on the problems involved in caring for the chronically ill, were sent to the following persons in California: Number of letter questionnaires Category mailed County welfare directors _______________________________________ 5‘4 County hospital administratm-s __________________ . _______________ 53 Presidents of hospital councils and conferences ____________________ 9 Presidents of county medical societies__", ______________________ 40 Local health officers ___________________________________________ 08 Presidents of local osteopathic societies 94 Osteopathic hospital administrators } """"""""""""""""" Executives Of voluntary welfare agencies _________________________ 99 The letters sent to persons in each Of the above categories were based upon a draft letter which was presented to the Chronic Disease Advisory Committee at its March 19th meeting. Revisions recommended by the members of the committee and revisions by the appropriate state asso- ciations were incorporated in the letter questionnaires. A different type of letter than those referred to above was sent to each county grand jury foreman. These letters gave information about the chronic disease investigation, mentioned the letter questionnaires which had been sent tO persons in each county, and asked for comments and suggestions. In view of the differences among the questions in the several letter questionnaires, no attempt will be made to combine the tallies Of answers from the several categories of persons. The specific questions used in these letters, the number of replies received and detailed analyses of the responses are given in Appendix C—l through 0-7. A brief account of the Opinions expressed in the letters of reply is presented below. Problems in Caring for the Chronically III in California There is general agreement among the reSpondents in all categories that the care of the chronically ill in their communities is a serious problem because of the: (a) Difficulty in finding adequate nursing and convalescent homes for chronic cases; (b) Lack of hospital facilities for chronic cases needing intensive medical care; (c) Lack Of adequate facilities for chronic cases needing a custodial type of care; and (d) Lack of services, facilities, and trained personnel for the reha- bilitation of the chronically ill. On the last point (d) above, frequent mention was made of the program of the State Bureau of Vocational Rehabilitation, but it was pointed out that their services were inadequate or nonexistent in rural ‘- A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 127 areas and that there was no provision or little provision of services and facilities for rehabilitation other than vocational rehabilitation. In stressing the need for adequate nursing home facilities, attention was repeatedly called to the prohibitive costs Of nursing home care and to the need for improvement in the quality of such care. The shortage of hospital facilities for chronic cases—reported emphatically by all groups ——was frequently related to the general problem of shortages in all types of hospital facilities in the State. In addition to pointing out the need for additional custodial facilities, a number of respondents expressed serious concern about the poor condition of these facilities and the low standards of care prevailing in them. All groups Of respondents, except one, agreed that an important phase Of the problem of caring for the chronically ill is the inability of families, otherwise self-supporting, to pay for medical and related services for their chronically ill members. Opinions were divided among the groups of respondents as to the adequacy of: (1) Diagnostic services, (2) preventive medical services, and (3) coordination'in the provision Of all services for the chronically ill. This difference of. Opinion reflects, at least in part, the 1elatively adequate services in lartre iilban areas in contrast to the inadequate services in rural a1 eas ()n the question Of coordination, several respond- ents, refc1r1110 to their own communities, pointed out that it is impossible to coordinate Dnonexistent services. What Should Be Done Locally to Provide Adequate Service and Facili- ties ior the Care and Rehabilitation of the Chronically Ill? The letters of reply contained many recommendations on what should be done locally to provide adequate services and facilities for the chronically ill. The most frequently mentioned recommendation in the replies from respondents in each' of the groups was for more and better hospital facilities and services. Some respondents stressed expan- sion Of facilities ; others stressed “improved,” “better staffed,” or “more accessible” facilities. Other recommendations for local action to meet the needs Of the chronically ill include the following: Provide additional nursing and convalescent homes Provide or expand rehabilitation services Provide bedside nursing and housekeeping services in the home Coordinate local resources Provide educational programs. A few of the respondents stated that services in their areas were adequate. Several stated that small counties with inadequate funds can- not provide for the care and rehabilitation of the chronically ill. Local Planning for the Care of the Chronically Ill The questionnaires sent to all groups requested information on local planning for the care Of the chronically ill. Some Of the respondents answered that there was no planning in their county or community; others answered that they knew of no such planning. Of those who stated that their county or their community was engaged in planning in this field, most of them describedplans for construction or expansion of 128 A CHRONIC DISEASE PROGRAM FOR. CALIFORNIA hospital and related facilities; a few described plans for integrating loeal facilities and services and a few stated that local health councils are becoming active in this field. What Should the State Do to Help Localities Provide Adequate Services and Facilities for the Care and Rehabilitation of the Chronically Ill? Many recommendations were Offered on what the State should do to aid localities in this field. The recommendation mentioned most fre- quently in the letters of reply called for financial assistance to localities ——financial assistance for construction of hospitals and related facilities for the care of the chronically ill. Other recommendations offered by a number of respondents include the following: Expand rehabilitation services Provide state subsidies to def ‘ay costs of service (including home care services) for the chronically ill Develop or assist in the development of diagnostic clinics Develop research centers and conduct research Provide consultation services to counties Establish standards for care Recruit and train personnel or subsidize training of personnel Conduct and expand health education programs Expand and improve local health services. A small number of respondents stated that this is a local problem ——that the State should not help the localities to provide adequate services and facilities for the care and rehabilitation of the chronically ill. What Aspects of the Chronic Disease Problem Deserve Special or Intensive Study? The questionnaires asked for information on what aspects of the chronic disease problem deserve special or intensive study. Persons in each group were asked to answer this question from the standpoint of their own field of interest, e.g., as county welfare director, local health Officer, county hospital administrator, etc. The answers reveal a wide variety of subjects and problems sug- gested for special or intensive study. It is doubtful whether any signifi— cant phase Of the. chronic disease problem is omitted in the combined suggestions of the respondents. The suggestions can be classified into two broad groups: (1) Those naming specific diseases requiring special or intensive study, and (2) those describing problems, common to a number of the chronic diseases, relating to the ctt'ects of these diseases on the individual and the com— munity. In the latter group are many suggestions for studies of the need for services and facilities and of methods for providing adequate care for the chronically ill. A number of respondents stressed the need for developing preventive programs, additional and improved rehabili- tation services, and adequate nursing home, convalescent home and cus- todial care programs. Several respondents called attention to the prob- lem of financing care for the chronically ill and the need for studies Of the economic factors in chronic illness. Housing, educational programs, personnel, home care services, and statistical studies were not ignored among the many suggestions Offered. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 129 Special Questions on Hospital Facilities for the Chronically Ill Questionnaires sent to administrators of county general hospitals, to hospital conferences, and to executives of voluntary welfare agencies included the following special questions on hospital facilities; “Should the following categories of patients needing hospitalization be cared for in the same hospital or in separate and independent facilities? (a) Chronic-ally ill adults and chronically ill children? (b) Acute cases and chronic cases? (0.) Indigent chronic patients, and private chronic patients able to pay for their hospitalization "Z ’ ’ “Should hospital care for the chronically ill be centralized in one large facility in the community or should it be decentralized, i.e., provided in all general hospitals in the community?” On the first of these questions, the county hospital administrators were divided in their opinions—some favored segregation through sep- arate and independent facilities, others favored the use of the same hos- pital for the paired-01f categories of patients. The executives of voluntary welfare agencies were predominantly in favor of the use of the same hos— pital, and were opposed to segregation. The hospital conferences were not clearly in favor of either position on this issue. On the second of the above questions, more county hospital adminis- trators were in favor of “centralization” than “decentralization. ” More of the executives of voluntary welfare agencies were in favor of “decen- tralization” than “centralization.” Again, the hospital conferences were not clearly in favor of either position. The apparent lack of agreement among the opinions of the respond- ents in these three groups could perhaps be resolved if questions were asked giving more details about the size and type of community to be servedby these facilities. 9*lr81 79 130 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA APPENDIX C-l REPLIES TO LETTER QUESTIONNAIRES SENT TO COUNTY WELFARE DIRECTORS On May 5, 1948, letter questionnaires were sent to all county welfare directors (58) and replies were received from 38 directors.1 The questions in the letter, tabulations of replies, sample answers, and brief summarizations are given below. QUESTION 1 Figure A presents the tabulation of responses to each of the parts of Question 1. FIGURE A TALLY OF ANSWERS TO QUESTION 1 Total Replies: 38 ]. Is the care of chronically ill welfare clients in your county a prob- lem because of the following: Qualified" Yes No Yes No or No :lnS’tlTPI‘ :1. Lack of diagnostic services to determine the exact condition of the patient and the type of treatment needed? ___________________ __ 25 7 (l h. Lack of hospital facilities for chronic cases needing intensive medical care? __________ IT 1.": 5 ] c. Difficulty in finding adequate nursing and convalescent homes for chronic cases? ____ 30 2 4 2 (1. Lack of adequate facilities for chronic cases needing a custodial type of care? _________ 16 S ‘5 S) 0.. Lack of preventive medical services such as school health programs and health and maintenance programs for adults? _______ 4 10 16 S f. Lack of services, facilities, and trained per— sonnel for the rehabilitation of the chroni- cally ill? _____________________________ 1S) 4 7 8 1;. Lack of coordination in the provision of serv- ices for the chronically ill? ______________ T 1-1 2 15 h. Inability of families, otherwise selfisupport— ing, to pay for medical and related services for their chronically ill members? ________ 15 S 5 10 ‘ “Qualified yes or no" is the classification used for the “yes, but" and the “no, but” answers and for other answers which are not L'lt‘lll'l)’ atflnuative or negative. QUESTION 2 .2. “What do you think should be (long locally to provide adequate services and facilities for the care and rehabilitatton of the chronically ill?” Ivomtttes from which replies were received: Alpine, Amador, Butte, Colusa, Contra Costa, Del Norte, Fresno, Glenn, Humboldt, Inyo, Kern, Kings, Los Angeles, Mendocino, Merced, Mono, Napa, Nevada, Orange, Plumas, Riverside, Sacramento, San Bernardino, San Diego, San Francisco. San Joaquin, San Luis Obispo, San Mateo, Santa Barbara, Santa Clara, Slskiyou, Sonoma, Stanislaus, Sutter, Tehama, Tuolumne, Yolo, Yuba. Tr, A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 131 This question was answered in 34 of the 38 letters of reply. The rec- ommendations contained in these answers are tabulated and quoted below. TABULATION Number of times Recommendation mentioned Establish or expand county hospital facilities _______________________________ 12 Additional convalescent and nursing homes ________________________________ 8 Develop public subsidized convalescent and nursing homes ___________________ 7 Provide hospital and clinic facilities for medical indigents where charges would be based on ability to pay __________________________________________ 7 Provide bedside nursing and housekeeping services in the home ____________ ____ -) Formation or expansion of local health departments 5 Small counties with inadequate funds cannot provide for the care and rehabili— tation of the chronically ill _________________________________________ 4 Strengthening rehabilitation services _____________________________________ 4 Added custodial facilities ___________________________________________ ____ 4 Employ medical social case workers ______________________________________ 3 Additional public health nurses ___________________________________________ 2 Coordinate and integrate medical and related services ______________________ __ 2 The following recommendations appeared only once: Develop edu- cational programs emphasizing early diagnosis and treatment; study the adequacy of present services and facilities for the care and rehabili- tation of the chronically ill; adequate public assistance to provide the type of care required by the chronically ill welfare client; clarification of eligibility requirements for medical care; provide physician’s services in the home; provide occupational and recreational therapy services in the home; visiting teachers for adults should be provided; provide serv- ices in the home community when the chronically ill person lives at a distance from the county hospital; additional trained staif for total chronic disease program. Quotations From Answers to Question 2 1. “We should like to see the hospital enlarged to care for more patients because lack of beds, equipment and personnel have made it diffi— cult at times. Our community is also in need of a health center. We would like to see this established and some planning by the State to help provide adequate services and facilities for the care of medical indigent and chron- ically ill persons.’ ’ 2. ‘ ‘ To expand local facilities for the chronically ill, the County Hos- pital needs to be reconditioned and enlarged. For lack of boarding homes for the aged, too much of its space is at times taken by aged women.” 3. “It is our opinion that the problem would be lessened consider- ably with the establishment of a county hospital.’ ’ 4. “There are several answers that could be given to this question. One is to develop a larger county hospital with some type of fee system which would permit the self-supporting individual to obtain adequate diagnostic services and medical care at a cost he could afford. The plan behind this would be both to prevent and, if possible, to arrest or cure chronic disease before the cost in loss of earnings, public assistance, med- ical care and hospitalization became too great. ” 5. “I believe the establishing of a county health program including all of the accepted features of a complete program would be a start 132 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA towards more adequate services for the chronically ill. It follows that a modern county hospital is needed to provide the intensive medical care required in individual cases. ’ ’ 6. “Develop subsidized nursing and convalescent homes where the rate Of pay could be adjusted to the person’s ability to pay and where recipients Of public assistance could pay for their own care.” 7. ‘ ‘ I feel that as far as our local situation is concerned, the first need that should be met to provide adequate service and care for the rehabili- tation Of the chronically ill is the establishment of custodial and public nursing home services for such cases. The second step should be a strength- ening of the services Offered by our State Department of Rehabilitation so that more cases could be considered by that department. After these facilities and services were available, thought could be given to more perfect coordination of the various facilities.” 8. “It is impossible for our small county with inadequate funds to provide for the care and rehabilitation of the chronically ill. ” 9. “Provide medical care of highest standard, coordinate and inte- grate medical services, provide services for the entire community and not for the indigent alone, rehabilitation to prevent dependency. Expansion and development of home care services, including visiting nursing serv- ices, housekeeping services, and adequate public assistance to provide the type of care required by the chronically ill welfare client.’ ’ 10. “Additional private rest and convalescent homes are needed, as well as additional home service and public health nurses on the staif of our county health department. Arrangements for the providing Of house- keepers should also be explored furthcr, since no agency is providing such services in families not actually aided by that agency.” 11. “Supplementary services covering housekeeping, nursing, home occupational or recreational therapy, visiting teachers for both school age and adult should be provided if persons are to be kept alert and self- reliant.” 12. “Develop diagnostic clinics, particularly for cancer, diabetes, and cardiac conditions, where all laboratory facilities would be available, but where the charge would be on the basis of ability tO pay. ” QUESTION 3 3. “Is your county planning to do anything in this field?” This question was answered in 29 letters of reply. Yes _________________________________________________ 18 No __________________________________________________ 4 Not at present time ____________________________________ 6 Plans unknown to welfare director _______________________ 1 Quotations From Answers to Question 3 l I YES 1 7 1. “ The expansion of county personnel is being taken care Of by our board of supervisors. At the request of county departments a full time state rehabilitation worker will be provided after July 1st. Additional physical facilities, including beds and clinic space is being planned for our general hospital and in connection with hospital, branches located outside of county seat. The Council of Social Agencies is conducting a A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 133 complete survey of the health needs of the county and will in the coming year provide additional coordination facilities between public and private agencies.” 2. “At the present time both a county health program and a new, modern, county hospital are under consideration.” 3. “At the present time there is some discussion among the members of our county governing board regarding the advisability of entering into contracts with local private hospitals for the care of the indigent case. If this is done, better services will be available and much of the present difficulty of transportation will be eliminated.” 4. “Plans are under way now for a new chronic and custodial sec— tion in the county hospital. The public health department is expanding and broadening its services in the field clinics.” 5. “The county is planning to expand its hospital facilities and probably have some kind of rest home facilities in connection.” 6. “The county is planning additional physical improvements and additions to present facilities. High cost of construction is undoubtedly a delaying factor.” QUESTION 4 4. “What do you, think the State should do to help the localities to provide adequate services and facilities for the care and rehabilitation of the chronically ill?” This question was answered in 29 letters of reply. The recommenda— tions contained in these answers are tabulated and quoted below. TABULATION Number of times Recommendation mentioned Financial assistance to counties to provide services and to construct facili— ties (hospitals, nursing homes, custodial units) ___________________ 17 Expand rehabilitation services ______________________________________ 6 Develop diagnostic clinics _______________ 3 State subsidy to provide bedside nursing serv1ce in the home ______________ 3 Recruit and develop nursing and convalescent homes ____________________ 3 Provide consultation services to counties ______________________________ 3 Develop research centers with clinical facilitie _________________ 2 Provide facilities for chronically ill children ______________________ 2 Expand health education programs __________ _ _ _________________ 2 Establish adequate care standards ___________________________________ 2 The following recommendations appeared only once: Develop uni— form eligibility requirements for county medical care; work with the Federal Government to develop a plan which would permit recipients of public assistance to enter public institutions without discontinuance of assistance grant; analyze costs of various types of care for chronically ill; provide trained personnel; conduct studies to determine need for services and facilities; provide specialists services to rural areas. Quotations From Answers to Question 4 1. “It is my belief that the State of California should share in all cases needing medical treatment or hospitalization where the patient is unable, financially, to pay for the services rendered. And this is particu- larly true when the patient is a transient or has not established residence 134 A CHRONIC DISEASE PROGRAM FOR. CALIFORNIA in the county. If something could be done about this problem, it would be much easier for the welfare director to get care for all persons who needed it and who are not financially able to take care of the cost. ” 2. ‘ ‘ The State should bear a larger proportion of the cost of hospital care. Hospitalization for chronically ill old people is now assisted by the State only in those cases who have received old age assistance and then only in the maximum amount of $30 per month, whereas the cost of such cases’ care is between $6 and $7 per day. The cost of the care of the chron— ically ill in these and other instances is becoming a very great burden upon the county’s ability to finance.” 3. “It is my belief that the State, through appropriate grants of aid and administration, could assist very materially the local political subdi- visions so that adequate services and facilities for the care and rehabili- tation of the chronically ill would be more readily available.” 4. “We believe that there is a need for expanding the functions of the Bureau of Rehabilitation. At the present time they have two rehabili- tation officers in this area, which in our opinion is not sufficient to take care of the large number of cases requiring rehabilitation.” 5. “By the development of traveling clinics for diagnostic services, which clinics could be “rented” by the counties, it seems more people in the State would have a chance of discovering the onset of chronic illness. Particularly in rural areas, laboratory facilities are frequently not available to doctors. By the use of traveling clinics the local doctor would not have to refer the patient into a metropolitan center, with all its attend- ant expense, in order to avail himself of the best techniques.” 6. “The State could well develop a program to find adequate nursing and convalescent homes for chronic cases. Inasmuch as the local county government could not license these types of homes, it would be well to stimulate such interest.” 7. “I feel that the State should provide a more active consultation service to county physicians and welfare directors.” QUESTION 5 a. “From a county welfare standpoint, what aspects of the chrome disease problem deserve special or intensive study?” This question was answered in 27 letters of reply. The recommenda— tions contained in these answers are tabulated and quoted below. TABULATION Number of times Recommendation mentioned Study the need for services and facilities for the aged chronically ill and/or senile aged ___________________________________________________ 1 Develop additional preventive programs Rehabilitation ____________________________________________________ Need for adequate nursing home, convalescent and custodial facilities ______ Study methods for providing adequate care _______________________ Case finding surveys ___________________ Educational programs ______________________________________________ Study the need for facilities for specific disease groups ____________________ Need for psychiatric clinics and beds _________________________ Study of the economic factors in chronic illness ________________ i __ Adequate housingr ____________________________________________ __ Uniform eligibility requirements ______________________________________ l l l-‘HNMDDWOOWACICDO A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 135 Quotations From Answers to Question 5 1. ‘ ‘ From the viewpoint of the county welfare department one of our major problems is that of the care of the chronically ill, particularly the aged group.” 2. “I. feel from a county welfare standpoint, the care of the senile aged deserves special and intensive study. It is the most pressing current problem we have and is ever increasing.” 8. “I believe the prevention of incapacity due to chronic illness is an aspect that warrants study.” 4. “Broadening vocational rehabilitation services to include many cases not eligible under present system.” 5. “An educational campaign is certainly indicated to convince the public that prevention or early diagnosis and cure is cheaper than long- time care.” 6. “With respect to those cases directly affecting welfare depart— ments, it would appear to me that special emphasis might be given to study methods of providing better nursing and convalescent and custo- dial type of care for those cases requiring such care.” 7. “Welfare directors, physicians, and related professions, need tO make sound practical studies on how best to treat, care for, and rehabilitate persons with chronic illnesses. In my opinion, there is not now sufficiently coordinated efforts on the part of the various indi- viduals and agencies engaged in this problem.’ ’ 8. “For chronically ill persons other than old people, methods of correlating our efforts at retraining and rehabilitating handicapped people.” 9. “ It is my feeling that emphasis should be placed upon the study Of the inability of families to provide the necessary medical care for chronically ill, however, WllO are self-supporting otherwise. I feel there is a lack of realistic appreciation of the actual problem as it exists. ” 10. “ It appears at the moment that one of the most useful tools that could emanate from a study would be the establishment of a reasonably uniform needs test which could be applied to applicants for assistance because of chronic illness.” 1]. “I believe that housing of the chronically ill is probably the most important problem. Many people are released from the hospital to the county welfare department. The county welfare department must place them in the best housing available which is dormitory care in the lower end of town. Food is provided for them through the local res- taurants, and the amount of money given is not enough for them to select proper diet and I might add that most of the people would not know what a proper diet is and also the restaurants would not have it avail— able. After a few days of this type of living and diet, they are ready to be patients for the county hospital again. If these people released from the hospital could have proper supervision in their eating and dwelling, I believe that the rehabilitation problem would be much more sensibly solved.” 136 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA APPENDIX C-2 REPLIES TO LETTER QUESTIONNAIRES SENT TO COUNTY GENERAL HOSPITAL ADMINISTRATORS On June 25, 1948, letter questionnaires were sent to each County General Hospital Administrator (53) in California. As of August 25th, replies have been received from 17 of these Administrators.1 The questions in the letter, tabulations of replies, sample answers and brief sunnnarjzations are given below. QUESTION I Figure A presents the tabulation of responses to each of the parts of Question 1. FIGURE A TALLY' OF ANSWERS TO QUESTION 1 Total Replies: 17 1. Is the care of the chronically ill in your county (1 problem because of the following: Qualified’r Yes N 0 Yes No or No Answer :1. Lack of diagnostic services to determine the exact condition of the patient and the type of treatment needed? ___________________ 2 13 __ 2 h. Lack of hospital facilities for chronic cases needing.r intensive medical care? __________ (i 8 1 2 c. Difficulty in finding: a sufficient number of nursing and convalescent homes for chronic cases? _______________________________ 13 2 _- 2 d. Lack of adequate facilities for chronic cases needing a custodial type of care? ________ 12 4 __ 1 0. Lack of preventive medical services? _______ 1 11 3 2 f. Lack of services, facilities, and trained per- sonnel for the rehabilitation of the chroni- cally ill? _____________________________ 9 1 4 3 g. Lack of coordination in the provision of serv— ices for the chronically ill? _____________ 6 7 1 3 h. Inability of families, otherwise self—support— ing, to pay for medical and related services for their chronically ill members? _______ 10 3 1 3 ' A tally of answers by county is available for review by the committee. 1’ “Qualified yes or no” is the classification used for the “yes, but" and the “no, but" answers and for other answers which are not clearly affirmative or negative. 1 Counties from which replies were received: Alameda, Humboldt, Lassen, Placer. Plumas, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, San Luis Obispo, San Mateo, Santa Clara, Sonoma, Sutter, Tuolumne, Yolo. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 137 QUESTION 2 2. ”What do you think should be done locally to provide adequate services and facilities for the care and rehabilitation of the chronically ill?” This question was answered in 12 of the 17 letters of reply. The opinions contained in these answers are tabulated, and sample quota— tions are given below : Number of times Opinions * mentioned " Increase hospital facilities and services for care of the chronically ill____ 6 Expand rehabilitation program ____________________________________ 2 Provide for physician services for home care. cases ___________________ 1 Provide additional housing facilities _______________________________ 1 Encourage medical interest in geriatrics ____________________________ 1 Old age security allotment he continued after admission to county hospital 1 Requires a state level type of service ________________________________ 1 Local services are adequate _______________________________________ 2 * More than one opinion was expressed in several of the answers to this question. Quotations From Answers to Question 2 “Local services adequate.’ ’ “Here at this hospital we have long seen the need for construction of a new chronic wing to get our chronically ill out of the fire traps in which they are now housed. All of the wards are crowded, and air condi- tions not good in some, to say nothing of the inflammable wooden building construction. The long-planned fireproof wing for chronics is delayed on purely financial grounds.” “ * ”“ * should be provided as integral part of services rendered by the acute general hospital. ’ ’ “Emphasize rehabilitation and occupational therapy. Encourage medical interest in geriatrics. Perhaps create a residency in geriatrics in general hospitals. ’ ’ QUESTION 3 3. “Is your community planning to do anything in this field?” This question was answered in 14 of the letters of reply received. Of the 14 answers to the question, six stated “nothing” or “nothing definite” or “no progress visible”; two stated “don ’t know”; three replied that additional hospital facilities were being planned; of the remaining three answers, one stated that there was planning of housing facilities, another indicated that general interest had been aroused, and one stated : “much ado about nothing. ” 138 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA QUESTION 4 4. “What do you think the State should do to help the localities to provide adequate services and facilities for the care and rehabilitation of the chronically ill?” This question was answered in 14 of the replies received. The opin- ions contained in these answers are tabulated, and sample quotations are given below : Number of timex Opinions “ ' mentioned ” Subsidize construction of hospital facilities for care of the chronically ill__ 2 Render financial assistance __________________________________________ 2 Subsidy to defray cost of medical care for the chronically ill _______________ 1 Improve facilities and thereby elevate standards of medical care __________ 1 Have separate state institutions for the chronically ill __________________ l State control or partial control of county hospitals _________________ Provide funds for housing: __________________________________________ l The acceptance of state aid means the. surrender of local independence _____ 1 Establish uniform irogram of residence requirements for indigent. aid _____ l 1 Initiate program of rehabilitation in the hospital and follow—up in nursing homes ________________________________________________________ 1 Provide occu )ational theI-a )ists _____________________________________ 1 1 Educate the public ________________________________________________ l Questionable whether state aid would help solve the problem ____________ 1 Exhaust ossibilities of irivate industrv coping with the problem ________ l P I . _‘ More than one Opinion was expressed in several Of the answers to this questIon. Quotations From Answers to Question 4 “ "“ ’"‘ ’"‘ should attempt to improve and increase the facilities avail- able for all types of cases, thereby elevating the standard of medical care and practice in the community, and this will be reflected in the care of the aged and chronic. ’ ’ “It is highly questionable whether state aid to the localities would do much in solving the problem. It is even questionable in the mind of the undersigned whether state hospitals for the transient type individual would be of any benefit. ” “Financial assistance by State~either in aiding with the construc- tion problems or direct subsidizing to defray costs of medical care for the chronically ill.” “ it * * financial assistance in construction phase and subsidy for rendition of care.” A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 139 QUESTION 5 5. “From a county hospital administrator’s standpoint, what aspects of the chronic disease problem deserve special or intensive study?” This question was answered in 13 of the 17 replies received. The sub- jects mentioned in these answers are tabulated, and sample quotations are given below: Number of times Subjects " mentioned “ Specific diseases or conditions (including geriatrics) Alcoholism ______________________________________________________ 2 Chronic arthritis ________________________________________________ 2 Asthmatic conditions ___________ _ _______________________________ 1 (Rheumatic fever. crippled persons. tuberculosis, cancer) ___________ 1 Geriatrics ____________________________________________________ 1 Facilities for diagnosis and treatment ________________________________ 2 Problem of caring for transients who are chronically ill __________________ 1 Actual providing for sufficient beds __________________________________ 1 Results to be obtained by rendering more intensive and up-to-date care to the chronically ill ________________________________________________ 1 Develop more doctors and nurses primarily interested in the chronic con- ditions _______________________________________________________ 1 Occupational therapy and specialized medical social service ______________ 1 Statistical studies __________________________________________________ 1 * More than one subject was mentioned in several of the answers to Question 5. Quotations From Answers to Question 5 “Biggest problem in this community has always been alcoholism. Of those cases now residing: in the county hospital as custodials (that is, indi— viduals not requiring active care and residing here out of convenience or lack of other place to no) 100 percent have come to this stage through alcoholism. That is, the alcoholism did not, of course, induce the chronic disease but the continued drinking over many years resulted in a complete loss of self respect, initiative, and financial standing. This is also a prob— lem with the acute case. For example out of 240 major fracture cases handled in 30 months, 92 percent were directly attributable to alcoholism. This number of fractures is greater than the combined total seen by all other practitioners in the county. ’ ’ “The greatest problem in this county is the fact that a very large proportion of the chronically ill patients are transients with no legal resi- dence and are thereby shunted from county to county until they become terminal cases. Further, patients of this type are not receptive to treat- ment even if it is offered them.” “ * * * facilities for the diagnosis and treatment in this locality.” “ (a) Rheumatic fever (b) Crippled—both adults and children (c) Tuberculosis ((1) Cancer (e) Chronic arthritis.” 140 A CHRONIC DISEASE PROGRAM FOR. CALIFORNIA QUESTION 6 Question 6 and a tally Of the answers to it are given below: 6. ”Should the following categories of patients needing hospitaliza- tion be cared for in the same hospital in separate and independent facili- ties?” Inde— Same pendent Qualified No hospital facilities answers answers :1. (‘hronicnlly ill adults and chronically ill children _____________________ 7 4 3 3 l). Acute cases and chronic mixes __________ (S 6 2 3 c. Indigent chronic patients, and private chronic patients able to pay for their hospitalization __________________ a) 5 [0 0‘1 QUESTION 7 7. “Should hospital care for the chronically ill be centralized in one large facility in the community or should it be decentralized, i.e., provided in all general hospitals in the community?” In answer to this question, eight Of the respondents favored centrali- zation ; two favored decentralization; four gave qualified answers; and three did not answer the question. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 141 APPENDIX C-3 REPLIES TO LETTER QUESTIONNAIRES SENT TO HOSPITAL CONFERENCES On June 25, 1948, letter questionnaires were sent to each of the nine Hospital Conferences in California. As of August 25, replies were received from six of the nine Conferences.1 The questions in the letter, tabulations of replies, sample answers and brief summarizations are given below: QUESTION 1 Figure A presents the tabulation of responses to each of the parts of Question 1. Sample answers to the several parts Of this question are. shown immediately following Figure A. FIGURE A TALLY' OF ANSWERS TO QUESTION 1 Total Replies: 6 1. Is the care of the chronically ill (who are not in the indigent cate- gory) in the area served by your conference a problem because of the following: Qualified? Yes No Yes No or No Answer :1. Lack of diagnostic services to determine the exact condition of the patient and the type d treatment needed? ___________________ 1 4 1 __ 1). Lack of hospital facilities for chronic cases needing intensive medical care? __________ 4 __ 2 _._ 0. Difficulty in finding,r a sufficient number of nursing and convalescent homes for chronic cases? _______________________________ 5 __ 1 __ (1. Lack of adequate facilities for chronic cases needing a custodial type of care? _________ 5 __ 1 __ e. Lack of preventive medical services? _______ 1 1 4 __. f. Lack of services, facilities, and trained per- sonnel for the rehabilitation of the chroni— cally ill? _____________________________ 3 1 2 __ :5. Lack of coordination in the provision of serv- ices fOr the chronically ill? _____________ 4 __ 2 __ h. Inability of families, otherwise self-support- ing, to pay for medical and related services for their chronically ill members? _______ 6 __ -_ __ ‘ A tally of answers showing the replies of each of the Hospital Con- ferences is available for review by the committee. T “Qualified yes or no” is the classification used for the "yes, but” and the “no, but” answers and for other answers which are not clearly affirmative or negative. 1Replies were received from the following conferences: Central Coast Hospital Conference (Area covered: Santa Clara, Santa Cruz, San Benito, San Maeto, and Mon- terey) ; North San Joaquin Valley Hospital Conference (Area covered: San Joaquin, Merced, Stanislaus, Calaveras, Tuolumne, and Mariposa; Redwood Empire Hospital Conference (Area covered: Mendocino, Sonoma, Marin, Napa, and Lake); East Bay Hospital Conference (Area covered: Alameda and Contra Costa) ; San Francisco Hos- pital Conference (Area covered: San Francisco); San Diego Hospital Council (Area covered : San Diego County). 142 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA QUESTION 2 2. “What do you think should be done locally to provide adequate services and facilities for the care and rehabilitation of the chronically ill?” The answers to this question in the six letters of reply are quoted below: “This council has set as its goal the complete integration Of all the hospital facilities in the county. The small rural hospitals will channel their more serious cases to the larger city medical centers. Chronic cases who may be rehabilitated will be released to approved nursing or con- valescent homes where rehabilitations will be carried out, still under the direction of the original physicians in the case.” “Suggest county or state aid or both to help defray costs in private hospitals and nursing homes. ” “"‘ * * more and better health facilities, chronic hospitals, and convalescent and nursing homes.” “"" " * space and facilities be made available in general hospitals.’ ’ “Provide chronic care facilities. Provide personnel to care for patients in the newly provided institutions. Provide funds with which to construct new facilities, train personnel and meet part of the cost of Operating these facilities. Provide funds with which to Offer home care for selected chronic care cases. ” “* * * should provide adequate chronic beds which should be associated closely with the acute general hospital whether it be. volun- tary or county. All chronically ill patients cannot be sent to the county hospital. The voluntary hospital should assume its rightful share of these.” QUESTION 3 3. “Are the communities in your area planning to do anything in this field?” Of the answers to this question in the six letters of reply, two stated “NO”; one stated “Yes” and another gave “ ‘3” as answer; one stated that “a portion of the area is planning to improve facilitiesflthe rest are not”; and one stated that the council is planning “the complete integra- tion of all hospital facilities in the county.” QUESTION 4 4. “What do you think the State should do to help the localities to provide adequate services and facilities for the care and rehabilitation of the chronically ill?” The anwsers tO this question in the six letters of reply are quoted belOW: “We feel the State should exert its efforts to the implementation of the Public Health Nurse program, urging local health departments to expand preventative medical functions, and continue such studies as this.” “Suggest county or state aid or both to help defray costs in private hospitals and nursing homes. State help for low-income bracket patients in manner similar to E.M.I.C. ” “"“ " * the State should aid the counties financially and otherwise to provide adequate facilities.” “"‘ “ "‘ State subsidies same as T.B.” rfi—m A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 143 “Provide chronic care facilities. Provide personnel to care for patients in the newly provided institutions. Provide funds with which to construct new facilities. train personnel and meet part of the cost of operating: these facilities. ” “* * "‘ should furnish grants-in-aid not only to the county hos- pitals, but to the voluntary hospitals so that the over-centralization of chronically ill patients is not fostered and to convalescent homes.” QUESTION 5 5. “From the hospital conferences" standpoint, what aspects of the chronic disease problem deserve special or intensive study?” The answers to this question in the six letters of reply are quoted below: “1st—l’reventive Medical Service. 2nd—Rehabilitati0n.” “Care for the chronically ill in low income brackets.” “* * * scope of services, location of centers and method of financ- ing.” “it * * terminal cases.” “Chronic care facilities Home care “* * * study the number of patients who are suffering.r from dlsease both within and without the hospital. ” “These can best be determined it would seem on a basis of study of the actual diseases and the deaths as reported in vital statistics.” QUESTION 6 ”Should the following categmies of pat1ents needing hospitaliza- tion be ca1cd for in the same hospital or 111 separate and independent facilities 2’ ’ ’ A tally of the answers to question 6 are given below: Same Independent Qualified No hospital facilities answers answer a. Chronically ill adults and chron- ically ill children _____________ 3 2 1 — b. Acute cases and chronic cases _____ 3 1 2 — c. Indigent chronic patients, and pri- vate chronic patients able to pay for their hospitalization ________ 1 2 3 — QUESTION 7 7. “Should hospital care for the chronically ill be centralized in one large facility in the cmnmunity or should it be decentralized, i.e., pro- rz'dcd in all general hospitals in the conmtunity?” Of the answers to this question in the six letters of reply, two favored decentralization; one favored centralization; and three gave qualified answers. 144 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA APPENDIX C-4 REPLIES TO LETTER QUESTIONNAIRES SENT TO PRESIDENTS OF COUNTY MEDICAL SOCIETIES On June 23, 1948, letter questionnaires were sent to the presidents of county medical societies (40) in California. As of September 10, replies have been received from 10 of the county medical society presidents.1 The questions in the letter, tabulations of replies, sample answers and brief summarizations are given below: QUESTIONS 1 AND 2 Questions 1 and 2, and the replies to these questions, are given below: 1. “Is there a problem with re- spect to the care of the chronically ill in your county?” “There is no specific problem as to the care of the chronically ill in this county." 2. “If so, what do you believe is the origin of the problem?” “There is a definite problem regarding adequate domiciliary care and nursing for the chronically ill.” “Restrictive building codes, hamperiITg regulations regarding the operation of convalescent homes, and prohibitive building costs are combining to prevent an increase of facilities commensurate with the growth of (this area) .” Alyesng NO specific answer2 “There is a definite problem with respect to the care of the chronically ill in (this) county." “This problem is largely the result Of in- adequate facilities for the care of this class of patients. The rapid growth of the community is also addixn,r to the strain on the existing, inadequate fa- cilitics.” “Inadequate facilities—rapid increase in “Yes” community growth.” “Yes": Facilities“ I “Yes” ”Increased longevity.” “Yes” "Lack of facilities.” Inadequate hospitalization, inadequate “Yes": housing.2 “Yes” “Lack of facilities and coordination.” 1Counties from which replies had been received: Alameda, San Francisco. San Diego, Sacramento, Santa. Clara, Santa. Barbara, Sonoma, and Riverside. Two replies gave no identifying information from which the county could be determined. 2 Entries based on context of the letters Of reply. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 145 QUESTION 3 Figure A presents the tabulation Of responses to each of the parts of Question 3, which is a continuation of Questions 1 and 2. FIGURE A TALLY' OF ANSWERS TO QUESTION 3 Total Replies: 10 For purposes of continuity, Questions 1. and 2 are repeated here: 1. “Is there a problem utith respect to the care of the chronically ill in your county?” 2. ”If so, what do you believe is the origin of the prob- lem?” 3. Does it concern any of the following Qualified? Yes No Yes No or No Answer a. Inadequate diagnostic services to determine the condition of the patient and the type of treatment needed? _____________________ __ 7 2 1 b. Lack of hospital facilities for chronic cases needing hospital care? _________________ 8 __ 2 __ c. Difficulty in finding adequate nursing and convalescent homes for chronic cases?____ 8 1 __ 1 (1. Lack of adequate facilities for chronic cases needing a custodial type of care ? ________ 7 __ 2 1 e. Services, facilities, and trained personnel for the rehabilitation of the chronically ill?___ 5 3 1 1 f. Lack of coordination in the provision of serv- ices for the chronically ill'! ______________ 1 5 2 2 g. Inability or lack of desire of families, other- wise self—supporting to pay for services for their chronically ill members? ___________ 21 4 2 2 * A tally of answers by county is available for review by the Committee. 1' “Qualified yes or no" is the classification used for the “yes, but” and the “no, but” answers and for other answers which are not clearly affirmative or negative. 1 One reply stressed “lack of desire"; the other stressed "lack of ability to pay." QUESTION 4 4. “What if anything do you. think should be done locally in your county to provide adequate services and facilities for the care and reha— bilitation of the chronically ill?” This question was answered in each of the 10 letters of reply. The Opinions contained in these answers are tabulated, and sample quotations are given below: Number of times Opinions "‘ mentioned * Better hospital facilities or expand hospital facilities _________________ 3 Expand county custodial facilities __________________________________ 2 County should make available more nursing and convalescent liomes____ 2 Encourage private enterprise and philanthropy to provide adequate facilities __________________________________________________ 1 Adequate, low cost housing ; housekeeper service ; physio-therapy and occupational therapy for rehabilitation; medical supervision regard- less of income ___________________________________________ _ Sheltered housing program ________________________________ Home for Old folks _______________________________________ _ ___ Handle alcoholics as chronically ill and treat them as patients __________ Encourage State to improve care of the insane ________________________ (See, also, opinion expressed in the first quotation below.) ' More than one opinion was expressed in several of the answers to this question. NHL-8179 HHHHH 146 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA Quotations From Answers to Question 4 “In this county under the committee on distribution of medical care a study is being made of part pay and modified pay schedules to take care of cases in which the cost of medical care is a definite factor and which are not eligible for county care. \Ve shall have a definite plan in this field in the next month or six weeks. ” “Stop discouraging private enterprise and philanthropy. Encourage private enterprise and philanthropy to provide adequate facilities for chronic cases of nonpsychiatric nature. Encourage state to improve care of the insane.” “Some things which could be done locally to take care of this prob- lem are: Adequate low cost housing, housekeeper service, physio-therapy for physical rehabilitation and occupational therapy for occupational rehabilitation, also medical supervision regardless of income. ” “The provision of hospital and convalescent beds in our community would be the greatest aid to provide adequate services and facilities for the care of the chronically ill. An attempt, sponsored by county medical society, is geing made to have these facilities increased.” “ We all recognize the need for a ‘home’ for old people where they do not lose their self—respect and interest in life. Even those of us in the medical profession know how difficult it is to care for our own parents in our own home and yet how many of us can afford $200 or $300 a month for their care ‘I ’ ’ “The county should make available more nursing or convalescent homes to the chronically ill.” A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 147 QUESTION 5 5. “Is your county planning anything in this field? ” This question was answered in each of the letters Of reply received. Of the 10 answers to the question, seven stated or described the planning of facilities; one stated “an attempt is being made for closer coordina- tion Of facilities of State and county and diiferent agencies and private physicians”; one stated “distant future”; and one answer was “no.” QUESTION 6 6. “Do you think the State should help the localities to provide ade— quate services and facilities for the care and rehabilitation of the chroni- cally ill.’ ’ Number of times Opinions mentioned “N01, __________________________________________________________ 6 “Yes” _________________________________________________________ 2 Qualified answers (see first two quotations below) ____________________ 2 Quotations From Answers to Question 6 “If this is a problem of government, then Of course we will have to expand the charity services to include those not indigent. If this is to be done, then further taxation will become necessary. If different parts of the State have a heavier load of this type of patient, then state aid should be given to those areas having an excessive load, so that the whole State will share. ’ ’ “An attempt is being made for closer coordination of facilities of state and county and different agencies and private physicians.” “The State should not help the localities to provide adequate services and facilities for the care and rehabilitation of the chronically ill. It is our feeling that this is a problem that can be well cared for locally, and that the State should not enter into this place of the private practice of medicine.’ ’ “This county medical society does not believe that this problem is one belonging to the State and that at the present time it is being prop- erly handled by local authority. ’ ’ “I believe the State (or county) should build for three distinct types: 1. A place for those not tOO ill where men and women can be together, to carry on their hobbies (gardening, carpentry, knit- ting, etc.) Or where they may even marry. 2. A place for those who are semi-invalids and who are at present in too expensive rest homes. 3. A place for the bedridden and ill who are custodial patients and would take the load off the mental hospitals and county hos- pitals.” “I think the county should take care of this problem.” 14:8 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA QUESTION 7 7. “From the county medical society standpoint, what aspects, if any, of the chronic disease problem deserve special or intensive study?” All replies to this question are quoted below : “The problem of providing adequate care of chronic disease patients through the cooperation of private enterprise and the medical profes- sion.” “Improvement in the care of the chronically ill will have to come with actual advances in medicine in the respective diseases. As these improved methods of care and treatment arrive, the county medical society should make every effort to have the information available to all its members. At the present time, while 80 percent of the care of the tuberculosis cases is being done under state, county, or federal agencies, I do not think that this method applies to the remaining group of chronic diseases.” “We feel that the financing of the construction of private hospitals and adequate nursing homes is a phase of the chronic disease problem which deserves special and intensive study.’ ’ “ Finance private hospitals and adequate nursing homes.” “Tuberculosis.” “How to provide nursing and convalescent homes in small com- munities. ” “Rates in nursing and convalescent homes are so high that many private patients are unable to afi’ord care in these homes.” A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 149 APPENDIX C-5 REPLIES TO LETTER QUESTIONNAIRES SENT TO LOCAL HEALTH OFFICERS On July 5, 1948, letter questionnaires were sent to each County Health Officer (55) and to each full-time City Health Officer (13) in California. As of August 25, replies have been received from 14 county and six city health Officers.1 The questions in the letter, tabulations of replies, sample answers and brief summarizations are given below. QUESTION 1 Figure A presents the tabulation Of responses to each Of the parts of Question 1. FIGURE A TALLY' OF ANSWERS TO QUESTION 1 Total Replies: 20 1. Is care of the chronically ill in your comimmity a problem because of the following ? Qualifiedl‘ Yes N 0 Yes No or No Answer :1. Lack of diagnostic services to determine the exact condition of the patient and the type of treatment needed? ___________________ 7 6 ‘l 4 1). Lack of hospital facilities for chronic cases needing intensive medical care? _________ 11 1 4 4 0. Difficulty in finding adequate nursing and convalescent homes for chronic cases it... 16 __ 1 3 d. Lack of adequate facilities for chronic cases needing a custodial type of care? _________ 10 1 4 5 e. Lack of preventive medical services such as school health programs and health mainte- nance programs for adults? _____________ 5 6 3 6 f. Lack of services, facilities, and trained per— sonnel for the rehabilitation of the chroni- cally ill? _____________________________ 11 __ 4 5 5;. Lack of coordination in the provision of serv- ices for the chronically ill? _____________ 6 '5 2 7 h. Inability of families, otherwise self-support— ing, to pay for medical and related services for their chronically ill members? _______ 10 1 3 6 ‘ A tally of answers by county and city is available for review by the committee. 1' “Qualified yes or no" is the classification used for the “yes, but” and the “no, but” answers and for other answers which are not clearly affirmative Or negative. 1Couuties from which replies were received: Alameda, Del Norte, Humboldt, Kings, Lassen, Monterey, Riverside, Sacramento, San Bernardino, San Francisco (city and county), San Luis Obispo, Solario (and Vallejo City), Sonoma and Sutter-Yuba (a bi—county health department). Cities from which replies were received: Alameda, Los Angeles, Oakland, Palo Alto, Pasadena, and Santa Barbara. 150 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA QUESTION 2 2. “What do you think should be done locally to provide adequate services and facilities for the care and rehabilitation of the chronically ill?” The question was answered in 12 of the 20 letters of reply. The opin- ions contained in these answers are tabulated and some are quoted below: TABULATION Number of times Opinions * mentioned " Increase hosliital facilities and services for care of chronically ill _______________ 5 Diagnostic services and facilities ___________________________________________ 3 Provide or expand rehabilitation program or services _________________________ 3 Provide convalescent and custodial type of care ______________________________ 2 ' Establish a planning committee or health coordinating council __________________ 2 Provide additional housing facilities ________________________________________ 2 Provide education and health maintenance programs for adults _________________ 2 Establish nursing and convalescent homes“ ______ 1 Establish a system of consultants to advise physicians in nonmetropolitan areas" 1 Greater promotion of health and hospital insurance ___________________________ 1 ' More than one opinion was expressed in several of the letters. Quotations From Answers to Question 2 “Locate the chronically ill persons and determine the type and extent of their disability.” “* * ’* more beds added and better diagnostic and laboratory facilities provided for the care Of the chronically ill.” “* *‘ " increase both private and public hospital facilities and services. ” “In the expansion of the local hospital, special provision should be made for the care of chronic illness. ” “Planning committee (possibly through welfare council) to study needs, recommend additions and to coordinate efforts that are interre— lated to make existing facilities go farther. ” “There should be a chronic disease wing on each of the local hospitals in the small centers. These wings should be prepared for little more than custodial type of care. More intensive care and better diagnostic facilities should be established in connection with the Community Hospital as well as the County Hospital, and arrangements should be made with the specialized chronic disease hospital in connection with the medical school for still more extensive and specialized care. A system of consultants should be set up to supply the physicians with advice. ' There should be established a chain of convalescent or rest homes under state licensure and with adequate medical nursing direction. They should give primarily custodial care. These convalescent homes and the small hospitals mentioned in above, should offer rehabilitation services. Of course all this requires trained social workers, occupational therapists, physio-therapists, nurses and money. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 151 More promotion of health and hospital insurance might help in providing care for persons who are border-line as to finances. There should be established rheumatic fever, tumor and similar clinics and an increased emphasis in ease-finding in tuberculosis. ” QUESTION 3 3. “Is your community planning to do anything in this field?” This question was answered in 13 Of the 20 letters of reply. Of the 13 answers, four stated “no community planning” or “the community is doing nothing in this fielt ” ; two stated that there was some community planning, but so far no results had been achieved; and five stated the community was planning the construction or expansion of hospital facilities. Of the remaining two answers, one stated the community was doing some planning in housing and the other stated that there was planning but did not identify the type. QUESTION 4 «i. “What do you think the State should do to help the localities to provide adequate services and facilities for the care and rehabilitation of the chronically ill?” This question was answered in 15 of the 20 replies received. The Opinions contained in these answers are tabulated and some are quoted below: Number of times Opinions * mentioned * Subsidize construction of hospitals for care of the chronically ill ________________ 5 Subsidize training of personnel ____________________________________________ 4 Subsidy to defray cost of medical care for the chronically ill ____________________ 2 Establish small convalescent centers as rehabilitation centers ___________________ 2 Expand the Vocational Rehabilitation Program ______________________________ 1 Expand and improve local health services _____________ 1 Help in finance and advice ________________________________________________ 1 Supplement local plans for medical and hospital care and allied services, after consultation with local agencies and where local resources are inadequate _____________________________________________________ 1 State should not become involved until there is definite knowledge of the need for this care _______________________________________________________ 1 Depends upon one’s political philosophy _____________________________________ 1 ’ More than one Opinion was expressed in several Of the answers tO this question. Quotations From Answers to Question 4 “Whether the State should participate in assisting localities to finance projects depends, Of course, upon one ’s political philosophy and whether one feels that local communities should solve their own prob- lems, including the financial aspects, or whether we should look to the State to do this for them.’ ’ “It will probably be necessary for the State to provide a fairly heavy subsidy for construction of facilities for the care of the chronically ill.” “I think if the State could participate in hospital construction for the chronically ill it would give the greatest stimulus for better care of these people.” 152 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA “Financial assistance by State-either in aiding with the construc- tion problems or direct subsidizing to defray costs of medical care for the chronically ill.” “* * * expand its Vocational Rehabilitation Program to include Vocational Counseling and Occupational Therapy as well as Vocational Rehabilitation Services in the various communities. The State might also consider offering training stipends in pathology to physicians in the hope that eventually some of them will filter out to the rural areas.” “Help in finance and advice.” QUESTION 5 5. “From a local health officer’s standpoint. what aspects, if any, of the chronic disease problem dose/"w special or intensive study.” This question was answered in l], of the 20 letters of replies received. Of the 11 answers, four listed specific diseases (chiefly, cancer, heart disease and mental disease) ; two stated that the preventive aspects of the chronic disease problem deserve special study; and the remaining five answers listed a variety of subjects for special study (cg. facilities for diagnosis and treatment, housing, medical care, rehabilitation, the economic and social problems of the chronically ill). Quotations From Answers to Question 5 “preventive medicine. The early diagnosis of tuberculosis in stages when it is more easily controllable prevents chronic disease. The early detection and diagnosis of rheumatic fever before the heart is damaged prevents chronic disease. The isolation of carriers Of streptococcus and their treatment before further damage is done to the body prevent chronic disease, and this runs through the whole gamut of such processes of such diseases which leave crippling defects. \Ve may say perhaps a little more—if we had a definite method of preventing poliomyelitis we could certainly avoid crip- ling defects. There are. however, other diseases which lead to chron- icity regarding which it is questionable as to whether they fall in the field of public health, but are more in the nature of an individual problem of the patient himself and it would seem that perhaps these conditions could best be met by educating the American public to consult their physicians early and to have a periodic check-11p. We might use the problem Of diabetes as an example of this situation.” ‘ ‘the preventive aspects of the chronic disease problem ’ ’ “emphasis of mental hygiene, cancer, cardiac and circulatory diseases” “Housing, medical care and rehabilitation.” “One of the major problems of chronic illness is economic. Many persons in the middle income class are deterred from seeking med- ical care because of inability to pay, despite the generosity of the A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 153 medical profession in furnishing a great deal of free service. I believe that it is well and proper for each individual to pay for his own care so far as possible but some protection against unusual and expensive illness is needed.” “Both the problem of chronic illness and the economic problem become more acute with old age. Although an increasing number are being protected by sickness insurance, such coverage usually ceases when the individual is no longer gainfully employed. Protection for the remaining years is needed.” “We are staffing our out-patient clinics with a public health nurse and feel that in this way we can find out what a great many of the problems are. I feel, from the health officer’s standpoint, we are allowing a large group of useful citizens to feel that they have no place in community activity.” 154 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA APPENDIX C-6 REPLIES TO LETTER QUESTIONNAIRES SENT TO PRES- IDENTS OF LOCAL OSTEOPATHIC SOCIETIES AND ADMINISTRATORS OF OSTEOPATHIC HOSPITALS On July 12, 1948, letter questionnaires were sent to presidents of local osteopathic societies and administrators of osteopathic hospitals. A total Of 94 questionnaires were sent; 18 replies 1 were received as of August 25, 1948. The questions in the letter, tabulations of replies, sample answers, and brief summarizations are given below: QUESTION 1 Figure A presents the tabulation of answers to each of the parts of Question 1. FIGURE A TALLY' OF ANSWERS TO QUESTION 1 Total Replies: 18 1. Is the care of chronically ill in your cmmmmity a problem because of the follmm'rng: Qualified? Yes No Yes No or No Answer :1. Lack of diagnostic services to determine the exact condition of the patient and the type of treatment needed? ____________________ (i 8 __ 4 1). Lack of hospital facilities for chronic cases needing intensive medical care? __________ 13 2 _- 3 (3. Difficulty in finding adequate nursing and con- valescent homes for chronic cases? ________ 12 3 1 2 (1. Lack of adequate facilities for chronic cases needing a custodial type of care? _______ 12 4 __ 2 e. Lack of preventive medical services such as school health programs and health mainte- nance programs for adults? _____________ 7 ‘5 3 3 f. Lack of services, facilities, and trained per- sonnel for the rehabilitation of the chroni- cally ill? _____________________________ 14 2 ] 1 ,2. Lack of coordination in the provision of serv- ices for the chronically ill? _____________ 8 4 1 5 h. Inability of families, otherwise self—support— ing, to pay for medical and related services for their chronically ill members? ________ 1T) 1 1 1 ‘ A tally of answers by county is available for review by the committee. 1* “Qualified yes or no" is the classification used for the “yes, but" and the “no, but" answers and for other answers which are not clearly affirmative or negative. llteplies were received jrom the following counties in California: Kern, Los Angeles (6 replies), Orange, Riverside, San Bernardino, San Diego, Santa Barbara, Santa. Clara, Santa, Cruz, Tulare. One reply was received from the Redwood Empire area, and two replies gave no identifying information from which the county or area could be determined. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 155 QUESTION 2 ,2. “What do you think should be done locally to provide adequate services and facilities for the care and rehabilitation of the chron- ically ill?” This question was answered in 15 of the 18 letters of reply. The opinions expressed in these answers are tabulated, and sample quotations are given below: Number of times Opinions mentioned Hospitals, clinics, nursing or convalescent homes _______________________ (These opinions in some instances specified state or federal assistance and in some instances stressed “accessible" and “better staffed" institutions.) State or federal aid for the chronically ill _____________________________ 2 Private physicians and surgeons (M.D. and D.O.) should contribute 4} day weekly to county service __________________________________ Establish a sound national physical program __________________________ Nothing. We are well provided with many facilities ____________________ (See, also, first two quotations below.) HHi—I Quotations From Answers to Question 2 “It seems to me that there are adequate facilities available. How- ever, they are not available to the person who is a property owner and with a modest income. He can not afford private care and hospitalization over a long period, yet is not eligible or is too proud to use county aid. I would prefer a decentralization of county hospital care with sub- sidy to private hospitals for care of those able to pay a portion of their fees.” “There were mixed opinions on this item. Some felt that nothing should be done, others felt that a clinic or institution for the care of chronic diseases would be ideal but possibly not practical. The private physicians see a possibility of more institutional treatment under such a set-up; less chronic disease in their offices. ” “I do not believe much can be doné in the local community to solve this problem and that care and rehabilitation of the chronically ill is going to have to come from aid by state or federal funds.” ‘ ‘ To correct this, in our opinion, it will be necessary to have tax sub- sidized clinics, etc., set up to provide adequate services for the chron— ically ill. ’ ’ “We are well provided with many facilities. ” “Hospitals for all the people, backed by federal and state aid, finan- cially.” “Adequate state or federal aid for chronically ill.” “More and more satisfactory rest homes.” QUESTION 3 3. “Is your community planning to do anything in this field?” This question was answered in 13 of the 18 letters of reply. Of the 13 answers, three stated “no”; four stated “not to our knowledge” or 156 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA “not known”; one stated “yes.” The remaining answers to this ques- tion are quoted below: “To the best of our knowledge there is a county program of this type under way but progressing slowly. Our profession however, is not consulted and will not be included in any of this work. \Ve feel that there should be some type of facilities made available to the osteopathic pro- fession.” “Has made survey for hospital.” “* "‘ * more financial relief.” “* ’l“ * agitation to revamp the county hospital—otherwise noth- ing.” “Nothing for the ‘chronie,’ as such. District and private hospitals are on the agenda. ” QUESTION 4 4. “What do you think the State should do to help the localities to provide adequate services and facilities for the care and the rehabilita- tion of the chronically ill?” This question was answered in 13 of the 18 letters of reply. The opinions expressed in these answers are tabulated, and sample quotations are given below: Number of times Opinions mentioned * State (and federal) subsidies to or financial aid for construction of local hospital and clinics _______________________________________________ 6 Cooperate financially, with federal aid ___________________________________ 2 Additional state or county hospitalization for chronically ill ________________ 1 Rest homes and less red tape in licensing: rest homes ______________________ 2 Initiate public health programs _________________________________________ 1 Chiefly a local problem ________________________________________________ 1 Better cooperation, county and private __________________________________ 1 (See, also, the first quotation below.) ' More than one opinion was expressed in several replies. Quotations From Answers to Question 4 “At least bridge the gap and care for patients in the county less than a year who require care but are not eligible at general hospital short of one year’s residence.” “I feel that if state or federal funds could be allocated to local hos- pitals to increase their facilities for this care that it seems the only logical solution to the problem.” “ Chiefly a local problem.” “* * ’l“ for one thing—use more common sense in licensing rest homes and less red tape.” “”" * * initiate public health programs.” “To correct this, in our opinion, it will be necessary to have tax sub- sidized clinics, etc., set up to provide adequate services for the chroni- cally ill.” “Establish clinics with subsidies for existing hospitals and to aid in the construction of others.” A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 157 QUESTION 5 5. “From the osteopathic physician and surgeon’s standpoint, what aspects of the chronic disease problem deserve special or intensive study?” This question was answered in 15 of the 18 letters Of reply. Of the 15 answers, two stated “all aspects”; two state( “rehabilitation”; five stated “equal privileges for osteopaths in governmental institutions”— using this or similar language; others stated “more financial relief”; “arthritis and uremia—with modern facilities for handling same”; “relation of postural defects to visceral disease”; “arthritis and high blood pressure”; and “development of branches of preventive medicine and chronic medicine”. 158 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA APPENDIX C? REPLIES TO LETTERS TO EXECUTIVES OF VOLUNTARY WELFARE AGENCIES On July 26, 1948, letter-questionnaires were sent to the executives of 99 voluntary welfare agencies. Replies were received, as of Septem- ber 8, from eight 1 health and welfare councils and from seven 2 com- munity chests. One reply was received from a state voluntary health agency, but this has not been included in the tabulation. The questions in the letter, tabulations of replies, sample answers and brief summarizations are given below : QUESTION 1 “1. Please indicate the geographical area served by your agency or agencies.” Footnotes 1 and 2 indicate the areas served by the agencies from whom replies were received. 1East Bay Health Council; Santa Clara, Health Section of Council of Social Agencies ; La Canada Valley Chest and Welfare Council; San Francisco, Health Council of Community Chest (this reply summarized questionnaires received from 11 member agencies) ; Chico Council of Social Agencies; San Diego Community Welfare Council; Long Beach Community VVeIfare Council ; Santa Barbara Community Chest. llAlhambra, Concord, Redlands Area, Monterey Peninsula, Vallejo, Napa, Wash- ington Township (Centerville ). 159 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA N I I «H H I I n H I I v IIIIIIIIIIIIIIIIIIII i298: . -82: E hznomaosu :3: new moomzcm 53$: Hz; 13:65 .Sw man 3 ,wnflpoanswfiwm $332.3 .3583 we Dana: AS N H H HH H I H m. 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I I N m H m N N IIIIIIIIII gowom: 23:39: we vane 25 Hz; 255cm 23 «o 555:8 85$ 23 win—~33“ 3 33:3 ~53:me mo xuafl A5: .5825 SIN .8 3% a? 3% $.52: o? .3 3% a? new wawtu e2 3 3h Pd ”wk 92. ewfizuzo ck. 3.53:0 SKI fiufize30 Exes 23:?» 3§=E=EQ 3.8530 2J8 3:385 SwSeE a £533 Misha“: 3.». amaowfiogfi of 98 9:8 2: .3 39% Ms: :H .N: N ZOHhmMDO 160 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA QUESTION 3 3. “What do you think should be done locally to provide adequate services and. facilities for the care and rehabilitation of the chronically ill?” This question was answered in 12 of the letters Of reply received. In the 12 answers, the following suggestions were made the number of times indicated: Expand hospital facilities _______________________________________ t Coordinate resources ____________________________________ 4 Establish or expand home nursing service _______________ 4 Establish more publicly financed services _______________ 3 Establish housekeeping service ________________________ 3 Strengthen rehabilitation program ____________ _ _________ 3 Study the problem locally _______________________________ 3 Establish custodial facility for elderly patients-_ ______ 2 Expand nursing home facilities ________________________ 2 Establish medical social service- _________ 2 Initiate educational program--- --------- 2 Establish preventive facilities" ------ 1 Establish a health department__ - - - ______ 1 Expand medical clinics ------------------------------------------ 1 Improve transportation; case—finding; housing; home-care; occupa- tional therapy; employment Opportunities; relax residence require» ments ____________________________________________________ 1 each QUESTION 4 4. “Is your community planning to do anything in field?” This question was answered in 13 of the letters of reply received. ’l‘hese answers are summarized below: Health councils becoming active in this field ________________________ 4 N0 ______________________________________ 4 Surveys recently completed __________________ 2 Yes __________________________________________________________ 1 Hospital district being formed ____________________________________ 1 New hospital eventually _________________________________________ 1 QUESTION 5 5. “What do you think the State should do to help the localities to provide adequate services and facilities for the care and rehabilitation of the chronically ill?” Among the 12 replies to this question, the following suggestions were made the number of times indicated : Aid financially (non-specific) ____________________________________ Subsidize care __________________________ 5 Financial assistance for facilities --------- 3 Establish standards for care _____________________________________ 3 Train personnel ________________________________________________ 2 Provide leadership -_ 2 Conduct educational programs __________________ 2 Subsidize local preventive clinics _________________________________ 1 Expand facilities and services for psychotics _______________________ 1 Establish housing program ______________________________ 1 , Provide low-cost or free custodial care ----- _ _______________ 1 Conduct research _____________________________________________ 1 Supply lists of specialists ________________________________________ 1 Compel local areas to assist this group ____________________________ 1 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 161 QUESTION 6 6. “From a voluntary welfare agency executive’s standpoint, what aspects of the chronic disease problem deserve special or intensive study?” Among the 11 replies received, the following suggestions were made the number of times indicated: Prevention ____________________________________________________ 3 Financing __________ 3 Rehabilitation ____ 3 “All aspects"__ 2 Nursing homes _________________________________________________ 2 Custodial care _________________________________________________ 2 Alcoholism ____________________________________________________ 2 ”Actual care,” housing. hospitalization, research, nursing care, psycho- logical aspects of treatment. study, old age services, sheltered work- shops, cancer clinics, and prepaid plan _________________________ 1 each QUESTION 7 7. ”Should the following categories of patients needing hospitali- eation be cared for in the same hospital or in separate and independent facilities?” Separate Qualified and inde- yes No Name pendent or no answer (a) “Chronically ill adults and chronically ill children _____________________ 9 l. 2 3 (b) Acute cases and chronic cases _______ S) l, 2 3 (C) Indigent chronic patients, and private chronic patients able to pay for their hospitalization __________________ 10 _ 2 3 QUESTION 8 8. “Should hospital care for the chronically ill be centralized in one large facility in the community or should it be decentralized, i.e., provided in all general hospitals in the community?” Centralized ___________________________________________________ 2 Decentralized _______ 6 Qualified (yes or no)- 2 No answer ____________________________________________________ 5 11~—L—8179 APPENDIX D REPORTS OF TECHNICAL ADVISORY GROUPS Technical Advisory Group Reports Are Attached as Appendix D-l Through Appendix D-6 n; i: .mw Ff... ‘ . Ma. .5. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 165 APPENDIX D-I THE CANCER PROBLEM IN CALIFORNIA AND RECOMMENDATIONS FOR A CANCER CONTROL PROGRAM A Report Prepared by the Cancer Commission, California Medical Association A. STATEMENT OF THE PROBLEM I. How Cancer Affects the Public 111 California, as in the United States as a whole, the magnitude of the cancer problem has increased steadily during the past several decades. As a cause of death, cancer is today second only to heart disease. In 19-17 there were over 14,000 cancer deaths in California, and it can be esti- mated that approximately 50,000 persons with cancer were alive at some time during the year. For these patients and their families, cancer fre- quently means suffering and economic loss. For the community it means, often times, increased dependency and the loss of many persons in the productive years of life. 2.'The Nature of Cancer (causes, prevention, methods of treatment, effectiveness of treatment) Very little is known concerning the exact cause of most human cancer. There is a small limited field of occupational cancer where the disease is definitely known to follow exposure to sunlight, exposures to such chemicals as coal tar products, the inhalation of nickel and asbestos and to the exposure to radioactivity. The cause of such major cancers as stomach, intestine, breast and female genital organs has not been estab- lished. A relationship has been shown between cancer and chronic irrita- tion and inflammatory conditions such as dental caries and inflammatory lesions of the uterine cervix, and these facts are important in the preven- tion of some cancer. Animal experimentation has shown that there are usually several different causes in any individual tumor and that there are as many kinds of cancer as there are kinds of human tissue. The fact that cancer is essentially a multiplicity of diseases initiated by many and often interacting causes makes the problem of cancer control entirely different from that of tuberculosis and other infectious diseases where a single definite cause is known and where that cause can be con- trolled by sanitation or isolation. Cancer is not contagious or transmitted by contact and is not a hereditary characteristic. Hence the diagnosis of cancer is not subject to mass methods and the control of cancer is limited to the attack upon the lesion in the individual patient. The prevention of cancer with our present knowledge includes public health measures in known occupational cancer and it includes the dis- covery and treatment of certain chronic inflammatory diseases that fre- quently precede cancer. \Vith our present knowledge the treatment of cancer is limited to the actual physical destruction of the growth by surgical removal or by radiation with X-ray or radium before these lesions have spread from the original site of occurrence. That this treat- ment is elfective in early cancer is demonstrated by clinical reports from 166 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA hospitals, clinics and individual physicians throughout the United States. These statistics show five-year cures in early lesions reach 95 percent in cancer of the skin and at least 75 percent in early cancer of the breast and uterus. Most early accessible cancer is curable by properly applied present methods. Cancer seldom remains localized to its point of origin but spreads with varying rapidity locally or throughout the body where it becomes inaccessible or where it cannot be removed. \Vithin a few weeks or months the curability of any case may drop 50 percent, and late cancer is usually incurable. 3. Barriers to Application of existing Knowledge (ignorance, lack of facilities, quacks, etc.) It is estimated that 30 percent of the patients that now die of cancer could have been cured had they received effective treatment early when the lesion was discoverable. With our present knowledge the one weak spot in cancer control is the period of delay between the development of cancer and the effective treatment of the lesion. This delay is largely due to ignorance, indifference or fear on the part of the public. The individual does not know the meaning or serious— ness of abnormal symptoms and hesitates to seek advice from the phy- sician. Frequently he attempts to cure himself with useless remedies or he seeks the services of an advertising irregular who promises a sure cure Without surgery. When the cancer is discovered there is frequently delay in carrying out the physician’s program because of a variety of reasons. The recognition of early cancer is often difficult and may require consultation and special examinations. The failure to obtain such con- sultation and necessary examinations immediately may cause serious delay before a diagnosis is made and effective treatment is instituted. Many of our rural cities and counties do not have adequate specialists or hospital facilities in the county, and while these are available in adjacent counties, the fact that they are not easily available often adds to the delay in prompt diagnosis and treatment. One cause for the delay in early diagnosis and immediate effective treatment arises from the lack of hospitalization for certain indigent groups. \Vith our large immigration there is an increasing load of indigent cancer patients who are not entitled to care in tax supported hospitals because of residence. 4. Indication of How an Organized Program Would Reinforce the Serv- ices Periormed by Individual Practitioners The services performed by the individual private practitioner would be reinforced by a program organized to accomplish the purposes as set forth in the basic requirements, i.e.: (1) Statistical research; (2) edu- cation, both for the public and for the medical and allied professions; (3) encouragement and assistance in establishing and maintaining diag- nostic and treatment clinics for indigent patients7 and for support of consultative tumor boards for all patients; (4) provision of adequate hospital beds for the care of the patients with advanced cancer; and (5) services for those who desire or must of necessity be cared for at home. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 167 The results obtained would include a broadening Of the doctors’ concept Of cancer, and an appreciation of the difficulties in early diag- nosis and of the relative values of the present known treatments. The physician would then come to accept the desirability Of consultation .similar to that in a tumor board to aid both him and his patient in obtain- ing the best treatment. He would be given an opportunity for continuing “post graduate” instruction in the progress of treating this disease. He would be furnished information 'eoncerning nature and prevalence Of the disease, not only in the Nation or State, but in his own community. By the enhancement of hospital facilities when needed he would have a place in which to properly carry out his treatment. Finally, with ade- quate home services, the terminal case would be well cared for. 5. Indication of Likely Benefits of a Program in Terms of Ultimate Decrease in Community Costs and Improvement of the Public Health The morbidity from advanced cancer usually extends over a con- siderable period of time involving continued disability and suffering for the patient and a large financial outlay for the family. Where the head of the family is involved this means complete loss of earning ability as well as large expense. The 14,000 deaths per year from cancer in Cali- fornia represents the disorganization of a substantial number of families over a long period of time with a consequent economic loss to the com- munity and a burden upon the community in indigent cases. By con- servative estimate at least 4,000 of these 14,000 patients each year could be cured through early diagnosis and early effective treatment. This preventable mortality and consequent morbidity can be reduced by an adequate cancer control program. Also, a program of palliative treat- ment Of cases not curable will increase the length of life and economic usefulness and will relieve suffering. 6. Summary of Extent and Progress of Cancer Control Programs to Date The cancer control program Of each state in the country was out- lined in the April, 1946, issue Of the Journal of the National (lancer Institute. At that time the Cancer Commission of the California Medical Association and the California. Division of the American Cancer Society were engaged in lay and professional education, and there existed one cancer clinic per 287,808 persons. However, there was no mention of several elements essential to a complete cancer control program. During the past two years through the cooperation Of the California Medical Association, the American Cancer Society and the State Depart- ment of Public Health further steps have been taken. These have included: Surveys Of existing cancer services and facilities in nine counties, carried out in cooperation with county medical societies; exten- sion Of the professional education program to the nonmetropolitan areas of the State, through visiting teams Of specialists; training of physicians in the new cytologic technique for the detection of early cancer and the establishment of a training center in the technique at the University of California; conduct Of cancer institutes for nurses; increase in the num- ber of tumor boards to (SO—largely concentrated in the metropolitan areas ——(of which 22 have been approved by the Cancer Commission of the California Medical Association and 29 are receiving financial assistsance from the California Division American Cancer Society); Operation on 168 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA an experimental basis of three “cancer detection centers”—in addition to a nonallicd one operated by the LOs Angeles County Cancer Prevention Society; initiation Of :1 Tumor Record Registry with participation of 20 hospitals; and intensification of lay educational activities. During the past year the California Division of the American Cancer Society has expended on this program $585,657.71. the State Department of Public Health $144,033 (federal funds). ln addition California has had available for research on cancer $326,742 from the national Office of the American Cancer Society and the (‘ommittee on Growth, $194,403.42 from the US. Public Health Serviced“ and $250,000 from the State Legislature (granted over a two-year period to the I’ni- versity of California). Although a number of important elements of the cancer control program have been initiated, it should be noted that there are some large areas of the State in which the population has not as yet received full benefits of the program. B. OBJECTIVES TO BE ACHIEVED The objectives of a cancer program deal with (1) prevention, (2) control and detection, and (3) palliative treatment. (1) Prevention The causes of most types of cancer have not been determined, and with our present knowledge there are few logical prevention measures. There are, however, certain types of cancer where a causative relation has been established and where prevention is possible. In certain industries workers are exposed to carcinogenic agents. The production and refinement of paraffin oils and certain coal tar prod- ucts and the use of certain analine dyes in industry are definite hazards in the production of cancer. Prolonged exposure to radioactive materials and radioactive energy in science and industry are similar hazards. Occupational cancer involves a small portion of industry, but the risk is sufficiently great to justify the continued supervision by the State Health Department and the Industrial Accident Commission and the promulgation of suitable pro- tective measures and the instruction of both the workers and manage- ment in the dangers involved. Intraoral cancers have a definite relationship to dental caries, jagged infected teeth and poor dental hygiene. The dental profession is doing splendid work in reducing the incidence of mouth cancer by intensified public health education regarding dental care. This is a valuable pre- ventive measure. The incidence of skin cancer is definitely related to prolonged exposures to wind and intense sunlight, as in the Imperial Valley farm workers. The incidence of cancer also is related to the irri- tation of pigmented moles, continued unhealed ulcers of the skin, mouth and lips, and to such conditions as nasal, rectal and uterine polyps. Public education in regard to the danger of these conditions and the need for corrective measures will be an effective preventive measure. ‘ For summary of all U.S. Public Health Service Funds allocated to California. for cancer control for the year preceding August 31, 1948, see Supplement “B" ($1,501,- 286.42). See page 175. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 169 (2) Control and Detection The cure of most accessible cancer is inversely proportional to the lapse of time between the incidence of cancer and the time when it is effectively treated. In a higher percentage of cancer patients there is an important and unnecessary period of delay before the diagnosis and adequate treatment of the lesion. The elimination of this period of delay is a major objective in the cancer control program. There are two approaches to this major objective: (1) Periodic health examination in patients over 40 years of age and (2) public health education in cancer concerning the danger signals .and the need for immediate examination and treatment. Since cancer arises from the cells in the patient ’s body, cancer may develop and grow for a considerable period before it produces any symp- toms to indicate its presence. Tn accessible regions such as the mouth, rectum and uterus these lesions may be seen or felt by the physician long before the patient is aware of them. These symptomless early lesions in accessible regions may be discovered by periodic health examination. Public health-education directed to the necessity of going to the family physician for a regular physical examination will be an effective measure in case finding. Many large insurance companies provide the cost of annual exami- nation for their policy holders. Industry requires a physical examina- tion before hiring individuals, but usually this examination does not include the search for early cancer. Both industry and labor should be impressed with extending these required physical examinations to cover cancer. The second and most important approach to case finding in cancer is educating the public to seek immediate examination as soon as they detect symptoms. There is no method of mass survey similar to that used in tuberculosis and diabetes that can be applied to the discovery of early cancer. There is no simple test for cancer. The discovery of cancer and elimination of the delay before effective treatment of early cancer rests with the patient himself and the first physician he consults regarding suspicious symptoms. To attain this objective of early diagnosis and immediate effective treatment involves the education of the public in the curability of cancer. the danger signals of cancer and the need for immediate examination of the appearance of any of these danger signals. It involves the educa- tion of the medical profession to continually be alert to the signs of early cancer, to the critical need of adequate. examination and early diagnosis. It involves the need Of adequate and accessible clinics for the indigent. To implement this primary objective of immediate diagnosis and effec- tive treatment requires that every person be able to obtain prompt examination for cancer in his private physician ’s Office, and when he is unable to pay for a. private physician that he has immediate access for examination to an appropriate institution. The present primary objective of: eliminating delay in the diagnosis and adequate treatment of cancer requires also an adequate and acces- sible consultation in the management of a. cancer patient. The diagnosis of early cancer is often difficult. Since cancer is a multiplicity of diseases that may involve diliferent portions of the body with many manifesta- tions, the indications for treatment may be varied and complex. Every 170 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA physician in the management of a cancer patient should have accessible consultation with other physicians and specialists. In the larger cities consultation can be readily obtained with the physician’s conferees. In smaller communities and for indigent patients such consultation can be provided by consultative tumor boards in California where the physician may take his patient for group consultation concerning both diagnosis and treatment of the patient. Many of these tumor boards are recently organized and not well developed and are not sufficiently used as yet by the physicians. This consultation service is being further developed by the medical profession in the State so that every physician may have access to adequate group consultation for any cancer patient that pre- sents a diagnostic or treatment problem. Most of the counties with large populations have adequate facilities and well trained physicians to insure a high quality of medical care. Most of these counties have approved public and private general hos- pitals. Most of them can care for cancer in its various phases. These hos- pitals have complete surgical and radiological services. The quality of medical care in the treatment of cancer given by the staff in most of the general hospitals in California is equal to that found anywhere. Many of the smaller counties in the state have not the proper facili- ties for the treatment of cancer. This means primarily that certain coun- ties lack either trained surgeons, radiologists and/or pathologists and there are insufficient beds, hospital facilities or nursing service for the care of cancer patients. In some of the counties the population is too small and too scattered and the location for physicians inadequate to justify the establishment of local cancer facilities. However, the movement of adequately trained specialists into the smaller counties has been accelerated since the World War. (3) The Palliative Treatment of Cancer It is estimated by the American Cancer Society that practically one- half of the patients with developing cancer will not be cured with our present information and by our present methods. However, there are large possibilities in palliative treatment with the relief of symptoms and suffering, economic usefulness and prolongation of life. In the past it has been difficult to give adequate attention to the advanced cancer patient. Hospitalization has been largely on a custodial basis without sufficient emphasis 011 medical and nursing care. Many of the cases of advanced cancer require medication, blood transfusions, surgical dressings and other measures that are difficult to carry out at home by an untrained member of the family. Thus the palliative care of the incurable cancer patient is one of the greatest needs and a major objective in a cancer control program. This objective has two divisions: (1) Sufiicient hospital beds with adequate care for patients that need hospitalization; (2) an organized program for adequate home care for cancer patients that do not need to be in the hospital. These two problems require careful study and plan- ning. Methods of solution cannot be outlined at this time and will differ in each county. Their solution is a primary objective in the cancer control program. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 171 Most of the general hospitals in California have been taxed to capac- ity with acute medical and surgical cases. Few. if any, are geared to the adequate care of the chronic disease patient. More attention needs to be given to the care and treatment of the chronic disease patient who becomes indigent because of prolonged illness. Primary considerations are that the incurable cancer patient receive a high type of medical care and that he is not considered a custodial case. It is also important that adequate care be provided for these private and indigent patients in the most economical manner. A large percentage of advanced cancer patients do not need pro- longed hospitalization. Some of these patients can be rehabilitated. A large percentage of advanced cancer patients requires only a short period of hospitalization and then can be equally well cared for at home if they have proper medical supervision and adequate nursing care. An organ- ized program of home care for cancer patients will reduce the number of hospital beds needed, will relieve mental and physical suffering and alleviate the social and psychological problems of the family. Such an organized program of home care can be conducted at a fraction of the expense of keeping these patients in the hospital. Most cancer patients prefer to stay at home. A study of the problem of palliative care in California is attached as a supplement. SUPPLEMENT A Palliative Treatment of Cancer Certain general considerations concerning the management of advanced cancer cases are pertinent in approaching the problem of their adequate care. There are multiple methods of approach, involving such questions as type and location of institutional facilities, segregation or nonsegregation from other types of chronic disabling disease, and the proper place of domiciliary care under an organized plan for professional supervision. Each of a number of conflicting concepts have advantages and disadvantages and the objective should be the formulation of a pro— gram which will achieve maximum benefit for the greatest number of patients. Realism demands that this goal be reached without dissipation of effort by a limited number of highly trained professional consultants or cancer therapists, whose participation is nevertheless essential in cer- tain phases of the program. The economic aspect of the problem may be expressed in terms of reasonable limitation in primary outlay of funds and annual costs compatible with the primary objective the maximum betterment of the unfortunate patient with incurable cancer. Approximately 25 percent of all cancer cases are being cured with ‘ present methods of treatment. The present status and trend of cancer research offers little prospect of any radical therapeutic changes in the foreseeable future, so that the major portion of the cancer problem will almost certainly continue to be in the palliative management of the incur- able patient. The estimated current case load in California is 45,192 while the number of deaths from cancer in the State for 1947 was 14,000. The incidence rate in a geographic area of this size is roughly equivalent to density of population and thus the predicted incidence, case load and 172 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA death rate can be. estimated for any county or city unit on a population basis. Cancer is a large group of separate diseases occuring in all portions of the body and its management is much more complex than, for example, that of. poliomyelitis or even heart disease. Even in a single organ cancer can behave with remarkable variability from patient to patient. The spread of cancer characterizing the progress of the disease can involve every organ and tissue. It is obvious that a disease of such disparate behavior requires the full range of medical. specialization. Thus, facilities for care of incurable cancer must include ready access to consultative serv- ices of specialists in all branches of medicine. Palliative management of cancer is not solely the care of so-called “terminal” cases. Certain patients regarded as hopeless problems by some physicians may be determined eligible for measures which make them once again useful members of society for varying periods of time. Such palliative measures are important both to the individual and the State. The patient may not only enjoy a. longer life but frequently is spared from a long and painful period prior to exodus. He may become economically productive and at least the length of institutional or domi— ciliary care may be greatly shortened. Many cases not suitable for rehabili- tative measures are greatly benefited, their course made more tolerable and their nursing care simplified by special measures which may be radio- logical, surgical, neurosurgical or medica. it is therefore of importance for the incurable cancer case to have the benefits of examination by a trained physician or in an institution where all pOssible facilities for special care are available. In some state and municipal units a corollary derived from this has been that some cancer patients require care in a special cancer hospital. This poses a fundamental question which requires consideration of features more complex than simply getting the. patient and the profes- sional staff together under the same, roof. Elsewhere are observations stressing the belief that the importance of the cancer hospital as a special institution is properly in the fields of medical education and research and not primarily in the care of patients. in respect to the immediate problem, the question is whether any benetit would accrue to incurable cancer cases by segregating them in one or more institutions in this State. A negative answer is based on the following considerations : ]. It is impossible to attract a competent. well trained staff, either attending or resident, to such an institution without teaching or research facilities. 2. If located at a site remote from a medical center, the professional staff becomes uninspired and the level of care becomes little more than custodial. 3. Only a few such institutions would be possible, probably not more than two, and that portion of the patient-population at any distance from these hospitals would either refuse to divorce themselves by distance from family and friends or suffer loss of morale thereby. 4. The capital outlay is large and far exceeds that required for enlarging present county operated facilities in the State. 5. If located in a metropolitan area, the necessary concentration of patients in a small area is discouraging to patients who are ambulatory A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 173 and active. If located in a rural site, with advantages of space, air and convalescent facilities, the caliber of the professional care deteriorates. (Vide 2.) 6. If located in a metropolitan area, the cost per patient day will approximate that of a general county hospital ($15.00) while with a decentralized plan and diversion of suitable patients to convalescent facil- ities or domiciliary care the cost should be less than half of a general hos- pital budget. The proper care of the incurable cancer patient is thus divisible into two separate phases, require dissimilar mechanisms for maximum benefits consistent with economic realism. A. The patient should first have the benefits of a thorough examina- tion, which, if necessary, should include specialists competent to perform any special surgical, radiological or other measures for maximum pallia— tion. If no definite measures can be employed, the patient no longer requires the facilities of this complete organization but may require ade- quate nursing care and medical supervision. Some of the patients for whom definite measures are employed may return to an active life, others will be discharged to “convalescent” care. The average stay for patients not suitable for definitive treatment might be seven days, for those in whom specific measures are employed, approximately four weeks. B. The major portion of the remaining life span of a patient with progressive, incurable cancer, often referred to with malapropism as a “terminal case,” need not. be spent in the strange confines of a major institution. Excluding those complications requiring hospital care, the best care for such a patient who has a home and someone with a modicum of intelligence to run it, is domiciliary care. If the patient’s comfort can be assured by simple measures applicable at home, regular visits by specially trained nurses, and periodic visits to or by a physician, the average citizen is far happier at home than when subjected to hospital life. The complexity of the modern hospital is geared to the management of acute disease; it is economic wastefulness to board incurable patients with lingering illnesses in the marble halls Of scientific medicine. The requirement for good domiciliary care is necessary home nursing by pro- fessional, specially trained visiting nurses, and the coincident instruction of the lay attendants in simple nursing, including administration of hypodermics, dressings, irrigations and nutrition. Add to this supervision of the patient by a physician at intervals of one week to one month depending on individual requirements, and one will have accomplished ideal management in the happiest possible fashion for at least 75 percent of incurable patients with home and family. A considerable fraction of patients are lacking either in a suitable home or in the availability of some person or persons to provide full- time care. The latter deficiency may be due to temperamental unsuit- ability of relatives for any sort of nursing duties. The majority of patients with no opportunity for domiciliary care are in the indigent group and require institutional care by some mechanism entirely or partially tax supported. For the reasons set forth above, full scale completely equipped hospital facilities are not necessary for this purpose. Segregation of these patients in special wards in a large hospital or in any metropolitan site results in a charnel house atmosphere; active ambulatory patients 174 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA with months to live are restricted in small quarters with those who are confined to bed or dying of the disease. The advantages of living space for ambulatory patients, the possibility of segregation of patients according to their degrees of disability or special nursing problems, and a far more pleasant background can be accomplished by locating such institutions in a rural area. At the same time the care of these patients must not be allowed to sink to a custodial level. For this reason, such institutions, which could be euphemistieally referred to as “convalescent” facilities, should be in departments of county hospitals, and in geographic proximity to the parent institution. Members of the staff of the cancer clinic of the county hospital should rotate on service at these units and make regular visits. Resident medical care should be provided by rotating an adequate num- ber of residents and interns through this special service. Patients in whom complications arise which require new measures would thus receive prompt attention. The application of new methods of treatment should be an important activity in these institutions. Consultants in such special- ties as neurosurgery, urology and anesthesia should be designated from the staff of the county hospital and from the department of pathology should perform as many autopsies as possible. Autopsy findings cor- related with records of original treatment will provide an accumulating wealth of material necessary for new clinical studies of methods and treatment. Nursing care of patients can be well done with a minimum of gradu- ate nurses as supervisors, supplemented by more readily available nurses’ aides. Minor surgical facilities radiographic equipment and routine laboratory tests should be available. Major surgery and radiation therapy would be accomplished more effectively by transfer of such patients to the main county hospital or physician’s offices. The thesis developed herein concerning the care of incurable cancer patients emphasized the necessity of individualization of management. The problem in each patient depends on the nature and predicted prog- ress of his disease, his home facilities and the availability of care at home, his economic situation, and other more imponderable factors. The plan proposed, in outline, may be reduced to the following scheme : A. Preliminary work-up and management of patients believed to have incurable cancer. 1. If necessary admission to a general hospital, county or private, conducting an approved cancer clinic. With the necessary clinical, radiographic and laboratory data available, the staff of the cancer clinic may : (a) Designate patient for medical palliative care only (b) Determine definitive surgical, radiological or other measures of treatment to be employed under their direction. A few will be temporarily rehabilitated, the remainder may be eligible for B. B. Long term palliative care of established cases of incurable cancer. 1. Suitable cases may be returned to their homes for supervised care as indicated herein, and more fully outlined in the “Montefiore Plan,” q.v. Subsequent complications or terminal events may require their admission to facilities indicated below. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 175 2. Patients without home or attendants for home nursing admitted to facilities operated by county hospitals, preferably in adjacent rural sites, and staffed by members of the hospital cancer services and by residents and interns from the parent institution, serving on rotation. The plan is designed to Obtain the advantages of maximum pallia- tion for the patient with increased longevity and usefulness compatible With a comfortable life. At the same time it avoids segregation and crowd- ing terminal cancer cases in special centralized cancer hospitals at greatly increased costs without equivalent returns in improved management. The plan would utilize existing county-operated hospital facilities and per- sonnel, amplifying the usefulness and increase the number of approved cancer clinics in California and contribute further to the education of resident and intern staffs of county hospitals in the management of cancer. SUPPLEMENT B Funds to California, From U. S. Public Health Service for Cancer Control and Cancer Research Prior to August 31, .1948 Research Grants: (Julie :20, 10—18) Stanford University: l'niversity of California Lurk _________________ $17,820 00 (lreenherg ____________ $10200 00 Kirkinan ______________ 5,842 00 Bustick __ ___________ 5,333 ()0 (‘uttimr _______________ 5.292 00 Shimkin _ ___________ 70,372 50 ——~— Kirk ___- ________ 3,240 ()0 Mt. Zion (San Francisco) : Moon ___ ________ 2,071 02 liisliind _______________ $8.450 00 I‘Iiler _________________ 5.724 ()0 “ Brooks ________________ 13,608 00 University of Southern California: \Vinzler _______________ $5,985 00 College of Medical Evangelists: Melil __________________ 6,453 00 Schindler _____________ $11,010 00 —~— Levine _______________ 5.5300 00 l“el]o\\‘slii])s: (‘alit'orn'a Institute ’l‘eehnolou'y. Dougherty _____________________ $500 00 I'niversity of California. Berlin __________________________________ 500 ()0 Teaching Program : College Medical Evangelists (12/11/47) _______________________ $25,000 00 University Southern California til 711/45)”. ._ ______________ ,vfi 23.000 00 University of California (2/48) _______________________________ 25,000 00 Construction Grants: I'niversity of California _______________________________________ 341000.000 00 Los Angeles County Hospital (Cancer unit) ____________________ 371.255 00 Cancer Teaching Grants via California State Board Health: University of California (Traut’s cytologie prog) ____________ . _ $43,320 00 California State Board of Health, non-metro. prof. ed _____________ 0 975 00 Cancer Control Program (California State Dept. Health) Control program (original grant) ______________________________ $124.03?) 00 (Money spent at end of fiscal year—$100,545 00) Tumor Registry, special grant _________________________________ 20,000 00 176 A CHRONIC DISEASE PROGRAM roe CALIFORNIA METHODS TO BE USED TO GAIN OBJECTIVES 1. Analysis of the Problem Statistical services in the field of cancer have numerous uses essential to the achievement of the above objectives. Such services are designed to provide: (1) Knowledge of the extent of the total cancer problem in the population; (2) information for epidemiological investigations of the relationship between the different types of cancer and age, sex, race, mari- tal status, occupation and other factors; (3) a basis for evaluation of pro- gress in control of the disease; (-1) a basis for estimating the need for professional and other services and facilities in the care of cancer patients ; and (5) material useful for both professional and lay education. In addition. the development of statistical services stimulates the improvement of case records and record systems, and the follow-up of cancer patients. At the present time statistical services are not adequate for all of the above purposes. Mortality statistics for California have been tabulated systematically since 1906, and they provide the only relatively complete body of statistical knowledge about cancer in the State. Statistics on living cases in California—4hr example. the total number of cases in the population, the number of new cases occurring each year, the duration and survival of cancer cases such statistics. though potentially more useful than mortality statistics are a 'ailable only to a very limited extent. At present they are adequate only to give a partial indication of the total magnitude of the problem. Much more information on cancer morbidity is needed. In order to obtain adequate morbidity information it is necessary that the original sources of the information be complete and accurate. Requirements for such completeness and accuracy are: (1) Medical rec- ords of cancer cases containing full histories and complete notes on diagnosis and treatment; and (2) unit record systems in medical insti- tutions whereby all records for each patient are kept together in one place. A central tumor registry has been established by the State Depart- ment of Public Health with the emlorsement of the Cancer Commission of the California l\"ledical Association. The registry represents one method for obtaining cancer morbidity information. It serves to improve cancer records. to assist in follow-up of cases. and to stimulate professional edu- cation. The registry is based on voluntary rather than compulsory report- ing of cases. llospitals and clinics i‘iarticipating in the registry receive statistical consultation on their record systems, are assisted in their follow—up work, and receive statistical tabulations of their own cases. The registry has been in operation for only a brief period but has already shown its value not only in terms of laying the groundwork for better morbidity statistics. but also in terms of service to the participating hos- pitals and clinics. A 2. Preparation of Professional Personnel (undergraduate education, post—graduate and in-service training) 1. Undergraduate M cdfeal Education—This is being accomplished with increasing effectiveness by the medical schools of California and lies wholly within their sphere. Teaching concerning cancer is most extensive A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 177 in the fields of pathology, surgery, gynecology, radiology and internal medicine. MaJOI 1tv opinion favors instruction being given as parts of these fields of medicine as distinct from courses in oncology. Insofar as medical education conforms with the requirements of the Council on Medical Education, the standards of the Association of Amer- ican Medical Colleges and the provisions of the law relative to licensure it should not be interfered with. Medical educators are in the best position to judge the merits of methods of instructions. However, under-gradu- ate 1nedical education in cancer is being re-evaluated by the faculties of the medical schools. The National Cancer Research Institute of the United States Public *lealth Service has made available grants 11p to $25,000 for approved projects submitted by any medical school for the coordination and intensification of cancer instruction in its various departments. Four medical schools in California have availed themselves of such grants. The under-graduate instruction in cancer in schools Of dentistry and schools of nursing should be carefully studied and organized to give proper emphasis and training in this disease. 2. Graduate (in-service) IL'ducation—There has been a progressive increase in the average duration of graduate training. This is in part due to the desire of young physicians to qualify for specialty boards and special societies. There has also been a realization that further training falling short of these objectives is of great value. There is an increasing number of hospitals seeking approval for intern and resident training. In order to qualify, a hospital must meet the requirements of The Council on Medical Education and Hospitals of the A.M.A. or the American College of Surgeons. Training programs require numerous conferences including tumor clinics, X-ray, pathological and cliniopathological conferences. Large numbers of patients are hospitalized for malignant disease and the intern or resident is given clinical instruction concerning cancer on the wards in the course of diagnosis and treatment of these cases. The quality of the training offered in hospitals varies and depends largely upon the competence and interest of the attending staff. This applies to the diagnosis and are of all diseases, including cancer. Staff appointments are made in different ways and by different types of governing bodies of the hospitals. Hospitals should be encouraged to improve the professional com- petency of their staffs (and this 1s being done to a considerable extent). The California Medical Association has appointed a committee composed of members of medical school faculties to advise and assist hospitals 111 attaining positions which will permit approval for graduate training. Hospitals lacking tumor boards or clinics should be encouraged to establish them. There is continuous improvement in graduate training which Will continue at an accelerated rate and legislation toward this end would not be desirable. It would be more apt to be productive Of harm than benefit. 12—L-8179 178 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 3. 1’asl-Graduale E ducatiun—The medical schools, the medical pro- fession and the American Cancer Society have been active in this field in cooperation with the Department of Public Health. The medical schools provide post-graduate courses some of which include instruction in the diagnosis and treatment of cancer and some of which are devoted wholly to this purpose. The California Medical Association has an extensive post-graduate program which includes presentations concerning cancer. This carries information to the physician in his home community. The Cancer Commission has published its studies in California Medicine. These are to be gathered together in monograph form and sent to the physicians of the State. The Cancer Commission holds exten- sive refresher courses at least annually in each of the northern and southern portions of the State. Additional regional conferences are held. Teams of speakers are sent to the county societies to offer informa- tion and instruction concerning cancer. These teams consist of well quali- fied speakers, some of whom are drawn from other states. These activities are carried out in conjunction with the California Division of the American Cancer Society and the California Department of Public Health. The annual meeting of the California Medical Association and its monthly publication devote considerable attention to cancer. Post-graduate education for physicians can be best provided by the medical schools and the medical profession. These agencies most clearly understand the needs and the methods of meeting them. Significant studies are being made and continuous improvement can be expected. Legislation toward this end would be undesirable. Similar post-graduate training should be available to the dental profession and is being developed. Refresher courses in cancer have been given by the Dental School of the University of Southern California and the Dental School of the University of California at San Francisco. These courses have received financial support from the California Divi- sion of the American Cancer Society. A program of symposia or con- ferences on cancer should be made available through the State Dental Association in the nonmetropolitan areas throughout the State. Education should be planned for all professional groups which are concerned with cancer. Not only physicians and dentists but also nurses, social service workers, health educators, medical record librarians require a continuing educational program in their individual fields if they are to assume their proper responsibilities in cancer control. As in the case of physicians and dentists these groups have formed state and local associations which should be given encouragement and assistance in planning and conducting appropriate educational activities. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 179 PROVISION OI" PHYSICAL FACILITIES AND MEDICAL AND RELATED SERVICES (Listing the type, number and distribution of present facilities and services, with an estimate of what further facilities are needed, and a discussion of methods Of organizing and financing immediate facilities and services.) (1) Facilities The following outline is presented to show some Of the factors to be considered in organizing and financing needed facilities, and various methods of organizing and financing such facilities. 1. Factors to be Considered 1. Number, size, and type of facilities needed in relation to existing facilities and to the population and geographical area to be served. to 949?.» Location Of facilities: In or near existing related hospital and medical facilities, In separate and independent locations, Accessible to population to be served, Assurance of availability Of trained personnel to staff facil- ities, In relation to current planning for additional hospital beds and facilities, If construction, purchase, maintenance and Operation are to be financed locally—assurance of the ability of the area to finance the facilities. 3. Standards of construction, maintenance and operation: a. b. c. Recommended by professional organizations, Required by law or government agency regulation, Required by law or regulation as a condition for receiving financial assistance from: (1) Government agencies (2) Voluntary organizations 4. Ownership and control: a. Type Of ownership and control may be influenced by need for financial assistance from governmental agency grant pro- grams. 5. Public attitudes : a. Public recognition of the need for the facilities is an important factor if financing is to be done by bond issues, direct use of taxes, or by voluntary contributions. II. Methods of Organization 1. Type of ownership and control: a. b. 0. Private and proprietary, Private and nonprofit, Government (city, county, district, state, federal). 2. Geographic basis Of organization Of needed facilities: a. b. 0. Local, District, Regional, 180 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA d. State-Wide, e. Bi-state, tri-state, etc., f. National. 3. Institutional basis Of organization: a. As an expansion or an addition to an existing institution or facility, b. As part of a new or soon to be constructed facility, c. Related administratively and operationally to an existing or new facility, but not physically a part of or adjacent to it, (1. Not related administratively, operationally, or physically to any existing or new facility. III. Methods of Financing 1. Type of funds: a: Private funds—for investment purposes, b. Private funds—«loaned on a noninterest bearing basis, 0. Private funds—donated for nonprofit uses, (1. Tax funds—including government bond issues. 2. Geographic source of funds: a. Local, b. District, 0. Region, (1. State, e. Bi-state, tri-state, etc., f National or federal. 3. Methods of financing (related to type and source of funds) a. Promotion, b. Public campaign, 0. Legislation. (2) Professional and Other Services (Including the maintenance and stutling of facilities for the provision of services) Although facilities have been separated from services in this discus- sion, it is Obvious that they cannot be considered as separate and distinct problems. The type and organization of facilities cannot be divorced from considerations of the type and distribution of services to be pro- vided; the financing of services is obviously related to the type of owner- ship and control of facilities, etc. Many of the factors listed in the above outline apply in general to services as well as to facilities. In the financing of services, as well as the financing of the main- tenance and operation of facilities, there are additional features not shown in the above outline: i.e., services may be financed in Whole or in part; (a) On a fee for service basis; (b) On a prepayment or insurance basis (also, on a mutual benefit or cooperative basis) ; (e) By tax funds for indigent patients; ((1) By voluntary contributions of funds; (e) By the providers of service—through the contribution of their services. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 181 DEMONSTRATION PROGRAM Many and varied techniques of cancer control have been carried out in other states over the past 10 years. Some of these techniques have been effective particularly in the small states, notably in Con- necticut. Some Of these techniques may be applicable in California, others may not be necessary or practical. The approach will necessarily be diflferent in metropolitan regions and distant rural areas in this large State. In order to demonstrate the methods and value of cancer control techniques in California, experimental programs are being conducted in various fields. The Chronic Disease Section of the Department of Health has established a program of reporting cancer morbidity and mortality in 20 California hospitals on a pilot basis. This program is developing a method of statistical studies and the reporting Of cancer suitable to the needs in California. The Los Angeles County General Hospital Tumor Board (with membership representing the University of Southern California Medical School and the College of Medical Evangelists) is developing a follow-up program for cancer patients not only for statistical study but to provide medical supervision and palliative care to patients who have had cancer. \Vith the assistance of the California Division of the American Cancer Society, an experimental program of cancer detection centers has been conducted in four California cities to determine the effectiveness of this method of case finding in cancer. The Vaginal Smear Laboratory of the University of California extended its services to the physicians in the adjacent areas, this service constituting a demonstration program of the value of the cytological technique in the Bay Area. Continuation of the demonstration phase of this program does not constitute, however, continuation of the service aspect on a free basis. A promising field for demonstration programs would be the organ- ization of a service of home care for advanced cancer patients similar to the Montefiore Plan. Such demonstration programs to be conclusive require the approval and support of the medical profession, the hospital and the community. Such programs, set up on an experimental basis are desirable to indicate the methods of cancer control that will be feasible and eifective in this State. - STATE AID TO LOCAL AGENCIES (With discussion of the desirability as to types of programs and administrative measures.) In the field of cancer control, state aid to local agencies may take several forms. Consultation services exclusive of diagnosis and treatment Of diseases in reference to special problems, represent one means of aid. Direct financial assistance should not be given other than for care of indigent patients. For personnel, equipment, and services for indigents is another means. Also, state aid may be provided in the form of assistance and advice in the recruitment and training of personnel for cancer control work in local areas. Furthermore, in these phases of the control program which are specifically benefited by joint activities of local and non- 182 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA local agencies (cg. lay education, statistical research, and adminis- trative research) state aid could assist in making such joint activity possible and effective. RESEARCH (Discussion of the feasibility of a research program within the State.) Further advances in the prevention, treatment, and cure of cancer is dependent almost entirely upon research. Inasmuch as cancer is a phenomenon of abnormal growth, the fundamentals of which deal with the problem of life itself, cancer research necessitates investigation of many detailed problems, not only in clinical medicine but in the basic sciences (chemistry, biology and physics). The universities, medical schools and research institutes in Cali- fornia associated with clinical facilities form the basic units of cancer research in the State. There is great need for increased expanding support of these institutions. There is also need for continued support of administrative research in order that more precise information may be obtained concerning methods for providing the necessary services for cancer patients (such as in the field of home nursing, convalescence, and rehabilitation). Statistical research is being conducted by the California Department of Public Health. This desirable type of research requires the systematic collection of statistics and the evaluation of results from year to year. For example, careful analyzing of cancer mortality statistics will assist in determining the relative importance of cancer in various sites of the body, differences in cancer among sexes, in different races, and different geographic sections of the State. Such statistical research implies search for the most successful techniques for morbidity studies, such as com- pulsory reporting of cancer, or the use of voluntary tumor registries. A clinical cancer research program embodies not only an expansion of present basic research, but the training of research fellows and pro- grams of grants- in— aid to the various institutions in the State. Cancer research basic and clinical 1s now being conducted in vary- ing degrees in the universities, the five medical schools, and the California Institute of Technology. In May, 1947, the State appropriated $250,000 to the Regents of the University of California to be expended during the ensuing two years for the purpose of conducting “additional research on the origin, preven- tion, and cure of cancer,” in the University of California (and its com- ponent divisions). During the two years preceding August, 1948, the national office of the American Cancer Society through the Committee on Growth had allocated $326,742 to California institutions for research and fellowships; of this amount the sum of $170,147 has expired and $156,595 is current. The California Division of the American Cancer Society has allocated $181,236.25 and the U. S. Public Health Service through the National Advisory Cancer Council $194,403.42. For total amounts ($1,501,286.42), see page 175 It is desirable that funds be available not only for continued support of fellowship and grant- in- aid programs to teaching and research institu- tions in the State but for expansion of facilities as needed so that these institutions may be better able to utilize research funds available from other sources, namely: A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 183 (a) The American Cancer Society. (b) U. S. Public Health Service (The National Advisory Cancer Council). The erection of buildings and the provision of such facilities for cancer research should be on the basis of a specific contract with the institution, and that contract should be terminated when the facility is completed. In this regard state aid may be necessary to provide construc- tion funds. HEALTH EDUCATION (Outlining specific plans for reaching the public, affected individuals and their families, professional and other groups, and outlining the various needs, methods and media to be used, including schools and colleges. Discussion of joint plans for voluntary and public agencies.) Health Education Relative to Cancer The objectives of health education relative to cancer must be moti- vated through knowledge rather than through fear. This can only be done by the proper education of the public. The most profitable medium in any educational program is the youth of our Country. Once the adult has reached maturity or middle age, there is little profit in attempting to change his or her mental attitude towards cancer by virtue of an occasional brief public lecture or public demonstration. A. Objectives: 1. TO gradually instill into developing youth factual information about cancer, presented as a problem to be solved but not one to be feared. 2. To inculcate into the present generation their responsibilities relative to voluntary support Of a cancer program. 3. To stimulate a genuine interest in their active participation in the solution of the cancer problem, if not now in the future. 4. To train elementary, high school, and college teachers in the best educational techniques for the presentation of the cancer problems to their future students. 5. Careful study of elementary, high school, and college textbook content with a view of coordinating cancer information with courses in hygiene, physiology, biology, sociology and economics. 6. Continue adult lay education as at the present. B. Application of Program 1. Policy determination of methods at the state level by the Depart- ments of Health, Education, and the California Medical Association. 2. Actuation of the program at the local level by the Departments of Health, Education, the local medical society, and the social agencies. COORDINATION IN THE PROGRAM At the present time the cancer control program in California is being conducted through close cooperation between the Department of .Public Health, the California Medical Association and the California Division of the American Cancer Society. The faculties of the medical schools in California have also cooperated generously in the field of pro— fessional education in cancer. 184 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA For the last 15 years the American Cancer Society, formerly the American Society for the Control of Cancer, has been conducting a pro- gram of lay education in cancer which has been rapidly expanding dur— ing the last three years. The California Division of the Society now has 28 organized branches in the larger counties in California which are information centers for lay education in cancer and for service to cancer patients. During the last three years the California division has con- tributed largely to professional education of physicians and to grants- in-aid in the medical schools in the State. The California Medical Association established a. Cancer Commis- sion in 1931 which has been developing a program of professional edu- cation in cancer except during the var years. Two studies on the diag- nosis and treatment of cancer have been prepared and published. Through the cooperation of the medical schools, refresher courses in cancer have been held in Les Angeles and San Francisco. The faculties of the medical schools have also assisted in cancer conferences in other areas through— out the State. During the past three years this program Of professional education has been underwritten by grants from the California Division of the American Cancer Society, and during the last year has had gen- erous support from the California Department of Public Health. The California Medical Association and the component county medical soci- eties have cooperated closely with the county branches of the American Cancer Society. The Cancer Commission of the California Medical Asso- ciation has also stimulated and assisted in the formation of tumor boards for consultation on cancer in many of the hospitals throughout the State. The commission has also cooperated with the Department of Public Health in cancer surveys in several counties. Since 1929 the staffs of public and private hospitals have been developing cancer clinics for indigent patients as well as initiating group consultation services for the patients of private physicians. 1n the past two years the California Division of the American Cancer Society has made financial grants to these organizations in private hospitals to assist them in developing their programs. During the past two years the California Department of Public Health through its Chronic Disease Service has been developing a cancer control program in cooperation with the Cancer lommission of the Cali- fornia Medical Association and the California Division of the American Cancer Society. A central Tumor Registry has been organized in the department for reporting and tabulation of cancer cases in more than_ 20 pilot hospitals. The registry includes cases extemling back over a period of five years and is also set up on a current basis. The mechanism for conducting this registry and statistical studies connected with it have been set up by the Chronic Disease Service. The Association of California Hospitals has cooperated in developing the Central Tumor Registry and in encouraging hospital participation. Mortality statistics in the State are being analyzed. A cancer survey has been conducted covering counties including a majority of the state’s population. The Department of Public Health, through financial grants and the services of its cancer consultant, has taken an important part in the program of professional education. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 185 Thus the program of cancer control that has been set up in California integrates the work of the California Medical Association, the American Cancer Society, the medical schools, hospital clinics and tumor boards and the Department of Public Health. There is no duplication of effort or projects. The future planning for cancer control should be based on the continuation and expansion of the cooperation. EVALUATION The cancer mortality rate adjusted for age and sex changes in the population represents the ultimate measurement of a cancer control program. Periodic review of the trends in mortality from cancer of various sites and types would be a useful guide to control efforts. As morbidity reporting is perfected and preventive services devel— oped the cancer incidence rates will become a criterion of progress and will suggest areas for special attention. Survival rate is another good criterion of progress. One valuable measure of success, especially of the educational pro- gram, lies in the amount of delay between the patient ’s recognition of symptoms and his first visit to a physician. The average period between the first consultation and the start of treatment indicates the adequacy of the educational program. In addition to the above long—term measures of the effectiveness of COntrol efforts, regular program review ought to include such items as the number of hospitals and other agencies participating in the tumor record registry and the number of reports being received, the number of persons reached in educational programs—both lay and professional—— the proportion of pathologic confirmations of diagnoses for the various sites of cancer, and the number of tumor boards and cancer clinics in operation, their distribution and the number Of patients seen by them. A sampling method for determining public knowledge and attitudes is desirable in estimating the effectiveness of educational activities. SUMMARY AND RECOMMENDATIONS I. Program Content Cancer research, basic and clinical, is now being conducted in vary- ing degrees in the universities, the five medical schools and California Institute of Technology. Additional physical facilities should be pro- vided in these institutions to make it possible for them to utilize fully potentially available grants for cancer research from the National Cancer Institute Of the United States Department of Public Health, the American Cancer Society and other volunteer agencies. H. Cooperating Agencies Close cooperation should be intensified among the California Depart- ment of Health, the California Medical Association, the California Division of the American Cancer Society, the Association of California Hospitals and the California Dental Associations. III. Lay Education in Cancer 1. Adult and community education should be continued and further promoted through means of lectures, radio, literature, and exhibits. 2. Information centers of the American Cancer Society should be increased in number and extended to the smallest communities With a 186 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA system of volunteer workers. This includes training schools for volunteer workers. 3. Public school curricula should be modified as necessary to include cancer information in courses in biology, zoology, physiology and public health education at both the high school and college levels, with a similar limited program in secondary schools. 4. Home education by public health nurses and visiting nurses should be encouraged within desirable limits. All categories of persons not doctors of medicine, however, should be cognizant of the limits of their fields of activity and should not transgress these limits. Education in this respect is desirable. IV. Professional Education 1. Medical schools must continue to give proper emphasis on teach- ing cancer for medical students, interns and residents. 2. Refresher courses in university centers for practicing physicians should continue tO receive support and be increased in number as necessary. 3. Conferences and teaching clinics should be available for every county medical society, particularly in rural areas. 4. Professional meetings on cancer should be held periodically in county medical societies and hospital staffs. 5. Similar undergraduate and postgraduate education on cancer should be developed for dentists. 6. It is desirable that there be adequate graduate education in cancer for public health nurses. medical social workers and medical record librarians in their respective fields Of activity. V. Statistical Studies: Central Tumor Registry 1. It is desirable that the central tumor registry be expanded on a voluntary basis to include all hospitals and clinics and such private physicians’ offices as considered practical. VI. Diagnosis and Case Finding 1. A reference panel of physicians is desirable in every county medical society and in each community to whom patients may be referred for diagnosis and/or periodic health examination. 2. Cancer clinics in public hospitals are desirable for the diagnosis and treatment of indigent patients, and their establishment should be encouraged. 3. Cancer clinics for diagnosis and treatment of indigent patients in general hospitals that have an out-patient department are desirable and their establishment should be encouraged. 4. Creation of consultative tumor boards in general hospitals should be continued in order to give group consultations on: (a) suspected cancer patients in the hospital, (b) to private physicians on patients who are suspected of having malignant disease. 5. Development of consultative tumor boards in rural areas where needed can be assisted by utilizing the services of specialists in adjacent counties. 6. The California Society of Pathologists by resolution in December, 1947, have collectively and severally agreed to furnish tissue diagnosis A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 187 for all private patients at fees depending upon the patient ’s financial status. These services of the private pathologists for patients in the lower income groups should be widely publicized and more extensively used. VII. Prevention of Cancer 1. The industrial hazards of prolonged exposure to carcinogenic chemicals and to radiation in industry should be subject to public health regulations. 2. The prevention of cancer is best effected at this time by lay and professional education. VIII. Palliative Treatment 1. Chronic disease beds in both private and public hospitals or attached to such hospitals utilizing the visiting and resident staff to insure maximum scientific and humane care should be provided in or by each county. 2. Patients in nursing homes should be under adequate medical supervision. 3. Home care for cancer patients, including the services of private physicians, the staffs of public hospitals, public health nurses and volun- teer workers in the county branches of the American Cancer Society (the Montefiore Plan or some modification thereof) should be provided by the counties. IX. Cancer Detection Centers and Cancer Hospitals Cancer detection centers for the examination of well persons are not included in this program. The case finding yield of 0.1 to 0.5 per— cent in such centers is not an efficient public health measure when bal- anced against the exorbitant expense. It is estimated that there are over 1,900,000 persons in California (1946) between the ages of 45 and 65 years (the so-called cancer age). It is inconceivable that any number of detection centers can make complete physical examinations of the majority of this number of persons even once a year. Experience has shown that the cancer detection center is not a practical-method of mass survey comparable to the methods used in tuberculosis, syphilis or dia- betes. This program does not recommend the establishment of inde- pendent cancer hospitals in California. The present trend in hospital planning is toward general rather than special hospitals. The majority of cancer patients can be treated as well in properly equipped general hospitals or in the private offices of physicians. This procedure would be little altered by the erection of two or three large, expensive, independent cancer hospitals. The program of research and training of physicians is well estab- lished in our universities, our five medical schools and in the California Institute of Technology. More buildings and facilities may be required to develop the research program in some of these institutions, but the expansion of research and resident training in these existing schools will be more effective than that obtained by building special cancer hos- pitals. Cancer research is primarily dependent upon the basic sciences and such research, to be productive must necessarily be closely integrated with the institutions in which those disciplines are followed. 188 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA ADMINISTRATION. FINANCING AND LEGISLATION I. Administration The administration of the official projects for the control of cancer as now set up in the Chronic Disease Service of the California Depart- ment of Public Health is adequate and satisfactory and should be con- tinued. Additional personnel or space for the central tumor registry may be necessary. No independent division of cancer control in the Depart- ment of Public Health is recommended. H. Funds At present the Chronic Disease Service is receiving and spending federal funds for their cancer control program. The continuation of such federal grants may be contingent upon the State of California sharing this expenditure. State funds should be appropriated to supple- ment federal grants necessary to conduct the projects of the Chronic Disease Service and replace federal grants if these are reduced or with- held. State funds for the program of cancer control should be appro- priated to the California Department of Health and administered by the Chronic Disease Service of that department. State funds should not be used by the Department of Health for the diagnosis and treatment of cancer. The functions of a public health department do not encompass the practice of medicine. III. Lay Education The program of lay education in cancer in California is being well conducted and properly expanded by the American Cancer Society and its California Division. The financing of this program is made possible by public contributions during the April Campaign of the American Cancer Society, and by additional private contributions. The adminis- tration of this program should continue in the California Division of the American Cancer Society. Health education in public schools and state colleges is now con— ducted as a joint program of the Department of Education and the Cali- fornia Department of Public Health. State funds appropriated to the Department of Public Health should be used in the cancer program in cooperation with the Department of Education and with the California Division of the American Cancer Society. IV. Professional Education Under-graduate education in medical schools is now being assisted by federal funds administered by the National Cancer Institute of the United States Public Health Service. At the graduate level residencies and fellowships in cancer are being financed by the National Cancer Institute and the American Cancer Society. Professional education in cancer for the practicing physician is being developed as a joint program of the California Medical Association, the California Division of the American Cancer Society and the Cali- fornia Department of Public Health. This cooperative program should be continued. State funds should be available to the California Depart- ment of Public Health and should be used to include the production of educational material such as teaching films and lantern slides as well A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 189 as to share the expense of Refresher Courses, meetings, teaching clinics and symposia on cancer for physicians and dentists. Federal funds administered by the California Department of Pub- lic Health are now being used to finance professional education in the cytological diagnosis of cancer at the University of California. State funds should be used to supplement or replace federal funds for such post-graduate courses for practicing physicians and/ or technicians when requested by the medical schools. State funds administered by the Chronic Disease Service should also be available for post-graduate education in cancer as it pertains to their specific duties and activities for public health nurses, medical social workers and record librarians. This type of professional education should be conducted in cooperation with the Cancer Commission and state organizations of these various groups. V. Statistical Research Statistical research in cancer morbidity and mortality should be conducted on a continuing basis in California. Data for such research should be collected from all available sources. The tumor registry pro- gram, which is providing basic morbidity data, should be expanded to include voluntary reporting of cancer cases from hospitals, clinics, and as many physicians as may be deemed practical by the Cancer Commis- sion of the California Medical Association. Funds should be made avail— able to compensate these reporting sources, at least in part, for expenses incurred in such reporting. Cancer statistical services should be conducted by the California Department of Public Health and state funds should be used to support the cancer statistical services, including the tumor registry program. It is emphasized that the reporting of cancer cases to the California Department of Public Health shall be on a voluntary basis. VI. Curative and Palliative Treatment The medical care of the indigent is the responsibility of the county government. Cancer, however important, is only one phase of the prob- lem of medical care, so that the curative and palliative treatment of indi- gent cancer patients should be administered by county authorities and financed from county tax funds. It is again recommended that state funds be not used for the diagnosis and treatment of cancer. VII. Research Grants-in-aid for cancer research are available to teaching institu- tions in California from the National Cancer Institute and from the American Cancer Society. These grants are largely dependent upon the facilities and personnel in any institution available for the conduct of such research. Lack of adequate housing and physical facilities in our teaching institutions may restrict the availability of such grants. A sur~ vey should be made of such facilities for cancer research in each of the existing teaching institutions, the five medical schools and the California Institute of Technology to determine their need. The erection of build- ings and the provisions of such facilities for cancer research should be on the basis of a specific contract with the institution, and that contract 190 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA should be terminated When the facility is completed. In this regard state aid may be necessary to provide construction funds. GENERAL STATEMENTS l. A program of cancer control is in the process of development in the State of California under the auspices of the Cancer Commission of the California Medical Association and the California Division of the American Cancer Society, in cooperation with the California State Department of Health. 2. The educational program Of the Cancer Control Project will cause progressively future expansion and development of the over-all program. 3. State funds should not be used in diagnosis and treatment of cancer except in instances of county indigent patients Whose residence is not clarified to the extent that county responsibility is established. 4. State funds may be legitimately used to provide adequate housing for physical facilities in our teaching institutions in order to expand and promote cancer research in the State of California. SUMMARY No legislation is needed to develop the various projects of the Cancer Control Program except for its educational, research and statistical aspects. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA ‘ 191 APPENDIX D-2 THE HEART DISEASE PROBLEM IN CALIFORNIA AND RECOMMENDATIONS FOR A HEART DISEASE CONTROL PROGRAM A Report Prepared by The Heart Advisory Committee California Tuberculosis and Health Association A. GENERAL STATEMENT Paul D. White, one of America’s outstanding cardiologists, has statedfi“ that “cardiovascular disease constitutes the major public health problem of our day.” Mortality As a cause of death, heart disease ranks first by a wide margin. In California during 1947, heart disease accounted (Table 1) for 32,535 deaths—one-third of all deaths which occurred during that year. If the closely related vascular diseases are added, the combined total amounts to almost half of all the deaths which occurred in California during 1947. Although mortality from heart disease increases with age, it is by no means limited to persons in the older age groups. In 1947 five percent of those (lying of heart disease in California were under 45, and 31 percent were between 45 and 64. Table 1 shows the number of deaths in California in 1947 attributed to the major groups of cardiovascular-renal diseases. Analysis of the trend of mortality from heart disease over a period of years is complicated by the changes that have occurred in diagnostic concepts of the medical profession, and in statistical assignment of the primary cause of death. Because of these changes, there has been a shift- ing of terms within the total group of cardiovascular-renal diseases. Part of the deaths which in 1910 or 1920 would have been attributed to intra- cranial lesions of vascular origin (cerebral hemorrhage and apoplexy) or to nephritis, are today assigned to heart disease or to other diseases of the circulatory system. For this reason the mortality trend of the cardiovas- cular-renal diseases should be considered as a whole. The trend in Cali- fornia is shown in Table 2. It will be noted that between 1910 and 1947 the number of deaths from cardiovascular-renal diseases increased from under 10,000 to almost 50,000. Most of this rise, however, is attributable to increase in population and to aging of the population (the age-adjusted death rate remains rela— tively stationary). The age-specific death rates (Table 2) show that for persons under 45 years of age the death rate from cardiovascular-renal diseases has been decreasing. It is in this age group that the eifects of infectious processes on the heart and kidneys are most commonly found. For persons between 45 and 74 the death rate from cardiovascular dis- eases has remained relatively constant; the death rate among persons in the productive years of life continues at a high level. For those 75 and Older it has actually been increasing. In this advanced age group the arteriosclerotic and other cardiovascular-renal diseases are prominent. * Chapter on Heart Disease, Preventive Medicine in Modern Practice, New York Aculemy of Medicine, 1942, page 427. 192 ' A CHRONIC DISEASE PROGRAM FOR CALIFORNIA Morbidity Mortality data do not by themselves give a full picture of the magni- tude of the heart disease problem. Comprehensive morbidity information is needed, but is not available. An indication of the extent of heart disease disability in one segment of the California population may be obtained from the reports of the California Disability Insurance Program. Under this program in 1947 approximately 3,000,000 persons (for the most part industrial employees) were eligible to receive cash benefits of $10-$20 per week for wage loss due to disabilities, starting after a one—week waiting period. Benefits were not paid beyond a maximum of 23.4 weeks. It should be noted that this program does not cover housewives, farmers, business or professional persons. Employees are covered by either the state plan or voluntary plans and benefits vary with the different types of plans. Under the state plan in 1947 benefits were paid for a total of 89,160 spells of disability. Of these 12,858 spells were due to the cardiovascular diseases, with benefits amounting to $2,835,058 for 148,671 weeks of dis- ability. Among those covered by voluntary plans for the same year bene— fits were paid for a total of 35,998 spells of disability. Of these, 3,155 spells were due to the cardiovascular diseases, with benefits amounting to $582,819 for 21,716 weeks of disability. These statistics pertain only to those in the working force at the time of becoming ill. They do not include persons with heart disease who are chronic invalids and outside the work- ing force. Many persons with heart disease symptoms do not lose time from work, but continue until they die suddenly; this is especially true of coronary artery disease. Nature of Heart Disease It should be noted that the terms heart disease and cardiovascular disease actually cover a multiplicity of diseases with varied causes. A small proportion of heart disease is congenital; some of these cases are now considered to be due to virus infections during pregnancy. A sub— stantial amount of heart disease arises from infectious processes, such as diphtheria and especially rheumatic fever in childhood, and syphilis which usually occur during early adult life. High blood pressure and arterio- sclerosis are the principal causes of cardiovascular disease in later life. Certainly a great deal of work remains to be done in determining the causes of cardiovascular disease in later life. Even now we know that the incidence of heart disease is much higher when diabetes or obesity is present. Though we do not understand the precise cause of all forms of heart disease, we do have sufficient information upon which to base action for the reduction of deaths and disability from heart disease. Medical science has recently produced numerous techniques which can be utilized in the attack on heart disease. Among these should be mentioned the use of drugs in preventing and treating infectious processes, surgical treatment for cer- tain forms of congenital heart disease and of high blood pressure, and the improved methods of treatment for the heart diseases of adult life. A gen- eration ago the treatment of heart disease consisted largely of rest and medicine; today clinicians use a program of total management of the cardiac patient. The latter implies a broader approach involving a variety of medical and nonmedieal measures. Emphasis is shifting from the A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 193 handling of advanced heart failure toward early detection and continuous supervision in order to achieve a maximum working life, enjoyed in com- fort. As public responsibility for disabled persons increases, the mainte- nance of productivity becomes a matter of great social concern. Nowhere is this principle of minimizing the effects of ill health more significant or the ultimate benefits more promising than in the case of heart disease. B. OBJECTIVES OF A HEART DISEASE CONTROL PROGRAM Heart disease control encompasses four principal aims: Prevention of the disease or the arrest of its progress; early diagnosis and adequate medical treatment; rehabilitation of the patient; and alleviation of dis- tress among advanced chronic invalids. Although these goals are closely interrelated a brief discussion of each is given below. Prevention When applied to heart disease the term prevention refers not only to specific measures such as diphtheria immunization, but also to action taken for the control of certain diseases, e.g., rheumatic fever. This rep- resents a broadening of the concept of preventive medicine to include the prevention of the progress of disease. The prevention or reduction of obesity also tends to reduce deaths and disability from heart disease. Diagnosis and Treatment A comprehensive heart disease control program should include pro- vision of early diagnos1s and adequate treatment. These are, of course, primarily the responsibility of the medical profession. Rehabilitation In times past, rehabilitation has been regarded as aimed at indi- viduals with Obvious physical impairment. Today activities are being expanded to serve those with just as serious but not so obvious defects, such as heart disease. Rehabilitation of the patient with cardiac disability ideally should start with the early discovery of the disease. In far too many cases, patients seek medical attention only when long-standing symptoms indicate that advanced physical changes have occurred. For best results patients must be directed into the hands of the medical pro- fession early in the course of the disease. Hence, early case-finding is an important element of the program. Rehabilitation has been defined as the restoration of the handicapped to the fullest physical, mental, social, vocational and economic usefulness of which they are capable. In the‘case of the cardiac patients, the services properly include not only physical restoration, vocational training and placement, but also continued med- ical supervision in the guidance of the rehabilitation effort and the obser- vation of its effects. Alleviation Attention must also be devoted to the alleviation of discomfort among those for whom neither prevention nor rehabilitation is possible. This is the fourth objective of a comprehensive heart disease control program. The care of long-term cardiac illnesses in hospitals, in other institutions, 13—L<8179 194 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA and at home is an increasing responsibility. It will require the coordina- tion of effort from many sources—the medical profession; hospitals, nursing homes and custodial facilities; and the various home-care serv- ices such as bedside nursing, medical social service, and housekeeping. Plans for long—term heart disease should be closely integrated with those for long-term illness in general. C. METHODS Rheumatic Fever Program Rheumatic fever control activities have been carried out in several California counties during the past several years. A special report on this subject is now being prepared for presentation to the State Legislature. Statistical Evaluation—One of the primary elements in the attack on heart disease is the statistical study of morbidity as well as mortality from the various forms of the disease. Mortality data is available in fed- eral, state and local publications. Morbidity information, however, is not so available. Except for rheumatic fever, heart disease is not reportable; hence, data concerning incidence and prevalence including their rela- tionship to age, sex, race, occupational status and other factors can be obtained only indirectly. In developing a heart disease control program, a system for obtaining current general morbidity information would be extremely valuable. Professional Education—In view of the advances being made in the diagnostic and therapeutic aspects of heart disease, continuous dissemina- tion of new information to the medical profession must be provided. In addition to utilization of county medical society meetings and hospital staff meetings, special conferences on heart disease problems are desir- able. Thosc sponsored by the heart committees Of Los Angeles and San Francisco in recent years have proved popular and valuable. It is impor- tant that similar opportunities be made readily available to the physicians in rural areas who find it difficult to leave their practices to attend courses in the metropolitan centers. Educational activities for public health nurses, medical social workers and other professional groups are needed to encourage appreciation of their responsibilities in the care of patients with heart disease. Public Health Education—Progress against heart disease also requires general public understanding of its significance as a health prob- lem, and of the value of early diagnosis and adequate therapy. The importance of regular physical examinations throughout life for the prompt detection of heart disease and other defects must be continually stressed. The all too common attitude of doom with respect to heart dis- ease should be dispelled. Emphasis is needed on the fact that, provided reasonable care is taken, many persons with damaged hearts live their expected number Of years as useful members of society. Popular under- standing is essential not only for individual health protection but also for the development of community heart disease control activities. Research—To assure continued advances in our knowledge Of heart disease, adequate provision must be made for basic research in the labora- tory and in the clinic. The funds available for heart disease research have been trivial considering the magnitude of the problem. Almost entirely neglected has been administrative research, i.e., studies leading to improvement in the application of tools now at hand (such as the minia- ture-film as a technique for detection). A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 195 Demonstration Services—Inasmuch as organized efforts for heart disease control (other than rheumatic fever) are still in the formative period, emphasis will have to be placed on demonstration services. Screening Methods—One important field needing development is that of screening techniques for the early detection of heart disease, com- parable to similar endeavors in tuberculosis, syphilis, and diabetes con- trol. One device (the miniature X-ray film) has already been proved useful. A review of 70,000 miniature-films in Los Angeles revealed that approximately two percent of the general population surveyed had X-ray findings suggestive of heart disease. When thoroughly studied, one-half of this group (1 percent of the total population surveyed) was found to have clinically significant, previously unknown heart disease. This figure means that, starting from the approximately one million minia- ture-films which will be taken in the California tuberculosis control pro- gram during each of the coming years, approximately 10,000 cases of heart disease may be discovered each year. Accomplishment of this goal depends upon: (1) Proper interpretation of the miniature—film heart shadows, and (2) development of a system for follow-up of those with suspected heart disease so as to assure adequate examination. In addition to the miniature-film, several other devices have been proposed for screening the general population for heart disease and these should be adequately tested. Rehabilitation—Up to the present time in California there has been no organized program for the rehabilitation of cardiac patients. The State Bureau of Vocational Rehabilitation has been able to carry out only limited services for those with heart disease. How to assure proper indus- trial placement continues as a major unsolved problem in the field of heart disease control. A comprehensive effort in this diiection on a pilot basis might well reveal a pattern generally applicable throughout the State. It so, tremendous social and economic savings would result. Home Care—A demonstration program in the home- care of cardiac patients utilizing the various professional groups as a team, might well point the way to a considerable saving in hospitalization. Such a home- care program for cardiac patients should, of course, be integrated with similar endeavor for long-term illnesses as a whole. D. SUMMARY AND RECOMMENDATIONS Two of every six deaths in California are due to heart disease. Another one-sixth are due to other diseases of the blood vessels. A vast amount of morbidity with consequent social and economic loss also results from cardiovascular disease. Although basic research into the nature of heart disease remains a prime need, organized control activities can be developed with our present knowledge and available techniques. Heart disease control ought to include: (1) statistical evaluation of the problem and of control efforts; (2) professional education, for the auxiliary professions as well as for physicians; (3) general public education; (4) promotion of early case- finding through screening methods; (5) effective rehabilitation services; and (6) adequate services for long-term cardiac patients, including care in the home. 196 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA It is recommended that three steps be taken at this time toward the reduction of deaths and disability from heart disease: first, the develop- ment of a screening program for early detection with referral of cases to appropriate sources of medical care; second, the establishment of a com— prehensive rehabilitation service for cardiac patients including placement in industry; and third, statistical study of cardiac morbidity and mor- tality. In addition to these specific actions, it is recommended that in the development of a long-range chronic disease program attention be given to home-care services for patients with heart disease, and that the present educational activities pertaining to heart disease be expanded. TABLE 1 DEATHS FROM CARDIOVASCULAR-RENAL DISEASE OCCURRING IN CALIFORNIA: 1947 Number Cause of death of deaths Chronic rheumatic heart disease ____________________________________________ 1,706 Heart disease (except rheumatic) _____________________________________ 30,829 Diseases Of the coronary arteries and angina pectoris ___________________ 11,578 Other diseases of the heart __________________________________________ 19,251 Diseases of the circulatory system (other than heart disease) __________________ 2,880 Arteriosclerosis _______________________________________________ 1‘“ 2,131 Other diseases of the circulatory system _____________________________ 749 Intracranial lesions of vascular origin __________ 7,652 Nephritis _______________________________________________ , Oi Arteriosclerotic kidney _________________ 2,912 Other and unspecified nephritis ______________ 7 ___________________________ 991 Total _____________________________________________________________ 46,970 SOURCE: State of California Department or Public Health, Vital Statistics Records. TABLE 2 TREND OF MORTALITY FROM CARDIOVASCULAR-RENAL DISEASES DEATHS OCCURRING IN CALIFORNIA; 1910-1940 (Rates Per 100.000 Population) .4 ge- . Percentage Crude adjusted _ AVE—39991116 death rate Number of all death death “ 75 of deaths deaths rate rate under 45 45-74 and over 1910 ______ 9,064 28.0 381 .2 523.4 81.0 1010.8 6443.6 1920 ______ 14,999 31.8 437.7 549.1 68.2 1008.3 7911.0 38.6 451.1 542.9 50.7 1041.7 8118.2 46.9 545.1 545.1 42.5 1101.2 8332.5 48.4 475.6 " ‘Adjusted to the age distribution of the California population in 1940. The age- adjusted death rate is the rate that would have applied if the proportion of persons in the various age groups had been the same in 1910, 1920 and 1930 as it was in 1940. b Although it is known that on the average California‘s population was consider- ably younger in 1947 than it had been in 1940, sufllciently detailed age data. are not avail- able for the computation of 1947 age—adjusted death rates. SOURCE: State of California Department of Public Health, Vital Statistics Records. United States Public Health Service, National Office of Vital Statistics. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 197 APPENDIX D-3 THE DIABETES PROBLEM IN CALIFORNIA AND RECOMMENDATIONS FOR A DIABETES CONTROL PROGRAM .1 Report Prepared by The Chronic Disease Service, _ California Department of Public Health—In Consultatwn 'thh Several (‘ulifornia Members of the American Diabetes Assocaatwn A. STATEMENT OF THE PROBLEM A generation ago the diagnosis of diabetes was practically a sentence to a lingering death, especially among younger age groups. Today, with proper management of the disease, the patient may look forward to an almost normal life. Yet diabetes was responsible for 2,027 deaths in California during 1947, whereas in 1910 it accounted for only 378 deaths. This increased mortality from diabetes is due in part to the aging of the population (since the disease is more common in the older age groups) and to the increase in the population. Deaths from diabetes, however, do not fully indicate the magnitude of the problem; attention must also be given to the prevalence of the disease among the living. In a community-wide survey in Oxford, Massa- chusetts,1 over two-thirds of the population were tested for diabetes. Results indicated that 1.7 percent of the entire population had the disease. Of the 70 cases in the community, 40 were known prior to the survey and 30 were newly discovered as a result of it. By applying these ratios to California, it can be estimated 2 that there are approximately 170,000 persons afflicted with the disease in the State, with probably 70,000 of them unaware of it. That diabetes oftentimes causes extended periods of disability is revealed by data from the 1947 operations of the California Disability I nsuranee Program. During that year diabetes accounted for 540 periods of disability (a total of 5,833 weeks of benefits paid) among employees covered by the state plan, and 106 periods (a total of 585 weeks of benefits paid) among those covered by the voluntary plans. Although the exact nature and cause of diabetes have yet to be discovered, medical science has produced a specific and effective method of treatment as well as some knowledge of how to prevent the disease. Diabetes is characterized by inability of the body to utilize properly the sugar absorbed into the blood stream from digested food. This failure is associated with a deficiency of insulin, a secretion of one of the internal organs of the body—the pancreas. It is also associated with an increase in the blood sugar level and the “spilling” of sugar from the blood stream into the urine. Diabetes cannot be cured. However, with diagnosis early in the course of the disease and proper dietary and insulin treatment the individual with the disease may expect practically the same working efficiency and ~1—VV—ilkerson, Hugh L. 0., and Krall, Leo R., Diabetes in a. New England Town. J. .4. M. A., September 27,1947,V01.135,pp. 209-216. 2 Using the California Department of Public Health’s estimate of the 1947 popula- tion, i.e., 9,876,000. 14—L«8179 198 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA duration of life as those who do not have the disease. Diabetes is more common among obese persons; in fact, incipient forms of the disease may sometimes be arrested through reduction in weight. Diabetes is also familial, with incidence among relatives of diabetics considerably higher than in the general population. Mortality and disability from diabetes could be substantially reduced if all the knowledge about it were systematically applied. Lack of general public information concerning symptoms and failure to obtain periodic urine examinations results in many unnecessary complications and pre- mature deaths from diabetes. The medical profession, though increasingly aware of the disease, could contribute still further to its early detection by systematic search for it—especially among certain classes of patients such as the obese, the elderly, and the relatives of known diabetics. Once the disease is diagnosed, proper management involves continuing medical supervision including careful dietary instruction. Diabetics must be prepared psychologically if such management is to be successful. Another important step which should be taken to reduce deaths and disability from diabetes is to educate the public against the dangers of entrusting the care of diabetics to irregular practitioners and cultists. Needless deaths and disability result from harmful remedies recom- mended by quacks. An organized community diabetes control program would supple- ment the services performed by individual private practitioners prin- cipally through increasing public consciousness of the disease and its symptoms and through promoting early detection. Such a program would lead ultimately to a reduction in the diabetes toll and its personal and social costs. At present no complete diabetes control program exists in California. It might be mentioned, however, that in one community (San Jose) the County Medical Society and the City Health Department jointly carried out the survey in 1948 among approximately 1,000 industrial employees with the result that several cases of the disease were discovered. B. OBJECTIVES OF A DIABETES CONTROL PROGRAM Objectives of a diabetes control program include: (1) Prevention of the disease, (2) early detection and adequate treatment of the disease, and (3) palliative treatment of those suffering from complications such as disorders of the eye and circulatory systems. The reduction of obesity, particularly among relatives of known diabetics, would result in substantial prevention of the disease in its clinical form. A considerable amount of nutrition education has hereto- fore been concerned primarily with vitamins and the other so-called protective foods. Some of the life insurance companies have inaugurated broader educational programs, emphasizing the importance of normal weight. Nutrition programs of public agencies should also be concerned with the elimination Of obesity and the maintenance of normal weight. Early detection of diabetes would be favored by wide public knowl- edge of the symptoms of the disease, by increasing the alertness of the medical profession to diabetes, and by instituting screening surveys of selected population groups or even of entire communities. Once the disease is diagnosed the patient should have continuing medical supervision. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 199 Summer camps for diabetic children have proved their value not only in providing recreation, but also in teaching diabetic children the proper steps in the care of their disease. The further development of such summer camps merits wide support and encouragement. Provision should be made for the palliative treatment of those suffer- ing from the effects of the disease—not only in hospitals and other insti- tutions but also in their homes. Elderly patients often need assistance in caring for the debilitating effects of diabetes. C. METHODS OF CONTROL In attacking the problem of diabetes one of the first steps should be to carry out statistical studies of the morbidity as well as of the mor- tality from the disease. Inasmuch as diabetes is not a reportable disease, data concerning its incidence and prevalence can be obtained only indirectly. A current general morbidity information system (including data on diabetes) would be of great assistance in planning a program for its control. Analysis of hospital records is another possible source of information. Attention should likewise be given to the possibility of establishing community-wide diabetes registers similar to those estab- lished for cancer and other chronic diseases. Since progress in the scientific understanding of the disease has been so rapid (and advances are still being made) continuous profes- sional education is required for prompt diffusion of the new knowledge concerning diagnosis and treatment of diabetes. It is particularly impor- tant that physicians who practice in rural areas and who have been away from medical centers for some time be given the opportunity for contact with colleagues from the metropolitan institutions. In county medical society meetings, hospital staff meetings, and clinical conferences ade- quate attention should be paid to the problems of diabetes. Physicians with special interest and experience in the disease have an obligation to stimulate such attention. Other professional groups—particularly pub- lic health nurses and nutritionists—need continuing educational pro- grams indicating their opportunities and responsibilities in diabetes control. A program of health education, incorporating a well planned psycho— logical approach, should bring the facts concerning diabetes before the general public and should motivate proper action when the disease is suspected or known. Probably the most direct approach to diabetes control at present is the screening survey. Simple tests performed on small specimens of blood and urine now permit detection of signs which may mean diabetes. These tests can be applied inexpensively to large groups of people. Those for whom the results are suspicious must be given further study in order to determine whether or not diabetes is present. In this manner, many persons who are unaware of the presence of this serious disease would be referred to their physicians for care Which would prolong their lives and prevent disabilities. Organization of such screening programs should be carried out cooperatively by health departments and medical societies. Research into the fundamental aspects of diabetes should be inten— sified. Our techniques of control, while vastly improved over those of 200 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 25 years ago, are still far from perfect. Further investigation might well lead to more satisfactory means of treatment and may even throw light on the prevention of diabetes. Research is also needed into the methods of applying present information. D. SUMMARY AND RECOMMENDATIONS Diabetes, as a substantial cause of deaths and disability in California, merits greater attention from the medical profession and health depart- ments. Current knowledge of the disease if fully utilized would result in considerable improvement of health and saving of lives. It is recommended that a program of diabetes control be developed in California. Such a. program should include: Statistical studies, pro- fessional education, public education. development of screening surveys and research. Close cooperation between health departments and organ- ized medical bodies would be essential to the success of this program. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 201 APPENDIX D-4 THE EPILEPSY PROBLEM IN CALIFORNIA AND RECOMMENDATIONS FOR AN EPILEPSY CONTROL PROGRAM A Report Prepared by the Medical Advisory Committee on Epilepsy, California Society for Crippled Children The scope of the epilepsy problem has been well stated by the author- ity, Tracy Putnam, “The social and economic problems presented by the convulsive disorders are staggering. It is estimated that over half a million people in this country suffer from seizures about as many as have active tuberculosis! About 50,000 are in public institutions, the cost of their maintenance approaching $20,000,000. The expense of caring for those at large, many of them unjustly refused employment. probably amounts to over twice as much. These figures, of course, give no more than a hint of the frustration, anguish, economic loss and misery involved. Liberty of action of persons subject to convulsions is limited, often in an arbitrary manner, by the laws of many states.” Estimates of the economic loss represented by the potential earning capacity of epileptics who are potentially capable of being rehabilitated are not available, but undoubtedly run into many millions of dollars per year. We are at present attempting to obtain statistics as to the number of epileptics institutionalized in California and some idea of their cost of maintenance, but this is not as yet available. The situation of the epileptic might be strikingly modified if adequate therapy, which is now medically possible, were made available to the epileptics. As Doctor Putnam has stated, “Perhaps the most eloquent commentary on the subject of employment is the fact that the majority of people under treatment for seizures do find work. A recent survey by Doctors Lennox and Cobb shows that about three quarters of over a thousand patients, taken at random from many communities, were actually employed in a wide range of occupations.” With regard to the employability of such patients in industries, it is of interest that the Association of Casualty and Surety Companies, representing 61 capital stock insurance companies, has stated that the association does not advise against employment of persons suffering from any disability. Furthermore, it has been the general experience that physically handicapped workers are good workers and records indicate that they have fewer accidents than the average employee who has no particular concern about his health. Specifically, many employers of workers being treated for epilepsy have found them particularly appre— ciative, devoted and capable. Because epilepsy is predominantly a disease of youth, its prevention and cure from an economic standpoint is much more important than such other chronic diseases as cancer, kidney and heart trouble. “Recommendations” must necessarily be based upon what can be done about the problem and what agencies or groups are best qualified to carry out the desired program. 202 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA Consideration as to what can be done about epilepsy falls into two categories, ( 1) treatment, including rehabilitation of the epileptic and (2) research. A third consideration—prevention—might be mentioned in terms of “breeding it out” by education of prospective marriage partners and parents and sterilization of patients with marked epilepsy susceptibility. Rational treatment implies diagnostic study of the individuals and correction of all factors influencing the convulsive susceptibility. Greater advances have been made in studying the causes of epilepsy and its treatment in the last ten or fifteen years than in all previous time and intensive studies are continued along these lines. Several excellent anti- convulsive agents are now available and when properly prescribed, singly or in combination, and with adequate regulation of other factors which influence the convulsive susceptibility of the patient, the prospects of modern medical treatment are excellent. In several large series of patients, seizures have been arrested in as high as 80 percent of epileptic patients. Considering the rapid advances in the anti-convulsive therapy, it is not unreasonable to expect that this figure may be exceeded in the near future. In connection with the treatment of epilepsy it should also be emphasized that the rehabilitation of these patients involves the proper correction of the psychological, social and economic handicaps previously suffered by the epileptic. As already implied, research in the field of the convulsive states is necessarily largely confined to medical studies on the cause and treatment of epilepsy. “Recommendations” as to the groups and program of action that can most effectively deal with the problem of epilepsy may be summa- rized as follows : 1. Only physicians who are adequately trained with respect to con- vulsive disorders can satisfactorily treat or do research in this field; 2. The physician in treating epilepsy and conducting his research will necessarily call upon several other groups and facilities such as hospitals, certain special laboratories (such as electroencephalography, X-ray, etc), nurses, pharmacists, technicians, social service workers, psychologists, biochemists, physiologists, etc. These auxiliary groups must also be adequately trained to cooperate effectively in the plan of treatment or research outlined by the physician; 3. Adequate training of both the physician (neurologist, neuro- logical surgeon. psychiatrist, roentgenologist, etc.) and the ancillary technical specialists (technicians, psychologists, etc.) can be facilitated and better treatment assured the epileptic by the establishment of special epileptic centers. Considering the complexity of. the problem, the large number of specially trained physicians, technicians, etc., required, and the training and service implications of such centers, they must of neces- sity be located in cities and preferably in medical teaching centers. In this connection a survey of present personnel and facilities should be made and adequate centers established to utilize them more effectively. The proper development of centers, in large part already provided with adequate personnel and facilities, should be encouraged before starting new clinics in areas where personnel and facilities are not available and where adequate follow-up care could not be assured. _. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 203 4. If specialist physicians of the highest caliber are to be attracted to such centers and if such physicians are to be given the maximum opportunity to treat epilepsy effectively and conduct their research, certain principles with respect to the organization and running of such special centers are essential: a. A physician with proper training and qualifications should be placed in charge of the clinic and made responsible for its pro- fessional management and operation. N0 outside agency should attempt to manage or control the professional activities of these centers. The appointment of the director of the clinic would be in the hands of the hospital or medical school in which the center was located. As indicated previously, centers should be established in areas where personnel and facilities are wholly or in part already available rather than starting new centers in areas where personnel and facilities are not available. Lay or political influence with respect to appointments or the management should not be permitted if the quality of the clinics is to be assured. b. Standards for the center must be established by the physi— cians who are specially trained in this field. No agency or lay group should attempt to establish standards for such centers. The centers should be open for inspection at any time, however, and should encourage a postgraduate training program. Thus, any agency con- tributing funds for the support of such centers would be free to fol- low the work of the centers at all times and, if dissatisfied with the work of the clinic, could withdraw their support. c. Patient referral to' the center should be made by the physician or clinic who had taken care of him previously. In case the patient had no doctor or had previously attended no clinic, it would be proper for him or his family to contact the county medical society in their neighborhood and ask for information. The county medical society could then refer the individual to one of the established cen- ters or give the information to the doctor or clinic who had been taking care of the patient and who wanted to refer the patient for special care in this field. Physicians referring patients to an epileptic center should expect a report of the clinic’s findings and recom- mendations for the patient ’s follow-up care in the same manner as is now a well established practice in clinics for care of the medically indigent. The only exception to this would be in those instances in which the referring physician requested that follow-up care be given by the epileptic center. In all instances, however, definite arrange- ments for the professional follow-up services should be made as opposed to any loose arrangements in which neither the center nor the local physician accepted responsibility, or some other agency attempted to fill the gap. (1. Financial support from any source for such centers should be confined to: (l) Underwriting the expenses of transportation to the centers and the expenses of diagnosis and therapeutic work done at the center for patients who are medically indigent. Since A CHRONIC DISEASE PROGRAM FOR CALIFORNIA these centers would be established on a clinic basis, their own social service agencies would be passing on the latter point, namely, as to whether or not the individual applying for care fitted into the economic bracket which qualified him as being medically indigent and, therefore, properly entitled to clinic care. In this connection, it should be the social service agency of the clinic to pass on this matter rather than any outside agency. The fees paid by patients referred to the epileptic centers would, of necessity, be determined by the clinic and would vary from clinic to clinic depending upon their overhead and other expenses as well as support from various sources which might help to defray their expenses. Correspondingly, no outside agency should attempt to fix clinic fees. In the case of patients referred to the epileptic centers who (after being interviewed by Social Service) could not qualify for such care because of the fact that they were not medically indigent, they could seek private appointments with the physicians in charge of the clinics (if this was agreeable with the referring physician) or with any other physician whom their local doctor or county medical society might recommend. The professional fee in this instance would be determined by agreements between the physi- cian concerned and the patient. Again, no outside agency should attempt to fix the fees for such care. \Vith respect to the pay- ment of the clinic, laboratory or professional fees by an outside agency, the medical profession is opposed to any organization paying the medical bills of those who are able to pay for them- selves on the basis that there is no more reason to pay the medical bills of such individuals than there is reason for an outside agency to pay their grocery or clothing bills. Payment of medi- cal bills other than those for the medically indigent by any organization, whether it be governmentally sponsored or lay (such as the National Foundation for Infantile Paralysis, Inc., or the Red Cross, etc.), is foreign to our American tradition and should not be countenanced in our plans for the epileptic centers. (2) Underwriting certain expenses of the epileptic center itself such as the purchase of special equipment (electroenceph- alographic) or paying the salaries of a special administrative assistant who would aid the physician in coordinating the work in the center. 5. Research in the field of the convulsive disorders will, of neces- sity, be conducted by specialists in this field in teaching centers. The need for adequate facilities, equipment, space and technical assist- ance should be emphasized. The limitations in these respects which now exist and the need for adequate support should be stressed. 6. Education: This can be considered under two headings: a. The training of professional and technical specialists which can best be done by a survey of the undergraduate cur- riculum in the various schools concerned and by the training A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 205 afforded on a postgraduate basis in the epileptic centers pro- posed; b. Propaganda to the lay public on the subject through papers, magazine articles, pamphlets, lectures, radio broadcasts, etc., to make the public aware Of the problem, the availability of help in this field and to insure the support of the public. Such publicity is at present being handled by two national agencies and except to cooperate with these agencies and further their activities, additional special efforts along this line would not seem necessary. The soundest propaganda in the long run will come with the establishment of quality centers that will effec- tively deal with this problem. Well-controlled patients in the different areas of the State will result in more eifective “adver- tising’ ’ or “sales talk” than many articles or broadcasts.- 7. Legislation: Funds should be provided to encourage the establishment and to give continued support as may be required for such centers in the manner indicated above. Funds for research should, likewise, be made available. The amounts needed could be estimated only after a survey of the potential centers was made. 15—L-8179 206 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA APPENDIX D-5 THE DENTAL DISEASE PROBLEM IN CALIFORNIA AND RECOMMENDATIONS FOR A DENTAL DISEASE CONTROL PROGRAM A Report Prepared by The Bureau of Dental Health, California Department of Public Health Dental disease affects over 90 percent of our population. It affects 50 percent by the age of two, and steadily increases in incidence until it can be said that only rarely in an adult can the results of dental disease not be seen. Dental disease may have its foundation even before concep- tion in that improper maternal nutrition may result in malformations and faulty supporting structures. Average number of Age decayed teeth 2-5 __________________________________ 4 deciduous 6-12 __________________________________ 6 deciduous, 2 permanent 13-17 __________________________________ 4 permanent 18 __________________________________ 7 permanent Dental health and general health are directly related. Diseases of the teeth and supporting structures are not separate or isolated condi- tions with effects confined only to the oral cavity. Infection of the teeth and adjacent tissues often produces serious systemic damage in other tissues and structures of the body. Dental disease—a chronic condition in itself—is often considered to be a predisposing; cause of other chronic illnesses such as cardiovascular diseases, rheumatism and arthritis, gas- tric disturbances and cancer. Until recent years advances in dentistry were primarily concerned with restoration of carious teeth, replacement of teeth and elimination of infection. Today there is growing concern with the prevention rather than the repair of dental disease—prevention not only of dental caries (decayed teeth), but of orthodontic defects, of periodontoelasia, and of cancerous conditions originating in the oral cavity. There is growing recognition of the importance of research in all aspects of the problem of dental disease. The control of dental disease must be based on prevention with emphasis on early examination, diagnosis, treatment and dental health education. It is well recognized that there are not enough dentists at the present time to take care even of the yearly increase in dental caries, leaving aside the accumulated dental needs of the population. There are less than 15 percent more dentists practicing in California today than there were in 1940, but there are over 40 percent more people living in the State and adding to the demand for dental services. Rehabilitation of the mouths of adults who suffer from dental disease involves enormous costs. The Veterans Administration reported that in the Fiscal Year 1947-1948 the cost of dental treatment for approximately 1,000,000 cases of service connected dental disability was $55,765,831—over $55 per case. ,— A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 201 The only realistic approach to the problem of dental conditions is to direct major attention to children. All available means at our disposal must be utilized to control or prevent dental caries and their sequelae in children and thus promote good dental health in later life. The use of topical sodium fluoride is now an accepted and recommended procedure. It should be emphasized, however, that it is but an aid and not a cure-all, and that it should be used in conjunction With regular dental care, proper nutrition and good home hygiene. Dental disease can for the most part be controlled and control must start with the younger age groups. The dental health of our citizens can be improved by: 1. Developing and expanding research programs in prevention of dental diseases, and in methods of providing service for dental conditions. 2. Expanding education to motivate people to take better care of their own dental health and the dental health of their children. 3. Stimulating the expansion of programs in dental care for chil- dren utilizing all accepted preventive and control measures. 208 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA APPENDIX D-6 RHEUMATISM A Report * by the Northern California Rheumatism Association PROBLEM OF RHEUMATIC DISEASES IN UNITED STATES The most common cause of chronic illness in the United States is the group of rheumatic diseases. Approximately 7,500,000 Americans have arthritis or some other form of rheumatic disease. Nearly twice as many persons suffer from rheumatism as from heart disease; seven times as many have rheumatism as have cancer or tumors; and ten times as many suffer from rheumatism as have either tuberculosis or diabetes. In fact, rheumatism is more common than the total number of cases of tuberculosis, diabetes, cancer, and heart disease combined. It was indi- cated by the National Health Survey (Revised 1939), that the rheumatic diseases are first in prevalence, second in disability, and fourteenth in mortality in this country. “Those suffering from rheumatic diseases include every age group from childhood to old age. In the United States, 30,000,000 people, count- ing the families of arthritics, are acutely concerned with the medical, social, and economic reflections of that problem. The National Health Sur- vey of 1939 revealed that 97,200,000 days of work a year in the United States were lost as a result of rheumatic diseases. During the war years from January 1943 to May 1945, even among the highly selected groups of military personnel, rheumatic diseases accounted for a loss of 275,000 man-days. The hospital care of these patients would seem to have been neglected. While there are more than 100,000 “free” beds available for the care of tuberculosis patients, there are apparently not more than 200 “free” beds in the entire country specifically available for arthritic patients. The estimated yearly cOst of medical care alone for the total number of rheumatic disease patients in this country exceeds $100,000,- 000. Consequently, this group of diseases presents one of our most important social, economic, and medical problems.” “ "‘ * “The magnitude of this problem is great as manifested by the incidence of the diseases and by the many related social and economic problems. The rheumatic disease group is one of the oldest, and it is also one of the most neglected fields of medicine. Although there is a great deal that can be done immediately to benefit the patients afflicted, it must be recognized that all the rheumatic diseases with the exception of the specific infectious arthritides are of unknown etiology and pathogenesis and are without specific therapy.” * * * “The American Rheumatism Association recognized the seriousness of this problem and initiated action to correct the situation.” The association requested the National Research Council “to undertake a survey designed to serve as a basis for the development of a compre- hensive, long-term research program in arthritis and other rheumatic diseases.” " Abstraeted from the "Preliminary Report of Committee for Survey of Research on Rheumatic Diseases," Division of Medical Sciences, National Research Council, Washington, D. C. (mimeo.), November 12, 1948. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 209 Analysis of the findings of the survey, and consideration of the effective means of coping with the basic problems involved, led to the following recommendations: “A research and training program should be established. The research program should embrace: (1) Basic research; (2) clinical . evaluation; and (3) consideration of the socio-economic aspects of these diseases. Grants-in-aid and fellowships are necessary. Adequate financial support is essential for the recommended program.” 210 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA APPENDIX E PERTINENT INVESTIGATIONS CONDUCTED IN CALIFORNIA AND IN OTHER STATES SUMMARY Studies in California Growing interest throughout the State in the problem of chronic illness is shown by four studies made in California since 1945. These include a state—wide survey Of chronic and convalescent facilities con- ducted under the auspices Of the Association Of California Hospitals; two community-wide studies (Los Angeles and Santa Barbara Counties) that placed strong emphasis on the increasing need for services and facili- ties for the chronically ill; and a study of the need for chronic and con- valescent facilities in San Francisco. Integration of general hospital facilities with facilities for chronically ill patients was stressed in each study. Official Planning for the Chronically III in Other States Studies of the chronic disease problem have been conducted and chronic disease programs have been developing in many states through- out the country. Planning for the chronically ill has reached a relatively advanced level in Connecticut, Illinois, Indiana, Maryland, Massa- chusetts, New York and New Jersey. Studies made during the 1920 ’s and the early 1930’s were concerned for the most part With the institutional needs Of chronically ill indigents and the conversion Of almshouses to nursing homes. More recent studies, and programs which have evolved from these studies, have also been con- cerned with the institutional needs of chronically ill indigents, but have gone beyond this problem. They have taken up the problems of hospital facilities for the care of the chronically ill, and licensure of institutions (particularly nursing homes). In some instances, consideration has been given to research in chronic illness and to integration of institutional services, rehabilitation services, and home care services. With but few exceptions, studies and programs in other states have concentrated on the needs Of chronically ill persons, and not on the prevention of chronic illness. Local Planning in Other States Studies Of local services and facilities for the chronically ill have been made in many communities in other states. A number of communi- ties have established Central Services for the Chronically Ill, with func- tions including: (1) Provision of information concerning local services and facilities, (2) promotion Of community planning for the chronically ill, (3) public education, and (4) sponsorship and support of appropriate legislation. A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 211 APPENDIX E-l STUDIES PERTAINING TO CHRONIC ILLNESS CONDUCTED IN CALIFORNIA Survey of Chronic and Convalescent Facilities in California, by J. A. Katzive, MD. (for Council on Professional Practice, Committee on Convalescent and Chronic Care, San Francisco, Association of California Hospitals, 1945-46). “To ascertain the extent and adequacy of existing facilities, for the care of the convalescent and chronic sick, in the State of California" a study was made by means of a questionnaire sent to voluntary hospitals, comprising the membership of the Association of California Hospitals. “This study showed an absolute lack of chronic care facilities organized and established for the specific care Of the chronic sick. What few facilities do exist are in the nature of nursing or custodial homes providing bed rest and a minimum of nursing service; practically no supervised continuous medical attention is available and in no way resembles the organization and service provided for the acutely ill in a general hospital . . . “The need for providing additional chronic and convalescent care facilities should be brought to the attention of all those concerned with public health.” A Hospital Plan for Los Angeles County. (Selections from A Hospital Study by James A. Hamilton and Associates, Hospital Consultants, 1946-47.) On the basis of an inventory of existing facilities and services in Los Angelcs County, a plan was developed including provisions for additional treatment and reha- bilitation facilities, physically integrated with general hospitals. The report stated in part: “Every evidence would indicate that the problem of the chronically ill will be the greatest health and welfare problem to confront this community in a generation. To avoid the facility requirements of this problem from becoming unmanageable, much efiort must be expended in measures of prevention. Medical research, both in basic sciences and clinical research, into the causes, methods of prevention, and methods of treatment, should be actively undertaken. Social and economic research into factors other than physical damage which contribute to invalidism should be developed. Profes- sional education in the field of geriatrics, not only of physicians but of social workers, nurses, dietitians and rehabilitation workers should be provided. Health education, on a mass basis, directed toward nutrition and prompt medical attention should be conducted. Community services on a visiting basis to families caring for invalids in their own homes should be developed through the following specialists: housekeeping aides, nutrition advisors, diet therapists and recreational workers. Such investment at present would avoid much greater expense at a later perior .” Report of Citizens’ Advisory Committee on Health and Hospital Care to the Santa Barbara County Medical Society. (Report of Citizens’ Advisory Committee on Health and Hospital Care to Santa Barbara County Medical Society, Santa Barbara, EdWin C. Welch, Chair- man, 1947.) This report was made by a committee composed of representatives of 56 of the leading groups and organizations in Santa Barbara County. Recommendations of the committee—pertaining to services and facilities available to chronic patients in their own homes and in nursing homes and custodial facilities— included the following: 1. That clinic facilities be made more accessible; 2. That the county establish a chronic-custodial facility for the elderly chroni‘ cally ill patients; 3. That medical case work be provided at the chronic-custodial facility; 212 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 4. That the Santa Barbara Medical Society make a study of the medical atten- tion and service now being given the custodial—chronic cases. This study should include recommendations from the society as to how inadequacies in that service could be corrected. The study should also cover the. matter of a geriatric service to be included on the free staff of the county facility ; . That the California State Nurses Association consider establishing not only a nurses‘ registry for graduate nurses, but one that will include practical nurses, nurses’ aides and housekeepers. The committee considered the problem of hospital facilities for chronic cases as part of the overall problem of providing hospital services for all types of patients. To assist in coordinating services and facilities for the community as a Whole, recom- mendations were made for a Hospital Council, a Hospital and Health Advisory Committee, and a Joint Health Council (of public and voluntary health agencies). 0! A Summary of a Survey of Facilities for the Care of the Convalescent and Chronically Ill as Contrastcd with the Need for Such Care in the City and County of San Francisco. (Metz, Marian, from thesis, University of California School of Social \Velfare, September 13, 1947.) This survey made by a student. of the University of California with committees of the Health Council of the San Francisco Community Chest serving in an advisory capacity—concluded, in part, as follows: “The state and municipal licensing programs have provided a degree of protection for the occupants of the homes so that no evidences of obvious physical abuse or neglect of the types which have been headlined in other states were seen here. The faults in San Francisco’s program for the care of the chronic sick and convalescent persons seems to lie in omissions rather than commissions. There are slightly more than one- fourth as many beds available as current standards say are needed, and few, if any of these, provide all of the services needed to fulfill the objectives of these kinds of care. Most of the chronic facilities merely provide a resting place for the patient between the acute hospital and the grave, with no organized effort being made to restore the patients to useful, if limited and temporary. activity.” A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 213 APPENDIX E-Z OFFICIAL PLANNING FOR THE CHRONICALLY ILL IN OTHER STATES CONNECTICUT The State Legislature enacted legislation in 1947 to implement the following program recommended by the “Connecticut Commission on the Care of the Chronically Ill, Aged, and Infirm ’ ’: 1. A central institute be established for the study and treatment of cancer, arthritis, heart disease, kidney disease, and mild mental deteriora- tion, and $600,000 be appropriated for the purpose; 2. To increase chronic bed facilities in state-aid and municipal hos- pitals, $200,000 be appropriated for grants to these institutions; 3. Activities in the prevention, control, and clinic subsidization for ' cancer now being carried on by the State Department of Health, with the cooperation of the Connecticut State Medical Society, and with hospitals, be expanded to include all chronic diseases; 4. The commission to be continued, and $20,000 be appropriated for this purpose. ILLINOIS Two official studies were conducted in Illinois. As a result of the first study (1041-1945) a bill to license private nursing homes was passed and impetus was given to a program of con- version of county almshouses to county homes for the chronically ill. A series of bills passed by the Legislature in 1945: (1) Established the county homes as medical facilities to care for infirm and chronically ill persons, whether destitute or able to pay for maintenance; (2) permitted public homes, meeting the requirements of the Illinois Public Aid Com- sion, to admit appropriate Old-Age Assistance and Aid to the Blind recipients without the client losing his relief status; (3) permitted coun- ties not having their own eligible institutions to send appropriate cases for care to neighboring counties having acceptable facilities. The second study (1945-1947) shifted its emphasis toward the medi— cal aspects of the problem of care of the chronically ill. The major recom- mendations made as the result of the second study were : 1. A state research institute for the study of chronic disease and geriatrics be established in connection with the University of Illinois Medical College; 2. Through the cooperative efforts of state and local governments and public and private agencies, immediate attention be given to expand- ing the number of beds available to the chronically ill in (a) wings of general hospitals, (b) converted county homes, (0) infirmaries of non— profit homes for the aged, and in (d) private nursing homes of high standard; 3. All hospitals and related medical institutions be licensed; 4. To minimize institutionalization and to lower costs, provision be made in every county for visiting nurse and housekeeping services; 214 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 5. A program of rehabilitation of the chronically ill be developed including occupational and recreational therapy, vocational retraining, and social services; 6. For referral purposes, every county in the State to have a register of available approved facilities for the chronically ill; 7. Housing authorities give attention to the development of special apartment house facilities that will enable chronically ill persons to remain in the normal community; 8. No person afflicted with chronic disease be denied needed care because of insufficient funds. Supplementing these recommendations, a committee of the Illinois State Medical Society (consultant to the commission) issued a report giving specifications for medical supervision and care in institutions for the chronically ill. The commission’s recommendations, presented to the 1947 Session of the Legislature, were not enacted into law. INDIANA In Indiana attention was called by medical and public health leaders to the increasing proportion of the population over forty-five years of age, the fact that 350,000 citizens of the State are sixty years of age or older, and the possibility of extending the productive years of life. In 1945 the State Legislature added a section to the general health law of the State which provided that: “The State Board of Health shall provide facilities and personnel for research investigation and dissemination Of knowledge to the public concerning the health of persons of middle and advanced age and dis- eases common thereto * “‘ *. The State Board of Health is hereby vested with discretion in providing the means and methods for such research, investigation and dissemination of knowledge, and may make, adopt and promulgate rules and regulations for the purpose of establishing proper facilities and personnel and to carry out the work described in this section.” Subsequently the Division Of Adult Hygiene and Geriatrics was established within the State Board of Health. MARYLAND Maryland’s program for care of the chronically ill has derived pri- marily from the effort to provide adequate facilities and care for indi- gent and medically indigent persons. The program has been directed toward the construction of special chronic disease institutions to replace almshouses, and the provision of medical care for the indigent. In 1943, legislation was enacted providing for the building of three institutions for chronically ill indigent and appropriating $2,500,000 for this purpose. In 1945 a law was enacted to establish the Maryland Medical Care Program. The program provides medical and dental care for the indigent and medically indigent. It is administered by the State Depart- ment of Health in cooperation with the State Medical Society and with local advisory committees on medical care. Although the program was not developed specifically for the chronically ill, a very high proportion A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 215 of chronic disease cases requiring long-term care (heart disease, hyper- tension, arthritis, nephritis, etc.) are included. Of the persons receiving care under the program, approximately 50 percent are over the age of 60. MASSACHUSETTS Massachusetts was one of the first states in the country to give official recognition to the public health aspects of the problem of cancer and other chronic diseases. Starting with one of the earliest and most com- prehensive cancer control programs, Massachusetts has extended its program to include other chronic diseases. The cancer control program, under the direction of the Division of Cancer and Other Chronic Diseases, includes: 1. The operation of two cancer hospitals for the treatment of patients who can not be accommodated elsewhere, and for the study of the disease; . 2. Financial aid to cancer consultation clinics conducted in hospitals throughout the State; 3. Tissue diagnostic services Offered free to any physician in the State. In extending its program to other chronic diseases, Massachusetts has followed a pattern similar to that developed for cancer. The State is now supporting 20 beds at the Massachusetts General Hospital for the study and treatment of arthritis. In 1945, the State Legislature appro- priated $200,000 for the formulation of plans for a new chronic disease hospital of 800 beds. Plans are now being made to establish clinics for other chronic diseases like those in operation for cancer. NEW JERSEY The State Department of Institutions and Agencies has for many years called attention to the chronic disease problem, and has provided leadership and assistance in developing facilities for the chronically ill. In 1924, permissive legislation was en acted allowing counties to establish welfare houses to supplant almshouses. Three years later, the Nursing Home Act was passed requiring the licensing of nonpublic nursing homes. In the survey Of chronic illness conducted in 1931-1932, the Department of Institutions and Agencies collected and published data on the prevalence of chronic disease in the State, and made general recom- mendations on improving medical services and facilities. ' NEW YORK Official planning for care of the chronically ill in New York State has been carried on by a Legislative Commission created in 1938 and con- tinued through 1947. The scope of the commission’s work was very broad, encompassing all problems relative to the formulation of a long-range health program for the State. Chronic disease was selected by the commis- sion as one of the most pressing problems and the one to which the least attention had previously been given. Emphasis in the commission ’3 work in this field was on (a) regionalization of services and facilities; and (b) development of a program that “does not necessarily envisage, and 216 A CHRONIC DISEASE PROGRAM FOR CALIFORNIA is not dependent upon, any fundamental change in present methods Of payment for medical services. ” The commission’s recommendations made in 1947 included those listed below. 1. The state should designate an agency for developing, coordinat- ing, administering and carrying out a program of education, research, rehabilitation and improvement of facilities and services for the care of chronic illness. Such a program should be carried out in cooperation with both state and local official and voluntary medical, health and social agencies. 2. For the purpose of planning for care of the chronically ill, as in all medical planning, the state, exclusive of New York City, should be divided into five regions. New York City would comprise a sixth region. 3. Chronic disease hospital centers should be established in each region by the state. They should admit pay and part-pay as well as free patients. Whenever possible, they should be contiguous to a general hospital, near an approved medical school, and staffed and operated by state contract with such hospital and school.'They would provide special- ized facilities for diagnosis, treatment, teaching and research, and serve as chronic disease consultation and referral centers for physicians, gen- eral hospitals, and related institutions in the regions. 4. Hospital care for the chronically ill, other than that provided by the chronic disease hospital centers, should be made widely available in general hospitals throughout the state, preferably in designated wings, wards or floors of general hospitals or in contiguous buildings; and that there should be formal affiliation between such hospitals and the regional chronic disease hospital centers. 5. In the allocation of (state and federal) funds for aiding hospital construction, special consideration should be given to projects for the establishment or expansion of facilities for the care of the chronically ill in general hospitals. 6. Home services for the chronically ill should be expanded. They should include use of both official and voluntary bedside nursing services, and the provision of housekeeping aids. NO legislation was introduced to implement the recommendations of the commission. Upon termination of the commission, further develop- ment of the program was transferred to the New York State Joint Hos- pital Survey and Planning Commission. Locality Chicago, Illinois Baltimore, Maryland Boston, Massa- chusetts St. Paul, Minnesota St. Louis, Missouri Essex County, New Jersey A CHRONIC DISEASE PROGRAM FOR CALIFORNIA 217 APPENDIX E-3 PLANNING FOR THE CHRONICALLY ILL AT THE LOCAL LEVEL IN OTHER STATES Sponsoring agencies Central service for the chron- ically ill Of the Chicago Insti- tute of Medi- cine. Council of So- cial Agencies Council of So- cial Agencies Research De- partment Am- herst A. Wilder Charity Health and Hospital Di- vision, Social Planning Council Essex County Service for the Chroni- cally 111 Major Types of Recommendations and Progiams The service was established in 1944, and was the first of its type. Its functions include: (1) Pro- vision of information concerning local services and facilities for care of chronically ill persons; (2) promotion Of community planning for the chronically ill; (3) public education; (4) spon- sorship and support of appropriate legislation. On the basis of a study conducted in 1940, recom- mendations were made that chronic hospital fa- cilities in Baltimore be increased as part of the statewide program, and that consideration be given to a plan for home services for the chron- ically ill. 0n the basis of a study conducted in 1927 under the guidance of Haven Emerson, M.D., recom- mendations were made for: (1) Appointment of a standing committee on problems of the chronic sick ; (2) expansion of hospital facilities for the chronic sick; (3) expansion of social service in hospitals; (4) extension of the activities of Homes for the Aged to a service for aged persons outside the home. A booklet prepared in 1945 points to the need in St. Paul for a well rounded program for the chronically ill including institutional facilities, rest homes, foster-homes, out—patient clinics for the aged, recreational activities, occupational therapy, medical and social ease work. On the basis of a study conducted in 1946 recom- mendations were made for: (1) Establishment of a council on chronic illness; (2) expansion of hospital facilities and custodial facilities for the chronically ill, organized in conjunction with general hospital facilities, and including ade- quate physical and occupational therapy and social service ; (3) expansion of services for care of the chronically ill in their own homes includ- ing clinic services, visiting nurse services, and housekeeping services. The service was established in April, 1948, and is composed of representatives of the county medi- cal society and local chapters of voluntary health organizations. The service has undertaken a pro- gram that includes: (1) Establishment of a reg— istry Of local facilities and services; (2) estab- lishment of an informational and referral serv- ice; (3) promotion of public awareness; (4) conduct of a study of pertinent laws and ordi- nances. 218 New York City, New York Rochester and Monroe Coun- ties, New York Cleveland and Cuyahoga County, Ohio Philadelphia, Pennsylvania Pittsburgh and Allegheny County, Pennsylvania Richmond, Virginia Dane County (Madison) Wisconsin Milwaukee, Wisconsin L-8179— 3-49 The Welfare Council of New York City Committee on the Chroni- cally 111, Council on Postwar Problems Coordinating Committee on the Care of the Chroni- cally Ill, and the Benjamin Rose Insti- tute Central service for the chron- ically ill, Health Divi- sion of the Health and Welfare Council Health Divi- sion, Federa- tion of Social Agencies Committee on Convalescent and Chronic Care, Health Division, Richmond Area Com- munity Council The Friendship Fund Committee on the Care of the Chroni- cally Ill, Council of So- cial Agencies 3M A CHRONIC DISEASE PROGRAM FOR CALIFORNIA In 1933 the Welfare Council sponsored an exten- sive study of chronic illness made by Mary C. Jarrett. The study was influential in the estab— lishment of the Goldwater Memorial Hospital, a municipal hospital for the chronically ill where both medical and administrative research on chronic illness is conducted. The study also in— fluenced the establishment in New York City of a housekeeping service for chronically ill pa— tients in their own homes. The general pattern of this study was later followed in a number of other localities. 0n the basis of review of existing facilities and services, recommendations were made for: (1) Expansion of facilities for chronic patients in the county infirmary; (2) establishment of units in general hospitals for care of chronically ill patients; (3) expansion of infirmary care in private homes for the aged. A report prepared by Mary C. Jarrett in 1944 in eluded recommendations for: (1) Expansion of hospital facilities and custodial facilities for the chronically ill ; (2) expansion of services for the chronically ill in their own homes; (3) promo- tion of both lay and professional education. The service was established in March, 1947, as the result of surveys previously conducted by the Health Division. The purpose of the service is “to foster eifeetive community services for the care and rehabilitation of the chronically ill.” On the basis of a survey conducted in 1946-1947 by Claude W. Manger, M.D., and Mary C. Jar- rett, recommendations were made for: (1) As— sumption by the Health Council of the responsi~ bilities of a central service for the chronically ill; (2) expansion of hospital facilities and cus- todial facilities for the chronically ill; (3) ex- pansion of services for care of the chronically ill in their own homes—particularly visiting nurse service and housekeeping service. A report of the committee in May, 1948, included recommendations for development of a program of expansion of facilities—particularly facilities for convalescent-type care. 011 the basis of a survey recommendations were made for the building of a new institution for long-term patients. 011 the basis of a survey recommendations were made for: (1) Establishment of a central serv- ice for the chronically ill; (2) development of a program for expansion of hospital facilities, nursing home facilities and home care services for the chronically ill. 0 UC. BERKELEY LIBRARIES CDH?EL‘I?3‘I