Page 3, line 24, after "purposes" insert "of sections 4a to 4e, inclusive". Page 4, line 1, strike out "(e) This Act" and insert "Sec. 4e. Sections 4a to 4e inclusive of this Act". Hon. CLARENCE F. LEA, TREASURY DEPARTMENT, Chairman, Committee on Interstate and Foreign Commerce, House of Representatives. DEAR MR. CHAIRMAN: Reference is made to your letter of February 11, enclosing a copy of bill H. R. 9047, "To impose additional duties upon the United States Public Health Service in connection with the investigation and control of the venereal diseases," and requesting the views of this Department thereon. The bill provides for amendment of the act of July 9, 1918, by adding after section 4 of chapter XV thereof (40 Stat. 886; U. S. C., title 42, sec. 25) five additional sections. The act proposed to be amended established in the Public Health Service a Division of Venereal Diseases, and set forth its duties as "(1) to study and investigate the cause, treatment, and prevention of venereal diseases; (2) to cooperate with State boards or departments of health for the prevention and control of such diseases within the States; and (3) to control and prevent the spread of these diseases in interstate traffic." Enactment of the law of 1918 resulted largely from the findings of physical examinations in connection with the operation of the Selective Service Act, a war measure. These examinations revealed a high prevalence of both syphilis and gonorrhea. Their control, therefore, became an urgent problem of national defense. With the passage of the war period, however, and demobilization of the military forces, public interest in the control of these diseases was diverted to the many post-war problems. The Division of Venereal Diseases of the Public Health Service has functioned continuously since its creation, but with limited funds and facilities, and without the machinery for effective cooperation with the States in reducing the prevalence of venereal disease. There apparently has been little, if any, reduction in the incidence of either syphilis or gonorrhea from that time to the present. In contrast, a number of foreign countries have reduced the prevalence of these diseases to a small fraction of their previous rates. In December 1936 a conference on venereal disease control was held in the city of Washington. Nearly 1,000 health officials, physicians, and representatives of voluntary health and welfare organizations participated in this conference, and for 3 days gave careful consideration to the serious problems presented. One of the resolutions adopted stated the opinion of the conference that an annual Federal appropriation of $25,000,000 should be sought to enable the Public Health Service to cooperate with State and local health organizations in an effective national campaign for the purpose of reducing the prevalence of syphilis. The proposed legislation authorizes an appropriation of $3,000,000 for the fiscal year ending June 30, 1939, $6,000,000 for the fiscal year ending June 30, 1940, $12,000,000 for the fiscal year ending June 30, 1941, and $25,000,000 for each of the 10 fiscal years thereafter. These funds are to be allotted, under provisions set forth in the bill, for the purpose of assisting States, counties, health districts and other political subdivisions of the States in establishing and maintaining adequate measures for the prevention, treatment, and control of the venereal diseases, and for the purpose of making studies, investigations, and demonstrations to develop more effective measures of prevention, treatment, and control of the venereal diseases, including the training of personnel. The appropriations authorized by this bill would provide for the development throughout the country of adequate treatment and diagnostic facilities, for the more thorough organization of case finding and case holding work for the control of the venereal diseases, and for studies to develop better methods of prevention and control of these diseases. Studies by the Public Health Service of the number of people who seek treatment for syphilis and gonorrhea each year indicate that there are approximately 517,000 new patients with early syphilis who go annually to physicians, clinics, or some other source of treatment for their syphilitic infection. The estimate for gonorrhea is 1,037,000. There is also considerable evidence to indicate that as many people are infected with syphilis and gonorrhea each year who fail to seek treatment as are infected and report to a recognized source for treatment. The venereal diseases are among the most prevalent of all the communicable diseases, yet means for their control are known and can be made available if the funds are provided. H. R. 9047 contains sound provisions to accomplish this desirable result. The venereal diseases assume national importance because of the heavy demand on Federal, State, and local-tax funds in the care of end results; because of their communicable nature which makes isolated State action ineffective; and because their continued prevalence is a menace to national defense through lessened military and industrial efficiency in time of war. To delay Federal action until a time of national emergency would be unwise because of the time required to bring about effective control. Action now, however, would be a distinct measure of national preparedness. The Department favors the general purposes of this act. It does not favor, however, the specific amounts authorized. It is suggested that the amount authorized for each of the first 3 fiscal years not exceed $3,000,000 and that the amount to be appropriated thereafter be left for future determination. The citation of the existing law in line 4, page 1, should be changed to read chapter XV instead of chapter IV. It is recommended that the words "of sections 4a to 4e, inclusive" be inserted immediately preceding the words "of this act" on page 2, line 6, and on page 3, line 23; and that there be substituted for the words "This act" on page 3, line 24, the words "Sections 4a to 4e, inclusive, of this act." The bill is in the form of a direct amendment to the Army Appropriation Act for the fiscal year 1919. That act contained other permanent legislation. A reference to "This act" in an amendment to an act is deemed to refer to the original act which is amended and not to the act making the amendment. Thus, it is apparent that the Surgeon General should not be authorized (as he apparently would be by the present language of line 23, p. 3) to prescribe regulations with respect to matters in the Army Appropriation Act for 1919 which are outside the domain of the Public Health Service. I am informed by the Director of the Bureau of the Budget that with changes suggested the proposed legislation is in accord with the program of the President. Very truly yours, WAYNE C. TAYLOR, Acting Secretary of the Treasury. The committee held extensive public hearings on several pending bills relating to similar objective purposes as are embodied in H. R. 9047 and S. 3290. Having received a favorable report from the Treasury Department on the bill, H. R. 9047, with suggested amendments, the committee agreed upon the latter bill with some amendments and amended the Senate bill to conform to the amended House bill and then ordered the Senate bill, as amended, favorably reported to the House. There are six questions which your committee feel should be answered in considering such a measure as this. (1) Is the problem a challenging and a serious one? (2) Are the means available to cope with the problem? (3) Is Federal action necessary or can the problem be effectively and sufficiently handled by the States? (4) Does this bill contemplate administrative procedures of demonstrated effectiveness? (5) Do these proposals represent an economical expenditure of public funds? (6) Is there a public demand for action? Your committee believe the bill, as reported, answers each of these questions satisfactorily. We list below in our report our findings with reference to each one of these six questions. We send the bill to the House with the recommendation that it do pass. 1. IS THE PROBLEM A CHALLENGING AND A SERIOUS ONE? Repeated testimony from outstanding medical authorities and public health officials indicates that syphilis and gonorrhea are the Number 1 health problems of the Nation. They are two remaining great plagues. The taboo which has surrounded them has meant that physicians do not report them as regularly as the law requires. But careful surveys over a 7-year period conducted by the United States Public Health Service show that 1,116,000 cases of syphilis come to the attention of physicians for the first time each year, and that more than half of these are advanced cases, difficult to cure, which never before came under proper medical observation. Similarly, 1,037,000 cases of gonorrhea report annually for first medical attention. Much of this infection is innocent. The Surgeon General estimates that 50 percent of all infections with syphilis are innocent. These innocent infections include accidental infections, infection in marriage, infection of children by parents. Sixty thousand children are born each year with congenital syphilis. In addition, 25,000 stillbirths result each year from syphilis. Both syphilis and gonorrhea are responsible for thousands of abortions and miscarriages. One-half of all sterility, both in the male and female is due to gonorrhea. Eighty to ninety percent of pelvic inflammatory disease is likewise due to gonorrhea. These diseases, moreover, take a special toll of youth. Fifty-six percent of all infections with syphilis occur before the age of 25, onefifth before the age of 20. The age distribution of gonorrhea is similar. Striking, as they do, at youth, both have a special significance with relation to the future physical fitness and military efficiency of the Nation. Neither The problem is challenging not only because it is serious but because it is at present not adequately met. There are not sufficient treatment facilities. For example, early syphilis requires out-patient treatment for 70 weeks. Even should treatment with sulfanilamide which now offers such great hope in the treatment of gonorrhea fulfill its early promise, it will probably require hospitalized care. procedure is easily available to a large proportion of those who are infected with these diseases and who are now spreading them throughout the community. It has been estimated that if cases of syphilis remain in treatment for the full 70-week course required instead of the average of five to eight treatments as at present, existing facilities would be able to care for less than 25 percent of known cases of syphilis. There is need for training of physicians as well as the creation of public facilities for meeting the problem. 2. ARE THE MEANS AVAILABLE TO COPE WITH THE PROBLEM? The committee find that measures for coping with this challenging problem are definitely available, both medically and administratively, for syphilis. The treatment of syphilis is highly standardized and effective. Ten years ago the United States Public Health Service brought_together five of the leading syphilis clinics of the Nation: Mayo, Johns Hopkins, University of Pennsylvania Hospital, Western Reserve University Hospital, and University of Michigan Hospital. Noted syphilologists from these clinics combed 75,000 case records in their efforts to perfect treatment. The American treatment procedure, known by the name of this Cooperative Clinical Group, is the most effective procedure yet developed. If syphilis is discovered in its earliest stage it will effect 86 percent of cure, a level not achieved in the case of any other serious disease. Even in the case of mothers infected with syphilis, discovery of the disease early in pregnancy and the rendering of prompt and continuous treatment is almost certain to prevent the birth of a congenitally syphilitic infant. The problem of finding syphilis rests upon the serodiagnostic test. Within the past 5 years a similar study for the evaluation of serodiagnostic tests has brought them to a high state of perfection. Public-health measures for the control of syphilis have proven that these medical developments can be applied with administrative effectiveness. Though treatment and diagnostic procedures were not as highly developed during the war as they are now, in the 2 years of hostilities the venereal disease rate of the American Army was dropped from 92 per 1,000 to 16 per 1,000. The nations of Europe, Sweden, Denmark, Holland, and Great Britain have developed programs which dropped their syphilis rate from levels similar to ours down to points which range from one-twentieth to one-hundredth of the American rate. Some State programs have materially reduced the incidence of late complications such as paresis and locomotor ataxia, but the mobility of our population has made it impossible to effect like reductions in the number of new infections. 8. IS FEDERAL ACTION NECESSARY OR CAN THE PROBLEM BE EFFECTIVELY AND SUFFICIENTLY HANDLED BY THE STATES? The mobility of population referred to in the last paragraph is the strongest reason why individual State action cannot effectively eliminate the venereal diseases. Should any American State wipe out syphilis or gonorrhea tomorrow, the passage of people across its borders from neighboring States would bring the disease back as a major problem within a few months. Action by all the States is necessary. That action must be coordinated action under national leadership which will insure that each State will receive the necessary aid and will continue its pressure until the battle has been won. Unintegrated local action would waste local funds and could not be justified without such a concerted program. The scope of the problem, moreover, has reached a point where the resources of the States cannot now meet it. If a long range program such as is contemplated in this bill for a 13-year period can be undertaken, the experience of other national control programs would justify the belief that at the end of that time the problem would be so reduced that the States would then be able to hold these diseases in check with the minimum of Federal aid. There is, moreover, a previous evidence of responsibility for this problem on the part of the Federal Government in the fact that it has made the travel of infected persons across State borders illegal. 4. DOES THIS BILL CONTEMPLATE ADMINISTRATIVE PROCEDURES OF DEMONSTRATED EFFECTIVENESS? The procedures contemplated by this bill are based upon the findings of medical science and upon the methods of public-health administration referred to above. They follow closely the better adapted features of control programs developed abroad and in those American States which have gone furthest to meet this problem. The recommendation for State and local venereal-disease control programs which will be developed with Federal grants-in-aid under this bill made by the United States Public Health Service was drafted and introduced by the Conference of State and Territorial Health Officers who will apply them. Similarly, the financial procedures suggested in the bill follow closely those procedures laid down in title VI of the Social Security Act. There they have shown effectively that the administration of funds by the United States Public Health Service has proven the best means of stimulating State and local expenditures and action for the development of public-health facilities. As an evidence of the care with which these public-health authorities have made their recommendations the level of $25,000,000 set by the original bill was the result of scientific calculation which represents somewhat less than half the funds needed to meet the problem. It was contemplated that the other half would be provided by the States. The progressive annual increase until that level of $25,000,000 was reached was made at the suggestion of those health authorities because they realized that personnel were not available and that a period of several years would be necessary before a going-concern status could be reached. The steps suggested for the first 3 years represent estimates of the administratable level of the expenditure which might be most effectively achieved and not a provisional level of adequate expenditure. They would not be adequate to cope with the problem. In summary, both the administrative features contemplated and the financial procedures recommended in this bill are supported and recommended by the Federal, State, and local officials who will administer the funds. 5. DO THESE PROPOSALS REPRESENT AN ECONOMICAL EXPENDITURE OF PUBLIC FUNDS? Experts before the committee estimated that the actual cost of venereal disease, as it exists today, is over a billion dollars a year. Such figures depend upon estimated loss due to death, to failure of earning power, and to similar factors. As such, they are undoubtedly indicative, though statistically not exactly determinable, as would be figures on the cost of a war or a depression. Two end results of syphilis alone, however, represent a total several times as much as the amounts contemplated in this bill. The Surgeon General has estimated that the cost of care of the syphilitic insane in mental institutions in the United States exceeds $31,000,000 a year. The care, rehabilitation, and relief of those blind as the result of syphilis is estimated at $10,000,000 a year. If no other costs were taken into account, a program similar in effectiveness to those of Sweden or Great Britain would yield a dividend of more than 100 percent over a 20-year period. The committee, therefore, recommend not an expenditure but a genuine investment. It should be noted in this regard that had the wartime effort at venereal-disease control been applied to the civilian population from 1918 to 1925, as was done in Great Britain and the Scandinavian countries, this annual expenditure for the care of the syphilitic insane and the blind would not now be necessary. |