though the recent discovery of a blood factor, the hepatitis-associated or Australia antigen, in some patients with acute liver disease is a promising lead for at least some forms of this disease. The epidemiology of this disorder is actively being studied in this and in other countries. Nevertheless, the size of the problem is today not known. This is significant because viral hepatitis causes cirrhosis and acute fatal hepatic failure, both of which might be preventable by the development of a vaccine. Viral hepatitis is increasing in frequency because of its common occurrence in drug addicts in all strata of society. This problem has reached almost epidemic size in the disadvantaged. Liver disease, moreover, has become a sometimes dangerous and even fatal side effect of the administration of potent and useful drugs and is a limiting factor in the use of many medications. I also want to point briefly to another disease of the biliary system, namely, gallstone disease. It affects about 15 million Americans, occurs in 15 percent of all persons age 55 to 69, and produces medical care expenses in excess of $500 million annually. Despite this social importance of liver disease, patient care facilities and manpower trained and interested in prevention and management of these diseases are limited in the United States. By contrast, interest in liver disease is greater in the Latin countries, with their wellknown preoccupation with the "sick liver." The result in the United States is limited facilities for hospitalization, particularly for the patient with alcoholic cirrhosis and for the disadvantaged group. It is the impression of all of us interested in liver disease that mortality from acute hepatic failure could be reduced. This means that this disorder, which may be caused by hepatitis or an adverse drug reaction, is transient and potentially reversible. Complete cure may depend on the knowledge and interest of the attending physician. In the case of cirrhosis, restoration of a socially and emotionally satisfactory life is also possible. The lack of medical manpower is in part explained by the fact that many, even distinguished, institutions have no, or few, experts in liver disease, and that the teaching of liver disease including alcoholic liver injury in the curriculum varies in the medical schools throughout the country. The various National Institutes of Health, especially the Institute for Arthritis and Metabolic Diseases, have provided large amounts of money for research in the liver, and we want to express our deep gratitude at this point for this excellent support. However, the bulk of this money has been devoted to normal and abnormal biology of the liver, an excellent model in which to study many biological processes. Relatively little money, however, has been awarded for research in liver disease, particularly its management, and this support is fragmented by being spread throughout several institutes. The National Institute for Arthritis and Metabolic Diseases is concerned with metabolic aspects. The study of infectious hepatitis is supported by the National Institute for Infectious Diseases and Allergy and by the Research nad Development Command of the U.S. Army. The study of alcoholic liver disease is mostly supported by the National Institute of Mental Health. The toxicologic aspects are covered by the National Institute for General Medical Sciences and the Environmental Health Service. Support also comes from the National Cancer Institute, the National Institute of Child Health and Human Development, and the National Heart Institute. Extramural support by, and intramural research in, the proposed National Institute for Digestive Diseases and Nutrition may go a long way to consolidate these efforts and may direct them toward better delivery of health care for patients with liver disease. Such an institute, which exerts leadership in a field by initiation and organization of coordinated research in basic science, in clincal science and in improved health care, and also in demonstration of methods of management which this bill provides, will lend prestige to the field. Students, young physicians and paramedical personnel may be attracted to digestive disease, an area now less popular than fields given prominence by the existence of a recognized national effort. Since public information and education are key devices in prevention of these diseases, a governmental effort will be of great significance. Categorical institutes are considered by greater experts than myself as useful devices to combat disease, educate physicians and the lay public, and deliver health care. Therefore, an Institute for Digestive Diseases and Nutrition is considered an important tool by my colleagues and myself. Specifically, all members of the board of directors of the Digestive Disease Foundation endorsed this proposal yesterday. Moreover, the Steering Committee of the American Association for the Study of Liver Disease formally supports this proposal and this committee is already on record on the social impact in liver disease in an article published in the New England Journal of Medicine, an article which Senator Javits previously read into the Congressional Record (exhibit 3). Thank you for permitting me to make this statement. The CHAIRMAN. Thank you, Dr. Popper. Dr. Popper, is hepatitis more related to digestive diseases than to other categories? Dr. POPPER. Hepatitis is considered a disease of the liver and therefore a digestive disease. The CHAIRMAN. In one reference on page 3, you mention "hepatitisassociated or Australia antigen, in some patients with acute liver disease is a promising lead for at least some forms of this disease." What is the origin of the "Australia"? Is that where it was discovered? Dr. POPPER. The antigen was first found in the serum of an Australian aborigine, incidentally, and from this incidental discovery, the name Australia arises. It was discovered in this country by Dr. Blumberg working in Philadelphia. The CHAIRMAN. Thank you very much for your contribution here. I might have had some questions but time will not allow them. Thank you. Our next witness is Dr. Carroll M. Leevy, professor of medicine, New Jersey College of Medicine and Dentistry, Newark, N.J. Dr. Leevy, you may proceed in your own way. STATEMENT OF CARROLL M. LEEVY, M.D., PROFESSOR OF MEDICINE, COLLEGE OF MEDICINE, SETON HALL UNIVERSITY, JERSEY CITY, N.J. Dr. LEEVY. Mr. Chairman and members of the subcommittee, my name is Carroll M. Leevy, M.D., of the University of Michigan Medical School. I am professor of medicine and director of the Division of Hepatic Metabolism and Nutrition of the New Jersey College of Medicine and Dentistry in Newark. I am certified by the American Board of International Medicine, and Clinic Nutrition. I am president of the International Association for the Study of the Liver, a past president of the American Association for Study of Liver Disease, a member of the American Society of Clinical Nutrition, the American Institute of Nutrition and a member of the editorial board of the American Journal of Clinical Nutrition. I am engaged in teaching, research and patient care in the field of liver disease, and clinical nutrition. At the present time nine young physicians are being trained in my unit as hepatologists and nutritionists. I wish to testify in support of bill S. 3063 to establish an Institute of Digestive Diseases and Nutrition. Much knowledge has been acquired, but more information is urgently needed so that we can detect digestive and liver disease with greater facility in its early phase and prevent crippling end stage illness. Digestive and liver disease constitute the single most frequent cause of hospitalization in the United States. The lack of manpower to care for these patients is stressed in a recent article by Dr. Malcolm Tyor of Duke University (exhibit 1) which is attached to my statement. This is illustrated by the attached map (exhibit 2) which shows four States in the Union have no physicians trained or expressing a special interest in digestive diseases and eight additional States have only one or two. It is therefore essential that we focus attention and effort on control of digestive diseases equal to that currently given to heart disease, cancer, and mental disease. If this is done, we can interrupt the alarming increase in morbidity and mortality from digestive and liver disease. This thesis is supported by studies of both ghetto and affluent populations where there has been a two to threefold increase in incidents of liver disease largely due to escalation of causative factors without concommitant increase in trained personnel or facilities for proper diagnosis and treatment. An Institute of Digestive Diseases and Nutrition as described in the proposed bill is needed to train more specialists in digestive and liver disease and to elucidate better methods to prevent and treat this group of diseases. Development of a cohesive, broad, nationally supported research and educational program on various aspects of intestinal, pancreatic and liver disease would permit us to significantly reduce the morbidity and mortality and associated economic loss from these disorders in our country. Particularly attractive is the provision in the bill to foster demonstrations, to update information by practicing physicians on the cause, prevention and methods of diagnosis and treatment of digestive diseases and malnutrition while relaying to practitioners information on the application of new research findings. The recent public acknowledgement of the high incidence of undernutrition in many sections of our country has led to now Federal emphasis and support for nutrition which is much appreciated. This was reviewed in the September 1969 issue of Today's Health, an AMA publication for the laity (exhibit 3). It was pointed out that 35 to 55 percent of a representative segment of Americans studied in nutritional surveys suffered from one or more nutrient deficiencies. Our own studies in New Jersey indicate that over 80 percent of randomly selected hospitalized, indigent patients have clinical or laboratory evidence of vitamin deficiency. The current programs administered by the Institute of Child Health and Human Development, the National Heart Institute, the Institute for Mental Health and other Federal agencies have made significant impact on further understanding the causes and methods needed to control both under and overnutrition. Clinical nutritionists usually focus attention primarily on nutritional aspects of surgery, obstetrics, medicine, pediatrics, and various subspecialties such as heart, kidney, or liver disease. This is appropriate since it is necessary to develop ways and means to improve nutrition in the newborn, the growing child, the expectant mother, the aged and the sick and injured. Thus, all patients with liver disease require additional nutrients to repair cellular damage. The discovery of the importance of folic acid for liver repair represents a major breakthrough. We need additional practical advances of this nature. This requires increased support for basic and clinical research, more trained professional and paramedical personnel, and expansion of facilities to solve the problems related to food availability and composition, as well as nutrient intake, absorption, and utilization in health and disease. It is necessary to coordinate research, education, and health care activities in nutrition which presently exists in various agencies without curtailing any interest or need. This should occur through the establishment of an Institute. of Digestive Diseases and Nutrition which would simultaneously insure continuity of purpose and objective. Much progress has been made in improving health of the average American because of the various programs of the National Institutes of Health. Priorities emphasized in the past were most appropriate. The rapid, recent increase in environment imposed medical illness makes it now necessary to reorient priorities, to permit solution of the increased problems of digestive disease and malnutrition. A formally organized institute especially devoted to research, education and improvement in health care as described in bill S. 3063 is essential for this purpose. A national program of this nature will begin to fulfill our long sought objective of providing adequate health care for all Americans regardless of their area of residence. Thank you for the opportunity to make this statement. The CHAIRMAN. We will place in the record at this point the exhibits which are attached to your statement. (The exhibits referred to follow :) |